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.
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.
A systematic approach is called for.