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Case report Escalation of Support in DCD patient

Case report Escalation of Support in DCD patient. Dr Peter C Matthews Consultant Intensivist CLOD - Morriston Hospital. Presenting Complaint. 48 year old man Admitted to Singleton with: general decline in health not eating or drinking significant weight loss multiple ulcers

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Case report Escalation of Support in DCD patient

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  1. Case reportEscalation of Support in DCD patient Dr Peter C Matthews Consultant Intensivist CLOD - Morriston Hospital

  2. Presenting Complaint • 48 year old man • Admitted to Singleton with: • general decline in health • not eating or drinking • significant weight loss • multiple ulcers • Transferred to HDU • falling GCS • marked lactic acidosis

  3. Past Medical History • PTSD • former prison officer • Occipital CVA • seizures • Ex alcoholic • Partial gastrectomy 2010 for pyloric stenosis • Degenerative spinal disorder • Pneumonia 2012 • ventilated in ITU (tracheostomy) • Recent klebsiella pneumonia with lung abscess

  4. Immediate Management • Treatment by physicians for sepsis 20 cellulitis • Intubated and invasive monitoring sited • Seen by Consultant Intensivist • CT head - old changes • LP - NAD • Empirical broad spectrum cover including anti-virals • Transfer to Morriston ITU

  5. On-going management • Nutritional support • oedema +++ with low albumin • ? pellagra • CT abdomen • some abdominal tenderness • citrobacter from blood cultures • Treatment for bone marrow depression • thrombocytopenia • anaemia • HIV, Hep screen, TSH • Vasopressor for hypotension

  6. Progress • Extubated after 6 days • Vasopressors off • ECHO EF10% • Re-intubated day 7 • syphilis test • clostridium difficile testing (diarrhoea ++) - negative • Limitations discussed with family • DNACPR • not for RRT • not for CVS support

  7. Progress • Deterioration day 11 • hypotensive • increasing acidosis • oliguria • decreased GCS • Active withdrawal of treatment planned • SNOD informed • case discussed with HM Coroner • wife given permission for donation to proceed • SNOD asked ITU associate specialist if happy for vasopressor to be started to improve organ function and permission given • ventilator settings also adjusted by ITU nurse

  8. Unexpected Sequelae • Patient’s condition improves by the next day (day 12) • acidosis improving • urine output improving • GCS better and some appropriate responses documented • discussion between Consultant Intensivist and ACD for ITU • to restart active treatment • inform family that donation no longer being planned due to unexpected improvement in patient’s condition • Consultant Intensivist concerned about the short and long term consequences of the treatment escalation and discusses it with the SNOD

  9. Subsequent Events • Period of stability followed by another deterioration • unable to wean ventilation • profoundly weak • intermittent hypotensive episodes • After discussion with family day 16 • end-of-life pathway • WLST (extubation) • Discussion at a meeting of Consultant Intensivists • IR1 form submitted • Escalated to IR4 - on-going investigation

  10. Discussion

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