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Final clinical long case 51

Created: 8/4/2014
A 26-year-old woman had her fourth child 8 days ago. In the post-partum period, she has become progressively unwell. The HSV culture was positive for Streptococcus A. She is taken into hospital for evacuation of retained products. She has progressive shortness of breath. She is given continuous positive airway pressure of 10 cm H2O. The obstetrician wants to take her to theatre for a hysterectomy.

Benzyl penicillin
Heparin 5000 IU

Heart rate: 135 beats/min
Blood pressure: 109/68 mmHg
Central venous pressure: 8 cm H2O
Chest X-ray: right-sided hilar shadow; bilateral light diffuse haziness; left-sided small pleural effusion
ECG: sinus tachycardia
Arterial blood gases: pH 7.404
pO2: 12.3 kPa
pCO2: 3.6 kPa
FiO2: 70%
Base excess: -6.5 mEq/L
Haemoglobin 11.5 g/dl
Full blood count: platelets 20  109/L; white blood cells normal
Na+: normal
K+: normal
Urea: slightly raised
Creatinine: normal
Bilirubin and liver function tests: elevated
INR: 1.1
Activated partial thromboplastin time ratio: 1.2

1. Summarise the case
2. What is acute lung injury?
3. What is the cause of her sepsis?
4. What are the common organisms involved?
5. What antibiotics should she be given? (Sensitivity not available)
6. Why should be undergo a hysterectomy?
7. Does she have disseminated intravascular coagulation?
9. Describe your management of this case.
10. How would you pre-optimise the patient?
11. What fluids would you give?
12. Is the central venous pressure important?
13. What are the confounding factors in this case?
14. How would you induce this patient?

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