A 38 years old man with recent past history of treated hypertension and depression is transferred to your ICU from operating theatre. He had been undergoing shoulder arthroscopy under general anaesthesia.
His heart rate and blood pressure were stable for the first 45 minutes when he developed a sinus tachycardia (130 bpm) and severe hypertension (265/165 mm Hg). The anaesthetist treated this by increasing depth of anaesthesia, and repeated doses of metoprolol and hydralazine. The problem persisted and an arterial line was inserted. Invasive blood pressure was 305/178 mm Hg. BIS monitoring suggested deep anaesthesia (BIS 25).
Surgery was expedited and he was transferred intubated and sedated to the ICU for ongoing management.
1. What is your initial management?
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.