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Today's article is about, “Quick Tip for Families in Intensive Care: If Your Loved One's in ICU on Impella After Cardiac Arrest, Tracheostomy, Ventilated, Kidney Failure”
 

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Quick Tip for Families in Intensive Care: If Your Loved One’s in ICU on Impella After Cardiac Arrest, Tracheostomy, Ventilated, Kidney Failure

If you want to know what to pay attention to when your loved one is in intensive care after cardiac arrest with an impella or LVAD (Left Ventricular Assist Device) on a heparin infusion with a tracheostomy and kidney failure, and now in a septic picture, stay tuned. I’ve got news for you.

My name is Patrik Hutzel from intensivecarehotline.com and today, I have another tip for families in intensive care.

So, we are currently working with one of our members. By the way, we have a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com, if you click on the membership link.

In any case, so we’re currently working with one of our members who has their 51-year-old dad in ICU after cardiac arrest, potentially with a hypoxic brain injury as part of the cardiac arrest. Initially, he was placed on ECMO for poor cardiac function with a very poor ejection fraction. Ejection fraction is referring to the pump function of the heart. It’s been very low, around 20%.

So, he was placed on ECMO (extracorporeal-membrane-oxygenation). ECMO is a bypass machine that can take over the function of the heart for a period of time to give the heart time to recover. After about 3 weeks on the VA-ECMO (Veno-arterial extracorporeal membrane oxygenation), he was then placed on an impella pump, which is a smaller device to take over the function of the left ventricle of the heart.

He also had a tracheostomy even though he was on a heparin infusion and still is on a heparin infusion. Heparin is a blood thinner and that is what’s needed when someone is on ECMO or on an impella. So, there was a bit of a risk to do the tracheostomy, but he’s probably benefited from that.

Also, in regards to the hypoxic brain injury, the family has been telling us that he has definitely been obeying simple commands like trying to squeeze fingers when asked, trying to squeeze hands when asked, and he’s also trying to talk since he had the tracheostomy.

Now, currently, he’s developing a septic picture, i.e., it looks like he’s developing another infection, just one of the highest risks for someone in intensive care long-term.

So, let’s look at the clinical scenario of this man, so that it helps you understand if your loved one is in a similar clinical situation.

So, the patient continues to have a low systolic blood pressure via Doppler.

He’s maintaining on vasopressor support such as Levophed and vasopressin. An arterial line was reinserted for continuous blood pressure monitoring.

Impella required readjustment post-CT (Computed Tomography) scan. They need to reassess the impella function and into a proper positioning and adequate cardiac output.

So, because he’s got an infection, he had a CT chest, CT of his abdomen, and also a CT of his pelvis was done. It showed bilateral pulmonary infiltrates concerning for pneumonia versus pulmonary edema. Pulmonary edema means fluids on the lungs. Along with right groin, subcutaneous emphysema, likely due to a recent vascular procedure such as impella, ECMO decannulation, and femoral dialysis access. So, the subcutaneous emphysema is basically when air enters the tissue, and then patients blow up their skin, and it can often be treated with a pigtail catheter to remove the air.

Now, to complicate things, the nasogastric tube feeds were stopped due to a suspected ileus seen on CT and the nasogastric tube was placed for decompression. So, an ileus is basically a bowel obstruction. When does a bowel obstruction occur in ICU? Well, it can occur especially when patients are in a prolonged induced coma, when they’re not absorbing feeds, not opening their bowels, and so forth.

So, if enteral feeds, i.e., nasogastric tube feeds, remain on hold for an extended period of time, TPN (Total Parental Nutrition) should be considered to maintain nutrition. and that should be going without saying. TPN is basically intravenous nutrition.

White cell count is increasing to 34, he remains on meropenem and micafungin with repeat blood cultures pending results. A transesophageal echocardiogram is recommended to rule out infective endocarditis, given ongoing bacteremia and fungemia.

His kidney function is worsening with persistent elevated creatinine at 2.86, BUN (Blood Urea Nitrogen) on level 71, EGFR (Estimated Glomerular Filtration Rate) at 26. Severe 5-liter fluid overload and oliguria. Oliguria means minimal urine output. Urine output was 150 mL for 24 hours.

A new dialysis access has been placed, and CRRT (Continuous Renal Replacement Therapy) restart is necessary for volume removal. CRRT means continuous renal replacement therapy. It’s also known as hemodialysis or hemofiltration, to correct electrolytes, potassium, hyperkalemia acidosis, and hemodynamic stabilization. Strict intake and output and daily weight should be monitored closely.

So, he’s 5 liters fluid overload, so they have mismanaged his fluid balance. Imagine, you would be taking 5 liters in and nothing coming out. Your lungs wouldn’t cope, your heart wouldn’t cope, and certainly if you’re in kidney failure, your kidneys wouldn’t cope.

The fluid overload goes hand in hand with a low sodium, potassium is high because of the kidney failure and if potassium is high, what needs to happen when someone goes on dialysis or CRRT, potassium usually comes down.

But if he’s not going on dialysis or hemofiltration or CRRT (Continuous Renal Replacement Therapy), he needs to have potassium corrected.

Otherwise, there’s another risk of him going into cardiac arrest. One way to treat this is with insulin and dextrose infusion, or to clear out potassium with resonium. Also, lactate is high, which is not unusual for someone with a septic picture and also with cardiac (Heart) failure.

Next, hemoglobin is low at 7.8, platelets are normal. So, whilst he’s not needing a blood transfusion at this point, if hemoglobin drops below 7, he might need a blood transfusion. That might help him to come off vasopressors and inotropes. Hemoglobin is probably low because he was on ECMO for so long, and he’s also on CRRT on and off, and that also contributes to hemoglobin dropping.

The other issue that goes hand in hand here is that he’s still remaining in cardiogenic shock and ideally the impella should be weaned by now, but it can’t be weaned, which means the heart is still with a poor ejection fraction because he remains on vasopressors and inotropes.

What do vasopressors do and inotropes? Vasopressors constrict the blood in the periphery, so it can be centralized to the heart and increased blood pressure. Inotropes are trying to increase the contractility or the pump function of the heart. But neither of it has worked so far. So, the heart remains weak at this point.

He’s also still on Amiodarone. Amiodarone is an anti-arrhythmic drug because he has had VT (Ventricular Tachycardia), leading to cardiac arrest, which is why he’s on Amiodarone to prevent that from happening again. He’s also still on Precedex, which is sedation, and he’s also on heparin.

Now, with an ileus pending, he’s also not a candidate for PEG (Percutaneous Endoscopic Gastrostomy) placement, which I’m opposed to a PEG in a situation like this anyway. But just FYI (for your information), he’s not for PEG tube placement because of the ileus. Ileus, once again, is a bowel obstruction, but also, he’s also not for a PEG placement because he’s on a heparin infusion.

Let’s look at other organs. So, he’s an acute hypoxic respiratory failure. He’s on prolonged ventilation, originally intubated on the 7th of January. By the time of me recording this is on the 16th of February.

Complications include the acute pulmonary edema and setting of cardiogenic shock, RSV (Respiratory Syncytial Virus) and influenza, and sepsis, further complicated by encephalopathy, intubated on the 7th of January.

Tracheostomy was done on the 4th of February. Currently, he’s on pressure control 18 pressure, PEEP of 5, FiO2 of 30%, tracheostomy collar, 4 hours BD as tolerated, started on the 7th of February. So, that’s a good start.

Goal is for oxygen saturation, maintaining above 90% as feasible, maintain head of bed elevation, 30 degrees. That helps with aspiration precautions and also delirium precautions. He’s on regular nebulizers. He’s on daily weights. Obviously, CRRT needs to be restarted.

Monitor for complications from mechanical ventilation, including hypertension or the peak, ventilator-associated pneumonia, decreasing compliance with ventilator associated pneumonia or VAP.

The risk for anyone ventilated in ICU is whether with a breathing tube or with the tracheostomies to get ventilator associated pneumonia, and that is a real risk. The sooner you can get someone off the ventilator, of course, the lower the risk. Goes without saying.

The tracheostomy tube was placed on the 4th of February. It’s a Shiely tube, size 7, with routine tracheostomy care, such as daily dressing changes, as well as inner cannular changes.

Septic shock was secondary to bacteremia and candidemia. Therefore, he is on Levophed and vasopressin, but that’s also because of the cardiac failure.

Then, lactate needs to be monitored because a high lactate is a sign of septic shock, and it’s a sign that organs are not getting perfused, which is obviously a big concern at this particular point in time.

In the notes, it also says, most recent neurology note from the 2nd of February states, discussed with family that postcardiac arrest prognosis is indeterminate. That means it’s really open. It could go either way and at least it looks like the brain is intact, but the heart is definitely weak.

So, the question also is, can this gentleman have a heart transplant? We asked the family to advocate for that. At such a young age of 51, he should have a heart transplant, or he should be placed on a heart transplant list to give him the chance to have a heart transplant if one becomes available.

So, what medications is a patient like this on? Amantadine, ascorbic acid, which is vitamin C. Just before you ask, Amantadine is a medication that is antiviral and anti-dyskinetic medication used to treat Parkinson’s disease, influenza A, and side effects from certain drugs and medical conditions. So, this might help with waking up this gentleman and also helps with antiviral medication.

So, he’s on atorvastatin, which is an anti-cholesterol drug. He is on regular insulin. He’s on Atrovent nebulizers. He is on magnesium, meropenem, which is an antibiotic. Micafungin, which is an antifungal medication. He is on Pantoprazole, which is a proton pump inhibitor, also known as PPI, to prevent gastric ulcers or gastric bleeds, which he would be at high risk because of the heparin infusion he’s on, and also because of his long-term stay in ICU. The longer someone is in ICU, critically ill, the higher the risk for gastric ulcers or even gastric bleeds, which could set this man back big time.

He’s also on Ticagrelor, and he is on simethicone. Ticagrelor is an antiplatelet drug. He’s on Vitamin B and Vitamin D as well. He is furthermore on calcium gluconate, heparin, like I said, hydralazine, which is an anti-hypertensive drug. He’s on ondansetron, which is an anti-emetic drug if need be. Like I said earlier, he’s an Amiodarone infusion, Dexmedetomidine, also known as Precedex infusion, heparin, norepinephrine, Levophed, as well as vasopressin.

Just quickly coming back to the ileus, how should it be treated in ICU? So, like we said earlier, nasogastric feeds need to be stopped. Air needs to be let out of the stomach with the nasogastric tube so that decompression can happen, so there’s no abdominal swelling and enema might be given, and an enema might help to alleviate the ileus, the obstruction. If it’s a complete obstruction and nothing will pass through, then surgery might be needed, but that would be a last resort of enemas and just giving IV fluids and decompressing with the air might help to relieve the ileus and get the bowels going.

So, I hope that gives you a good overview of what to pay attention to if your critically ill loved one is in a similar situation.

I’ve worked in critical care nursing for 25 years in 3 different countries where I worked as a nurse manager in intensive care and critical care for over 5 years. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives for our clients in intensive care. You can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast section where we have done client interviews.

I know that our advice is absolutely life changing. I’m not exaggerating the slightest. You can join a growing number of clients and members. We have helped hundreds of members over the years to improve their lives instantly when they have a loved one in intensive care, making sure they can make informed decisions, have peace of mind, control, power, influence, making sure their loved ones get best care and treatment always.

That’s why I do one-on-one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. When I talk to you and your families directly, I make sure that there’s no stone left unturned. I also talk to doctors and nurses directly. When I talk to doctors and nurses directly with you or on your behalf, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care, and I hold them accountable, and we’ve done so for many years successfully. You will see that the dynamics will change very, very quickly in your favor, once the intensive care team knows that you have a clinician on your team that understands intensive care inside out, just as they do. I also represent you in family meetings with intensive care teams.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.

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