Question 27

College answer

Not available.

Discussion

a)

Decision to admit a patient like this for monitoring is made on the basis of the interplay of numerous factors, as follows: 

• Patient factors:
  • Frailty, i.e. physiological reserve, age, baseline function, and whether ICU admission and aggressive treatment are appropriate
  • History of chronic respiratory illness and other comorbidities
  • New acute respiratory complications, eg. hospital-acquired pneumonia
  • Clinical features suggesting worsening respiratory function, such as:
    • Deteriorating peak flow (eg. a PEF rate less than 250 L/min)
    • Falling FVC (say, below 20ml/kg, or a decrease of 50% from FVC predicted by age/height/gender)
    • Falling MIP (say, under 30 cmH₂O)
    • Falling MEP (say, under 40 cmH₂O)
    • Poor cough
    • Increasing PaCO₂
• Disease factors:
  • Time course of progression: i.e. rapid deterioration over recent days or stable plateau
  • Type of disease, eg. "vanilla" GBS vs Miller-Fisher
  • Involvement of the autonomic nervous system (it can produce the sort of haemodynamic instability that could make the ward staff very nervous)
  • Whether appropriate treatment has been started, and how long ago
• Environmental factors:
  • Evidence that the patient is not being monitored with sufficiently attentive diligence, eg. missing FVC data from previous days
  • Level of skill of ward staff where the patient remains
  • Monitoring capacity of the environment where the patient remains, eg. availability of continuous cardiac monitoring or oximetry
  • Capacity of the ICU or hospital to care for the patient with GBS (eg. availability of immunoglobulin or plasmapheresis  in a small regional hospital)

b)

Nonrespiratory complications of GBS include those directly related to GBS and those which are associated with the overall picture of prolonged immobility and long-term ICU stay:

• Airway complications
  • Poor cough and dysphonia (cranial nerve involvement)
  • Complications related to prolonged intubation or tracheostomy
• Circulatory complications:
  • Haemodynamic instability and dysautonomia due to autonomic involvement
• Neurological:
  • Paraesthesia
  • Pain from motionlessness
  • Psychological consequences of prolonged hospital stay 
• Gastrointestinal:
  • Ileus and constipation
  • Malnutrition due to swallowing dysfunction
• Haematological:
  • Increased risk of DVT and VTE
• Infectious complications:
  • Increased predisposition to infection due to multiple indewlling devices, immunosuppressant therapy and prolonged hospital stay
  • Hospital-acquired pneumonia
  • Sinusitis due to long term NGT requirement
  • UTI due to long term IDC requirement
  • Cross-contamination with MROs