Safety Brief and Night-to-Day Handover

OK, so good morning everybody, and can we start over with introductions? So I’m Jillian. I’m the night Reg. that’s been on. I’m Marie. I’m the medical student. I’m Andy, the registrar on call for today. Hey, I’m Rhona the nurse practitioner for A and B And I’m Rachel, nurse practitioner. fo A and B. I’m Graham I’m the consultant for 116C today. Gregor. I’m intensive care consultant for 116D. And so Gregory is the consultant on call today. The nurse in charge is Helen Stafford, and there aren’t any patients that need to be urgently reviewed. We’ve got eight patients on the unit. We’ve not got any expected rush-ins, and we’ve got one expected discharge.

So handing over the patients in bed, 35, is Andy Stewart. He is day six and he’s in ICU admission today. He’s a 77-year-old chap with a background of hypertension and diet-controlled type 2 diabetes. He was admitted following an out of hospital cardiac arrest. He didn’t receive any bystander CPR and had a total downtime about 45 minutes. He had TTM and neuroprotective measures, but unfortunately it was GCS3 oxidation hold and had a CT, which was suggestive of devolving hypoxic brain injury. There’s been extensive discussions with his family, and his care’s been reorientated towards comfort, indemnity, and his family have declined organ donation. He’s been extubated, he’s currently self-ventilating there, and he’s on morphine and midazolam infusions for comfort.

His family are with him. They’ve been seeing the chaplain over night. He’s got a DNACPR form and family are by his bed space and happy. That’s him. In bed 36 is Malcolm Thompson. He’s day four of admission, he is a 22-year-old chap who’s got fulminant hepatic failure following a deliberate paracetamol overdose. He’s met King’s College criteria but has been declined for listing due to recurring overdoses and ongoing drug and alcohol use. At the moment he is on SIMV. He’s on 30% oxygen and he’s being well protected and ventilated. He is on some 10 mls an hour a single strength noradrenaline aiming for a MAP of 70. He enterally fed. That’s being tolerated.

His synthetic liver function is worsening, so his PT is now over averaging 40 seconds. He continues on NAC and his BMs have been stable. With feed he’s positive to 500 mls, has had a good urine overnight. He’s had a sedation hold this morning and was E4M6 in his and is on propofol and alfentanil and he’s got antibiotics as per the fulminant hepatic failure protocol. In the next bed space is Emma Rogers. She’s day four of her ICU admission. She’s a 44-year-old lady who’s normally fit and well. She was admitted to the hospital CURB-3 community acquired pneumonia. We don’t have an organism yet for that. She required some high flow nasal oxygen.

That’s been weaned in the last 24 hours, and she’s gone on to nasal cannula oxygen this morning. She looks very well and is probably ready for discharge. She’s eating and drinking, she’s passing good volumes of urine, she’s in a neutral balance, she continues and IV Co-amoxiclav clarithromycin. From a job point of view for today, she still needs her atypical screening chasing, and she’s got discharge letter started for transfer to the ward. Has she had a viral throat swab? It’s improving some.

Bed 38 is Michelle Fraser. She is day two She’s a 26-year-old lady who is day two total colectomy for fulminant ulcerative colitis. which was unresponsible– unresponsive, sorry– to medical management. She’s got an epidural and is doing very well. She’s sitting out of bed this morning. In 28% oxygen, she’s got a good, strong cough. Cardiovascularly, she’s unsupported. Her peripheries are nice and pink and well-perfused, and she’s managing some steps. She’s got maintenance fluids going 65 mls an hour. Her epidural is running at 10mls per hour and she’s very comfortable with a sensory blocker at T6 and she’s not on any antibiotics.

Jason Elliott is the next patient. He is a 29-year-old man who is day two of his ICU admission. He’s a gentleman who sustained polytrauma where he was in a road traffic accident and was an unrestrained passenger who was ejected from the vehicle. In terms of his injuries, he has an unstable pelvic fracture which was fixed yesterday with an internal fixation in theatre. He’s got some thoracic injuries with a right sided flail segment right haemothorax and a right sided intercostal chest drain put in in resus which drained a litre of blood. And he’s got some left side pulmonary contusions. His state has been complicated by a right lower like crush injury and subsequent development of compartment syndrome.

He has developed an acute kidney injury and is required hemofiltration. At the moment, he is on SIMV He’s been lung protectively ventilated in 60% oxygen. He’s got the right sided intercostal drain still in situ and that’s still in situ and that’s swinging and draining still about 140 mLs over the last 24 hours. He’s got a MAP of 70 on 5mls an hour, single strength noradrenaline. He’s been enterally fed, and that’s tolerated. He is on CVVH in a neutral balance, remains anuric and is 100 mls positive this morning. He is E 4 on propofol at 10 miles an hour and alfentanil at two mls an hour. From an antibiotic point of view he is afebrile and isn’t on any antimicrobials.

Can I just ask? Was his GCS OK, it seemed?

Hold on. Let me check for you It’s not clearly documented. Certainly he was intubated in A&E. He’s had a CT of his head which showed some loss of white matter, white grey matter differentiation he’s got no injury requiring neurosurgical intervention. We haven’t been monitoring him from an ICP point of view. Brilliant. Thank you. And these people’s his pupils and things have been fine. And the next patient is Roger Stratford. He’s days 4. He’s a 26-year-old chap who came in with flu-like symptoms, decompensated heart failure with pulmonary edoema.

He’s coronavirus positive (NOTE: not COVID 19) on his throat swab. And he’s had an echo which has shown some severe LV impairment. And over the last 24 hours or so he’s shown some improvement with a furosemide infusion and high flow nasal oxygen At the moment he’s on 60% oxygen. His gases are acceptable PO2 of over 8. His furosemide infusion is going, and is otherwise, he is cardiovascularly unsupported. He is managing to eat and drink. He’s alert and orientated in a negative fluid balance of a litre and he isn’t on any antibiotics. OK. And the next patient is Antoine Charon who’s day three in ICU. He’s a 43-year-old man.

He’s got a new diagnosis of HIV infections with CD4 count of 100 and has PCP on a BAL. He’s got a severe ARDS-type picture with a [P/F ratio of about 13 kilopascals. He was proned last night for worsening respiratory failure And of note his family are not yet aware of his new diagnosis of HIV. From a systems point of view, for a respiratory point of view, he’s proned. He’s [on] long protective ventilation with PEEP of 12, and his FIO2 is coming down nicely with proning from 90% to 45%. He’s just on a single ml of single strength norad to maintain a MAP of 70. He is enterally fed and that’s been tolerated.

He’s passing reasonably good volumes of urine and neutral balance, and he’s on high dose Septrin and some Ambisome just as per the recommendations of a microbiologist. So his obligatory fluid intake is going to e quite high. So make sure we keep his fluid balance tight. Sure.

And the last patient to hand over is Rab MacVicar He’s a gentleman who is an overnight new admission He’s a 19-year-old chap who was found at home by his mum. And there was evidence of a mixed overdose of alcohol he’d been out with his friends. And there’s some benzodiazepines and Tramadol from here found near him. He’s had a normal CT of his head. His CK is normal. His acid base status was nice and normal. He did have a borderline QTc when he was admitted, but that’s now normalised on serial ECGs without us having to do anything about it. We’re aiming to wean his sedation and extubate him this morning, and of note, he had a normal paracetamol level.

So he has– we’ve just slipped him onto CPAP this morning. He’s on five on five. And he’s just on air. He’s quite actually stable. He’s got some maintenance fluds going. We haven’t put an NG tube down him em overnight because we think he’ll probably actually extubate quite early on. He’s passing quite good volumes of urine. his renal function is normal in this morning’s bloods. From a microbiology point of view he’s afebrile and on no antibiotics. So the plan for him is that he should extubate early on. I guess he would need probably a psychiatry review prior to discharge.

And those are our patients. And the unit is fine. Thanks very much. OK, we’ll let you get away home And so we decide to divide up the patients and start their daily reviews. Thank you. Thank you.