CASE REPORTESCALATION OF SUPPORT IN DCD PATIENT

Dr Peter C MatthewsConsultant 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

• Transferred to HDU• falling GCS• marked lactic acidosis

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

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

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

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

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

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

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

Discussion