Advance Decisions in Critical Care

 

An 85 year old man with good pre-morbid function was admitted to the ICU following emergency laparotomy for a ischaemic perforation of small bowel. He had undergone a small bowel resection and primary anastomosis. Preoperatively, the patient had been delirious and unable to consent for surgery, assent was granted by his wife.

Postoperatively, the patient required mechanical ventilation, vasopressor support and renal replacement on admission. He stabilised by day 5, but remained mechanically ventilated. On day 5 of admission, during a discussion between the surgeon and the patient’s wife, the wife admitted regret that she had not had “better” discussions with the surgeons pre-operatively and raised doubts as to whether the patient would have wanted such treatment. Following those discussions between the wife and surgical team, limitations on care were placed; renal replacement therapies would not be restarted and vasopressor support would not be escalated beyond the existing level. A DNR order was implemented. On day 10, during discussion with the duty ICU consultant, it emerged that the patient had a written advance decision refusing “aggressive medical treatment”.

 

The patient continued to improve but could not be weaned from ventilation. A percutaneous tracheostomy was sited on day 10. On day 15 he was liberated from mechanical ventilation and able to use a speaking valve. He had regained mental capacity sufficient to discuss his care and wished to continue given the progress he had made. It was agreed that he would not be mechanically ventilated in the event of deterioration and the existing DNR order was confirmed. Subsequently, it became apparent that the small bowel anastomosis was leaking; it was agreed that treatment would be non-operative.

In total the patient was treated on ICU for 20 days before he was placed on an end of life pathway and died.

 

What are the implications of Advance Decisions on Intensive Care?Read More »

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Facilitation Of Donation After Circulatory Death

 

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 »

Declining Admission to Intensive Care

An 86 year-old man was referred to ICU because of oliguria, acidaemia and decreased conscious level. He had originally been referred by the general practitioner to the acute general medicine team with unexplained weight loss, malaise and reduced mobility, 19 days previously. He had a longstanding history of bronchiectasis and COPD. He had been able to mobilise independently around his house and garden until suffering a pneumonia several months before this admission, and since required a four-times-daily care package.

During the current admission the patient had been treated for a further pneumonia on the basis of new chest x-ray changes, breathlessness and raised inflammatory markers. He had also undergone a CT chest/abdomen/pelvis for the unexplained weight loss. This was consistent with chronic COPD and bronchiectasis but no other positive findings. A week prior to ICU referral he was found to have acute kidney injury (creatinine 280 µmol/mL, baseline 90 µmol/mL) which had failed to improve. In the 24 hours prior to referral had become progressively drowsy and oliguric.

The patient appeared frail, cachectic and oedematous. He groaned in response to voice and could not follow commands. He had Kussmaul breathing at a rate of about 18 breaths per minute with SaO2 of 91% on 35% oxygen via facemask. Arterial blood gas showed pH 7.09, pCO2 7.1 kPa, pO2 9.1 kPa, base excess -9.3 mEq/L, lactate 1.3 mmol/L, glucose 8.7 mmol/L, creatinine 294 µmol/mL. His chest x-ray showed persistent bilateral patchy consolidation. He had a blood pressure of 98/55 mmHg with a pulse of 110 beats/min and cool peripheries. ECG showed sinus tachycardia. He was afebrile. Abdomen was soft and a urinary catheter had drained only 25 mL in the last 4 hours. Other than reduced responsiveness, neurological survey was non-diagnostic.

Evaluation of this patient revealed an elderly man who was severely unwell with acute kidney injury, probable sepsis, and a poor response to treatment to date. This was on the background of chronic suppurative lung disease, and diminished health for several weeks. No specific treatment limitations were in place. His next-of-kin was unaware of any prior expressed wishes and was under the impression that the patient would prefer active treatment. The referring team were of the opinion that intensive care should be considered.

Although no unifying diagnosis for this gentleman’s kidney injury had been identified, a single, rapidly-reversible condition was not apparent. The principal indication for intensive care was for renal replacement therapy for an unknown duration. In view of the status of his neurological, respiratory and cardiovascular systems, it was deemed that airway protection, invasive respiratory support and vasopressor treatment would almost certainly be required. His overall health status made the prospect of survival from a prolonged period of multi-organ support on intensive care highly unlikely. After discussion with the intensive care consultant and the referring consultant it was decided to withhold admission to the intensive care unit. Appropriate family discussions were held. The patient was actively managed on the ward for a further 12 hours, after which fluid management, antimicrobials and further investigation were ceased. He died the following day.

What uncertainties do we face when declining admission to intensive care?Read More »

Transplantation After Brainstem Death

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 »

Advance Directives

An elderly man presented to hospital with an acute abdomen. He was fit and well, with a background of well-controlled hypertension and chronic back pain. He had previously had admissions with a recurrent gastric volvulus, each time it had resolved spontaneously.

A CT scan was performed and revealed a gastric volvulus which was decompressed endoscopically. He was transferred to the high dependency ward post-procedure for observation as it was deemed high risk for recurrence and therefore likely that he would need surgery to correct it. Overnight he required increasing amounts of fluid and analgesia and suddenly deteriorated with a tachycardia, rising lactate and peritonitic abdomen. He was taken for an emergency laparotomy and had a gastrectomy. A feeding jejunostomy was inserted during the procedure.

The post-operative course involved a period of septic shock and multi-organ failure. He remained intubated, on a noradrenaline infusion and was receiving CVVH for renal failure. On the third post-operative day, despite a 24 hour sedation hold, he was showing no sign of any neurological recovery and was not eye-opening or obeying commands. It was at this point that his wife presented the team with an advance directive.

The advance directive was presented at a point in the care whereby the patient was already receiving high levels of support for his cardiovascular system (noradrenaline 0.3mcg/kg/min), respiratory system, renal system (CVVH) and gastrointestinal system (jejunostomy feed). It was discussed and a plan was made to, for the current time, continue management, but it was explained that the outlook was bleak.

His renal function worsened over the next few days (urea 27, creatinine 400) and despite a long sedation hold, he was still unable to obey commands. However,care was continued as both the cardiovascular and respiratory support was decreasing, with the noradrenaline having been weaned by day 6. He was extubated by day, but remained mildly confused and agitated. The following day, he became more tachycardic, tachypneoic and hypotensive. He deteriorated significantly to the extent where he became peri-arrest and was re-intubated. A CT confirmed an intra-abdominal/mediastinal catastrophe.

He once again developed severe septic shock with multi-organ dysfunction. His antiobiotics were restarted (meropenum) and an anti-fungal (fluconazole) introduced. NJ feed was commenced. He improved to the point of extubation on day 11, but again deteriorated. At this point, a decision involving his wife was made to palliate him. He died later that day

What are the implications of advance directives on the ICU?Read More »

Attempted Suicide and Treatment Withdrawal

A elderly man  was found unconscious at home having taken an overdose of prescription medication. This event may have been precipitated by a recent bereavement and worsening of his preexisting depression for which he had recently been reviewed by psychiatric services and commenced on an SNRI. He left a note at the scene of the suicide attempt, clearly stating that he intended to take his own life and did not wish to be resuscitated in the event of being found alive. He was discovered in his home by a relative who had been growing increasingly concerned as to his welfare, having not spoken to him for several days. On arrival in ED his Glasgow coma score (GCS) was 3/15. He was known to be taking venlafaxine for depression and amitriptyline for chronic back pain, and empty packets of each drug were found at his home.

He was intubated and transferred to the intensive care unit. Supportive care was provided including vasopressors (noradrenaline) for hypotension, electrolyte correction and ventilatory support. Plain chest radiograph showed a probable aspiration pneumonitis affecting the right upper and middle lobe. He was hypoxic with a high Fi 02 requirement and needed high levels of PEEP to maintain adequate oxygenation. His conscious level fluctuated over several days and he became increasingly agitated and exhibited signs of distress. At this stage it was not clear if he was orientated in time, place or person. He underwent percutaneous tracheostomy to facilitate weaning and reduce sedation requirements.

We were then able to wean him from sedation by day 11 of his admission. The patient’s ventilatory requirements were still high requiring mean airway pressures of 30 cmH2O, PEEP of 10 cmH2O, and an inspired oxygen concentration of 60%. At this stage he indicated to the ITU team that he did not wish treatment to be continued. We found him to be fully orientated in terms of time and place and he was aware of the preceding events and his intentional overdose. It was clearly explained to him that if treatment were discontinued he would die. He indicated to us that he had no intention of changing his mind.

We referred him to the liaison psychiatrist for the hospital who independently assessed and found him to be competent and able to fully understand the implications of such a decision, i.e. his likely death from respiratory failure. The psychiatrist also found him to be depressed but noted that this did not interfere with his competence and ability to give or withhold his consent. With his consent, his family were informed of this development. They had been agonizing for some time over whether they had made the right decision to call emergency services when they first found him. They attempted to dissuade him but his resolve was unshakeable. Invasive ventilation was withdrawn on the morning of his 15th day of ITU as per his wishes. Diamorphine was administered to reduce symptoms of respiratory distress. He died of hypoxia later that day. Cause of death was recorded as aspiration pneumonia.

Describe the ethical and legal framework utilised in the management of this patient.Read More »

Neuroprognostication Post Cardiac Arrest (Post TTM Era)

Neuroprognostication Post Cardiac Arrest (Post TTM Era)

A  young adult female with known diagnosis of poorly controlled type 1 diabetes mellitus was admitted with out-of-hospital cardiac arrest. She had only recently been discharged from hospital after an admission with diabetic ketoacidosis. On arrival she had a GCS 3 with minimal respiratory effort. She was in profound DKA. Her temperature was 34.7°C on admission to ICU and she had targeted temperature management aiming for 36°C which was achieved within 2 hours. Her pH had normalised to 7.35 within 8 hours. 48 hours later one pupil became fixed and dilated. CT brain was consistent with global hypoxic ischaemic injury. EEG and SSEP on day 3 revealed severe lack of normal cortical activity. After discussion with family, treatment was withdrawn on day 4.

How do we undertake neuroprognostication after cardiac arrest in the post-TTM era?

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Neuroprognostication after Cardiac Arrest

Neuroprognostication after Cardiac Arrest

A 30 year old man suffered a 30 minute cardiorespiratory arrest secondary to an asthma attack. He was resuscitated, had his severe bronchospasm managed and he was treated with therapeutic hypothermia at 33 degrees. Once rewarmed, his neurology was assessed over several days. He was ventilated on a spontaneous mode, but his pupils remained fixed and dilated and there was no higher motor function seen. A CT brain was consistent with severe hypoxic ischaemic injury. After discussion with the family, treatment was withdrawn.

How reliable is neuroprognostication after cardiac arrest? What modalities are tested? Is there a difference in patients treated with therapeutic hypothermia?

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Therapeutic Hypothermia after Cardiac Arrest (Peri-TTM)

Therapeutic Hypothermia Post-Cardiac Arrest (Peri-TTM)

An elderly man was resuscitated from out-of-hospital VF cardiac arrest. He remained deeply comatose post ROSC and was ventilated on the intensive care. His temperature control was not actively managed unless hyperthermia developed. 24 hours post admission he started to have myoclonic jerks and his pupils were fixed and dilated. CT brain showed evidence of severe hypoxic ischaemic injury. Treatment was withdrawn at 72 hours after discussion with family.

What is the rationale for the use of therapeutic hypothermia after cardiac arrest?Read More »

Organ Donation After Cardiac Death

DCD Organ Donation: Eligibility and Contra-indications

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 »