Case of the Month #56 The Protein Puzzle: A Case of Progressive Multi-Organ Dysfunction

Hemodynamic support

• Cautious fluid management (patients operate on steep Frank-Starling curve)
• Careful inotrope selection (dobutamine often preferred initially)
• Avoidance of excessive afterload reduction
• Maintenance of adequate heart rate (risk of rate-related cardiac output)

Arrhythmia management

• Prompt rhythm control for atrial arrhythmias
• Low threshold for temporary pacing with conduction abnormalities
• Amiodarone preferred for rhythm control
• Consider early ICD in survivors with high-risk features.

Renal support

• Early initiation of RRT for fluid control
• CVVHDF may be preferred to remove free light chains
• Careful drug dosing with renal dysfunction

Respiratory support

• NIV for cardiogenic pulmonary oedema
• Careful positive pressure ventilation (may reduce venous return)
• Cautious PEEP titration

Bleeding management

• Recognition of increased bleeding risk (factor X deficiency, vascular fragility)
• Prophylactic correction of coagulopathy for procedures
• Lower threshold for clotting product support