Presentation 2 - DR David Southern

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Dr David Southern

Consultant in Anaesthesia & Intensive Care

Wrexham Maelor Hospital


What is Intensive Care ?

A service for patients :


• With potentially recoverable conditions
• Who can benefit from
• more detailed observation
• Or more invasive treatment
• Who cannot be adequately managed in general ward areas
Patient 1
20yr old girl has prolonged tonic-clonic seizure
Proven grade 4 glioblastoma
Assisted with all activities of daily living

?
Potentially recoverable condition

Who can benefit from


more detailed observation
Or more invasive treatment

Cannot be managed on ward


Patient 2
80yr old man
Performs all ADLs unassisted
Sudden onset pneumonia
SpO2 85% on facemask , RR 35, dyspnoeic

?
Potentially recoverable condition

Who can benefit from


more detailed observation
Or more invasive treatment

Cannot be managed on ward


Patient 3
65yr old man
Elective aortic aneurysm
12L blood loss
Unsuccessful surgery- patient still bleeding
BP 70/40, HR 140, pale, ventilated, acidotic

?
Potentially recoverable condition

Who can benefit from


more detailed observation
Or more invasive treatment

Cannot be managed on ward


I have only ONE bed in ITU

Next available bed = Preston


5 hour return transfer time
ITU doctors already working at maximum capacity
So what do I do

?
With apologies for plagiarism
Its hard to get into ITU in Wales
Getting a Patient Admitted to ITU
• What we Intensivists like to think happens
Factors determining ITU admission
Getting a Patient Admitted to ITU
• What we Intensivists like to think happens
• What actually happens
0 1 2 3

Sessions of training
So who would you admit ?
Patient 2
80yr old man, performs all ADLs unassisted
Sudden onset pneumonia, SpO2 85% on facemask , RR 35, dyspnoeic

ITU reduces immediate mortality by 6%

Some hospitals admit (a) 2% of patients with pneumonia


(b) 86% of patients with pneumonia

ITU admission causes N0 increase in cost of hospital stay


And after admission, the facts change
80yr old man, performs all ADLs unassisted
Sudden onset pneumonia, SpO2 85% on facemask , RR 35, dyspnoeic

Worsening function over 12 months

Recent discharge from another hospital


And what do you do with the other 2 patients ?
Is there a different approach ?
Getting a Patient Admitted to ITU
• What we like to think happens
• What actually happens
• The way forward
Admission Criteria hasn’t worked
ITU referral :best practice
Consultant-Consultant referral is best : don’t delegate to juniors

Be clear what you are asking for : do you want


- admission to ITU
- an ITU specialist to confirm that admission inappropriate

Try to be objective about what benefit the patient will get from ITU

What are the patients wishes


Over to you

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