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 Delirium? Is this because of the Dialysis?
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 had a stroke in the ICU, and she is asking if ischemic infarct of the colon could be the reason for his death?
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 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
Patrik: Patrik speaking. How can I help?
Eva: Hi, Patrik. It’s Eva Peters calling from Perth, Australia.
Patrik: Yes. How are you, Eva?
Eva: I’m okay. However, my husband, Frank, that you were helping me with, he died early Saturday morning.
Patrik: Oh, my goodness. I am so sorry to hear that, Eva. What happened?
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Eva: Yeah. Thank you. I’m calling because I’m still looking for a little bit of feedback on what happened. On Friday, he had complained about some lower abdominal pain, and it was just a little tender. So, they did an X-ray, and what they thought that they saw was a pocket of gas and stool in the colon, and a bunch of gas. They figured that it would be able to work its way through. He’d had some period of time with some really loose bowel
movements, and they determined that it wasn’t C. Diff, and so they gave him the stool tightener.
Patrik: Like Lactulose or Coloxyl or an enema?
Eva: No, to actually tighten it.
Patrik: Oh, to tighten it. So, some Gastro-Stop, something like that?
Eva: Yeah. A binder.
Patrik: A binder. Okay.
Eva: That had seemed to work, but then he had a few loose ones. So, later on in the day on Friday, they had to change the filter on the CRT. While they had that off, they decided that they would give him a trial of the Norepinephrine. He had been on 2 all day, and so they just stopped it, and he went holding his own for about 45 minutes.
Patrik: He went what?
Eva: Hold his own.
Patrik: Holding his own. Okay.
Eva: For about 45 minutes. His MAP had been fairly high through the day, and it eventually settled down. They’d said a MAP of 50-55 off of medication was acceptable, so he was hovering around there, and then all of a sudden it started going down. I think it got down to about 39. They cranked on the medication again and got him up way high, and then started weaning him down off it again. Then, I think they tried taking him off it one more
time, for some reason.
Patrik: Always with the goal of a MAP of 55 or 50 you said?
Eva: Yeah.
Patrik: You see, what I meant to do last week, I thought that 55 was really low, let alone 50.
Eva: Yeah.
Patrik: Let alone 50.
Eva: After that, I think they had to actually have it higher, the Norepinephrine. He never got back down to 2 again. So, he went through the evening and at about 10 o’clock they gave him his sleeping medication, which always dropped his blood pressure when he actually went to sleep. I went
to have a bit of a nap at that same time, and at about midnight the nurse came to get me and said that he was just up and awake and restless, and I said no problem, that I would come. By the time I got there, the resident was there. His blood pressure had dropped again. I think at that time he was actually starting to do some burping, and they still had the feeds on; but he must have been in a little bit maybe more pain, and they were having difficulties keeping his blood pressure up. So, they
decided to take him for a CT scan, and so at about two in the morning-
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Patrik: Sorry, can I just ask: at that point when you say they had difficulty keeping his blood pressure up, at that stage when he went for the CT, was he still off the Norepinephrine?
Eva: He was on it.
Patrik: He was on it. Okay.
Eva: They had put it back on, and actually it was at a much higher level-
Patrik: Okay. And they would still have been-
Eva: – than he had been. Yes.
Patrik: Okay. All right. I’m following you.
Eva: So, they took him for a CT, and then brought him up; and what they had thought was a pocket of gas and stuff in his bowel, they said now was actually ischemic bowel and probably caused by a blood clot to the artery. By now, Frank was breathing pretty rapidly, and they did call in for a consult to see about doing surgery. They were having difficulties keeping his blood pressure regulated. So, the residents took a look and they came back
and said, “Well, we really don’t think he’s a good candidate for surgery, but the attending wants to come and take a look,” and I said to them, “There’s no way he’s gonna survive a surgery,” and it didn’t even take that long. Actually, at that time his breathing, his respirations and pulse, had already started slowing, and within three quarters of an hour he had died.
Patrik: When he passed away, was that on support with the Norepinephrine?
Eva: That’s a good question; I asked my friend today. I also asked her whether, as far as she knew, they had given him any of his medications, and she didn’t think so. They did give him … His phosphate was rising, and so they give the glucose and insulin.
Patrik: Yeah.
Eva: The phosphate changer. Is that what they call it?
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Patrik: Probably the potassium, right? Not the phosphate. Probably the potassium.
Eva: Okay. Right. Yeah. So, I can’t tell you. They did not ask us if they could stop it.
Patrik: When the potassium was rising and they started the dextrose and the insulin, I would imagine that was when he was off the dialysis machine?
Eva: Yes. You’re right.
Patrik: Yeah. Because the only reason the potassium would rise is, number one, kidney failure and being off dialysis.
Eva: That’s right. They had taken him off to go down to the CT.
Patrik: There’s a number of things here where I think questions will arise. Number one, one of the reasons he may not have been responsive to the Norepinephrine… that’s assuming that he was on Norepinephrine by the time he passed away, okay? Let’s assume he was on Norepinephrine by the
time he passed away.
Eva: Yeah.
Patrik: One of the reasons he might not have responded to the Norepinephrine is that his heart had another event or was so weak that it wasn’t responding to the Norepinephrine. Right?
Eva: They had done another ECG thinking that was possible, but I think that was negative.
Patrik: When you said the ECG was negative, meaning there was no event that they could point towards?
Eva: That’s right. Yes.
Patrik: In all of this, do you know whether your husband was in what’s called AF or Atrial Flutter? Do you know what I mean by that? It’s basically irregular heart rhythm, a controlled irregular heart rhythm.
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Eva: Yeah. So, earlier in the day they had done an ECG because the resident was wondering why his calcium levels were so high; he had hypercalcemia. He wanted to look at it to see if there was any indication on not the atrial, but on the other … I don’t know, I can’t tell you, but the attending said
that-
Patrik: I sensed that going in that direction. That’s going in that direction. If the atrium, for whatever reason there was something not right with the atrium, there’s a very high chance he might have been in AF or Atrial Flutter, a very high chance.
Eva: Okay. So, he looked at it, compared it to one of his other ones, and said, “No. It’s fine. There’s no change.”
Patrik: Okay.
Eva: That was in the afternoon. Later that night, no one said that there was any change to the heart rhythm.
Patrik: Just give me the timelines again. When was the first mention about potentially … I mean, in essence, they were referring to perforated bowels.
Eva: I thought it was blocked.
Patrik: Okay. Did they use the words “perforated bowels” or did they use a term like-
Eva: No.
Patrik: Okay. Ischemic bowels?
Eva: They called it ischemic.
Patrik: Okay. When was the first mention of that?
Eva: After the CT scan. So, we went down about 2:15, and would have gotten back up probably 3:00. Just after that, then the resident consulted with the radiology resident, and came back in and said that it was an ischemic bowel.
Patrik: How long after that did your husband pass away?
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Eva: He passed away at 5:30.
Patrik: How many hours after the CT?
Eva: That would have been two, maybe.
Patrik: My goodness. And that was 5:30 a.m. or p.m.?
Eva: 5:30 a.m.
Patrik: Were you there when it all happened?
Eva: Yes.
Patrik: Right. One thing that I’m trying to ascertain is, number one, when your husband’s heart stop, did they attempt any CPR?
Eva: No. By that time he was … When his heart stopped, he had totally shut down. I’ve attended a couple of … my father’s death and my mother’s death, and it was the heart stopped after the breathing stop, so it was not-
Patrik: Oh, I see.
Eva: The heart did not stop.
Patrik: Okay. But then the question comes up: if he stopped breathing first, why did they not intubate him?
Eva: Because we had said no intubation.
Patrik: And you were content with that?
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Eva: Yes.
Patrik: Okay. It’s so interesting … and I don’t even know whether that’s the right word, Eva … but just over the weekend, I’m working with another client who’s got an ischemic gut as well, was in a similar situation, and just this morning I was actually talking to the doctor and miraculously this client turned the corner. Having said that, this client has been dealing with ischemic gut now for a number of days, whereas for your husband it
seemed to be coming out of nowhere. You haven’t mentioned that when we first spoke.
Eva: No. There was no indication.
Patrik: No, there wasn’t. What I am wondering about is how could that happen? One of the issues in ICU, generally speaking, is to manage bowels. Because as soon as a patient is in ICU, the risk for bowel obstruction is huge because of sedation, because of patients being immobile, because of changes in nutrition and
what not, right?
Eva: Yeah.
Patrik: So, if you go through a list of risks you need to manage in ICU, bowel motion is one of the risks. Right? What’s what I’m wondering. From what I understand, you’re talking about there was some diarrhoea. Did I understand that correctly, that there was some diarrhoea?
Eva: Yeah.
Patrik: So, how could he go from a bowel obstruction to diarrhoea? Now, that can happen, don’t get me wrong, but it doesn’t … Because sometimes bowel motion is bypassing the obstruction and then there can be diarrhoea.
Eva: That’s what they said.
Patrik: Right, but it’s not common. Do you know if your husband had been on any aperients leading up to this?
Eva: What is that?
Patrik: Aperients or laxatives like … I mentioned a few names. Lactulose.
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Eva: No.
Patrik: Coloxyl?
Eva: No. He wasn’t on any kind of laxative at all.
Patrik: Are you sure?
Eva: Yeah. You mean in the hospital?
Patrik: In ICU or in hospital. Particularly in the ICU, particularly.
Eva: Our first day in ICU they did, so that would have been three weeks prior, because he had not had a bowel movement. I believe they used some of the natural kinds of ones.
Patrik: They could have used … natural. I’m just trying to think. Unfortunately, I haven’t come across many natural ones in the last few years, but there would be natural products. Maybe just even something like peppermint oil sometimes. But most of the time they’re using chemicals; let’s face it.
Eva: Well, they tried to start fairly-
Let me just take a look here. You think that’s related?
Patrik: Absolutely.
Eva: One of the things that he had used at home … No, I don’t have it here. It was a mild laxative.
Patrik: Do you remember what it was?
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Eva: It might have been Senokot.
Patrik: Yeah. Senokot.
Eva: Or Dulcolax, something like that.
Patrik: Right. What was the other one?
Eva: I’m gonna say it’s Dulcolax, but the other name it kinda sounds…
Patrik: Yeah. Absolutely. Dulcolax, Senokot, they’re the most common ones. Then, in ICU you might also give things like Movicol or Lactulose or you might do an enema.
Eva: Right.
Patrik: What was your husband’s nutrition status in the last few days? He was fed through a nasogastric tube.
Eva: Yes, and he was on a renal formula.
Patrik: Yes, a renal formula. Okay.
Eva: Yeah. So, 35 millilitres per hour.
Patrik: Okay. So, what’s important to know, Eva, is really when a patient goes into ICU, as I said, one of the first issues that comes up, or one of the issues that needs to be managed, is simply bowel motion. Because when patient to into ICU, generally speaking they become immobile, they often end up in an induced coma. I don’t know that this was the case in your husband’s situation on this admission, but still he would have been bed bound, which means bowel, gut motility, is slowing down, increasing the risk for a bowel obstruction.
Eva: Right.
Patrik: When was the last time your husband had his bowels open? Do you know? With the diarrhoea as well.
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Eva: Not long before. It had settled down to about three in a day, and I’m not sure if he had one that day.
Patrik: But he would have had a bowel motion the day before, you think?
Eva: Yeah.
Patrik: The reason I’m trying to be so detailed here is a bowel obstruction, generally speaking, happens if somebody hasn’t got their bowels open for three-plus days. I’m not saying it doesn’t happen if people do open their bowels regularly, but it’s less likely.
Eva: How does that fit in with what they said about a blood clot?
Patrik: Oh, okay.
Eva: So, the bowel was obstructed, but the problem was that he was ischemic because of the lack of oxygen.
Patrik: I see. Okay. Yes, you did mention that. Sorry. Yes, that would make sense. Had they used the term mesenteric infarct?
Eva: No. They called it an ischemic bowel.
Patrik: Yeah. That’s fine.
Eva: But they also said that it probably came from his heart surgery, and the ECMO juice, and was a blood clot in the artery in the bowel.
Patrik: While he was on the dialysis machine, do you know whether he was on heparin?
Eva: Just started.
Patrik: Just started that particular day?
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Eva: Yes. He was on heparin injections prior.
Patrik: But not on an infusion.
Eva: Not on an infusion, but they started … I can’t tell you for sure if they talked about starting the heparin infusion that day; perhaps they had not, because they were asking about that for his surgery.
Patrik: Right. And you are almost certain that he didn’t have heparin prior to Friday or Saturday.
Eva: Not an infusion.
Patrik: Okay. That’s definitely increased the risk. I’m getting very specific here: do you know if the days before, the filter, the hemofilter, was clotting?
Eva: Yeah.
Patrik: It was?
Eva: Yeah.
Patrik: Okay. So, that’s a sign to me that his anticoagulation was probably inappropriate. Do you know what I mean by anticoagulation?
Eva: Yeah. He wasn’t getting enough of it.
Patrik: That’s right.
Eva: And that’s why they were talking about going to a heparin infusion instead.
Patrik: Yeah. But that should have potentially happened earlier, especially if the filter was clotting. If you have somebody on the hemofilter and the filter keeps clotting, you need to weigh up do you give heparin or do you need to change to a citrate filter. Now, again, I’m very specific here. A lot of units, in this day and age, use citrate filter instead of heparin; but at the end of the day, it prevents-
Eva: They don’t use citrate filters here for some reason. There was that discussion.
Patrik: Right. Okay. Go on.
Eva: On the last exchange status … He went through filters a lot, and on the last one there was a fairly large clot that was in the chamber, that they were trying to stretch-out the filter as long as they could.
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Patrik: Sure. Let’s just look at this from a worst case scenario point-of-view. The worst case scenario is really that they didn’t manage the anticoagulation; because of that, he had an infarct, what’s called a mesenteric infarct, and he had an ischemic gut because of that. With an ischemic gut, he probably went into septic shock and his body couldn’t cope, right?
Eva: Yeah.
Patrik: Now, that’s our theory. Okay? That’s our theory. In order to get any evidence for that, the only evidence you could get from that is, number one, to review the medical records; or number two, and probably more importantly, you could ask for a coroner report.
Eva: Yeah.
Patrik: Have you considered that?
Eva: I have. Yeah. That didn’t even occur to me that … Because they talked about the clot, they talked about the fact that he had … They didn’t review it properly. The surgery residents, they said that he’d had a clot to his eye, and also the ones in his brain from the surgery. So, I wasn’t even thinking about the fact that this could have come from the CRT.
Patrik: Look, I wouldn’t say that it’s come from the CRT, but one way to manage the risk … You see, just as much as you need to manage bowel motions in ICU, you need to manage the risk of immobility. One way to manage the risk of immobility is to give something like heparin or any other anticoagulant … like Clexane or there’s Fragmin, there’s others out there … but you need to manage the immobility, the risk for a deep vein thrombosis that
could develop into a thrombus, and then develop into a mesenteric infarct. Right?
Eva: When you are showing that you have clots in the CRT, what does that tell them? It never seemed to be anything that was a concern to them except for the fact that the filter wasn’t lasting so long.
Patrik: If I was to look after a patient on a hemofilter and there are clots, I know that this filter isn’t going to last.
Eva: Right.
Patrik: Right? That’s from a nursing perspective. I know the filter will clot very soon, that’s the first thing that I recognise, but I also recognise that the patient is at risk of developing potentially a thrombus if the patient is not on any anticoagulants or anticoagulation. Now, what would I do as a bedside nurse? As a bedside nurse I would go back to the doctor and I would say, “Hey, this filter keeps clotting. Can we start some
heparin?” or in other units get him on a citrate filter, right? I know that’s not the case, but those would be the suggestions, and that would also usually then take care of managing the risk for clotting, for a thrombus, that could develop in the body.
Eva: So, that would be a heparin infusion rather than the shot?
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Patrik: It depends on the filter. On the filter you would not bother with a shot; you would go on a heparin infusion.
Eva: Well, he’d always been on shots. He’s been on shots for seven weeks.
Patrik: Okay. Even in the days leading up to this?
Eva: Yeah.
Patrik: But you could assume-
Eva: He wasn’t always on the CRT. This visit to the ICU, he’s been on the CRT, or had been on the CRT then entire time.
Patrik: Yeah.
The 1:1 consulting session will continue in next week’s episode.
