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 »
A 22-year-old female recent migrant presented at 31 weeks gestation (gravida 2 para 0) to the obstetric unit. She was complaining of diminished fetal movements. She had been well up to that morning but was complaining of increasing abdominal discomfort, and was becoming distressed. Examination showed she was not in labour but her abdomen was tender. Cardiotocograph showed a fetal heart rate of 130 bpm and poor variability. Two hours post admission, she was re-examined by obstetricians. Abdominal ultrasound failed to identify a fetal heartbeat. A diagnosis was made of intrauterine death, and initially a placental abruption was suspected. Ultrasound showed no thrombus and an intact placenta and so this was excluded. She was diagnosed as having a late miscarriage and the pain was assumed to be due to ongoing miscarriage. She was transferred to labour ward and a morphine PCA commenced for analgesia.
She received a dose of IV antibiotics on arrival to labour ward. At this point it was noted her oxygen saturations were falling and she was becoming increasingly drowsy, and this was felt to be due to sensitivity to the PCA. She was reviewed by obstetric anaesthetists who performed an arterial blood gas, which showed a marked metabolic acidosis with serum lactate of 6.3, and a diagnosis of severe sepsis was made. There was concern that the retained fetal material was the focus, and she was taken to theatre for emergency caesarian section. She was then transferred to ITU. By this stage she had developed established disseminated intravascular coagulation and pulmonary oedema. She developed rapidly worsening multiorgan failure and shock refractory to large doses of noradrenaline and died that evening, 8 hours post admission. Cause of death was found to be group A streptococcal sepsis.
What is the significance of sepsis in obstetric patients?Read More »
A thirty eight year old female smoker was admitted via A+E following sudden onset occipital headache with visual disturbance and collapse with loss of consciousness lasting approximately five minutes. She had complained of unusual headaches a week prior to this event, but these were short lived and not associated with any neurology. On arrival in resus she had recovered to a Glasgow coma score (GCS) of 14/15. She demonstrated neck stiffness and photophobia, as well as general irritability. Plain computerised tomography
scan (CT) performed showed a subarachnoid haemorrage in the region of the middle cerebral artery, with the presence of blood in the sylvian fissure.
She was transferred to the ITU for monitoring and blood pressure control with invasive arterial and central venous pressure monitoring. She was treated with nimodipine to prevent vasospasm. Contrast CT performed showed an aneurysm at the bifurcation of the middle cerebral artery, and this was felt to be the origin of the bleed. She underwent uneventful endovascular coiling of this aneurysm the following day under general anesthesia, and was discharged to the neurosurgical team for ongoing care afterwards.
What are the secondary complications of subarachnoid haemorrhage and how are they managed?
A forty-year-old motorcyclist was admitted to the ITU following a road traffic accident involving a stationary vehicle. She sustained a fractured right distal radius and multiple left sided rib fractures, involving ribs 2 to 9, with a free floating flail segment. She developed respiratory distress due to underlying lung contusions and a haemopneumothorax and was treated with two left sided intercostal drains, endotracheal intubation and invasive ventilation. She developed ARDS with bilateral infiltrates and PF ratio of <200mmHg, with normal cardiac function on transthoracic echocardiography. She was tracheostomised on day 12, and had a protracted ventilatory wean further complicated by a ventilator associated pneumonia. She was enterally fed during this period but began to develop an ileus and gut dysmotility, resistant to prokinetic treatment, leading to large volume gastric aspirates. She became visibly malnourished and was commenced temporarily on parenteral nutrition and IV glutamine. The ileus resolved over the following week and weaning recommenced, having ceased due to diaphragmatic splinting. She eventually weaned from the ventilator and was discharged from the ITU on day 40. She was profoundly weak due to a critical illness acquired weakness.
What is the role of glutamine supplementation in critical illness?Read More »
A sixty year old man was admitted to the ITU with respiratory failure. He initially presented with a week long history of limb weakness that started in his legs. CSF sampling showed elevated protein levels and a diagnosis of Guillain-Barré Syndrome (GBS) was made. Symptoms progressed to weakness in coughing and deep breathing. Serial vital capacity measurements progressively deteriorated. His vital capacity on referral to ITU was 1.2L (roughly 15ml/kg), he was having difficulty expectorating and had an acute respiratory acidosis with hypercapnia. Treatment was commenced with intravenous immunoglobulin. He was initially treated with non-invasive ventilation but he continued to deteriorate largely because of sputum retention. He was sedated, intubated and invasively ventilated and after 7 days he underwent percutaneous tracheostomy to facilitate bronchial toilet and weaning. His respiratory function improved slowly and he was decannulated after 22 days of invasive ventilation. He was discharged back to neurology services for rehabilitation after a further 9 days on ITU. He remained profoundly weak on discharge and was unable to mobilise or transfer without assistance.
What are the clinical features of Guillain-Barré Syndrome and how is it managed on the ICU? Read More »