Table 1: Initial eﬀect of metaraminol boluses. Systolic Diastolic MAP Table 2: Initial blood gas results. Bicarbonate PCO2 Case Reports in Medicine Time since admission to ED in hours In ED In ED 1 hour after admission Taken from medical SHO clerking 3 hours after admission 5 when ﬁrst seen by ICU 5 given metaraminol in boluses at intervals of 5–10 minutes. 5:20 5 then given calcium gluconate (20 mLs of 10%) followed by glucagon 10 mg as a bolus 5:30 6 7 noradrenaline started here 8 9 10 11—admitted to ICU- vasopressin started here along with glucagons infusion 12 adrenaline started here Time since admission to ED in hours In ED venous gas recorded 5 hours post ED 11:25—on trauma mask 12:00—now on NIV 13:00 19:30 20:54—bicarbonate started on basis of this gas—50 mLs/hr of 8.4% Total 200 mLs given 22:54 17:00 18:00 23:57 25:00 26:06 27:01 28:26 29:32 rise in MAP over the initial period. At 14 hrs after admission to the ED, she was administered 150 mL bolus of intralipid 20% over 5 min and an infusion of 3 mL·kg−1·hr−1 was then started (650 mL given in total). Twenty hours after admission to the ED, sodium bicarbonate (200 mLs of 8.4%) was administered; again without response haemodynamically but with an improvement in the acid base status. By this point, she had a severe metabolic acidosis (see Table 2). At this time (18 hrs after presentation to ED, Figures 1, 2, 4, and 5), she was refractory to vasopressin (0.02 units·hr−1), adrenaline (0.24 mcg·kg−1·min−1), noradrenaline (0.29 mcg· kg−1·min−1), glucagon (0.12 units hr−1), hyperinsulinaemia- euglycaemia (800 units hr−1), and calcium (3 mL·kg−1·hr−1 of 10%). She remained anuric and her renal function was deteriorating (peak creatinine 231 mmol·l−1 and urea 14.6 mmol·l−1) (at 48 hrs after admission to ED) Metaraminol bolus of 0.5 mg 0.5 mg + 0.5 mg 0.5 mg + 0.5 mg pH 7.371 7.3 7.34 7.36 7.3 7.26 7.27 7.26 7.25 7.31 7.32 7.35 7.34 7.33 7.33 7.34 BE −2.3 −3.9 −6.2 −5.8 −9.4 −10.4 −10.3 −11.2 −13.3 −10.1 −8.0 −6.2 −6.0 −5.8 −5.7 −5.1 122 70 75 80 72 110 125 120 90 70 75 80 90 85 95 21 19.3 19.5 16.8 16 16.1 15.5 14 16.2 17.9 19.3 19.5 19.7 19.7 20.1 61 40 43 50 46 68 62 74 50 48 43 48 55 47 50 7.49 4.84 4.52 4.49 4.7 4.54 4.5 3.95 3.93 4.53 4.51 4.96 4.91 4.97 4.95 81 50 54 63 55 82 84 89 63 55 54 59 67 60 65 PaO2 7.9 9.37 7.83 9.56 9.43 8.26 10.00 10.89 7.83 9.47 8.58 10.08 9.73 9.64 9.11 3 Pulse 100 100 90 96 98 99 89 86 85 85 85 85 85 95 80 Lactate 1.79 2.5 2.5 6.44 5.87 6.25 7.78 6.27 4.23 3.63 2.89 2.40 2.05 1.77