I was on a gruelling set of night on calls as a FY1 doctor, hoping for it to be a quiet July summery night, but little did I know what mayhem I was walking in to. A&E was just heaving and we were handed over eight patients by the day-team. Around 11 PM the crash bleep sounded alarm with an alert to go to the respiratory ward. Fortunately we were able to revive the patients, but my SpR had to stay back to sort out the aftercare when one of the O&G nurse practitioners asked for help with a patient who was persistently hypotensive. My SpR asked me to go and assess the patient and promised that he would be there as soon as possible. I felt proud that the SpR trusted me, but I was also a little anxious. I was on my way alone to assess a potentially complex patient.

On arrival the nurses told me that Rebecca, who was 25 years old, had been gradually worsening over last 24-48 hours. She was four days post-partum and had lower abdominal pain. On examination she had a clear airway with normal breath sounds and saturation. However, her blood pressure was 70/50 mmHg with pulse rate of 140 per minute. She was sweaty with warm peripheries. I was very concerned that she had sepsis, as sometimes occurs when some placenta is retained post-partum. Sepsis Cardiovascular Basics

I inserted a wide bore cannula and commenced fluid challenge and asked for the leg end of the bed to be raised to improve venous return. Frank Starling Relationship

I took bloods for cultures, prescribed antibiotics immediately and obtained an ABG as per the “sepsis 6” bundle. Sepsis CareTaking An Arterial Blood Sample


The ABG showed: Arterial Blood Gas Basics


This picture was what I’d expected and feared: acidaemia (due to the increased lactate production by poorly-perfused organs relying on anaerobic metabolism) and borderline hypoxaemia with clear hypocapnia (classic VQ mismatch). She had sepsis, her blood pressure had sunk as a consequence and her organs (including her lungs) were struggling to keep up. The VQ mismatch hinted strongly that her lungs were in trouble and she was in danger of respiratory failure. V Q Mismatch

Despite 2 litres of fluid challenge, Rebecca remained hypotensive and was now in septic shock. We called the intensive care registrar and she decided to transfer Rebecca to the HDU for insertion of a central venous line and noradrenaline (a good vasopressor) infusion. I remained busy with other jobs but was happy to see her during post take ward round to be normotensive on the HDU.

When I came back for my shift in the evening I was shocked to learn that Rebecca was now in ITU, intubated and ventilated. It seems that her breathing had worsened during the daytime and despite being ventilated with supplemental oxygen (FiO2 – 0.6) her ABG at 5pm was little different to when I had first examined her on room air: The Alveolar Gas Equation


Her chest X-ray showed bilateral lower zone fluffy shadowing. She was initially supported with CPAP but subsequently had to be intubated. I wondered if I was too aggressive with the fluid challenge, but my SpR reassured that ALI/ARDS pathophysiology is predominantly leaky lungs rather than fluid overload and patient needed ventilation due to poor lung compliance. Lung ComplianceA R D SPositive Airway Pressure Ventilation

I visited ITU every day over the next few weeks to check on Rebecca’s progress. After 4 days she had a tracheostomy (“That makes it easier to wean patients off ventilation”, my SPR told me when I asked later) but her condition worsened further and she was transferred to a specialist ECMO unit. She eventually started getting better and was gradually weaned off ECMO and subsequently off the ventilator. She finally was transferred to postnatal ward after a full 22 days.



I was on a gruelling set of night on calls as a FY1 doctor, hoping for it to be a quiet July summery night, but little did I know what mayhem I was walking in to. A&E was just heaving and we were handed over eight patients by the day-team. Around 11 PM the crash bleep sounded alarm with an alert to go to the respiratory ward. Fortunately we were able to revive the patients, but my SpR had to stay back to sort out the aftercare when one of the O&G nurse practitioners asked for help with a patient who was persistently hypotensive. My SpR asked me to go and assess the patient and promised that he would be there as soon as possible. I felt proud that the SpR trusted me, but I was also a little anxious. I was on my way alone to assess a potentially complex patient.

On arrival the nurses told me that Rebecca, who was 25 years old, had been gradually worsening over last 24-48 hours. She was four days post-partum and had lower abdominal pain. On examination she had a clear airway with normal breath sounds and saturation. However, her blood pressure was 70/50 mmHg with pulse rate of 140 per minute. She was sweaty with warm peripheries. I was very concerned that she had sepsis, as sometimes occurs when some placenta is retained post-partum. Sepsis Cardiovascular Basics

I inserted a wide bore cannula and commenced fluid challenge and asked for the leg end of the bed to be raised to improve venous return. Frank Starling Relationship

I took bloods for cultures, prescribed antibiotics immediately and obtained an ABG as per the “sepsis 6” bundle. Sepsis CareTaking An Arterial Blood Sample


The ABG showed: Arterial Blood Gas Basics


This picture was what I’d expected and feared: acidaemia (due to the increased lactate production by poorly-perfused organs relying on anaerobic metabolism) and borderline hypoxaemia with clear hypocapnia (classic VQ mismatch). She had sepsis, her blood pressure had sunk as a consequence and her organs (including her lungs) were struggling to keep up. The VQ mismatch hinted strongly that her lungs were in trouble and she was in danger of respiratory failure. V Q Mismatch

Despite 2 litres of fluid challenge, Rebecca remained hypotensive and was now in septic shock. We called the intensive care registrar and she decided to transfer Rebecca to the HDU for insertion of a central venous line and noradrenaline (a good vasopressor) infusion. I remained busy with other jobs but was happy to see her during post take ward round to be normotensive on the HDU.

When I came back for my shift in the evening I was shocked to learn that Rebecca was now in ITU, intubated and ventilated. It seems that her breathing had worsened during the daytime and despite being ventilated with supplemental oxygen (FiO2 – 0.6) her ABG at 5pm was little different to when I had first examined her on room air: The Alveolar Gas Equation


Her chest X-ray showed bilateral lower zone fluffy shadowing. She was initially supported with CPAP but subsequently had to be intubated. I wondered if I was too aggressive with the fluid challenge, but my SpR reassured that ALI/ARDS pathophysiology is predominantly leaky lungs rather than fluid overload and patient needed ventilation due to poor lung compliance. Lung ComplianceA R D SPositive Airway Pressure Ventilation

I visited ITU every day over the next few weeks to check on Rebecca’s progress. After 4 days she had a tracheostomy (“That makes it easier to wean patients off ventilation”, my SPR told me when I asked later) but her condition worsened further and she was transferred to a specialist ECMO unit. She eventually started getting better and was gradually weaned off ECMO and subsequently off the ventilator. She finally was transferred to postnatal ward after a full 22 days.



I was on a gruelling set of night on calls as a FY1 doctor, hoping for it to be a quiet July summery night, but little did I know what mayhem I was walking in to. A&E was just heaving and we were handed over eight patients by the day-team. Around 11 PM the crash bleep sounded alarm with an alert to go to the respiratory ward. Fortunately we were able to revive the patients, but my SpR had to stay back to sort out the aftercare when one of the O&G nurse practitioners asked for help with a patient who was persistently hypotensive. My SpR asked me to go and assess the patient and promised that he would be there as soon as possible. I felt proud that the SpR trusted me, but I was also a little anxious. I was on my way alone to assess a potentially complex patient.

On arrival the nurses told me that Rebecca, who was 25 years old, had been gradually worsening over last 24-48 hours. She was four days post-partum and had lower abdominal pain. On examination she had a clear airway with normal breath sounds and saturation. However, her blood pressure was 70/50 mmHg with pulse rate of 140 per minute. She was sweaty with warm peripheries. I was very concerned that she had sepsis, as sometimes occurs when some placenta is retained post-partum. Sepsis Cardiovascular Basics

I inserted a wide bore cannula and commenced fluid challenge and asked for the leg end of the bed to be raised to improve venous return. Frank Starling Relationship

I took bloods for cultures, prescribed antibiotics immediately and obtained an ABG as per the “sepsis 6” bundle. Sepsis CareTaking An Arterial Blood Sample


The ABG showed: Arterial Blood Gas Basics


This picture was what I’d expected and feared: acidaemia (due to the increased lactate production by poorly-perfused organs relying on anaerobic metabolism) and borderline hypoxaemia with clear hypocapnia (classic VQ mismatch). She had sepsis, her blood pressure had sunk as a consequence and her organs (including her lungs) were struggling to keep up. The VQ mismatch hinted strongly that her lungs were in trouble and she was in danger of respiratory failure. V Q Mismatch

Despite 2 litres of fluid challenge, Rebecca remained hypotensive and was now in septic shock. We called the intensive care registrar and she decided to transfer Rebecca to the HDU for insertion of a central venous line and noradrenaline (a good vasopressor) infusion. I remained busy with other jobs but was happy to see her during post take ward round to be normotensive on the HDU.

When I came back for my shift in the evening I was shocked to learn that Rebecca was now in ITU, intubated and ventilated. It seems that her breathing had worsened during the daytime and despite being ventilated with supplemental oxygen (FiO2 – 0.6) her ABG at 5pm was little different to when I had first examined her on room air: The Alveolar Gas Equation


Her chest X-ray showed bilateral lower zone fluffy shadowing. She was initially supported with CPAP but subsequently had to be intubated. I wondered if I was too aggressive with the fluid challenge, but my SpR reassured that ALI/ARDS pathophysiology is predominantly leaky lungs rather than fluid overload and patient needed ventilation due to poor lung compliance. Lung ComplianceA R D SPositive Airway Pressure Ventilation

I visited ITU every day over the next few weeks to check on Rebecca’s progress. After 4 days she had a tracheostomy (“That makes it easier to wean patients off ventilation”, my SPR told me when I asked later) but her condition worsened further and she was transferred to a specialist ECMO unit. She eventually started getting better and was gradually weaned off ECMO and subsequently off the ventilator. She finally was transferred to postnatal ward after a full 22 days.




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