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 Mom is in the ICU for Septic Shock. Is it Possible For My Mum To Be Weaned From the Ventilator and Be Extubated?
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 Laura as part of my 1:1 consulting and advocacy
service! Laura’s mother is in the ICU for Septic Shock and is asking if her mum’s current status is viable for safe transfer to another hospital.
My Mom is in the ICU for Septic Shock. Why Do the ICU Team Wants Her To Be Discharged?
Hi Patrik.
It’s Laura.
My mom’s ABG is: 33 CO2 and PO2 76
Today 12-23 I will send pics of monitor screens
Thanks
Laura
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Thank you, Laura, for sending through the pictures and the ABG result.
Please note the following.
Your mom is on minimal ventilation support and might be able to come off the ventilator.
She is on 40% oxygen, a PEEP of 5 mmHg and a pressure support of 10 mmHg.
Those are almost “extubatable” parameters, meaning your Mom should be close to get extubated as long as she can follow commands.
Also, what’s your Mom’s weight roughly?
ABG looking good, the only parameter needing to come down before extubating (removal of the breathing tube) is the FIO2 or oxygen level. 40% is juts about too high and ideally it should come down to 35% or less.
I’m surprised they are taking ABGs because on the monitor it doesn’t indicate that she has an arterial line so they can take ABG’s.
Do you also know what her chest x-ray shows?
Does she have a chest infection or Pneumonia?
Kind Regards
Patrik
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Hello Patrik,
Thanks for emailing me back.
I believe her lungs are clear. Doctor showed me chest x ray of lungs. Said they’re ok. They took an ultrasound of her heart yesterday. I think it’s ok, however I haven’t heard results.
My mom’s weight is like 250. Very edematous. Especially legs and feet.
I talked to kidney doctor and I told him of our new resolve to save my mom and he upped the BUMEX and said she’s not a good candidate right now for dialysis. But we will have a meeting
tomorrow for our goals and prospects regarding my mom going forward.
She’s getting a blood transfusion now also. Thank you.
Laura
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Thank you Laura,
Yes, by you having joined the membership you will be able to keep the conversation going.
The reason I asked for your Mom’s weight is to find out if her volumes on the ventilator are adequate,
I assume you are referring to 250 pounds, which equals around 113kg. Her volumes on the ventilator are around 340 ml which may be too low for her weight.
Ask the doctors about that. Other numbers look good. Bumex might help with reducing the swelling and oedema, however dialysis will remove fluids faster.
Bumex might also damage the kidneys in the long run. Did they tell you why she is not a candidate for dialysis? Get some facts!
It’s good that she had a blood transfusion. Do you know what bloods she had? Red blood cells? Platelets? FFP (Fresh frozen plasma)? I remember you saying her Platelets were low. Also are they still giving her Albumin? What about the Levophed/Norepinephrine? Is it still running?
As far as the meeting is concerned, if you want me to, I can be there over the phone.
Make sure the goals of care that you want for your Mom as her advocate and medical power of attorney are going to be met.
You now have literature that you can refer to as far as end of life decision making is concerned! The law is on your side, anything less could be perceived as murder.
Kind Regards
Patrik Hutzel
Critical Care Nurse Consultant
Consultant and Advocate for Families in Intensive Care
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Hello Patrik,
She was on 1 mcg levo, now levo off. BP 95/50 (70).
She’s breathing on her own today with minimal support of machine. Also, same yesterday they hooked her back up last night so she could rest.
I talked to kidney doctor. I told him we are being proactive with all procedures to save her life. He ordered doubled BUMEX at 1mcg. She received type O positive blood. I went to lunch and now I’m back it’s not there anymore.
Her urine output is low as well as nephrostomy bag low. The kidney doctor acted like she’s not a good candidate for dialysis right now. I will have to talk further about that soon. We’re supposed to have a meeting with our goals and prospects tomorrow. Kidney Doc asked what our goal was. I said to bring her back to her baseline and bring her to her home. I have a professional hospital bed I bought already waiting. Also, my
mom responds to commands. She lifted both arms, opens her eyes. She’s very weak. No feeding tube as it was not processing the food. BP now 93/44 (64).
Thank you.
I forgot to mention this update: kidney doctor ordered a renal ultrasound, and off Levo, now has dopamine 2mcg (BP support) BP read 106/51 (74). Still breathing in her own with minimal support for the day. Thank you.
Laura
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Hi Laura,
Please see my responses to your questions in red below.
Hello. She was on 1 mcg levo, now levo off. BP 95/50 (70).
She’s breathing on her own today with minimal support of machine. Also, same yesterday. They hooked I back up last night so she could rest.
> Yes, she was breathing on minimal support on ventilation in the picture. She is close to extubation (removal of the breathing tube) according to the numbers.
I talked to kidney doctor. I told him we are being proactive with all procedures to save her life. He ordered doubled BUMEX at 1mcg. She received type O positive blood. I went to lunch and now I’m back it’s not there anymore.
> Why have they given red blood cells? Most likely because HB or haemoglobin is low. Find out how low HB was and why they think it has dropped? Most likely because of bilirubin being high and your Mom being jaundiced, but please find out and get the facts! It’s also likely that with the red blood cells being transfused that they were able to stop the Norepinephrine.
Her urine output is low as well as nephrostomy bag low. The kidney doctor acted like she’s not a good candidate for dialysis right now. I will have to talk further about that soon. We’re supposed to have a meeting with our goals and prospects tomorrow. Kidney Doc asked what our goal was. I said to bring her back to her baseline and bring her to her home. I have a professional hospital bed I bought already waiting. Also, my
mom responds to commands. She lifted both arms, opens her eyes. She’s very weak. No feeding tube as it was not processing the food.
> Ok, it’s very positive that she is more alert and following commands! If she can’t tolerate food she needs to have TPN (total parenteral nutrition) also known as intravenous nutrition ASAP. Again, withholding nutrition is
medical negligence in my mind and doesn’t aid your Mom’s recovery.
BP now 93/44 (64).
Thank you.
Patrik
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Hi Laura,
Dopamine is often being used for kidney support only.
If you look at the blood pressure with 106/51(74), the number in brackets is actually the most important number.
If it drops below 65, the risk that the kidneys are not being perfused properly is very high and therefore urine output drops, urea and creatinine usually rise. Let me know if you don’t know about urea and creatinine and I will explain.
Dopamine is usually specifically used to increase the number in brackets also known as mean arterial blood pressure.
The aim when weaning somebody off ventilation is to keep them “dry”, hence fluids need to be kept off the lungs in order to enable extubation. “Wet” lungs would work against extubation (removal of the breathing tube)
Also, the number 51 in the blood pressure suggests that your mother is a little bit “dry” which is probably a good thing. I know you are saying she’s very oedematous, however it sounds like this is a result of low Albumin and probably low haemoglobin as well.
Just because she is oedematous doesn’t necessarily mean her lungs are “wet”.
The minimal ventilation support and the ABG’s are looking good!
Get the nutrition going, your Mom will need that strength! Don’t let them starve her!
I hope this helps! Let me know what you need next!
Warm Regards
Patrik
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Hi Patrik,
URGENT REQUEST. THE ICU INTENSIVIST is telling me we have two hours to take my mom out of this hospital. Providing NO POLICY! I am calling around to try to get her in other hospital.
My mom’s info:
On pressure support only for Respiratory
Levo 14mcg and vaso .04
Making more urine today.
BUMEX 1mcg. Still threatening us that in two hours they will do comfort measures and discharge her. The charge nurse gave me policy.
Nurse here said we could sign for Hospice and put DNR in place, pull her off respirator and blood pressure supports, then en
route home, tell ambulance driver I change my mind and Code status to full code and go to other hospital. I don’t think I can find a doctor to admit her to Mildred hospital. (where we want to go)
Well I spoke with the kidney doctor and he showed me that my mom’s bilirubin levels are going up and I guess the stent isn’t working on her case. Bilirubin is 17.1. The bulky lymph nodes are probably pressing on small bile ducts and they’re not draining. This is a new piece of the puzzle that wasn’t explained well to me. So, I here we are. I appealed with Medicare to buy time also.
Many thanks
Laura
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Hi Laura,
Sorry it took me a while to get to this.
It’s a busy time of the year.
There is a small chance that removing life support, sending her home and en route send her to another hospital might work.
It might not and then it would be too late for your Mom. I would not sign a DNR.
Push them for continuation of treatment. I can talk to them also.
Have you reminded them about the state law in Minneapolis?
If you want to talk to me, we can do so now.
Kind Regards
Patrik
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Hi Laura,
Just a quick summary from our phone call.
1) Ask to buy time for second opinion and that it might take you some time to find a doctor providing a second opinion because of the Christmas holidays
2) Get meeting with the doctors/ nurses to discuss and get resolution regarding the conflict
3) Contact the supreme court for an injunction
I would be very happy to be in the meeting over the phone if you get to a meeting.
Start using stronger language with the team and use language such as “murder” and “killing my Mom”.
Furthermore, appeal to their faith and religion and ask them not to remove life support on Christmas day.
Let me know what you need next.
Warm Regards,
Patrik
Hi Patrik,
The main doctor at ICU has a doctor here to get my mom a second opinion.
Should I accept or should I wait to find my own doctor?
Thanks. Laura.
Hi Patrik,
Well I went ahead and spoke with Dr Kurt, the second opinion doctor. Actually, I feel pretty good talking with him because he said some things that might buy us time, etc.
- He’s independent, please see business card below.
- He said we can order an ultrasound of abdomen. I think to check flow of mesh stent /bilirubin. Bilirubin-17 level
- He said she may be a candidate for transfer to LTAC, but we would have to state, “LIMITED CODE”, meaning no chest compressions.
- He said no tracheostomy until she’s off pressers
- Creatinine- 3.38. WBC-28
- Right kidney is ok left kidney has stone in ureter, I guess. -not obstructing
- Said TPN is not safe right now because of bilirubin level?
Many thanks,
Laura
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Hi Laura,
I’m very pleased that you managed to get a second opinion that you feel OK with.
It’s all about buying time for now.
1) I believe an ultrasound of the abdomen is absolutely necessary. I would go as far as a CT scan of the abdomen. Ask for both. Bilirubin level is sky high with 17.
With Bilirubin so high, there is also a risk that haemoglobin (HB) is remaining low. If HB is low the likelihood for higher doses of Levophed/Norepinephrine and therefore life support. You mentioned a few days ago your Mom had a unit of red blood cells. One day after the Levophed was off. This may not have been coincidental, but a direct result of replacing red blood cells via transfusion.
The signs are there that Levophed and vasopressin went back on due to the sepsis, however an untreated low HB will not help your Mom.
2) Agreed that your Mom might be a candidate for LTAC if she can get through this. She would need to be off inotropes/vasopressors such as the Levophed or Vasopressin to be able to go to LTAC. Generally speaking, I’m not in favour of LTAC, in your Mom’s situation going to LTAC might be a good thing if she can
improve. We can talk more about LTAC when the time comes. The pros and cons.
3) I don’t agree that tracheostomy can only be done after your Mom has come off the inotropes/vasopressors. Many Patients in ICU have tracheostomies whilst being on inotropes/vasopressors such as Levophed or Vasopressin.
4) Creatinine way too high and WBC shows clear sign of infection/sepsis. Normal WBC is 4-11. What is the urea level?
5) TPN can cause a faster breakdown of Bilirubin, however I have found no literature that suggests that TPN can’t be given with high Bilirubin. Ask him how they want to get your mother’s strength back without nutrition.
6) Also, given that he’s an intensivist, he should also almost get his own GI doctor in for a second opinion to look at the underlying abdominal issues causing all of this. Keep them on their toes!
Kind Regards
Patrik
The 1:1 consulting session will continue in next week’s episode.
Kind Regards
Patrik
