Category: 12.2

Communicates effectively with members of the health care team

Emergency Coronary Angiography After Out-of-Hospital Cardiac Arrest

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A 70 year old woman suffered an out of hospital cardiac arrest whilst playing golf. She received bystander cardiopulmonary resuscitation and two shocks from an automated external defibrillator which restored spontaneous circulation. She was intubated at the scene  and arrived in the resuscitation department cardiovascularly stable, well oxygenated and unconscious in the context of propofol sedation.

There was no prodrome suggestive of a specific aetiology for the cardiac arrest but information from relatives described an ex-smoker with hypercholesterolaemia and diet controlled diabetes mellitus who had previously undergone percutaneous coronary intervention (PCI) for ischemic heart disease. She took regular aspirin, statin and beta-blocker. A post resuscitation 12 lead ECG showed sinus rhythm, left axis deviation and non-specific lateral ischaemia. Troponin was elevated above 200 ng/L.

In view of this she was loaded with dual antiplatelet therapy and underwent emergency coronary angiography which demonstrated occlusion of two small branches (OM1 and PLV) but no large vessel coronary artery occlusion to explain the cardiac arrest. The occluded vessels were not stented. Subsequent echocardiogram and cardiac MRI demonstrated old circumflex territory scar but an otherwise normal heart and ultimately it was agreed that the cause of cardiac arrest was probably ventricular arrhythmia secondary to scar.

She was ventilated for 24 hours with targeted temperature management before being woken and extubated. Although she was initially confused, her neurology improved over approximately 48 hours such that she was discharged with no apparent neurological injury. An implantable cardiac defibrillator was placed prior to discharge to prevent sudden cardiac death from any future arrhythmia.

Clinical questions:

  1. In survivors of out of hospital cardiac arrest should we proceed to early coronary angiography with a view to PCI?
  2. If so, should we apply this approach to all such patients or only a subset?
  3. If we do proceed to early coronary angiography, should this occur before or after other investigations, specifically computed tomography (CT) of the head and chest to look for intracerebral bleed and pulmonary embolism?

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Facilitation Of Donation After Circulatory Death

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A previously fit and well 45 year old man presented to the emergency department with a two-hour history of a sudden onset severe headache associated with weakness, vomiting and photophobia. He had a normal breathing pattern and oxygen saturations of 96% in air. He was hypertensive with a non-invasive blood pressure of 220/115mmHg and a pulse rate of 85 beats/minute in sinus rhythm. Neurological examination revealed a Glasgow Coma Scale (GCS) of 14/15 with a dense hemiparesis, with hemisensory neglect and dysarthria.

He deteriorated and dropped his GCS to 5/15. He was intubated and an urgent computed tomographic (CT) brain scan was performed that revealed a large right-sided intraparenchymal haemorrhage with 4mm of midline shift. Blood tests including full blood count, urea and electrolytes and clotting screen were normal.

He was discussed with the neurosurgeons who felt transfer to institute intracranial pressure monitoring or surgical intervention was not indicated. His blood pressure was managed with a labetalol infusion aiming for a target systolic blood pressure of ≤ 160mmHg. Seizure activity was managed with a 15mg/kg loading dose of phenytoin followed by a maintenance dose of 300mg once daily nasogastrically. Sodium levels were monitored closely and hypotonic fluids avoided.

By day 5 he was making spontaneous respiratory effort, and his pupils were equal and sluggishly reactive. His GCS remained 3/15. A repeat CT was performed on day 9 due to no improvement in his clinical condition and revealed extension of the intraparenchymal haemorrhage with 8mm midline shift, effacement of the ventricles and loss of sulcal definition. A discussion regarding end of life care was held with his family who raised the possibility of organ donation. In agreement with his family, end of life care was instituted and he became an organ donor after circulatory death was confirmed.

How can we facilitate Donation After Circulatory Death?Read More »

Transplantation After Brainstem Death

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A 38-year-old previously fit man suffered a grade five subarachnoid haemorrhage. Attempts at coiling failed and he suffered a catastrophic rebleed on-table whereupon his pupils became fixed and dilated. After a suitable sedation washout period he underwent testing which confirmed brainstem death at which point he was referred to the specialist nurse for organ donation. Following counselling of the family and appropriate assessment, donation of his kidneys, liver and heart was agreed.

Upon confirmation of brainstem death, mechanical ventilation was continued to ensure PaO2 greater than 10 kPa and limit peak inflation pressure to less than 30 cmH20. Vasoactive support was switched from noradrenaline to vasopressin 0.02 iu/kg/min. Methylprednisolone and intravenous triiodothyronine were administered whilst awaiting harvest. Blood antibody testing for HIV1+2, Hepatitis B and C, HTLV-1 and CMV IgG were all negative. A transthoracic echocardiogram confirmed good biventricular function; following discussion with the transplant retrieval team a pulmonary artery catheter was floated. Clinical measurements of cardiac output and mixed venous oxygen saturation were satisfactory. Adequate hydration was maintained with crystalloid by infusion and glucose control optimised in the range 8-10 mmol/L with insulin. The dedicated retrieval team performed the organ retrieval eighteen hours after confirmation of brainstem death.

How can we optimise organ function for organ donation?Read More »

Intensive Care Acquired Weakness

Intensive Care Acquired Weakness

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A cardiovascularly fit 65 year old man was admitted with septic shock secondary to community acquired pneumonia, which progressed to multi-organ failure. During his recovery it was noted that he had generalised weakness with no focal neurology. He underwent respiratory weaning, and rehabilitation therapy over the next 4 weeks but had persistent weakness at his ICU discharge.

How can ICU-acquired weakness be diagnosed and managed?Read More »

ICU Admission with Haematological Malignancy

Outcomes of ICU Admission with Haematological Malignancy

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An middle aged woman presented with a blast crisis following acute transformation of preexisting chronic myelomonocytic leukaemia. She failed to respond to several cycles of chemotherapy and underwent allogeneic bone marrow transplant. She subsequently developed neutropaenic septic shock and was found to have fungal pulmonary abscesses. Her sepsis was aggressively managed on ICU and she made steady progress and eventually recovered, and was discharged from hospital 5 weeks after her ICU admission.

What is the current evidence related to the mortality and morbidity associated with admission to intensive care for patients with haematological malignancy?Read More »

ECMO for Severe Refractory Hypoxaemia

ECMO for Severe Refractory Hypoxaemia

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An 60 year old woman developed ARDS secondary to pneumococcal meningitis. Despite optimal ventilatory management and restrictive fluid intake her oxygenation remained severely impaired. She was referred to the regional respiratory failure unit who established her on mobile ECMO for retrieval. She remained on ECMO for five days, weaned off the ventilator after three further days and made a full neurological recovery leaving hospital two weeks later.

Is there sufficient evidence to promote the use of Extracorporeal Membrane Oxygenation (ECMO) for the management of severe refractory hypoxia in the United Kingdom?Read More »

Organ Donation After Cardiac Death

DCD Organ Donation: Eligibility and Contra-indications

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A 35 year old man sustained a severe penetrating traumatic brain injury. His injuries were deemed to be unsurvivable, but he was not brainstem dead. He was on the organ donor register, and his family were keen to proceed with donation. He was admitted to the ICU to manage his end of life care and facilitate organ donation after circulatory death.

What are the eligibility criteria and contra-indications to organ donation after circulatory death?Read More »

Organ Donation

Improving Rates of Organ Donation

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A 75 year old man with stage 3 chronic kidney disease and ischaemic heart disease was resuscitated from a witnessed out of hospital VF arrest. CT head on admission showed a large intracranial haemorrhage with midline shift and effacement of ventricles. Neurosurgical intervention was thought to be futile. There were some family members abroad, who wanted to be present when treatment was withdrawn so care was continued for 24 hours awaiting their arrival. On the day that treatment was planned to be withdrawn, the possibility of organ donation was raised by a team member. The specialist nurse for organ donation (SNOD) was contacted, but was delayed by several hours. The local ICU consultant made the initial approach to the family when they were all present which was promising. A subsequent conversation took place when the SNOD arrived. Consent for organ donation was eventually refused. The family felt that further delay to treatment withdrawal was inappropriate.

How can we improve rates of consent for organ donation on the ICU?Read More »

Mechanical Ventilation in patients with COPD

Predicting Outcomes of Mechanical Ventilation in patients with COPD

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An elderly man with an infective exacerbation of COPD deteriorated during his medical admission with type 2 respiratory failure. He was commenced on ward-based non-invasive ventilation while establishing further history. He was on home nebulisers, was awaiting assessment for home oxygen, and was limited to household mobility only. He could not climb stairs. He had secondary polycythaemia. After discussion with the patient and family, a ward-based ceiling of care was set. He remained on NIV for several days before being weaned off and discharged to a rehabilitation facility after a two week admission.

Can we predict outcomes for patients with respiratory failure and COPD who require invasive ventilation?Read More »

Hepatic Encephalopathy in Acute Liver Failure

Management of Hepatic Encephalopathy in Acute Liver Failure

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A 30 year old woman with a background of substance abuse and deliberate self harm was found collapsed and semi-conscious following an overdose of co-codamol and was presenting late. It was possible that she had taken around 100g paracetamol. Her GCS was 11, and she had grade II/III hepatic encephalopathy. Her bilirubin was 60 and she had significant transaminitis with a lactic acidosis. . She was commenced on N-acetylcysteine despite undetectable paracetamol levels. Liver US was normal. Early repeat bloods showed worsening jaundice, transaminitis and rising INR. She was transferred to the regional liver unit initially for monitoring, but was subsequently admitted to the liver HDU. She did not require a liver transplant and recovered with conservative management.

What is the optimum management of hepatic encephalopathy in acute liver failure?Read More »