Palliative Care in Intensive Care

Carol Davies, David Harvie & Rob Chambers

Welcome back to FICMLearning Podcasts.

This month we have two fantastic episodes on Palliative Care. Gareth Thomas speaks with Dr Carol Davies (Consultant in Palliative Medicine at Southampton), Dr David Harvie (Higher Trainee in Anaesthetics and Intensive Care in Wessex) and Dr Rob Chambers (Consultant in Intensive Care in Southampton).

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ISARIC 4C: Lessons from >200000 in-hospital patients with COVID-19

Annemarie Docherty
ACCP Conference 4 Jun 2021

At our 2021 ACCP Conference we had a brilliant lecture from Dr Anniemarie Docherty on ISARIC 4C . Over the last 9 years ISARIC have been preparing for a major outbreak worldwide. In the wake of COVID-19 their team deployed immediately and has been collecting data and samples since the first cases were reported in the UK.

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Nutrition Protocols Won’t Treat a Patient as an Individual but a Dietitian Can

Samantha Cook

Leaving school I had little idea of what I wanted to be “when I grow up,” so I pursued my interests and choose to study BSc Biochemistry at the University of Birmingham.  Fast forward to my final year of study and I was little the wiser as to where I wanted my career to take me.  During finals my father underwent a Coronary Artery Bypass Graft and as part of his rehabilitation saw a dietitian – cue light-bulb moment

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Case of the Month #24

Grace Hoey

A 53 year old male currently on the Haematology ward is referred because of type 1 respiratory failure. He was diagnosed with acute myeloid leukaemia (AML) 3 months ago following a brief, non-specific illness where a spurious blood test demonstrated pancytopenia. He has no other health problems and his performance status is 1.

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Case of the Month #23

Stuart Edwardson
Arlene Wise

A 34 year old primigravida of Asian ethnicity at a gestation of 36+4 and BMI 24 has presented to obstetric triage. She describes a persistent cough for the last 4 days which is getting worse and has been advised by her GP to attend for further investigation. She is otherwise fit and well, and has had a low-risk pregnancy with no concerning features.

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Case of the Month #22

Christopher Shaw

A 60 year old man is admitted to the intensive care unit with spontaneous bacterial peritonitis on a background of alcoholic liver disease. He is treated with appropriate antibiotics. However, following admission to the unit he continues to deteriorate and requires intubation. He becomes hypotensive requiring fluid resuscitation and vasopressor support, oliguric and requires high ventilatory pressures. Examination reveals decreased air entry bibasally, with a firm, distended and tense abdomen.

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Shining The Light Onto Radiology Requests

Derek Smith

As is often said of critical care teams, radiologists are another group who can be considered in the small cohort of the last few “true generalists”. Depending on the size of your hospital your radiologist will be doing anything from checking line placement on a CXR, removing a disabling MCA clot in an acute stroke patient, assessing a post-transplant liver in the unit on ultrasound, reducing a paediatric bowel intussusception, be scrubbed in securing a TEVAR in a aneurysm, or a combination of the above…

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Case of the Month #19

Rathai Anandanadesan

A 60 year old woman was admitted to hospital with a one week history of increasing confusion and malaise. She was discharged from hospital 2 weeks previously after receiving treatment for a non-ST-elevation myocardial infarction (with aspirin and ticlopidine). Abnormal findings on clinical examination are a low-grade temperature (37.4°C), GCS 12 (E3V4M5), jaundice, and petechiae over her arms and legs.

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Case of the Month #18

Lucy Powley

A 35 year old woman presents to the Emergency Department with 1 day history of fever, urinary frequency and left loin pain. She has a urine dip positive for leucocytes, nitrites, protein and blood and raised inflammatory markers. She is diagnosed with pyelonephritis and started on IV amoxicillin and gentamicin. 24 hours later she reports diplopia, dysphagia and breathlessness. On further questioning she describes a 2 month history of diplopia towards the end of the day which she put down to needing new glasses and too much screen time.

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Establishing an ICU follow up service and the COVID response – Tea & cake to Teams!

Lucy Hogg

“I could take a look at that!”  were the fateful words I uttered which led me and my colleagues on a journey of discovery into ICU follow-up and ultimately in us establishing a new service in our hospital. 

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Case of the Month #17

Matthew Wright

A 74 year old gentleman is admitted to the critical care unit following a 3 week admission on the medical wards with pyrexia, malaise, lymphadenopathy and thrombocytopenia.  A diagnosis of sepsis of unknown origin has been made and he has been treated with multiple courses of antibiotics.  No clear focus of infection has been ascertained.  He has now developed multi-organ failure with a worsening transaminitis, an acute kidney injury, an increasing CRP and a pancytopenia.

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Case of the Month #16

Oliver Robinson

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.

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Eyes on the Prize – Why is Eye Care Important?

Duncan Philp

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. 

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Knowing Your Team – Part 3

Lauren Maher & James Bruce

Julie Highfield & Dorothy Wade

Welcome back to FICMLearning Podcasts.

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. 

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POCUS and the Sceptics

Alex Scott

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. 

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Knowing Your Team – Part 2

Paul Twose & Gareth Cornell

Susan McGowan, Helen Newman &
Rachel Jones

Welcome back to FICMLearning Podcasts.

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. 

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Clinical Lead Conference 2020

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.

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Case of the Month #11

Louise Hartley

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).

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Max & Kiera’s Law

Dale Gardiner
Phil Walton

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. 

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Max and Keira’s Law – The Bill That Was Pulled Out Of A Bowl

Claire Williment

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.

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Simon Conroy

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. 

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Working as an International Medical Graduate with a BAME Background during COVID-19

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.

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Case of the Month #5

Colin McAdam

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.

  1. What is your differential diagnoses?
  2. How would you investigate further?
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The academic response to COVID-19

Tony Rostron

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.

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Case of the Month #4

Pete Hersey

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.

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#BetterTogether: The Critical Care Team

Sarah Clarke

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.

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Decision Making Part 1

Danny Bryden, Dale Gardiner

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.

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Case of the Month #3

Rosaleen Baruah

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?  

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Case of the Month #2

Kyle Gibson

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.

Q1 – How does ethylene glycol ingestion present?

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‘Stepping down’ from Critical Care and into freefall: a patient’s perspective

Catherine White

What happens to your patients once they leave ICU?

What may be the end of the story for critical care healthcare professionals is usually the beginning of a long, difficult and sometimes very lonely journey for patients and their relatives.

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