KFH OSCE1

Question 1

ARDS definition

Answer 1

The Berlin Definition -2012

ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight and loss of aerated lung tissue with hypoxaemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiologiral dead space and decreased lung compliance

The essential components required to diagnose ARDS according to Berlin definition are:
* Development within one week of insult/worsening respiratory symptoms –acute
* Bilateral opacities on radiological studies not explained by effusions, collapse, or nodules
* Respiratory failure not explained by LVF or fluid overload
* PaO2/FiO2 < 300 mmHg on PEEP/CPAP ≥ 5 cmH2O with mention of oxygenation criteria

Question 2

Sepsis

Answer 2

SEPSIS-3 definitions were published in 2016 (JAMA, 2016):

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection

– Organ dysfunction can be represented by an increase of ≥ 2 points in the SOFA score

Septic shock is a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone

– Patients with septic shock can be clinically identified by:

i Vasopressor requirement to maintain MAP ≥65 mmHg

ii Serum lactate level >2 mmol/l in the absence of hypovolemia

– This combination is associated with >40% in-hospital mortality

Question 3

Equations

Abdominal perfusion pressure (APP)

Answer 3

APP = MAP − IAP

Question 4

Definitions

Intra-abdominal hypertension (IAH)

Answer 4

Sustained or repeated pathological elevations in IAP >12 mmHg.

Question 5

Abdominal compartment syndrome

Answer 5

Sustained IAP >20 mmHg (with or without an APP <60 mmHg)

Question 6

Grades

Intra-abdominal hypertension

Answer 6

Grade 1 12–15mmHg
Grade 2 16–20mmHg
Grade 3 21–25mmHg
Grade 4 ≥26mmHg

Question 7

Risk factors

IAH and abdominal compartment syndrome

Answer 7

1 Diminished abdominal wall compliance
i Abdominal surgery with tight primary closure
ii Trauma, burns, obesity
iii Prone positioning

2 Increased abdominal contents
– Intraluminal: ileus, gastroparesis, pseudo-obstruction
– Extraluminal: ascites, haemoperitoneum, pneumoperitoneum

3 Capillary leak
i Severe sepsis, trauma, pancreatitis, burns
ii Hypothermia
iii Acidosis
iv Massive transfusion v Fluid resuscitation, positive fluid balance

4 Other/miscellaneous
i Mechanical ventilation
ii Positive end-expiratory pressure (PEEP) >10 cmH2O
iii Increased head of bed angle
iv Shock or hypotension