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ICU Fellowship Vivas – Type 1 Respiratory failure, Determination of Brain death and Failed intubation
Dr Swapnil Pawar
Blog written by – Dr Madhuri Anupindi
Hypoxia may be secondary to complications from the bronchoscopy, complications from the anaesthetic/peri-procedural event, or an acute deterioration/progression in the underlying illness, causing her initial presentation on a background of severe restrictive lung disease.
Worsening of underlying illness: recent lung function tests are consistent with interstitial lung disease, which can be secondary to numerous aetiologies.
What are findings on lung function tests consistent with this patient having interstitial lung disease?
What is DLCO*corr?
This is the DLCO adjusted for haemoglobin. DLCO is the diffusing capacity for carbon monoxide which assesses the lungs ability to transfer gas from inspired air to the bloodstream. The DLCO is affected by factors that change the properties of the alveolar-capillary membrane and those that change haemoglobin and capillary blood volume.
Anaemia, decreases the blood’s carbon monoxide carrying capacity and thus decreases DLCO.
DLCO*corr, adjusts the DLCO for the patient’s haemoglobin.
Outline your immediate management of this patient
Management: targeted initial assessment aimed at identifying and treating reversible causes and contributors of her hypoxia and consideration of appropriate disposition for this patient.
Following acute assessment and treatment of identifiable reversible pathology:
I am concerned that this patient has a very poor prognosis and is showing signs indicating loss of brainstem function. However, the underlying pathology may have only affected the brainstem and there may still be blood flow and function in the cerebral hemispheres. Therefore, he does not meet the preconditions for clinical exam alone to determine if death has occurred.
I would ensure that there are no other confounders present (check organ function – UEC/LFT/TFT/metabolic parameters such as BSL, check temperature, ensure not paralysed and has not been given other sedative medications which may be longer lasting such as thiopentone) and organise for a repeat CT scan to evaluate for potential reversible causes such as a new haemorrhage or hydrocephalus. If there were no reversible causes or confounders and he remained GCS 3 with no signs of brain stem function on clinical testing, I would then organise for a four vessel digital subtraction cerebral angiogram. This would all be done in collaboration with the treating neurosurgical team and with ongoing discussions with the family to provide updates and support.
What are the preconditions that must be met in order to determine death by clinical examination?
These are outlined in the ANZICS Statement on Death and Organ Donation.
Firstly, there must be clinical or neuroimaging evidence of sufficient intra-cranial pathology to deteriorate to permanent loss of all neurological function.
The patient must:
What would be consistent with the absence of brain perfusion on four-vessel angiography?
Absence of intra-arterial contrast above the level of the carotid siphon in the anterior circulation and above the foramen magnum in the posterior circulation. If this is required, it must still be preceded by the performance of the parts of the clinical examination possible in that patient.
What are the other options for demonstrating the absence of brain perfusion?
If performing clinical brain death testing, what motor signs are compatible with permanent loss of brain function?
Spinal reflexes are compatible with permanent loss of brain function. These may include:
Equipment available: BVM, oropharyngeal and nasopharyngeal airways, ETT, LMAs, MAC blade, intubating bougie, intubating stylet, intubating LMA, video laryngoscope. Guide the junior registrar through appropriate steps following an unexpected failed intubation in a hypoxic patient who is known to be difficult to BVM ventilate.
There are several difficult airway algorithms available.
Emphasise: main priority is OXYGENATION while planning and optimising for a definitive airway
Once stable/rising sats then optimise again for intubation. Consider
Also, talk about essential non-technical skills like closed-loop communication, teamwork, role allocation etc.