A CRITICALLY ILL CHILD PRESENTING AT AN ACUTE TRUST- A CLINICAL AND ETHICAL CHALLENGE

Transcription

1 A CRITICALLY ILL CHILD PRESENTING AT AN ACUTE TRUST- A CLINICAL AND ETHICAL CHALLENGE DR SRIKANTH UPPUGONDURI CONSULTANT ANAESTHESTIST NEW CROSS HOSPITAL

2 CALL FROM PAEDIATRIC TEAM CALL FROM PAEDIATRIC REGISTRAR TO ANAESTHETIC REGISTRAR TO ASSIST WITH THE MANAGEMENT OF A CRITICALLY ILL CHILD ON THE PAEDIATRIC WARD ITU CONSULTANT ON-CALL AND ANAESTHETIC REGISTRAR RESPONDED IMMEDIATELY

3 ON ARRIVAL ON PAEDIATRIC WARD PAEDIATRIC TEAM IN ATTENDANCE CONSULTANT PAEDIATRICIAN, PAEDIATRIC REGISTRAR AND SHO TOGETHER WITH NURSING STAFF PATIENT IN PEDIATRIC TREATMENT ROOM MUM AT THE BEDSIDE PATIENT BEING MONITORED IN OBVIOUS DISTRESS

4 A : PATENT B: NASAL CPAP IN-SITU FIO2 80% PEEP 10CMH2O SPO % TACHYPNOEIC 40-50B/MIN C: CAP REFILL <2SECS TACHYCARDIC 130B/MIN BP 100/60 D: DROWSY BM 7.6MMOL.L

5 CAP GAS PH 7.17 PAO2 9.7KPA PACO2 8.6KPA BE -5.8 BICAB 19.6MMOL.L LACTATE 2.2MMOL.L

6 SIGNS OF POTENTIAL DIFFICULT AIRWAY ABNORMALLY LARGE HEAD (EVEN FOR A CHILD) LIMITED PASSIVE NECK EXTENSION SMALL MOUTH MUM SAID THEY HAD DIFFICULTY GETTING A TUBE DOWN WHEN HE WAS A BABY

7 DISCUSSION WITH PAEDIATRIC TEAM PATIENT DM 3 YEAR OLD CHILD ADMITTED UNDER THE CARE OF THE PAEDIATRICIANS 07/06/2015 GENERALLY UNWELL AND AGITATED SIGNIFICANT BACKGROUND HISTORY: SEVERE DEVELOPMENTAL DELAY DEVELOPMENTAL AGE OF <6MONTHS CRYPTOGENIC EPILEPTIC ENCEPHALOPATHY PEG FED VASCUPORT IN SITU- TUNNELLED IJ LINE

8 DISCUSSION WITH PAEDIATRIC TEAM DIAGNOSED AS LRTI COMMENCED ON ANTIBIOTICS FOR COMMUNITY ACQUIRED PNEUMONIA (CEFUROXIME AND CLARITHROMYCIN) HOWEVER DESPITE ANTIBIOTICS, DEVELOPED INCREASING OXYGEN REQUIREMENT OVERNIGHT HAD BEEN COMMENCED ON CPAP, BUT INCREASING OXYGEN REQUIREMENTS CXR THAT MORNING

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10 MANAGEMENT PLAN DISCUSSION WITH CONSULTANT PAEDIATRICIAN REGARDING THE APPROPRIATENESS OF ESCALATION OF TREATMENT IN THIS CHILD OPINION OF THE ADULT ITU CONSULTANT: YOUNG CHILD WITH VERY SEVERE DEVELOPMENTAL DELAY, DIFFICULT TO CONTROL EPILEPSY, PEG FED, ESCALATION OF TREATMENT TO INVASIVE VENTILATION WAS INAPPROPRIATE IN THIS CIRCUMSTANCE

11 CONSULTANT PAEDIATRICIAN ON-CALL AGREED THAT IT WOULD BE INAPPROPRIATE TO ESCALATE TREAMTENT.. HOWEVER PATIENT HAD AN ADVANCED DIRECTIVE IN PLACE STATING THAT THE MUM WANTED ALL TREATMENT OPTIONS TO BE ACTIVELY EXPLORED AND THE PATIENT WAS FOR FULL RESUSCITATION IN THE EVENT OF A CARDIO-RESPIRATORY ARREST. CONSULTANT PAEDIATRICIAN ATTEMPTED A BRIEF CONVERSATION WITH MUM REGARDING THE APPROPRIATENESS OF ESCALATION OF TREATMENT, HOWEVER MUM WAS ADAMANT THAT SHE WANTED EVERYTHING DOING FOR THE CHILD.

12 MANAGEMENT PLAN DECISION TAKEN TO TRANSFER THE PATIENT TO THEATRE TO ATTEMPT A GASEOUS INDUCTION CONSULTANT PAEDIATRICIAN TO CONTACT KIDS TEAM AND REQUEST DIFFICULT AIRWAY SUPPORT TRANSFERRED TO THEATRE SUITE TRAUMA THEATRE AND TEAM AVAILABLE AS NO TRAUMA CASES THAT MORNING

13 GAS INDUCTION TRANSFERRED TO ANAESTHETIC ROOM FULLY MONITORED (AAGBI GUIDELINES) PAEDIATRIC AIRWAY TROLLEY PRESENT GAS INDUCTION WITH 8% SEVOFLURANE IN 100% OXYGEN ABLE TO MANUALLY VENTILATE WITH MAPLESON F CIRCUIT AND GUEDEL AIRWAY IN- SITU GRADE IV VIEW!... BOTH WITH CURVED BLADE AND MILLER BLADE

14 DISCUSSION WITH PAEDIATRICIAN INFORMED PAEDIATRIC CONSULTANT THAT PATIENT WAS A GRADE IV VIEW AT LARYNGOSCOPY UNABLE TO INTUBATE COULD KIDS TEAM SEND AN ANAESTHETIST SKILLED AT DIFFICULT PAEDIATRIC INTUBATION THE PATIENT WOULD BE MANUALLY BAGGED WITH THE MAPLESON F CIRCUIT UNTIL THE ARRIVAL OF THE KIDS TEAM..

15 AFTER SOME TIME CONSULTANT PAEDIATRICIAN RETURNED WITH THE FOLLOWING ADVICE...

16 KIDS RETRIEVAL CONSULTANT AGREED THAT THE PATIENT WAS PROBABLY NOT A CANDIDATE FOR ESCALATION OF TREATMENT TO INVASIVE VENTILATION IN THEIR VIEW. HOWEVER KIDS DO NOT PROVIDE DIFFICULT AIRWAY SUPPORT. UNLESS THE AIRWAY WAS SECURED THEY WOULD NOT DISPATCH A RETRIEVAL TEAM TO RETRIEVE THE PATIENT...

17 FURTHER DISCUSSION BETWEEN ADULT ITU CONSULTANT AND PAEDIATRIC CONSULTANT ITU CONSULTANT REQUESTED PAEDIATRICIAN TO CONTACT KIDS TEAM AGAIN AND STRESS THAT THE PATIENT WAS A GRADE IV VIEW AND SKILLED PAEDIATRIC AIRWAY ASSISTANCE WAS NEEDED. THE REPLY WAS THE SAME.. KIDS DO NOT PROVIDE DIFFICULT AIRWAY SUPPORT. UNLESS THE PATIENT WAS INTUBATED THEY WOULD SEND OUT A RETRIEVAL TEAM.

18 MY ARRIVAL TRAUMA ANAESTHETIST ON-CALL ATTENDED THEATRE PATIENT BEING MANUALLY VENTILATED APPRAISED OF THE CLINICAL PICTURE

19 ADVISED TO CONSIDER VENTILATION VIA A LARYNEAL MASK AIRWAY SIZE 2.5 ILMA INSERTED ABLE TO MANUALLY VENTILATE VIA THE ILMA

20 SIZE 5.0MM CUFFED ETT INSERTED THROUGH ILMA. CAPNOGRAPH TRACE OBTAINED. HOWEVER UNCERTAIN AS TO WHETHER THE TIP OF THE ETT WAS POSITIONED IN THE TRACHEA OR JUST ABOVE THE LARYNGEAL INLET... TO CONFIRM THE POSTION OF THE ETT VISUALLY, FIBRESCOPE REQUESTED. ADULT DIFFICULT AIRWAY TROLLEY BROUGHT TO THE ANAESTHETIC ROOM. AMBU A3 DISPOABLE SCOPES PRESENT ON THE ADULT DIFFICULT AIRWAY TROLLEY IN OUR TRUST

21 SIZE 5.0MM CUFED ETT RAILROADED OVER AMBU A3 SCOPE. SIZE 5.0MM ETT IN-SITU OVER ILMA REMOVED AND FIBRESCOPE PASSED THROUGH THE ILMA CORDS SEEN VIA AMBU A3 SCOPE FIBRESCOPE PASSED THROUGH THE CORDS SIZE 5.0MM CUFFED ETT RAILROADED OVER SCOPE WITH SCOPE AND ETT IN POSITION, ATTEMPTED TO REMOVE THE ILMA

22 HOWEVER UNABLE TO REMOVE ILMA AS THE PILOT BALLOON COULD NOT FIT IN THE SPACE BETWEEN THE ETT AND THE ILMA... DECISION TAKEN TO SACRIFICE THE PILOT BALLOON... PILOT BALLOON CUT ILMA REMOVED AMBU A3 SCOPE REMOVED CONNECTED TO MAPLESON CIRCUIT WITH CAPNOGRAPH..

23 CAPNOGRAPHY AND AUSCULTATION CONFIRMED THAT AIRWAY WAS SECURED!! HOWEVER WITH NO PILOT BALLOON, UNABLE TO INFLATE ETT CUFF WITH LARGE LEAK +++ CUFF INFLATED USING A NEEDLE ATTACHED TO A SYRINGE AND INFLATING THE CUFF ARTERY FORCEPS USED TO CLAMP CUFF TUBING AND ETT CUFF SEAL MAINTAINED WITH 100% O2 AND 10CMH20 PEEP, SPO2 MAINTAINED AT 90-92%

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25 INFORMATION CONVEYED TO KIDS TEAM RETRIEVAL TEAM DISPATCHED ON ARRIVAL OF RETRIEVAL TEAM, A NEW SIZE 5.0MM CUFFED ETT RAILROADED OVER BOUGIE A-LINE INSERTED PATIENT TRANSFERRED TO UHNS PICU

26 QUESTIONS

27 THANK YOU!