This is the third hypothetical case discussion based on real cases submitted to the Resuscitology Team for analysis and debrief on the Resuscitology Course. Course participants are asked: “Please describe a resuscitation case that you have been involved in or witnessed that you feel (a) either had great learning points for other people on the course or (b) you feel didn’t go as well as it should and would appreciate the chance to analyse and discuss it.”

Case details are removed or altered to guarantee anonymity and confidentiality while preserving learning points. Cases are shared with the permission of the submitting clinician.

This case discussion was facilitated and summarised by Chris Nickson

A young adult female presents to the emergency department in septic shock. She has a diagnosis of metastatic cancer and is receiving chemotherapy. She is critically ill, with an altered mental state and is hypotensive.

She has no advance directive and the oncology consultant advises that “full resuscitation” should be performed. The ED team are not completely at ease with this, however, they continue to resuscitate the patient.

Eventually, the decision is made to intubate the patient, who has no externally apparent features of difficult anatomy. Two operators are unsuccessful with intubation attempts despite the use of video laryngoscopy. The patient is able to be oxygenated and ventilated until an anaesthetist is available to assist with the intubation.

Discussion points

• Recognition and initial management of septic shock, with specific considerations in oncology patients
• Should this patient be “for resuscitation”? How much is “too much”?
• How can we clarify the best course of action when there is uncertainty or differences of opinion?
• Why might attempts at intubation with video laryngoscopy fail, and how should we manage this?

Recognition and initial management of septic shock

Definition and recognition of sepsis is detailed in the LITFL CCC (https://lifeinthefastlane.com/ccc/sepsis-definitions/). Key elements to note:

• Layperson’ definition works best! Sepsis has 3 key components:
  • • Infection
    • Dysregulated host response
    • Organ dysfunction
• Recognition
  • • Suspected infection, and:
      • • Two of hypotension, altered mental state, and tachypnea (but lacks sensitivity) = sepsis
        • Sepsis with refractory hypotension + lactate >2 mM = septic shock
    • Beware of sepsis mimics…
• Rule of thumb: suspect sepsis in any patient with new organ dysfunction not otherwise explained

Initial management is detailed in the LITFL CCC (https://lifeinthefastlane.com/ccc/initial-sepsis-management/) under these headings:

• resuscitation
• early administration of appropriate antibiotics following blood cultures
• early source control
• judicious fluid resuscitation, avoiding excess fluids
• noradrenaline for refractory hypotension (septic shock)
• inotropes for septic cardiomyopathy
• therapies for refractory hypotension
• other experimental and rescue therapies
• ongoing supportive care and monitoring

What specific considerations are there in the oncology patient?

• Consider sepsis mimics (see: http://www.emdocs.net/mimics-of-sepsis/)
• Haemophagocytic lymphohistiocytosis (HLH) (see: https://lifeinthefastlane.com/ccc/haemophagocytic-lymphohistiocytosis-hlh/)
• Drug reactions – e.g. trial drugs, ATRA syndrome (APML)
• Neoplastic manifestations – e.g. Addison’s, hyperthyroidism, vasculitis
• Distributive shock – e.g. Anaphylaxis, Addison’s (other causes of shock/ hypotension)
• Endocrine – e.g. Addison’s, hyperthyroidism, DKA
• Aspiration
• Hepatic failure
• Toxicology – e.g. Salicylate poisoning, vasoplegic overdose (e.g. ACEI), hyperthermic toxidromes
• Nutritional deficiency – e.g. thiamine deficiency
• Gastrointestinal disorders – e.g. bowel obstruction, ileus, gut ischemia

Likely sources of sepsis

• Pneumonia, urinary tract infections, wounds
• Don’t forget:
  • • Deep abscess/ soft tissue infections
    • Neuraxial infection
    • Endocarditis
    • Skin (always look at the back!)
    • Intra-abdominal sepsis
    • Lines, devices, and indwelling catheters

Differences in the manifestations/ recognition of sepsis occur as oncology patients, and immunosuppressed patients, may lack normal inflammatory response

• Sepsis may be present with absence of:
  • • Fever
    • Leukocytosis
• On the other hand, fever and abnormal white count may occur due to the underlying malignancy or drugs

Effect of ICU/ critical illness on cancer

Sepsis may directly impact on tumour growth (Staudinger and Pene, 2014)

Many ICU drugs are thought to promote neoplastic growth:

• Catecholamines
• Sedatives
• Blood transfusion
• Hypoxia

Critical illness may:

• Worsen immunosuppression
• Worsen frailty

Should a young patient with metastatic cancer be “for resuscitation”? How much is “too much”?

Key considerations

• How certain is the information we have?
• What type of metastatic cancer and is the chemotherapy curative or palliative?
• What is the advice of the consultants and “where are they coming from”?
• What is the prognosis?
• What are the patient’s values?

How certain is the information we have?

• The general rule is “resuscitate before you prognosticate”
• When the information need to guide decision making is uncertain, an approach of ongoing resuscitation while actively gathering further information (e.g. from clinical notes, family, specialist teams) is usually wise. Life sustaining measures are reversible, death isn’t.
• As a team leader in this situation, it is useful to acknowledge the team’s discomfort, share your mental model, and check in on the team. For example, “This is a difficult situation. The patient may have a terminal illness, however, we do not know enough about them to be clear that stopping resuscitation is the right thing to do. I think we should continue resuscitation until we know more. Team, tell me what you think.”

What does ”metastatic cancer” mean? Is the chemotherapy curative or palliative?

• Not all cancer, and not all metastasis is the same!
• Therapies and prognoses are rapidly evolving – what we learnt in medical school may no longer be true! (duh)
• Example: malignant melanoma; advanced cancers may be essentially curable if they respond to modern therapies

What is the advice of the consultants and “where are they coming from”?

• We should remember to treat others with positive regard! (most people are doing their best, and they often do what do due to their circumstances, not because they are “bad”)
• We are all subject to cognitive biases (e.g. sunk costs) and affective biases (e.g. guilt, emotional attachment, sterotyping); and base our advice on different backgrounds of expertise and experience
• For instance (note these are generalisations):

  

What are the patient values?

• An understanding of patient values is best established when the patient is “well” and documented in an advance directive.
• Appropriately documented advance directives are legally binding in Victoria.
• If the patient is not competent, the “next of kin”/ family may act as surrogates to advise what they think the patient would want out of life and what is important to them
• The surrogates do not choose medical therapies, that is the job of a clinician – we should avoid asking “what do you want us to do?”.
• In time-critical emergencies surrogates may find it difficult to separate their own emotions/ needs from that of the patient; a useful question for surrogates is “if X was somehow able to be present in this discussion right now, what would X say?”
• Sometimes we have no guidance on patient values and we just have to do what we think is right based on the information we have – if we stop, the patient is dead; if we don’t stop we can stop later when further information comes to light…
• These issues are discussed further in the LITFL CCC page on “Families that want everything done”: https://lifeinthefastlane.com/ccc/patients-families-want-everything-done/

In most situations, the prognosis of the critical illness overrides the prognosis of the oncological diagnosis

• For most oncology patients with solid tumours admitted to ICU, the 6-12 month mortality is similar to non-oncology patients ((De Jong & Bos, 2009). Caveats to consider:
  • • Oncology patients are not a homogenous group
    • Data tends to be negatively biased by higher mortality in older studies
    • In the 1990s, oncology patients were considered very high risk (up to 90%) of mortality. At that time, immediate treatment limitations or even refusal of ICU admission for these patients were advocated. This pessimism may persist in people who trained in critical care around that time. (De Jong & Bos, 2009)
• As a rule of thumb; the number and severity of organ impairments is the best guide to prognosis. Other indicators include:
  • • Need of mechanical ventilation (especially for acute respiratory distress syndrome)
    • Vasopressor support (>4 hours) and therapies that have preceded ICU admission
    • The underlying neoplasm seems to have a little impact on the outcome
• The most frequent reasons leading a cancer patient to ICU are:
  • • Postoperative recovery
    • Respiratory failure
    • Infection and sepsis
• A suggested approach (Biskup et al, 2017; Kiehl et al, 2018):
  • • Patients with >6 months to live should have consideration of admission to ICU for trial of ICU therapy, with reassessment of progress at 3-10 days, then consideration of palliation if not improving
    • Patients with <6 months to live should have consideration of palliation if their illness would otherwise meet criteria for ICU admission
    • However, this approach should be tailored to the patient’s values (if attending a daughter’s wedding in 1 week is a dying patient’s life goal, then aggressive life-sustaining measures until that time may be acceptable to them)
• Cardiopulmonary resuscitation (CPR)
  • • Traditionally, CPR has been deemed inappropriate for most cancer patients due to poor survival to discharge (6% overall) (Sehatzadeh et al, 2014). However, these data are likely biased by older studies.
    • A recent retrospective study of 133 patients with cancer who required CPR found that 17% were alive at hospital discharge with good neurological recovery. (Champigneulle et al, 2016). However, improvement in CPR survival of oncology patients may be due to more selective performance of CPR through better use of consensus resuscitation plans.

Why might attempts at intubation with video laryngoscopy fail, and how should we manage this?

Key considerations

• Failed airway algorithm
• How to optimise intubation attempts: “STOPME” mnemonic
• Reasons why video laryngoscopy can fail

Failed airway algorithm – “ensure first attempt is best possible attempt”, for example:

• Plan A – Video laryngoscopy (VL) or direct laryngoscopy (DL) (up to 3 attempts)
• Plan B – supraglottic airway device (SAD) / bag-valve-mask (BVM) (can switch back to Plan A if in “green zone” (able to effectively provide alveolar oxygenation) and STOPME is performed)
• Plan C — FONA (front of neck access; i.e. emergency surgical airway)

How to optimise intubation attempts using the “STOPME” mnemonic:

• Suction
• Tone (administer neuromuscular blocker)
• Operator (change to most expert intubator available)
• Position (“ear-to-sternal notch” / “sipping the pint” position)
• Manoeuvres (bimanual laryngoscopy, head lift, two handed lift, jaw thrust)
• Equipment type and size: DL vs VL (using either a MacIntosh/ “standard geometry” or a Hyperangulated blade) or flexiscope.

Remember that DL commonly rescues VL, and vice versa! It makes sense to use a standard geometry VL blade that can also be used for DL, in most circumstances.

Specific reasons for failure of VL technique (see LITFL CCC for a description of video laryngoscopy: (https://lifeinthefastlane.com/ccc/video-laryngoscopy/)

• Education, training, and familiarity with specific VL equipment and technique for use
• Poor ergonomics
  • • Best if intubator and team can see screen in front of intubator (allows “shared mental model”)
• Poor view
  • • Need to use “Look in mouth / at screen/ in mouth / at screen” approach – avoid piercing the soft palate or tonsilar bed with a bougie or stylet!
    • Hyperangulated VL can be used for Column 1 issues (if able to insert in mouth), and Column 3 issues (e.g. stiff neck), but can make view worse/ tube delivery more difficult if these are not present (see Keith Greenland’s Two Curve Theory and Three Column approach here: https://lifeinthefastlane.com/ccc/three-axis-alignment-versus-two-curve-theory/)
    • Need optimal patient positioning for laryngoscopy (e.g. ear-to-sternal notch positioning)
    • Remember to use appropriate manoeuvres to optimise laryngoscopy (e.g. bimanual laryngoscopy, head lift, lift epiglottis vs seating in vallecula, two hands on laryngoscopy handle for forceful lift)
    • Avoid contaminating VL camera or light source with blood, vomitus, or secretions – suction as you advance the VL tip (“stay high and dry”)
• Failure of tube delivery
  • • Use a stylet with same curvature of a hyperangulated VL blade; this is generally better than a bougie, which tends to lose curvature
    • Keep laryngeal inlet in top third of screen and to the left of centre; allow bougie/ tube delivery to be visualised and allows room to manourvre tip through the laryngeal inlet (“stay high and dry, not too close”)
    • Deliver tube using a “stop, pop, drop” approach; to avoid the stylet/ ETT tip abutting the anterior wall of the trachea following passage through the laryngeal inlet, rotate stylet to the right when advancing into the trachea

Potential reasons for failure in this case based on the limited vignette alone (using STEPS and GPAS approaches)

STEPS approach:

Self/ Team Leader

• Stress – interpersonal conflict, moral distress, “HALT” factors (hungry, angry, lonely, tired)
• Experience/ expertise with technique

Team

• As per self
• Ability to speak up

Environment

• Equipment availability and familiarity
• Equipment setup and positioning

Patient

• Positioning
• Difficult laryngoscopy – LEMON: tumors (mouth, compressing or obstructing airway), radiation

System

• Availability of support and equipment
• Lack of training
• Culture (e.g. psychological safety and speaking up, silos)

GPAS approach:

Goal

• Resuscitation of septic shock (should resuscitation be performed? Is it septic shock?)

Plan (Strategy)

• Management of septic shock? (ABCs, culture, antibiotics, Rx haemodynamics, source control)

Actions (Tactics)

• Consult with oncology team (and others?)
• Airway assessment, timing and indications of intubation?

Skills

• Effective communication skills? Right people?
• Airway assessment skills?
• VL skills?

References

 

Biskup E, Cai F, Vetter M, Marsch S. Oncological patients in the intensive care unit: prognosis, decision-making, therapies and end-of-life care. Swiss Med Wkly. 2017;147:w14481. [article]

 

Champigneulle B, Cariou A, Vincent F. Cardiopulmonary Resuscitation and Benefit to Patients With Metastatic Cancer. JAMA Intern Med. 2016;176(1):142. [article]

 

De jonge E, Bos MM. Patients with cancer on the ICU: the times they are changing. Crit Care. 2009;13(2):122. [article]

 

Kiehl MG, Beutel G, Böll B, et al. Consensus statement for cancer patients requiring intensive care support. Ann Hematol. 2018;97(7):1271-1282. [article]

 

Mack JW et al. End-of-Life Care Discussions Among Patients With Advanced Cancer. A Cohort Study. Ann Intern Med 2012;156:204-210. [article]

 

Nassar AP, Dettino ALA, Amendola CP, Dos santos RA, Forte DN, Caruso P. Oncologists’ and Intensivists’ Attitudes Toward the Care of Critically Ill Patients with Cancer. J Intensive Care Med. 2017;:885066617716105. [article]

 

Nickson CP. Sepsis Definitions and Diagnosis. LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/sepsis-definitions/ [Accessed 14 December 2018]

 

Nickson CP. Patients and Families that “want everything done”. LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/patients-families-want-everything-done/ [Accessed 14 December 2018]

 

Nickson CP. Initial sepsis management. LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/initial-sepsis-management/ [Accessed 14 December 2018]

 

Nickson CP. Hemophagocytic lymphohistiocytosis (HLH). LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/haemophagocytic-lymphohistiocytosis-hlh/ [Accessed 14 December 2018]

 

Sehatzadeh S. Cardiopulmonary Resuscitation in Patients With Terminal Illness: An Evidence-Based Analysis. Ont Health Technol Assess Ser. 2014;14(15):1-38. [article]

 

Staudinger T, Pène F. Current insights into severe sepsis in cancer patients. Rev Bras Ter Intensiva. 2014;26(4):335-8. [article]