NDT Case study Paediatric H Bethan Thomas Specialist

NDT Case study Paediatric - H Bethan Thomas Specialist Nurse – Organ Donation Regional Collaborative November 2015.

Background • PEG fed- no swallow • 10 yr old • Cerebral Palsy • Global developmental delay • Microcephaly • Epilepsy • Scoliosis • Quadriplegia Regional Collaborative November 2015. • Previous abdominal compartment syndrome with bowel ischaemia leading to bowel resection • Worsening T 2 RF (normal p. CO 2 10 -14 reported by paediatrician) • Recurrent LRTI • Home O 2 • Recent discharge from hospital after admission for chest infection

Day 4 BSDT Preconditions • CVS stable on noradrenaline and dopamine – BP map 66 • • • p. CO 2 8. 95 p. O 2 49. 5 p. H 7. 41 GCS 3 - unsedated Temp 39ºC (>24 hours) Lab results: Na 153 K+ 3. 2 PO 4 1. 12 Mg 0. 69 Regional Collaborative November 2015.

Day 4 • Pupils 2 mm-fixed • BSDT startedbreathed during apnoea test • Test done by 2 PICU consultants • 2 nd set not done. Regional Collaborative November 2015. Test 1 Time Pre Apnoea Test 14: 13 Post Apnoea Test 14: 20 p. H 7. 412 7. 243 p. O 2 49. 5 8. 52 p. CO 2 8. 95 13. 6 HCO 3 - 41. 9 42. 4 ABE 15. 4 13. 1

Day 5 BSDT Preconditions • CVS stable on noradrenaline and dopamine – BP map 80 • • • p. H 7. 33 p. CO 2 8. 52 p. O 2 19. 3 GCS 3 - unsedated Temp 38. 7ºC (>24 hours) Lab results: Na 173 K+ 3. 1 PO 4 1. 36 Mg 0. 79 Regional Collaborative November 2015.

Day 5 Repeat BSDT ‘Gasped’ at the end of the second set of tests. Test 1 Time Pre Apnoea Test 13: 14 Post Apnoea Test 13: 22 Test 2 Time Pre Apnoea Test 19: 09 Post Apnoea Test 19: 28 p. H 7. 388 7. 189 p. H 7. 332 7. 123 p. O 2 58. 1 57. 5 p. O 2 19. 3 18. 7 p. CO 2 7. 65 13. 0 p. CO 2 8. 52 14. 4 HCO 3 - 33. 8 35. 8 HCO 3 - 32. 9 33. 8 ABE 8. 1 5. 8 ABE 6. 5 3. 1 Regional Collaborative November 2015.

• Parents given the option of withdrawing treatment after these tests Regional Collaborative November 2015.

Day 6 BSDT Preconditions • CVS stable on noradrenaline and dopamine – BP map 65 • • • p. H 7. 36 p. CO 2 7. 04 p. O 2 23. 2 GCS 3 - unsedated Temp 36. 8ºC (>24 hours) Lab results: Na 160 K+ 3. 7 PO 4 0. 8 Mg 0. 94 Regional Collaborative November 2015.

Day 6 • Third set of BSDT were performed • H breathed on the first set but after a prolonged time off the ventilator (around 7 minutes) Regional Collaborative November 2015. Test 1 Time Pre Apnoea Test 15: 46 Post Apnoea Test 16: 07 p. H 7. 357 7. 193 p. O 2 23. 2 18. 2 p. CO 2 7. 04 10. 8 HCO 3 - 28. 9 30 ABE 3. 5 1. 1

Outcome • Parents at this time were told that neurological death was now very unlikely to occur due to the amount of time past since her hypoxic event. • H’s parents remained positive about organ donation and proceeded as a DCD saving 4 lives. Regional Collaborative November 2015.

Discussion points • No CT scan was done. Known aetiology was history and clinical presentation. EEG day 2 - very low amplitude with no convincing cerebral activity • H was a known CO 2 retainer with normal CO 2 sitting around 10 -12 k. Pa and prior to admission 12 -14 k. Pa • H’s usual oxygen levels on facemask of 1 l Sa. O 2 >95% and on 2 l via nasal cannulae >90% Regional Collaborative November 2015.