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Slide 4 Deteriorating neurological status with rapidly increasing metabolic acidosis are indications for intubation and positive pressure ventilation. Continued cardiac instability and need for increasing doses of noradrenaline prompt the use of a non invasive cardiac output monitor to enable more empirical management of fluids and inotropes. Instigation of haemofiltration is necessary to manage rapidly diminishing urine output and escalating metabolic acidosis. Nasogastric tube is passed at time of intubation to enable enteric feeding. During this rapidly changing situation two nurses are required to assist medical staff with the instigation of therapies. Family stay in a designated relatives room with refreshments/telephone, aware that some time may elapse before they can return.

Slide 5 Before intubation and instigation of positive pressure ventilation takes place, cardiovascular stability must be maximised. Central venous pressure [indication of fluid filling] and mean arterial pressure [indication of organ perfusion] parameters are used at this stage. BiPAP [bi positive airway pressure] is commenced as full mandatory ventilation. Arterial blood gases determine ventilator parameters. Oxygen remains unproblematic for the patient but a high respiratory frequency [produces higher then normal minute volume] is necessary to lower pCO2 and assist in the management of an increasingly acidotic pH. Short acting sedative [propofol] and opiate [alfentanil] are chosen in the light of patient renal dysfunction. These are given by continuous infusion to sedate and promote comfort. Chest X ray confirmed position of ET tube and indicated clear lung fields at this stage. The nurse is responsible for recording all ventilatory observations and identifying any changes. Regular blood gases are interpreted by both nurse and doctor. Ventilator parameters are altered with the aim to normalise pH. Frequent chest auscultation helps to identify the need for endotracheal suction which should be carried out on a need only basis. Suction can compromise haemodynamics. Close observation is paid to patients sedative state the aim for the nurse is to enable comfort without over sedation, which could further compound hypotension.

Slide 6 The aim is to continually monitor the patient from the moment of admission. Priority insertion by medical staff of arterial cannula and central venous catheter [CVC] enable continuous invasive blood pressure and central venous pressure [CVP] recording. These readings together with information obtained by non invasive cardiac monitoring [NICO - see next slide] enable accurate manipulation of fluids and inotropes to maximise organ perfusion. Arterial blood gases are taken at hourly intervals to provide further information and plot patient progress. Other blood tests - full blood count, clotting and biochemistry screen - give vital information and guide treatment. Recording observations and plotting patient progress are the bedside nurses responsibility. Information is constantly relayed to the doctor with whom decisions are made with regard to fluid and inotrope management. The nurse must give intravenous antibiotics as prescribed. Constant vigilance to the progress and extent of pupuric rash by the nurse provide visual information of the progress of the disease.

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