Q1. Interpret the ABG. What is the likely cause of this acid-base abnormality?

• Primary metabolic acidosis with respiratory compensation
• pH 7.19, HCO₃⁻ 11, BE -10 → high anion gap metabolic acidosis
• Likely cause: lactic acidosis due to ongoing tissue hypoperfusion/septic shock

Examiner Commentary:
Focus on pattern recognition: HAGMA + raised lactate + shock = perfusion failure. Show full interpretation, not just the final answer.

Q2. What are the likely causes for his current respiratory failure? (Name up to 3, in order of likelihood)

1. ARDS secondary to sepsis/peritonitis
2. Abdominal compartment syndrome (ACS) causing diaphragmatic splinting
3. Aspiration pneumonitis during early post-op period

Examiner Commentary:
Structured ranking shows prioritization skills. Mentioning ACS here is excellent — given tense abdomen, high bladder pressure, and respiratory distress.

Q3. What does the bladder pressure suggest? How does it influence your management now?

• Bladder pressure 24 mmHg suggests abdominal compartment syndrome (ACS).
• ACS compromises renal perfusion, venous return, and diaphragm excursion.
• Immediate decompression steps:
  • Ryle’s tube suction
  • Flatus tube insertion
  • Deep sedation ± neuromuscular blockade
  • Consider surgical decompression if refractory

Examiner Commentary:
EDIC loves candidates who detect ACS early. Don’t stop at stating it — always describe the next specific interventions.

Q4. Would you transfuse blood products at this stage? If yes, which ones and what targets will you aim for?

Yes — indications for transfusion are present.

• PRBCs: Hb 7.4 with ongoing losses → target Hb >7–8 g/dL (may aim higher in ongoing bleeding or poor oxygenation)
• Platelets: 90k but stable; hold unless <50k or procedural requirement
• FFP: INR 1.8 → consider if invasive procedure is planned or ongoing bleeding
• Fibrinogen (if available): maintain >1.5 g/L
  Send samples for TEG/ROTEM to guide further correction

Examiner Commentary:
Mentioning transfusion thresholds + specific product use shows applied knowledge. Bonus if you mention point-of-care tools like TEG.

Q5. List 3 immediate interventions you would initiate right now to improve oxygenation and perfusion.

1. Intubation and mechanical ventilation for impending respiratory failure (SpO₂ 88% + RR 38)
2. Start or escalate norepinephrine to maintain MAP ≥65
3. Decompression measures for suspected ACS (NG tube, sedation, monitor for need of surgery)

Examiner Commentary:
Candidates who think of oxygenation + perfusion + abdominal pressure as an integrated response show maturity. Don't delay intubation in a deteriorating patient.