A 22 year old woman presents to hospital with a 3 day history of abdominal pain and vomiting. Examination reveals that the patient is jaundiced and acutely confused (GCS 14/15). Blood results demonstrate pH 7.25, lactate 6.7, glucose 2 mmol/L, Na 135 mmol/L, K 3.2 mmol/L, urea 2 mmol/L, creatinine 69 μmol/L, ALT 7050 U/L, ALP 132 U/L, Bilirubin 82 μmol/L, INR 7.
Many patients in the ITU are unable to look after their own eyes so it is vitally important that we take care of them on their behalf. They are at higher risk of eye damage both as a result of their acute illness and due to the treatment they receive on ITU.
This is the third part of our podcast series on ‘Knowing Your Team’ where we aim to gain a greater understanding of the roles of the different members of the critical care team. This month we will be looking at the roles of the psychologist and occupational therapist in the management of critically ill patients. I hope you will enjoy listening and continue to learn about the real benefits of creating a well-integrated critical care team.
A 48 year old woman recently commenced chemotherapy for a new diagnosis of acute myeloid leukaemia. She attends the Day Bed Unit to have routine bloods checked prior to her next dose of chemotherapy. Since her last assessment, she sprained her ankle and is taking regular ibuprofen.
As I was saying at the odd conference before we were so all so rudely interrupted, Point of Care Ultrasound is finally coming of age in the UK. It has taken a while – the first diagnostic use of ultrasound was in the 1940s by a neurologist, a comparatively rapid pickup from the first demonstrations of Non-Destructive Testing for metals using ultrasound in 1928.
A 34 year old woman presented to the Emergency Department with a two day history of progressively worsening double vision, followed by ataxia and slurred speech. She reports a diarrhoeal illness eight days ago, though this has now resolved. She is normally fit and well and takes no regular medication.
In the second part of our podcast series on ‘Knowing Your Team’ we will be looking at the roles of physiotherapy and speech and language therapy in the management of critically ill patients. It is so inspiring, listening to how these specialists have an enormous amount to offer in both the acute and long-term rehabilitation of critical care patients.
On 30th November 2020 the Faculty held its annual Clinical Leads Conference. all attendees had access to pre-recorded lectures which where then discussed in the Q and A session held on the 30th. We would now like to give access to these pre-recorded sessions and they can be access below. The recorded Q and A session is available below, we suggest watching the lectures first.
These sessions will be available until 15 January 2021.
Enhanced Care: Dean Dr Alison Pittard
ACCP Training and Accreditation – the future: Ms Rachel Pascoe, Lecturer in Nursing at University of Plymouth
Life After Critical Illness: Immediate Past-Dean, Dr Carl Waldmann, Dr Joel Meyer, Dr Andy Slack
Changes to Clinical Commissioning of Critical Care Services – The Future? Professor Jane Eddleston, Commissioning Lead
Getting it Right First Time (GIRFT). Critical Care and possible implications for your unit: Dr Anna Batchelor, GIRFT Lead
How to set up and run a Critical Care Research Nurse Team: Ms Jade Cole, Team Lead, Cardiff Critical Care Directorate, and Research
Animation Support on ICUs: Professor David Wald
Full Conference Question and Answer Sessions: recorded on Zoom 30 November 2020
A 65 year old woman has a cardiac arrest at home. She is in VF and receives 2 DC shocks by the paramedics before return of spontaneous circulation (ROSC) is established. She is intubated at the scene and is taken to her local hospital.
A 40 year old male was admitted to intensive care unit requiring intubation and ventilation for community acquired pneumonia. He developed acute respiratory distress syndrome (ARDS) and on day 2 commenced an atracurium infusion for worsening hypoxaemia.
Despite two sessions of prone ventilation he failed to improve and required high ventilatory pressures. On day 5 he was placed on venovenous extracorporeal membrane oxygenation. (VV ECMO).
On the 20th May 2020, the legislation relating to consent for organ donation changed to an opt out system. As critical care plays a pivotal role in the organ donation process, these two podcasts give a clinical perspective on the importance of the new legislation and how it impacts on the discussions we have with family members about consent for organ donation.
There are also some interesting anecdotes & lessons learnt from the awareness campaign and implementation strategy used in Wales when this law was first introduced in 2015.
Max and Keira’s Law came in to force on the 20th May 2020 and brought renewed hope to the thousands of people on the UK transplant waiting list. The legislation introduced ‘opt out’ as the legal basis for organ donation consent in England and is expected to lead to an additional 700 transplants a year. However, the path to getting the new legislation in place was far from smooth.
This month Matt Bromley talks to Simon Conroy about frailty and its implications for critical care. Simon is a professor of geriatric medicine in Leicester and the clinical lead for the specialised clinical frailty network.
He has a particular interest in translational research in the acute care setting and has made significant improvements in the recognition of frailty amongst older people presenting acutely to hospital and how this can be used to inform decisions about clinical management.
A 63 year old man with a history of hypertension and ischaemic heart disease has been admitted to the intensive care unit with refractory hypotension due to severe sepsis. Inflammatory markers are raised and CXR has revealed a right lower and middle lobe pneumonia.
We were approaching the end of April. We had just come through a CQC inspection, COVID was in full swing on our 13 bedded unit, running 3 times our capacity having spilled out into our main theatres, anaesthetic rooms and recovery.
Back at the start of the year, we all watched the news with curiosity about a place called Wuhan, and a new coronavirus that was ravaging the city. We continued to watch with further interest as it made its way towards Europe.
An unresponsive 76-year-old male is admitted to the intensive care unit. He has a past medical history of bipolar affective disorder (treated with lithium and valproate), self-harm and previous suicide attempts.
Shashi Chandrashekaraiah, Sushruth Raghunath, Avinash Jha, Arif Akbar, Ikenga Samuel & Mohammed Elshamy
International Medical Graduates (IMGs) account for approximately 25% of the current UK trainee doctor workforce and are predominantly of black Asian and minority ethnic (BAME) backgrounds. There has been a lot of discussion during the current COVID-19 crisis about IMGs and their contribution to the NHS, VISA/Immigration health surcharge and the more important topic of increased mortality among BAME doctors from COVID-19.
A previously well 76-year-old male presents to ED having been found on the floor at home by a relative. Collateral history reveals ‘flu-like’ symptoms and headache within the last week.
On arrival he is soiled, agitated and combative with a GCS of 9/15 (E2 V2 M5). There are no obvious localising neurological signs. Pupils are equal and reactive. Temperature is 39.0.A basic delirium screen in ED is negative (urine dip and chest x-ray). As you continue assessing the patient, he has a short-lived generalised tonic-clonic seizure.
For those of us who contribute to patient facing research, there were signals in early March that our working lives were about to change. The safety implications related to recruitment of and sampling from patients in studies who were potentially infected with SARS-CoV-2 needed to be considered. As a result many NIHR portfolio studies, supported by their funders, decided to pause recruitment.
A 67 year old man has been admitted overnight to the intensive care unit. He presented with flu-like symptoms and a non-productive cough. His wife reported that he had been ‘seeing things’. Investigations revealed hypoxaemia, lobar consolidation, neutrophilia and a raised lactate dehydrogenase.
You suspect the patient may have Legionnaires’ disease.
One of the difficult jobs during this pandemic is not only our dedication and commitment to best care of our patients, but the supervision and support of those less familiar to the Critical Care environment. This may be our own trainees, but also others for whom the decision to come to our ‘space’ hasn’t necessarily been their own; and includes other specialty trainees, senior medical staff, nursing colleagues and allied health professionals.
In the first part of this series, Danny Bryden and Dale Gardiner give their views on decision making, particularly with respect to admission to critical care. They also discuss wellbeing, and the impact of COVID-19. Danny is vice dean of the FICM. Dale is a consultant in anaesthesia and ICM in Nottingham, and is the national clinical lead for organ donation with an interest in medical ethics.
A 54 year old woman with a history of hypertension presented to the emergency department with a sudden onset severe headache. Her GCS was E3 V3 M6 on arrival, but deteriorated over the next 2 hours to E3 V2 M5. A CT brain demonstrated an intracerebral haemorrhage and a CT angiogram confirmed a ruptured middle cerebral artery aneurysm. She was intubated and ventilated for transfer to the regional neurosciences unit where she underwent a successful endovascular coiling procedure the following morning. On sedation hold she is now GCS E1 VT M1.
What are the potential causes of her reduced level of consciousness?
A 40 year old male was found unresponsive in the garden. Initial GCS was 9 (E3V2M4) which deteriorated to 7 (E2V2M3) on arrival to the emergency department. ECG and CT brain were both normal. An ABG demonstrated a high anion gap metabolic acidosis (pH 7.0) with an increased osmolal gap (>10mOsm/kg). In view of unexplained decreased level of consciousness along with high anion gap acidosis and high osmolal gap, ethylene glycol toxicity was considered to be the most likely diagnosis.
25 year old male is admitted to critical care following a motorcycle
accident. He hit a car travelling at
60mph, was thrown over the roof and skidded 20m down the road. His injuries include a fractured pelvis,
unilateral rib fractures from 6-10 on the left, and a fractured lateral
malleolus also on the left.