Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in
Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
My Critically Ill Husband is On Dialysis and in the ICU Due to Septic Shock. Is There Any Negligence on the Part of the Healthcare Team?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Eva as part of my 1:1 consulting and advocacy service! Eva’s husband had a cardiac bypass surgery sustained stroke in
the ICU and is asking why her husband died with an acute ischemic gut.
My Critically Ill Husband is in Septic Shock. Was His Ischemic Gut Related to the Cardiac Arrest?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Eva here.”
PART 1
PART 2
PART 3
PART 4
PART 5
PART 6
PART 7
Eva: So, that would have been 12 days or 10 days.
Patrik: Right.
Eva: But he was just getting a morning and an evening heparin shot.
Patrik: Right. One way or another, you could argue that if he had a mesenteric infarct, he wasn’t on enough anticoagulation; you could argue that probably without even having a coroner report, because at the end of the day that’s what’s happened, according to them.
Eva: They said this was left over from his first heart surgery, and you’re saying if he’d had any bowel movements that wouldn’t be?
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Patrik: No, no. It’s got nothing to do with bowel movement as such. Because now that I understand, it wasn’t related to bowel movement; it was related to having the infarct or the ischemic gut, right? And now I’m trying to find out why did he had this infarct, this thrombus, and the short answer to that is probably because he may not have been on enough heparin.
Eva: Are they not related?
Patrik: You mean like bowel movement and the anticoagulation?
Eva: They showed me very clear x-rays in the afternoon, “Here he is. This is his colon. In the colon is a pocket of gas with a little bit of stool underneath it. Then, here’s other gas bubbles, and he’s burping-up stuff,” and they said, “This is why he’s tender in his abdomen is because of this pocket of gas and stool, and it should just work its way through.” Then, when they stopped the Norepinephrine and that-
Patrik: Uh-huh (affirmative).
Eva: It was immediately then, or very close after, that then he had that massive drop in blood pressure. So, were they related or not related? I guess I don’t understand.
Patrik: I would say it was related and I’ll tell you why. With the ischemic gut, there’s a very good chance your husband went into a septic shock.
Eva: Why didn’t they treat that then?
Patrik: That is my question, too. They should have started on broad spectrum antibiotics. Maybe that did happen; maybe it didn’t.
Eva: No, it did not. Not until after the CT scan.
Patrik: I guess they had to have the evidence first, what’s happened, which is why they did the CT scan. I guess up until the CT scan, they were only guessing.
Eva: So, the ischemic gut was not anything to do with the gas and the stool?
Patrik: It’s hard to say. I wouldn’t know with the information that you’ve shared, but the question is what was first. Was the infarct first, causing ischemia, and then basically the dead bowel tissue. That’s what ischemic gut means; it’s basically dead bowel tissue. Then, from there, we don’t know. Was that infarct hours before? We don’t really have any timeline.
Eva: Well, the first drop in blood pressure was shortly after they started on the trial off of blood pressure medications, and that was several hours-
Patrik: Eva, just give me one second. Sorry. Just give me one second. I’ll be right back.
Eva: Yeah.
(silence)
Patrik: Sorry about that, Eva.
Eva: That’s okay.
Patrik: It’s hard to say. Or I’m trying to make sense what happened first. When was the first time they talked about this?
Eva: In the afternoon they took the x-ray of his bowels.
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Patrik: That was Saturday?
Eva: That was Friday.
Patrik: Friday. Okay.
Eva: They took the x-ray of the bowels. Then, he was off the CRT, so they decided to do a trial off the blood pressure medication altogether. So, I started taking pictures every 15 minutes. He was very sedentary through that day. Personally, I think probably the ischemic gut started a while ago, and they chalked it up to delirium and not sleeping.
Patrik: Did your husband say anything about abdominal pain the days before?
Eva: Just on Friday was the first day that it was enough to… and that’s when they said it was just this pocket of gas and stool. But they had previously been in there and using ultrasound. They used ultrasound for his gallbladder, all of that abdominal area, on numerous occasion. Is that not something that would show up
then?
Patrik: You would think so.
Eva: And the gas pocket was pretty big; I mean it was very visible on an x-ray.
Patrik: My explanation, at this point in time, is that your husband went into septic shock, and his overall condition has been so weak that he couldn’t fight it, would be my theory. At the same time, if you wanted closure on this, the coroner could eventually get a report. When I say the coroner, no, no. That’s probably
not the right … a biopsy, pathology report.
Eva: Yeah.
Patrik: That would give you close. They would find something.
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Eva: I am just wondering why … They still felt along that there was something that was underlying this, why they couldn’t get his blood pressure stabilised, why his blood cell count was still high; it was about 10.1.
Patrik: On Friday?
Eva: Yeah, on Friday. His lactate had gone up a little bit, again it had gone from normal up to 2.1, I think, or something.
Patrik: And his lactate, at that stage, I would argue would have gone through the roof.
Eva: Probably it had by nighttime.
Patrik: Yes. Also, his white cell count should have gone through the roof as well, I argue.
Eva: I didn’t see those numbers; they didn’t come back with them. Obviously, his potassium was … the kidneys?
Patrik: When somebody’s in kidney failure and they go off the dialysis machine, their potassium is usually the first thing that widen.
Eva: Enough that they would have to do that rather than just getting-
Patrik: One reason they would have done the glucose and insulin is simply they would have checked the blood gas; and doing the blood gas, the potassium would have come back I would imagine higher than 6, and that usually triggers a dextrose and/or glucose and insulin infusion.
Eva: Okay.
Patrik: So, they’ve done the right thing, I have no concerns there, but what doesn’t make any sense to me really is where does this, what I refer to as mesenteric infarct … I should send you a link to that so you know what I’m talking about.
Eva: Okay.
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Patrik: That this makes a little bit more sense to you. Just give me one sec. When you type that into Google it comes up as bowel infarct.
Eva: Right. So, at this time the bowel actually would have already died?
Patrik: It’s likely and I’ll tell you why. It’s just like with any organ. When any organ loses blood supply and oxygen supply for more than three minutes, tissue dies. The cutoff really is three minutes, so there’s not much time.
Eva: So, if they had sent him for a CT scan to begin with … I don’t understand how they could have mistaken a pocket of gas for an infarct.
Patrik: I don’t think they’re mistaken in that. I do believe that with the infarct there is a high chance that a pocket of gas might have developed; but at the same time, I do believe that anybody in ICU who’s immobile, if you take an x-ray of the bowels there is often gas. So, that could just be-
Eva: Okay. But on these x-rays you won’t be able to see the infarct?
Patrik: Haven’t you said they did a CT scan instead of-
Eva: Well, they did the x-ray in the afternoon, and then the CT scan was not until 2:30 in the morning.
Patrik: You wouldn’t see the infarct in this x-ray, but probably you would see it in a CT scan.
Eva: Oh, yeah, they saw it in the CT scan. But seeing that bowel obstruction, and knowing that he already or still had some underlying infection of some sort, would it not have been reasonable to send him for a CT scan then?
Patrik: Absolutely.
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Eva: So, why did they wait 12 hours?
Patrik: I can’t answer that question. They shouldn’t have waited. For example, one thing that could have triggered a CT scan is … My question is, as soon as they had indication that something’s not going in the right direction, one thing that they should have done straight away is take blood to see whether infection markers are going up, for example.
Eva: Well, they did. They’ve been taking blood all along.
Patrik: Okay. For example, if the infection markers went up, the next question should have been, “Where is this infection?”
Eva: Would the blocked bowel have … How come they couldn’t have seen the infection when they took the x-ray?
Patrik: That’s not detailed enough. If somebody has an ischemic gut, they can usually only get the evidence for that in a CAT scan.
Eva: Okay.
Patrik: I’m not concerned there that they haven’t done the right thing, but what I am obviously concerned is have they done it quick enough.
Eva: Well, the first time his pressure dropped out was about six o’clock.
Patrik: 6:00 p.m.?
Eva: 6:00 p.m. So, it was not until midnight that … And I don’t quite understand why now they thought of the ischemic gut whereas at six o’clock they didn’t. They knew there was that pocket of gas, but you’re saying that’s different than…
Patrik: A pocket of gas: if you take an x-ray of someone who hasn’t had their bowels opened for a number of days in the ICU, they would have a pocket of gas.
Eva: Right.
Patrik: Right?
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Eva: So, did that mask the ischemia?
Patrik: No, not really. Because the ischemia you can really only find evidence for the ischemia in a CAT scan, not in an x-ray. I have not seen a patient that you can find evidence or diagnose an ischemic gut in an x-ray. You can assume and then do a CT next. You can think, “Oh, yeah, there could be an ischemic bowel. So, let’s do a CT scan next.”
Eva: If you have an ischemic bowel, do you always have to operate?
Patrik: No, and sometimes you can’t. I’ll tell you when you can’t, especially if you’re on high doses of life support, you can’t go for surgery; you wouldn’t survive, or most likely you wouldn’t survive.
Eva: Right. So, if they had started antibiotics at six o’clock, would that have made a difference?
Patrik: Potentially. But it also depends on whether those antibiotics would have been sensitive to whatever infection he was dealing with. Let’s just say he was getting an antibiotic, Meropenem, but that wasn’t actually sensitive to the infection he was dealing with, it would have been almost useless; it would have been of no, with no-
Eva: Right. But can’t they determine which one is correct to use.
Patrik: Yes, they could, but that would take 24 to 48 hours.
Eva: Are there not ones that are specific?
Patrik: There would be some that are specific. They would have to do a screen first. They would have to do some screening first. Do you know whether that screening happened? By screening I mean taking blood cultures.
Eva: No. They didn’t even consider that it could be any kind of infection until after the CT scan.
Patrik: Why didn’t they consider any kind of infection? That’s what I’m wondering. Have they taken blood and looked at the infection markers, number one? Has he shown signs of an infection like having a temperature, do you know?
Eva: No, he didn’t. Mind you, I felt being on the CRT system masked that.
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Patrik: Absolutely, yes. Absolutely, yes. However, the minute he came off the CRRT, his temperature could have gone up; and sometimes the temperature of patients, when they come off CRRT or ECMO or anything that’s external, the temperature rises quite quickly.
Eva: Well, by that time it was way too late anyway.
Patrik: I think, from what you’re telling me, one way to get answers is to look through the medical records. I would also do a … I can’t think of the word now. Not the coroner, but a pathology report; I’m just drawing a blank now.
Eva: Like an autopsy?
Patrik: Autopsy. Thank you. An autopsy. That would give you some answers. The question is whether you would want that for your husband or whether your husband would want that.
Eva: I still come back to this whole idea of doing him on a trial off of the blood pressure medication. That, I think, what I’m-
Patrik: I don’t like that.
Eva: Having such a low MAP-
Patrik: I tell you what I have-
Eva: could that have-
Patrik: The answer is yes.
Eva: contributed?-
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Patrik: Yes, definitely, and I’ll tell you why. So, with a low blood pressure, irrespective of whether you take the MAP or you take the systolic blood pressure. You know what I mean with systolic blood pressure?
Eva: Yeah.
Patrik: Right. So, irrespective of whether you take the MAP or the systolic blood pressure, let’s just say you have a blood pressure of 80/40 with a MAP of 50, right?
Eva: Yeah.
Patrik: Your blood pressure is low, which means the blood flow in the body is slowing right down, okay? So, what does that mean? It means the risk to develop a blood clot is even higher. You are immobile already, which is increasing the risk for a blood clot. Now, your blood pressure is low, and that’s increasing the risk for a clot even more. But there is something else that makes it even more likely to develop a blood clot. When somebody’s
having an ejection fraction of 20-30%, the risk that a blood clot develops in the heart is even higher than anywhere else in the body. Because with a decreased contractility, the cardiac output is reasonably low with an ejection fraction of 20-30%, making it very likely, making the risk very high, for a blood clot to develop in the heart, in the chamber.
Eva: Okay.
Patrik: A lot of patients with a low ejection fraction are on high doses of anticoagulation.
Eva: I don’t know what the dosage was.
Patrik: You can find out. So, those would be the risk factors probably contributing to all of this.
Eva: Yeah.
Patrik: When your husband was on ECMO was he on heparin?
Eva: Yes.
Patrik: On high doses of heparin? Do you remember?
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Eva: That I can’t tell you.
Patrik: Those three ingredients: low blood pressure, no anticoagulation of scale, I would say, and the heart working with a significantly decreased contractility, as well as being immobile, those are the risk factors that make it more likely to develop a blood clot, absolutely.
Eva: Right. Well, and that day they didn’t move him around at all. He was pretty much in the same spot for hours.
Patrik: To a degree, I’m glad you had made the decision, leading up to this, that you didn’t want him to be intubated, and at least you had some clarity there.
Eva: Yeah.
Patrik: But still, a lot of patients when they do pass away in the ICU they are often on ventilation but your husband, for whatever reason, didn’t fit that criteria. Did you ask how he could develop that clot? Did you ask the doctors there what their-
Eva: Their theory was that it had been there since the surgery.
Patrik: That the clot was there since surgery?
Eva: Yeah. They said that he was throwing clots during the surgery, and so obviously they’re the ones that led him to-
Patrik: They think it was there all the way along, but nobody picked it up? Or by the time they picked it up it was too late?
Eva: Yes.
Patrik: I doubt that and I’ll tell you why I doubt that. I’m not a gastric surgeon. I’ll tell you why I question that. Let’s just say the clot was there for the last two weeks, three weeks, I don’t know, and it would have caused an ischemic gut, he would have shown signs of sepsis much earlier, much earlier.
Eva: It was two weeks ago that he went into septic shock.
Patrik: What was the reason for the septic shock then? They must have given you a reason then.
Eva: They said it was pneumonia.
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Patrik: Exactly. That’s what I remember.
Eva: They treated the pneumonia and said, “There seems to still be something else,” because his white blood cell count never went down, and they really seemed to think that was why there was still this difficultly with the blood pressure, with the low blood pressure.
Patrik: I’ll give you another reason why I think it wasn’t there for the last two weeks. Number one, your husband would have shown abdominal pain, probably severe abdominal pain; that’s number one. Number two, with an ischemic gut, a bowel blockage is usually the next indicator; and by the sound of things, he continued to open his bowels. If anything, he had diarrhoea.
Eva: Well, no. He did have a bowel blockage.
Patrik: Sorry?
Eva: He did have a bowel blockage. He had this gas and stool that was stuck in the colon.
Patrik: Okay. But didn’t you say he had diarrhoea the day before?
Eva: It had settled down because they gave him the tightener; but a few nights before that, about five maybe, and he was like 11 bowel movements through the night.
Patrik: I tell you that doesn’t make sense to me. I sent you a link, I texted you a link in the meantime, with mesenteric infarct.
Eva: Right.
Patrik: If you look at… and I’m just looking this up. Just give me one sec. You know, one thing that happens is his gut motility is slowing down, and you’re not having diarrhoea or anything, you are having an obstructive bowel, right? It doesn’t make any sense to me at all. And not having abdominal pain … I’m just looking this up.
Eva: Sorry. I’m just trying to get you on speaker.
Patrik: Right. I’m just looking this up. Signs and symptoms: severe abdominal pain.
Eva: Well, it certainly wasn’t severe.
Patrik: Right. Then, finally it’s confirming that, in the Wikipedia report here, “shock phase can develop as fluids start to leak through the damaged colon lining. This can result in shock and metabolic acidosis with dehydration, low blood pressure, rapid heart rate,” all that sort of stuff. It actually says that
diarrhoea can be part of it, it actually says that, but the thing that’s missing to me is abdominal pain.
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Eva: Now, he wasn’t great for perceiving pain.
Patrik: Sure.
Eva: Never. I mean out of 10 it was a 6.
Patrik: That’s significant.
Eva: And it didn’t really change throughout the day.
Patrik: It also says here that the best method of diagnosis is a CT.
Eva: Yeah.
Patrik: Right. So, as I said, I have not seen that being diagnosed with an x-ray.
Eva: Right.
Patrik: How do you feel about potentially getting a hold of the…
Eva: List of records?
Patrik: Yeah. Looking at the medical records, but also potentially getting an autopsy done so you can get some answers? I can’t make that decision for you, but it certainly would provide you with some answers.
Eva: I guess that they would say it was exactly what they said it was. My question is why exactly what you said, given the fact that he goes through filters so often, why was he not on a higher dose of heparin, and I guess would alter his risk, and why wasn’t it picked up earlier?
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Patrik: Yeah. Because the risk factors were there.
Eva: Absolutely. And as soon as they started talking bowel obstruction seems that they should have looked at ischemia.
Patrik: Yeah.
Eva: Not at two in the morning.
Patrik: That’s right. Did they consult a gastric surgeon, do you know?
Eva: No.
Patrik: Right.
Eva: Well, they consulted with the surgical resident.
Patrik: Sure.
The 1:1 consulting session will continue in next week’s episode.
