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Acute Medicine Skills Part One
- 1. Acute Medicine andAcute Oncology Workshop Dr Sarb Clare- Consultant and Lead Acute Medicine Dr Clare Philiskirk- SpR Acute Medicine Dr Ash Lillis – SpR Acute Medicine
- 2. Acute Medicine AndAcute Oncology • Acute Oncology is a sub- speciality of Acute Medicine • We need each other to thrive – for our patients! • We need your specialist skills/knowledge and you need our generalist skills/knowledge • For acutely unwell cancer patients we need your help! - Impact of treatment - Prognosis - Escalation of treatment/ceilings of care
- 3. Objectives • Case Examples •How do we approach and manage the acutely unwell patient with cancer? ( Skill set ) • How do we deal with life threatening diagnoses ? • How do we make decisions with regards to treatment escalation plans?
- 4. Case 1- History •Pablo is a 53 year old who has metastatic renal cancer. He has had surgery, being reviewed in Oncology clinic and he complains of a 6 week history of intermittent left sided CP, some progressive SOB, associated with palpitations. • PMH- Hypertension • DHx- Amlodipine 10mg od
- 5. AO refers toAcute Medicine? PE • Sats- 93% air • HR- 112bpm • RR-16 • BP- 152/99 • Clinically very well • Not keen to come into hospital
- 6. Further Exam • Rightsided parasternal heave • Systolic murmur • Raised JVP • Right leg swollen and tender calf • Po2- 9.7Kpa on Air
- 12. Do we thrombolyse? A-Yes B- No C- Not Sure D- Needs CTPA before I decide E- Call for Help
- 14. Massive Versus SubMassive PE Massive PE- Clear Guidance • Hypotension • Tachycardic • Tachynoiec • Hypoxic • PERI- ARREST • THROMBOLYSE Sub-Massive PE- Unclear Guidance • Haemodynamically stable but evidence of Right Heart Strain • Echo ( Bed side) • Raised Troponin • Raised BNP • Evidence of thrombolysis is unclear
- 15. Sub Massive PE-Management • Studies PEITHO 2014 and MOPPET 2013 • Increased risk of intracerebral bleeds >75 yrs • Risk of major bleeding • Similar improvement even with anticoagulation • No mortality benefit • Long term Pulmonary hypertension not observed/significant
- 16. Case 1 Continued.. •Patient shows signs of haemodynamic instability • Patient transferred to ITU and thrombolysed with half dose atleplase in view of pericardial effusion • Haemodynamics improve within 4 hours and patient transferred from ITU to Chest ward and discharged on life long enoxaparin
- 17. Take home messages •PE is the most common condition we see - 1st presentation as cancer - Consequence of cancer • Massive PE Versus Sub Massive PE Management • Having cancer does not mean we will not TREAT or ESCALATE • USS for Acutely Unwell Patients – Would AOS team consider training in this? Empowering( Chest/Ascitic aspirates drains, Pericardial Effusions)
- 18. Patient 2 Dr ClarePhilliskirk ST5 Acute Internal Medicine
- 19. Carmel, 63 yearold female Recent diagnosis of Stage 3c Endometrial Cancer Previously fit and well, was working as a carer until 1 month ago Phone call to her specialist nurse from her family • General decline over the past few weeks - Decreased mobility, not got out of bed for 3 days - Confused and agitated - Not eating and drinking Advised to bring her into AMU for assessment
- 20. Medical Clerking History confirmed •Decreased mobility • Poor oral intake • Confused PMH – hypertension DH - Amlodipine Examination • Dehydrated • Normal cardiovascular/resp/abdo examination • No obvious focal neurology (difficult) Observations Temp 36.5 BP 145/80 HR 78 Sats 96% RA RR 18
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- 22. Blood results FBC HB 10.3 WCC9.6 Neuts 6.7 Plts 168 INR 1.0 Biochemistry Ur 18.5 Cr214 Na 147 K 4.6 Ca 5.2 Alb 31 LFTs - Normal CRP16
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- 25. J waves inHypercalaemia
- 27. Immediate Management Fluids Bisphosphonates Where? Cause forhypercalcaemia?
- 28. Progress Repeat bloods 48hrslater Ca 4.7 Na 151 K 4.2 Cr 250 Ur 19 Further treatment options…….
- 29. 48hrs after that….. Bloods Ca3.6 Ur 24 Cr318 K 5.4 Na 161 Clinically Remains confused, drowsy mostly but agitated at times Difficult maintaining IV access Minimal oral intake Urine output <10ml/hr
- 30. What should wedo next? A. Continue aggressive treatment on the ward with fluids/NG feeding/further bisphosphonates B. Accept that she is deteriorating despite our best efforts and aim for best supportive care C. Refer to ITU D. Refer to renal for haemodialysis
- 31. What can Level2 Care add? Access – fluids, blood sampling NG feeding + NG water Higher intensity nursing care Haemofiltration
- 32. Progress 5 day admissionto Critical Care • Central line and Arterial line • NG feeding • Reversal of AKI • Confusion improved Transfer to Gynae ward • On-going hypercalcaemia – denosumab being considered • Having physio/rehab with aim for surgery
- 34. Patient 3 Dr AshlingLillis ST7 Acute Internal Medicine
- 35. Patient 3 73 yearold Previous Ischaemic Heart disease (Myocardial infarction 2004),Type 2 diabetes, hypertension and rheumatoid arthritis Worked in a shop and retired 12 years ago Ex-smoker Limited exercise tolerance due to pain in hip & knees prior to cancer diagnosis
- 36. Diagnosed with ovariancancer 6 months ago. • Stage 3 at diagnosis (abdomenal deposits, no distant metastases, BRCA negative) • Treated with de-bulking surgery • Slow Post Operative recovery • Now on 3rd cycle of chemo (1x sepsis admission)
- 37. Presentation Breathless on exertion Worseat night when trying to sleep, some ankle swelling no fever, mild non-productive cough, no chest pain Much worse today so called her CNS and as breathless at rest said go to local ED Triage Obs- RR 24, Spo2 89% on air, BP 111/65, P92 (regular), GCS 15, CPR 2s, Temp 37.4
- 38. Stabilise and assess EDget the ball rolling ABC approach- sit up, high flow oxygen ECG- Sinus Rhythm, Left BBB (old) poor r wave progression, non specific changes Labs- mild acute kidney injury, high WCC, elevated LFTs, troponin and BNP requested but not yet available ABG
- 41. what’s your diagnosis •Pneumonia • Heart Failure • Progressive disease • Myocardial infarction
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- 43. Initial Treatment of CCF Highflow oxygen Immediate treatment- GTN (IV or sublingual) Furosemide 40-80mg IV Continuous Positive Airways Pressure (CPAP) Coronary care bed Assess for ischaemia, sepsis, progressive disease Continuous Positive Airways Pressure Coronary care bed Assess for ischaemia, sepsis, progressive disease Initial Treatment of Congestive Cardiac Failure (CCF)
- 45. The big questions Whatwill we do if this doesn’t work? What is the prognosis from her underlying disease? What does she know about her prognosis? What discussions have been had around escalation of care and end of life wishes? What are we going to say to her and her family?
- 46. Looking worse, feelingworse…. Increasing oxygen requirement Acute kidney injury and acidosis Progressive hypotension Becoming confused ALT>400, Cool to touch Brain Naturetic Peptide (BNP) >1500, Troponin mildly elevated
- 47. What next? Possibilities include •Intubation and ventilation & Renal Replacement therapy on ITU • CVC and inotropes on HDU • Increase CPAP and give more furosemide • Best supportive care
- 48. Multi organ failure- anacute medic approach • Patient, What do you know, what do you want? • How many organs have failed? • Can we reverse the underlying cause? • Prognosis of multi organ failure? • Prognosis of multi-organ failure in advanced cancer?
- 49. Consideration of criticalcare in cancer ‘I want you to do everything for her doctor’ • Honest discussions are key • Reversibility of issues are key • Critical care ‘Is like running a marathon every day’ • Severe functional limitation at baseline is associated to mortality in ICU • Treatment escalation planning (TEP) offers an opportunity to explore expectations about prognosis, outcomes, CPR and advance care planning
- 50. ICU and Cancer •Adult oncology ICU patients who don’t require ventilation have a ~25% in-hospital mortality, similar to that of non oncology ICU patients • Multiple organ dysfunction syndrome has the worst prognosis, >60% when 2 or more organs fail and near 100% when 4 or more organs fail. • Disease-related factors that are associated with worse prognosis in the critically-ill cancer patients: • poor response to chemotherapy, • cancer relapse or progressive disease • progressive or recurrent disease,
- 51. Progress Discussion with criticalcare, oncology and family Further invasive treatment not likely to be successful Best supportive care in hospital, died with family present that night