Regional Collaborative November 2015. NDT Case study Paediatric - H Bethan Thomas Specialist Nurse ...

Regional Collaborative November 2015.

NDT Case studyPaediatric - H

Bethan ThomasSpecialist Nurse – Organ Donation


Background

• 10 yr old• Cerebral Palsy• Global developmental

delay• Microcephaly• Epilepsy• Scoliosis

• Quadriplegia

•PEG fed- no swallow

•Previous abdominal compartment syndrome with bowel ischaemia leading to bowel resection

•Worsening T2RF(normal pCO2 10-14 reported by paediatrician)

•Recurrent LRTI

•Home O2

•Recent discharge from hospital after admission for chest infection


Day 4 BSDT Preconditions

• CVS stable on noradrenaline and dopamine– BP map 66

• pCO2 8.95 pO2 49.5• pH 7.41• GCS 3 - unsedated• Temp 39ºC (>24 hours)• Lab results: Na 153 K+ 3.2 PO4 1.12 Mg 0.69


Day 4

• Pupils 2mm-fixed• BSDT started-

breathed during apnoea test

• Test done by 2 PICU consultants

• 2nd set not done.

Test 1 Time

Pre Apnoea Test14:13

Post Apnoea Test14:20

pH 7.412 7.243

pO2 49.5 8.52

pCO2 8.95 13.6

HCO3-

41.9 42.4

ABE 15.4 13.1



• CVS stable on noradrenaline and dopamine – BP map 80

• pH 7.33• pCO2 8.52 pO2 19.3• GCS 3 - unsedated• Temp 38.7ºC (>24 hours)• Lab results: Na 173 K+ 3.1 PO4 1.36 Mg 0.79


Day 5Repeat BSDT‘Gasped’ at the end of the second set of tests.Test 1 Time



Test 2Time



pH 7.388 7.189 pH 7.332 7.123

pO2 58.1 57.5 pO2 19.3 18.7

pCO2 7.65 13.0 pCO2 8.52 14.4

HCO3-

33.8 35.8 HCO3-

32.9 33.8

ABE 8.1 5.8 ABE 6.5 3.1


• Parents given the option of withdrawing treatment after these tests



• CVS stable on noradrenaline and dopamine – BP map 65

• pH 7.36• pCO2 7.04 pO2 23.2• GCS 3 - unsedated• Temp 36.8ºC (>24 hours)• Lab results: Na 160 K+ 3.7 PO4 0.8 Mg 0.94


Day 6

• Third set of BSDT were performed

• H breathed on the first set but after a prolonged time off the ventilator (around 7 minutes)

Test 1 Time



pH 7.357 7.193

pO2 23.2 18.2

pCO2 7.04 10.8

HCO3-

28.9 30

ABE 3.5 1.1


Outcome• Parents at this time were told that

neurological death was now very unlikely to occur due to the amount of time past since her hypoxic event.

• H’s parents remained positive about organ donation and proceeded as a DCD saving 4 lives.


Discussion points

• No CT scan was done. Known aetiology was history and clinical presentation. EEG day 2- very low amplitude with no convincing cerebral activity

• H was a known CO2 retainer with normal CO2 sitting around 10-12 kPa and prior to admission 12-14 kPa

• H’s usual oxygen levels on facemask of 1l SaO2 >95% and on 2l via nasal cannulae >90%

Regional Collaborative November 2015. NDT Case study Paediatric - H Bethan Thomas Specialist Nurse ...

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