A 45-year-old intellectually handicapped man is admitted to your Intensive Care Unit for airway management.  He was nasally intubated for evacuation of a large dental abscess, which had caused airway compromise.

(b)       Within 24 hours he has become febrile, and has developed hypotension and bilateral large pleural effusions.  Describe your management of these problems.

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College Answer

The development of a fever within 24 hours of an evacuation of a large dental abscess is not unexpected (infection/inflammation). It would be reasonable to repeat cultures (especially of blood and available sputum) but the antibiotic therapy started to cover the expected causative organisms should not need to be altered. Non-infective causes of fever are possible at this early stage but are less likely. Other sites of infection (seeded from the oral source are possible [eg. osteomyelitis, endocarditis]).


Hypotension should be treated on its merits and could be due to any of or a combination of: hypovoalemia (relative/absolute), cardiogenic (ischaemia, arrhythmia [tachy- or brady-]), obstructive (pulmonary emboli, pericardial collection, tension pneumothorax, large pleural collections) or distributive/vasodilatory (sepsis, anaphylaxis, sedation [removal of endogenous catecholamines , or direct effects]). Management depends on the specific causes but requires a systematic approach (including careful clinical examination, assessment of fluid status ± more invasive assessments [echocardiography, PA catheter or other assessment of cardiac output).


New, large, bilateral pleural effusions are unusual and should be confirmed on more than an Xray appearance (eg. ultrasound, CT scan). Definitive treatment would be drainage via intercostal tube insertion (which would also allow sampling of fluid to be sent for microscopy and culture, protein and electrolytes, and cytology). Specific causes to be considered can be divided into transudative (eg. congestive cardiac failure, low albumin, constrictive pericarditis, ascites) and exudative (eg. pneumonia, intra-abdominal abscesses, oesophageal rupture, chylothorax). Treatment needs to also address the underlying cause.

Discussion

A systematic approach is called for.

  • Attention to the ABCS, with management of life-threatening problems simultanous with a rapid focused examination and a brief history
  • Airway
    • Assess the volume of bronchial secretions; collect some for culture
  • Breathing/ventilation
    • Assess the effect these effusions are having on ventilation with an ABG and adjust ventilator settings to maintain normoxia and normocapnoea
  • Circulatory support
    • Systematically assess the causes of the hypotension
    • Start management with a fluid bolus; assess the need for vasopressors
    • ECG and TTE to rule out a cardiac cause of the effusion
  • Supportive management
    • Correct hypoalbuniaemia
    • Address the need for nutrition if the patient appears to be malnourished
  • Specific management
    • Culture blood and urine as well as sputum
    • Collect a sample of pleural fluid for analysis and culture
    • Consider adjusting the antibiotic regimen to cover a more broad range of pathogens
    • Consider a CT chest if the effusion fluid resembles something suspicious (eg. frank pus of a ruptured abscess, or chyle)