Transcript Video The Exceptional Patient < Back to Summit23 Cracks in the Ice The Exceptional Patient Presented by Dr. Richard Thomas Now we have the last lecture of the day. Uh the last lecture of the day. I think the title is very interesting is The Exceptional Patient. So, which was given by Richard Thomas who is intensivist in the Royal Hampshire Country Hospital and is very much involved into the education for uh educational program and the knowledge and is a member of the College of Anesthesiology. So Richard uh yeah, you're there were close to me before. So I should have seen you. The floor is yours, please. So good afternoon. Uh My is Richard Thomas. Um Thanks very much for inviting me to talk Christian. Um And the title of my talk is called The Exceptional Patient. But actually the story I'm gonna tell you. It's a, it's a remarkable story, but the important thing here is actually about a very ordinary person. It's also I'm very aware that uh in today, I'm the only clinician that stood up here who's not a professor. I'm a very ordinary person. I work in a small ordinary hospital in England. Um So I work at Royal Hampshire County Hospital in Winchester. Uh And that, that's importantly part of the story because we don't have access to anything like extra corporal life support. We're not a cardiac center. We're, we're just a small peripheral hospital. And the story I'm gonna tell you about is using a targeted temperature management system to achieve rewarming during a prolonged hypothermic cardiac arrest. So fortunately in the country that I come from a severe hypothermia as a cause of cardiac arrest is rare and that's because of all the lovely weather we have in England. But when, when we were writing up this case report, we scoured the literature and we found that the longest prolonged CPR was nine hours when uh extra corporal life support was, was used and five hours and 44 minutes when it wasn't used. Now our case report, we documented 6.5 hours of CPR in a severely hypothermic patient who was warned really just using non invasive techniques, including the use of a feedback controlled temperature controlled device. So this is Barry who is 74 year old male and he had a number of comorbidities. So he was obese, had well established type two diabetes with complications and he was uh hypertensive and he was retired and he lived on his own in supported accommodation. So I in England that he'd have his own flat and perhaps he would have a warden who would come in and check on his, his welfare from time to time. But essentially he was, he was, he was living on his own and he was about to go out and play snooker with his friend and his friend uh could see him through the window, um collapsed in, in his flat. Um And then the friend uh went to call, call for help and this was about 1930 the outdoor temperature. So this, this happened February 22. So the story is, is, is, is nearly two years old. Um The ambulance was called straight away and there were access problems at the flat. So by the time the police had forced the door and the paramedics had attended the patient. Um, nearly an hour and a half had passed when the paramedics uh gained access. They found Barry Perry arrest. Um And those are his vital signs and his G CS with three and the paramedics recorded a tympanic temperature as 23 °C and they couldn't looking around, they couldn't see any reason why the gentleman's collapsed. He was dry fully clothed. There was no obvious signs of hypothermia or causes for hypothermia but equally well, no, no real causes why the why the patient had collapsed. So he was taken into our emergency department and he arrived at 10 o'clock, the tympanic temperature was 25.9 °C and non invasive rewarming measures were commenced. He then suffered an asystolic cardiac arrest. 10 minutes later had a return of spontaneous circulation after one cycle of CPR and then he remained per arrest. Until he rearrested um at, at 2230. So as the intensive care consultant on call for that night, I went down intubated the patient ventilated them. Um We then we did some manual CPR but then we, we moved over to using the Lucas device to continue the the chest compressions. And we continued our non invasive rewarming with warmed fluids. Um A device called Bear Hugger, which is a sort of forced hot air and blankets. But obviously for the clinicians in the audience, you can see a problem here. There's how do you keep this patient? You know, how do you try and warm this patient up when so much of the patient is going to be exposed due to the clinical situation? I I was quite proud of myself that I managed to get an ulterior lining and we also managed to put a oesophageal temperature probe in. So this is a graph of what happened to his temperature over the next uh next period of time. What made the difference was when we started using the temperature controlled device. Now, this device we was was would be situated on my intensive care unit and it's the sort of device that I'm sure many of you are familiar with for inducing hypothermia after cardiff rest. And in the back of my mind, I obviously very familiar with using it for, for cooling patients down. I thought, you know, I think there's a button that actually increases temperature as well. So I went off to get this device and connected it to the patient. But what, what we had noticed um was that the patient was continuing to cool down despite the warmed fluids, the bear hugger, the blankets, turning the temperature up. And, and what the graph shows you really is that after a period of time where we, we hit a sort of plateau to me, this was an absolute game changer is over the next few hours, the patient's temperature started to, to normalize. So the the technology we use, so it consists of four disposable single use adhesive gel pads. And through that you get a flow of temperature controlled water. Um as long as you're continuously monitoring, and I say we use the esophageal temperature as what we believed was the ideal measure of core temperature. Then it's a feedback device. So it will um it will automatically um deliver the temperature of the water in the pads to, to, to obtain the temperature that you have set. And in England, we have a organization called Nice. So the National Institute of Clinical Excellence and at the time, we were, you know, back in February 2022 this was a device that Nice had authorized us to use in, in the in cooling patients after cardiac arrest. So we, we kept on for 6.5 hours. So, so I think it was about four o'clock in the morning. Um We, we slogged on, um we'd made a decision not to give any symptom mimetic drugs until the temperature was 30 degrees. And we finally achieved return of spontaneous circulation once the temperature was 30 degrees. But at that stage, the output was inadequate. Um So we continued CPR and we started some vasoactive infusions running. Um We finally stopped CPR after 6.5 hours when we've got a AAA nice, reliable um cardiff output. And then we waited for a couple more hours before we moved the patient. So I'd set a threshold of 32 °C. Um And then once, once the patient was at 34 decided it was safe to put a, a central line in. So within nine hours, we'd achieved normal theia or 37 °C core temperature. Um Nine hours after that, the patient was reliably off vasopressor. On day two was neurologically appropriate. But at this stage, failed a trial of extubation. And we later discovered he had eclampsia and pneumonia, which probably explains why he'd collapsed in the first place, but he was finally successfully extubated. On day eight, he had a few uh other problems which we got him through whilst he was on ITU. So he had an acute kidney injury for which he did need re renal replacement therapy, some small pulmonary emboli and, and a superficial chest wound from, from the Lupus device. But on day 49 he was discharged home with a full neurological recovery. And I, I followed him up last week because I knew I was gonna come and talk to you all and he's still alive and independent and enjoying his, his games of snooker with his friend. So, what did I learn from this case? Um I suppose I'd always imagined the patients that were going to survive from uh severe hypothermia where the case reports you read about and the the cases we've heard about this this afternoon, like the, the Danish rowers, the German Children that seem to go under under the ice all the time. What I learned was that this is actually possible in, in an elderly, you know, and co morbid patient, I used my previous sort of experience, so I'm ex forces. So I do have some experience of dealing with hypothermic patients. So I knew that the heart is the hypothermic heart is more susceptible to malignant arrhythmias. It may be unresponsive to drugs and the defibrillation at low temperatures is often ineffective. And I try to sort of put that together in how we manage this patient. So in an ideal world, this uh severely hypothermic patients who have cardiac arrest, then extra corporeal warming is is is sort of held up as the gold standard. But you know, the small hospital I work in that's just not possible. So I was pretty impressed with, with what we achieved with um a device that in the, I've been a consultant 21 years now. So over 20 years as a consultant in intensive care, I've only ever used this device really to cool people down and I was quite impressed that it, it works the other way. Um And that's what I'm here to share with you. There's some references and I'm happy to take questions if that's deemed appropriate. You can stay with me on the podium for the questions from the audience. I would say I take a picture 6.5 hour CPR that's really motivated. So any questions the the mic is coming? Thank you very much. Just a very simple question. What was the serum lactate? And that patient who was uh six hours under CPI I in uh what were were the indicators of hyperperfusion? Um Thanks. I can't, I can't remember the exact I'm 113 is in the back of my mind, but of course, it would have changed over the course of the resuscitation. I think his initial lactate was 13 burn as a question here. Maybe because you are alluding to the German Children. So maybe maybe I don't have a question, maybe a comment or I try to find a conclusion where we all can live with. So first of all, congratulations to this case report and to this successful treatment of the patient. And I think we all have learned that hypothermia or cooling or temperature management may be of benefit, at least in some patients. And maybe we can all agree. Even Christian and Wilhelm may agree that if we would have an ideal world with low resuscitation rates of 80% and more, maybe temperature management is not as important anymore as it is now. So that brings me to the conclusion that we hopefully can all agree that it should be our aim to increase lay resuscitation rates all over the world to 80%. And maybe more. And the best way to do this is to have mandatory school Children education in CPR. That's my comment and it's work for all of us. Thank you. OK, maybe um a question about um two questions. The first one is you mentioned that your patients were some kind of low card status, you know, like recovering pre arrest. Did you observe any signs of life during CPR? Because it's something that even for emo is used as you know, a criteria, you know, push for a prolonged CPR in this patient and how you manage. Did you give any sedatives to the patients during? So the so prolonged CPR, that was two questions. So we, we didn't see any signs of life because we were running propol infusion. And do you think that, you know, in this case, there is a rule of sedatives for this prolonged CPR, the giving sedatives might just be kind of um helpful for the patients because it's of course painful to receive chest compression or whatever. Or you think that might be also ruling protective, you know, because it's a low questions about sedation, plus temperature management. So the fact that you give sedatives, I think it purely from a humanitarian perspective. So the, the intubation done was done with sort of minimal sedatives and we continued the infusion running just in case he was aware of this. And I have a last question for you again. Practical because it's, apparently it's not the first one you manage. Did you, did you give any hot fluids in the stomach in the bladder? Like, you know, when it's been described in many other cases, just to warm the patients faster than just using the device. Yeah. So this, this is why I thought of using the device because all those methods were associated with the temperature continue to fall. So yes, we warm IV fluids. The bladder was being irrigated with warm fluids. Um I, I don't think we had a nasal gastric tube at that stage, but we were just getting nowhere with the non invasive methods. We had um not, not, not, you know, also trying to cover the body with a real challenge when you've got a Lucas sort of hammering up and down. This is maybe last question from if you can. Oh, the old gentleman, how was his chest doing after six hours with Lucas? And how did you handle that? Well, it was a bit of a mess. Um And he did have this, he did have a wound that needed to heal. Um We did our best with gel pads and, you know, every time we stop the Lucas to check for, for, for a pulse, you know, just making sure that it was correctly positioned. In fact, he outlasted the Lucas cos the other thing I haven't told you about is we burnt the first Lucas out. So this was we, we got through two devices. Yeah. Should have called even the Lucas then. So thanks a lot for your presentation. Created by
