The critically ill patient

A case study and journal quotation

By Dr Ali Ahmed Sohail PGR Anesthesia, pain management and ICU SIHS
Call to Anesthesia and SICU

 A call was received from the medical HDU to Anesthesia on 4/7/23 at 2 30 pm

 With regards to an admitted patient requiring urgent critical care admission
due to ongoing acute deterioration of vital signs and possibility of acute
inflammatory/vs/septic process etiology of which was thought to be surgical
in nature
 Upon visiting the patient immediately thereafter in the MHDU it was noted
that the patient was in respiratory distress and was admitted under medicine,
endocrinology.
 Immediate action was taken to stabilize the patient and provide intensive
care as soon as possible
Case history
Pt name Ehsan ullah, k/c of DM,HTN, recreational drug use (poorly controlled)was admitted
under medicine on 3/7/23
With the following Presenting complaints
SOB with exertional dyspnea
Chest heaviness
Diaphoresis
Decreased urinary frequency since 3 days
b/l creps on inspiration with decrease air entry bi baseler
Vitals on admission
Bp 110/50
spO2 93 at RA
Hr 90 bpm
Temp was not recorded
No examination was done to rule out organic cause other then chest auscultation
h/o of present illness and general exam
 On arrival in MHDU
 55 year old male pt, well built with tall stature lying in bed, extremely irritable and agitated with
rapid shallow breaths rr approx. 40. distended abdomen, and skin cold and clammy to touch, qSOFA
>2 (> 10% mortality)
 CNS GCS fluctuating between 15 and 12. complaint of SOB during lucid intervals
 RESP Auscultation revealed b/l decreased air entry up till upper zone raising the suspicion of silent
chest
 CVS no positive finding on auscultation
 On exposure there was ulcerated tender nodular skin lesion extending from groin to thigh (R side)
WARM to touch
 Pt was an uric
 Vitals available
 spO2 86 at RA
 HR 100 bpm
 BP N/A
 No cyanosis, clubbing or lymphadenopathy
Spot diagnosis and action in response to
call
 As the condition observed previously. Spot diagnosis of resp distress with
concomitant/secondary to septic shock was made. Cause most likey to be groin
abscess, differential forniers gangrene, fasciitis, as such it was a surgical ailment
 Immediate call to surgery was made and care of patient was to be shifted to them
 This was important more so for the reason that this patient could not be
transferred under care of SICU unless primary care team was surgical
 Incase of delay patient was to be shifted to medical ICU with immediate effect
until surgery took over
 Immediate start of SSC bundle was initiated, large bore iv with 30ml/kg fluid, pt
was already on broad spectrum ntibiotic
 Baseline investigations including (cbc,lft,rft,coag profile, s/e, blood culture ) with
cm for 2 pints whole blood and ABGS
Information relay
 The acute nature and urgency of response for the patient was relayed to Duty
doctor, The surgery team , The Anaesthesia team and the SICU team
 Relevant consents for ICU care, mechanical ventilation, inotropic support and
detail health education regarding abysmal prognosis of the condition was
done by all 3 teams in tandem to the family/guardian of the patient.
 The surgery team had documented shift of care and as such without delay the
patient was shifted to SICU where SSC bundle was done and mechanical
ventilation constituted.
 The above actions effectively stopped a code blue
Journal quotation

Does early shifting of the patient to ICU reduce mortality in sepsis? If so then how
early in the disease process?
Association between the timing of ICU admission
and mortality in patients with in hospital sepsis

 Nation wide cohort study

 Source journal of intensive care ( European journal of critical care, biomed
central pool)
Methods
nation wide cohort, 13 hospitals with adult patients admitted from inhospital
to ICU for sepsis
 Inhospital sepsis was defined as sepsis diagnosed in general ward
Results

 Early admission where median time to admission in ICU was 1.9 (0.8 to 3.2)
hours after diagnosis
 Late admission where median time was 12.9( 8.6 to 24.4) hours from
diagnosis
 Primary outcome
 There was no significant difference between mortality of both groups
 Even in centres with RR teams available
Secondary outcome

 There was no significant difference in ICU stay for both groups aswell where
patients survived
 Early admission 11 to 38 days
 Delayed 9 to 37 days
 However early admission did result in less patients who survived being
discharged to a nursing and or palliative care facility
 The study itself however did not have enough data to discredit the 6 hour
derivative of the SSC campaign with regards to shifting to ICU
Conclusion

 In the study above early admission to icu did not show decreased mortality in
comparison to delayed admission
 However there was morbidity benefit to those admitted within 6 hours of
diagnosis and the data provided is not enough to completely disprove that
early admission to ICU for the septic patient does not give mortality benifit