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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2901_Библиотеки_им_академика_М_И_Перельмана
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Case 30
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TIMEPOINT 1
Ms Jones, a 32-year-old marketing consultant,
attends her GP with a 5-week history of feeling
tired all the time, despite sleeping significantly
more than she used to. She says that she feels
exhausted all day long, even though she now gets
around 10 hours sleep compared to her previously managing fine with 6.
She is worried about her work as she feels
that she is letting her team down by not being
as good at her job as she was before. She finds
it difficult to concentrate during meetings and
has missed several important deadlines over
the last month. In her spare time, she used to
enjoy baking with her daughter, but lately she
has found that she is not interested in this and
would rather go to sleep.
She denies any attempts at suicide or self-harm
but admits she sometimes wonders whether her
family would be better off without her.
On examination, her observations are normal. Her general examination is unremarkable
although the doctor notes that her clothes appear
to fit loosely. On further questioning she reveals
that she has dropped two dress sizes due to weight
loss over the last 3 months.
Ms Jones has a past medical history of psoriasis and irritable bowel syndrome. For her skin,
she uses emollients regularly and adds in Dovobet
(calipotriol/betamethasone) when she has flares.
She is able to manage her IBS herself with a combination of laxatives and peppermint oil capsules
as needed. She has no known drug allergies. She
lives with her partner and 4-year-old daughter.
She drinks around 20 units of alcohol a week and
has never smoked.
What are diagnostic criteria for
depression (according to NICE
and DSM-IV/V: major depressive
disorder)?
Core symptoms
Loss of interest/pleasure in activities previously enjoyed (anhedonia)
Persistent low mood
Secondary symptoms
Change in sleep pattern – excessive sleepiness
or insomnia
Indecisiveness or inability to concentrate
Change in weight and/or change in appetite
Lack of energy or fatigue
Excessive guilt or feelings of worthlessness
Psychomotor agitation or retardation
Suicidal ideation or attempts
Patients must display five or more of the above
symptoms, including at least one of the core
symptoms.
e symptoms must occur for most of the day,
nearly every day, for at least 2 weeks, and be causing distress to the patient.
e symptoms must not be attributable to any
other medical condition or medication.
Severity criteria
Mild severity: five symptoms with minimal
social/occupational impairment
Moderate: five+ core symptoms with variable
social/occupational impairment
Severe: five+ core symptoms with significant
social/occupational impairment
DOI: 10.1201/9781351257725-30
159
160 Clinical Cases
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Table 30.1 Management options for treatment of depression
Mild–moderate Moderate–severe
First line
Second
line
Third line If SSRIs not tolerated, consider
With all interventions, review the patient after 2 weeks to assess progress.
Watchful waiting
OR low-intensity psychological
interventions
SSRIs If SSRIs not tolerated, consider
alternative, e.g. tricyclic antidepressant
SSRI AND psychological intervention
alternative, e.g. tricyclic antidepressant
Electroconvulsive therapy
What would be the first- and
second-line options for treatment?
Ms Jones would be classified as having moderate–
severe depression (Table 30.1).
Low-intensity psychological interventions
Guided self-help cognitive behavioural
therapy
Computerised cognitive behavioural therapy
Relaxation therapy
Psychological interventions
Cognitive behavioural therapy
Interpersonal therapy
Selective serotonin reuptake inhibitors (SSRIs)
e.g. fluoxetine, sertraline, citalopram
Warn patient about risk of bleeding and other
side effects, e.g. gastrointestinal upset
Check for drug interactions, e.g. St John’s
Wort, aspirin, clopidogrel
Make sure the patient is aware that it will take
time for the treatment to work fully (up to
8weeks)
Make sure the patient is aware not to stop
treatment suddenly (risk of SSRI discontinuation syndrome)
to find her sprawled on the bed, surrounded by
tissues and an empty paracetamol packet.
She says that she took a few tablets early in the
morning because she had a headache, but aer
that she was feeling so down that she kept taking tablets until she had finished an entire packet
of 16 tablets over the next couple of hours. She
denies taking them with any alcohol or any other
medications.
Her observations are normal and there is
nothing to find on examination.
She complains of feeling nauseous so is prescribed some anti-emetics.
What questions do you need to
ask for any overdose or poisoning
history?
Regarding the drug taken
What time was the drug taken?
Which drugs were taken?
How many tablets were taken/what were
the quantities?
Were the drugs taken with alcohol?
Depression history: including all core and
secondary symptoms
Suicide risk assessment, as below
What are the components of a
suicide risk assessment?
TIMEPOINT 2
Ten days later, Ms Jones is brought into the local
emergency department by her partner, who
reports that he came home from work at 7.30 pm
What led up to the attempt? What was the
tipping point or trigger?
Have they made any previous attempts at
suicide or self-harm?
Case 30: Timepoint 2 161
120 0.8
Plasma-paracetamol concentration (mmol ⁄ litre)
Plasma-paracetamol concentration (mg ⁄ litre)
Time (hours)
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What was the method of attempted suicide?
When and where did they to it? How were
they discovered?
Were alcohol or drugs involved?
Was it a spontaneous attempt, or had they
made plans in advance? Advance plans might
include: stockpiling medications, writing a
suicide note, making precautions to avoid
being found by others, preparing a will or
dealing with finances
How do they feel now? Do they feel sad, angry
or regretful? Would they attempt suicide
again now if they had the opportunity?
Do they have any protective factors? What do
they have to live for?
What features would make this
overdose high risk?
Staggered overdose
Overdose taken with alcohol
Overdose taken with an additional drug
High-dose overdose (over 150 mg
paracetamol per kg weight)
How should Ms Jones
be managed?
Consider giving activated charcoal if the
patient attends within 1 hour of ingestion of
>150 mg/kg paracetamol
If on or above the treatment line (Figure 30.1),
give N-acetylcysteine (NAC) = 3× back-toback infusions
Bag 1 = 150 mg/kg NAC (max 16.5 g) in
200 mL 5% glucose or 0.9% NaCl over 1
hour
Bag 2 = 50 mg/kg NAC (max 5.5 g) in 500
mL 5% glucose or 0.9% NaCl over 4 hours
Bag 3 = 100 mg/kg NAC (max 11 g) in
1000 mL 5% glucose or 0.9% NaCl over
16hours
Consider intensive care and psychiatric
referrals
110
0
0
Treatment line
2
4681012
100
90
80
70
60
50
40
30
20
10
Figure 30.1 Treatment line graph for paracetamol overdose.
14 16 18 20 22 24
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
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Key point
Use of the treatment line does not apply
in staggered overdose – all staggered
overdoses should be treated with NAC.
TIMEPOINT 3
Ms Jones is treated with N-acetylcysteine as per
protocol and moved to the acute medical unit
overnight. Twelve hours later, Ms Jones’ partner arrives to visit her. He shows the doctors a
picture of four empty wine bottles which he had
found hidden under the kitchen sink and then
goes in to see her. Ms Jones is asleep when he
arrives. He wakes her up to say hello, but she
is very drowsy. She opens her eyes slightly, and
he immediately notices that her eyes appear yellow. He goes to fetch a nurse who calls for the
doctor.
Ms Jones’ blood tests are repeated, including
an arterial blood gas (Table 30.2).
What does the ABG show?
e ABG shows evidence of a raised anion gap
metabolic acidosis. is could also be classified as
a Type B2 lactic acidosis (Table 30.3).
What are the criteria for liver
transplantation?
e most commonly used criteria are the King’s
College Criteria, which are as follows:
Patients should be referred for liver transplant
immediately if they have:
Table 30.2 Venous and arterial blood results
Venous blood tests
White cell count 8.0× 10
Haemoglobin 124g/L
Platelets 297 × 10
Sodium 142 mmol/L
Potassium 4.3mmol/L
Urea 6.4 mmol/L
Creatinine 420μmol/L
INR 7.2
Bilirubin 92 μmol/L
Alanine aminotransferase 1734 u/L
Alkaline phosphatase 143 u/L
Albumin 37 g/L
Arterial blood gas
pH 6.92
3.9 kPa
PaCO
2
10.5 kPa
PaO
2
5.8 mmol/L
HCO
3
Base excess –23.9 mmol/L
Lactate 8.4 mmol/L
Sodium 142 mmol/L
Potassium 4.2 mmol/L
Chloride 101 mmol/L
9
/L
9
/L
Ms Jones qualifies for a liver transplant and is
transferred to the local transplant centre. She
has the transplant and is started on tacrolimus,
azathioprine and prednisolone. She recovers well
from the operation and is discharged from hospital 2 weeks later once her liver function tests have
normalised.
TIMEPOINT 4
Arterial pH <7.3
OR all three of the following:
INR>6.5 or PT>100
Creatinine >300
Grade III/IV hepatic encephalopathy
Two months later, Ms Jones attends her liver specialist for a follow-up appointment. Prior to the
appointment, she was asked to have blood tests,
the results of which are given in Table 30.4.
Ms Jones denies any symptoms, and her
observations and abdominal examination are
normal.
Table 30.3 Types and causes of lactic acidosis
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Type of lactic acidosis Causes
A
(Secondary to hypoperfusion and hypoxia, causing
anaerobic glycolysis)
B
(Not related to hypoperfusion
and hypoxia)
(Associated with
underlying
disease)
(Related to drugs or
toxins)
(Inborn errors of
metabolism)
1
2
3
Case 30: Timepoint 4 163
Shock (septic, cardiogenic, or any other type)
Ischaemia
Seizure
Carbon monoxide poisoning
Malignancy
Infection
Liver failure
Renal failure
Pancreatitis
Diabetic ketoacidosis
Paracetamol
Salicylates
Methanol
Metformin
G6PD deficiency
Pyruvate decarboxylase deficiency
What could be causing these blood
test results?
confirms acute cellular rejection and Ms Jones is
started on high-dose steroids. Her usual immunosuppression regime is altered. Aer 1 week, her
Acute cellular rejection occurs in up to
50% of patients within one year of liver
LFTs have normalised again, and the consultant
is happy to discharge her.
transplantation
It is usually asymptomatic and picked up due
to deranged LFTs
e diagnosis is confirmed by liver biopsy
Treatment is using a short course of highdose steroids, aer which the patient’s usual
immunosuppression regime is increased
Chronic rejection may occur if the patient has
recurrent acute rejection, or acute rejection
that is refractory to treatment
What other complications are there
of liver transplantation, other than
acute cellular rejection?
Hyperacute rejection
Rare unless donor ABO-incompatible
Due to pre-formed antibodies against
donor major histocompatibility complex
Causes massive hepatic necrosis occurring within days
Ms Jones is admitted to the hepatology ward for a
liver biopsy and further monitoring. Liver biopsy
Table 30.4 Venous blood results
9
White cell count
Haemoglobin 131 g/L Creatinine 89 μmol/L
Platelets 346 × 10
MCV 87 fL Bilirubin 36 μmol/L
Sodium 137 mmol/L Alkaline phosphatase 178 U/L
Potassium 4.9 mmol/L Alanine aminotransferase 102 U/L
6.3 × 10
/L Urea
9
/L Albumin 34 g/L
Chronic rejection
Occurs aer months to years
6.7 mmol/L
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Usually presents with progressive
cholestasis
In later stages bile duct loss and fibrosis
are seen
Treatment is with escalation of immunosuppression or re-transplantation
Gra failure
Transplant does not start working
properly
Bleeding
Liver transplantation is particularly high
risk as patients may have clotting deficiencies secondary to the liver failure
Post-operative wound infection, opportunistic infection secondary to use of immunosuppressive medications, and malignancy
Transplanted patients are heavily immunosuppressed so at high risk
Post-transplant lymphoproliferative disorder
rombosis of the vena cava, portal vein or
hepatic artery
Biliary anastomotic leak
Biliary strictures
Secondary to poor preservation of
the liver during the transplantation
procedure
Disease recurrence
Hepatitis B, hepatitis C, alcoholic
liverdisease, PBC, PSC and autoimmune
hepatitis have all been documented as
having recurred in a transplanted liver
Case 31
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TIMEPOINT 1
Mr Roberts is a 64 year old who works as a registrar for births, marriages and deaths who has
found the last 2 years the hardest of his otherwise
unblemished 34-year career, partly connected to
his closest colleague leaving to move to Canada. He
has found he has been working unpaid extra hours
– and work thus has felt immensely stressful. He
has experienced several relatives passing away, was
divorced 4 years ago and felt this work would help
him sort out his financial affairs. He has become
increasingly lonely and rarely visits the GP. Mr
Roberts was usually fit and well with no past medical history, but he has taken a total of 11 sick days
in the month leading up to his hospital admission.
On the day of admission, the neighbour comes
out of her house, and is surprised because Mr
Roberts usually turns on his favourite radio ‘talk
show’ immediately aer starting his car to drive
to work; it seems his car has been running for a
very long time inside the garage, but she hears no
voices from the radio.
She calls the police in case something is wrong.
ey arrive, crank up the garage door, see tubing
from the exhaust to the driver and immediately
call an ambulance.
On arrival Mr Roberts has the following
features:
Respiratory rate: 29/min
Oxygen saturations: 99% on room air
Temperature: 36.5°C
Blood pressure: 130/80 mmHg
Heart rate: 110 bpm
GCS: 14/15
Which toxicological influences can
be present despite normal oxygen
saturations?
Carbon monoxide and methaemoglobin can
both be potentially present in significant concentrations despite normal oxygen saturations.
TIMEPOINT 2
Within 30 minutes of arrival, the emergency
department doctor assigned to Mr Roberts starts
working quickly because they are aware that the
likely diagnosis is carbon monoxide poisoning/
car-fume inhalation and there is a need to manage Mr Roberts pro-actively. e emergency
department doctor checks Mr Roberts’ carboxyhaemoglobin level and finds out that the result is
17%, far above the upper limit of normal.
e team contacts the National Poisons
Information Service and also speaks to the
regional hyperbaric centre who advises maximal
high-flow non-rebreather oxygen therapy but
not hyperbaric transfer. He makes step-by-step
improvements in carboxyhaemoglobin levels and
oxygenation via repeated blood gas tests.
What are the clinical indicators of
carbon monoxide poisoning?
ere are rather few, but they may include a
degree of pink/pale colouration of the lips/skin
and a normal value on bedside pulse oximeter
despite an appropriate history.
A physician associate student working with the
acute admitting medical team sees that there is a
clear need to use oxygen in Mr Roberts, but asks
her colleague a question about whether every
medical patient should have oxygen.
DOI: 10.1201/9781351257725-31
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166 Clinical Cases
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The use of oxygen for acutely admitted medical patients
Historically, innumerable numbers of acutely admitted adult medical patients, including
those with a variety of cardio-respiratory disorders, arrived in emergency departments with
a non-rebreather mask attached to high-flow oxygen. It is increasingly clear that oxygen is a
drug that needs coordinated prescription and careful titration. Recent evidence, whilst not
diminishing the need for oxygen in those for whom it is required, such as those with severe
hypoxia, suggest the need for an alteration in approach.
There are now several scenarios which are linked to harm associated with unwarranted oxygen therapy. The current evidence base shows worse outcomes in patients with stroke and
myocardial infarction where oxygen is not needed. New guidance now suggests not giving
oxygen to those with an oxygen saturation above 93%. Patients with COPD will generally have
a target saturation of 88–92%.
Similarly, alongside COPD, other patients with or at risk for Type 2 respiratory failure may have
a similar target including those with some severe neuromuscular disorders, obstructive sleep
apnoea, etc. As described above, higher target oxygen saturations (in the >93% category)
are now generally reserved where a particular need for oxygen delivery is required, including
carbon monoxide poisoning (as above), cluster headache and certain haematological emergencies such as sickle cell crisis.
When is hyperbaric oxygen indicated?
Hyperbaric oxygen is indicated when pressurised oxygen is required to increase the availability of oxygen in the body, beyond what is possible with standard oxygen delivery methods.
It is not without risks and therefore needs to be decided upon dependent on the degree
of clinical need.
The indications for hyperbaric oxygen in carbon monoxide poisoning include:
Carboxyhaemoglobin level > 20%
A failure to respond to high normobaric delivery of oxygen
Patient is a pregnant woman
In general terms, hyperbaric chambers have a range of clinical roles. Across the world there
are multiple registers of hyperbaric chambers that can be single- or multi-occupancy. A
general contraindication is pneumothorax. In terms of side effects, barotrauma to the ear
has been reported with other adverse effects much less common. In the UK there are several regional hyperbaric centres, often associated with coastal/nautical organisations. The
frequently considered indications for hyperbaric oxygen include carbon monoxide excess;
decompression illness (deep sea diving–related); gas/air embolism; necrotising soft tissue
infection; acute traumatic/thermic/radiation injury.
Case 31: Further Reading 167
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TIMEPOINT 3
Mr Roberts is transferred with ongoing, titrated,
prescribed oxygen therapy to the ward. On the
medical ward, once it is felt the oxygenation
issues have improved to a very significant degree,
attention then turns to the factors leading to the
suicide attempt. Liaison psychiatry assessment
takes place, and a detailed assessment of affect,
depression risk and future potential for self-harm
suicidality takes place. Community-based mental
health support arrangements are put in place.
Why should oxygen be prescribed
as a prescription medication?
e patient safety issues related to oxygen clearly
warrant the need for it to be prescribed; it is
colourless, odourless and flammable. In addition,
the required oxygen delivery – such as FiO2 – for
a given patient may change over time; prevention
of over-oxygenation is extremely important as it is
linked to lung injury and, in certain cases, hypercapnic Type 2 respiratory failure.
TIMEPOINT 4
Four weeks later, Mr Roberts has a day with work
scheduling at the lightest possible level as he scheduled a GP appointment in the morning and then
a meeting with his line manager and occupational
health representative in the aernoon. e meeting
at the workplace involves an overall review of his
physical and mental health information during his
overall duration with the employer. In the second
part of the meeting he is advised that professionals would join the meeting. ose joining include
an employment adviser, a union member and an
external occupational health adviser alongside
those already present. e employer looks at:
Areas of professional conduct and capability
Levels of experience
Health records
e outcome of the meeting is to calculate the
Bradford Factor.
What is the Bradford Factor?
e Bradford Factor (BF) is a human resource tool
that has been around for decades. It is thought to
be named aer work undertaken by the Bradford
University School of Management. e basic idea
is to find a formula that gives a numerical value
to patterns of absence, with a lower score signifying a better record. It is usually used as a disciplinary tool for sickness absence – and BF use
has led to people being sacked or otherwise having decisions made against them. It is a sickness
absence management tool, designed to impose
limits on workers’ absence, not to help them
overcome sickness or poor health, work-related
or otherwise. It is presented as a means of dealing fairly with the employer-defined problem that
many short absences are more disruptive to the
employer’s business activities than a single long
one. e formula puts a lot of weight on individual absences, and it produces a score over a
reference period, using a very simple calculation:
Bradford Factor = number of unrelated absence
periods² × days absent. For example, 10 days’
absence in the reference period (a year, say) could
occur as: 1 absence of 10 days, which would have
a BF of [(1 × 1) × 10] = 10; 5 absences of 2 days each
which would have a BF of [(5 × 5) × 10] = 250; 10
absences of 1 day each which would have a BF of
[(10 × 10) × 10] = 1000.
Following the professionals’ meeting, to clarify
the overall outcome of recovery from the carbon monoxide episode, a neuropsychological
assessment is arranged. e neuropsychological
assessment demonstrates some evidence of cognitive impairment. An informal further meeting
with the line manager means that the essential
importance of certification of births, marriages
and deaths means that Mr Roberts’ work duties
need to be altered. In fact, this is a collaborative outcome as Mr Roberts admits he has found
thoughts of changing roles a real consideration
recently. e employer finds a different role in
which Mr Roberts can be deployed in an area of
renewed interest, within the same organisation
with no long-term salary or pension implications
but incorporating some regular collective team
meetings and three monthly health checks for
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