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 ICU with Tracheostomy and Ventilated. Why Won’t the ICU Team Keep Her Off the Ventilator First Before Discharge?
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 Lorietta, as part of my 1:1 consulting and advocacy service! Lorietta’s mother has
tracheostomy in place but with ARDS and kidney failure. Lorietta is asking why does the ICU doctor is refusing to do hemodialysis for her?
My Mom is in ICU with ARDS and Kidney Failure But Why Does the ICU Doctor Say She Can’t Have Dialysis?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Lorietta here.”
Part 1
Part 2
Lorietta: Oh my goodness. Well, my neighbour where I live, he is Australian. Well he was born in South Africa, but then he was raised pretty much in Australia and he’s a Weber. So I would love to visit Australia eventually. I have had the opportunity, but it didn’t work out last year and I just had a full plate as they say.
Patrik: Look, it’s a beautiful country. No doubt about that, so is the United States. I’ve been over there.
Lorietta: It is. Yes. It’s lovely as well. But thank you. Please send me the information.
Patrik: I will.
Lorietta: I’m so glad we were able to communicate this evening and thank you for all of your help and your time, and we’ll get back in contact with you.
Patrik: Okay. Thank you so much. All the best for now.
Lorietta: Thank you.
Patrik: Thank you. Bye bye.
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Lorietta: Hello?
Patrik: Hi, is this Lorietta?
Lorietta: Hi, Patrik. How are you doing?
Patrik: Very good, thank you. How are you?
Lorietta: Well, I was very concerned. My mother’s caregiver wanted me to get to the hospital ASAP this morning because they indicated that she had kidney failure. Well, they didn’t say failure, kidney issues.
Patrik: Oh yes.
Lorietta: And no urine was being produced. And her urine has been so good over the past, since she’s been hospitalised. And so I asked for her to see a nephrologist. So she did see the nephrologist. He said she wasn’t a candidate for dialysis.
Patrik: Why not?
Lorietta: Because she was too far. Because he said she’s too frail.
Patrik: And that’s coming from a nephrologist or from the ICU?
Lorietta: From the nephrologist.
Patrik: Okay. What’s the ICU thing?
Lorietta: Well, I had to suggest the nephrologist consult, which was kind of disappointing. I thought that he should have made that suggestion.
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Patrik: Yeah.
Lorietta: She only sees a pulmonologist, she doesn’t see a hospitalist.
Patrik: Right, right. Okay.
Lorietta: So the pulmonologist, he just said there was a lot of fluid. The albumin isn’t really helping and the drip isn’t helping either. And that’s all he could tell me. And I said, “Well, please have her to see a nephrologist.” He did a renal ultrasound. They did the echocardiogram and they did a blood culture and I’m waiting on the results.
Patrik: Okay, so you mentioned in your email that she’s in adult respiratory distress syndrome (ARDS). Now, is that something that’s been newly diagnosed?
Lorietta: Today was the first day I’ve ever heard of that.
Patrik: Okay.
Lorietta: I’ve heard of pneumonia.
Patrik: Yep.
Lorietta: Respiratory disease. She was on seven days of antibiotic and her white blood cell count is increasing.
Patrik: Yes.
Lorietta: To like 26,000. And so today they put her on Merrem.
Patrik: Yes, Merrem. I’ve seen that in your email. Look, it is extremely disappointing that the Nephrologists thinks she’s not a candidate for dialysis. Now, here is what I can see, Lorietta. It’s like, if she is in adult respiratory distress syndrome, also known as ARDS, right?
Lorietta: Yeah.
Patrik: So when patients are diagnosed with ARDS, it’s probably the lung disease with the highest mortality. How can I put this in perspective for you? Well, number one, the first question is, what’s their evidence that she has ARDS?
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Lorietta: Okay.
Patrik: That’s the first question. The evidence is often in a chest x-ray.
Lorietta: Okay.
Patrik: So ask them how they diagnosed, how they came to the conclusion that she is in ARDS. That would be my first question for them if I was you. And to put that in perspective. So when patients come to intensive care with ARDS, and unlike your mom, they first come to intensive care with the primary diagnosis of ARDS. It’s pretty critical and the mortality is fairly high up. I would have to look up the numbers but as I said, it’s probably the
worst lung disease. And given that your mom has been in ICU and long term acute care for quite some time now, this is on paper not good news. But at the same time, I do want to know, well, how did they find out? How did they come to that conclusion?
Lorietta: Yes. Well, every time they turn her or clean her the oxygen saturation is dropping.
Patrik: And look, there is a good chance that she may have ARDS but again, they need to give you the evidence.
Lorietta: Okay.
Patrik: I guess it is concerning now that your mom has been battling this since you first contacted me and there hasn’t been any sign of improvement. There is a good chance she may have ARDS but again, where’s the evidence for that?
Lorietta: Thank you. Thank you. Yes, they just told me she has ARDS.
Patrik: Right.
Lorietta: No evidence, objective evidence.
Patrik: Right. So what’s important there to know is when patients come into ICU with ARDS, they often end up on sort of very specific treatment known as ECMO. I don’t want to get too medical here but if she has ARDS, it’s really important for you to understand that when patients get
diagnosed with ARDS, it’s not treatable. Patients often end up on ECMO. Basically, what ECMO is, they end up on a bypass machine, which is basically taking over the function of the lungs.
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Lorietta: Okay.
Patrik: Okay, that’s giving the lungs a rest. Keep in mind that when somebody first gets admitted to intensive care. ECMO is a very stressful treatment option. Given that your mom has been in ICU for so long now, I do believe that they would be very reluctant in putting her on ECMO because she’s probably too sick and she has no reserves. Are you there?
Lorietta: Hey.
Patrik: Hi, I don’t know…
Lorietta: Hey.
Patrik: I don’t know what happened.
Lorietta: Oh, that’s okay. Well, and tell me you were saying it’s called echo.
Patrik: No, no. ECMO, E-C-M-O. I’ll send you some information, when we come off the call. I’ll send it all to you.
Lorietta: Thank you.
Patrik: But one of the inclusion factors for ECMO is that you’re sort of within less than a week of the diagnosis and you haven’t been in ICU for prolonged periods, right?
Lorietta: Okay.
Patrik: Your mom’s general condition would be severely weakened at the moment, because of her prolonged stay, right?
Lorietta: Okay.
Patrik: When patients are in a situation like your mom, I can see why a nephrologist might say she’s not a candidate for a dialysis because I have seen that over and over again. Now that doesn’t mean we shouldn’t make the argument for a dialysis because at the end of the day, she’s critically ill and she’s got nothing to lose at this point in time as far as I can see, right. So I can see where the nephrologist stands and you know, if you would
have seen by now, they’re all fairly negative, very doom and gloom.
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Lorietta: Yes.
Patrik: If you don’t try, what’s the point?
Lorietta: Absolutely.
Patrik: But if the diagnosis of ARDS is accurate and they’ve tried all sorts of antibiotics already, the white cell count keeps going up, now she’s on the Meropenem, that’s all good. It looks like they are trying to use all the right antibiotics, but if it’s not helping, number one, there is a good chance that she’s in ARDS. And number two, if she is in ARDS, I do believe, with two months battling this critical illness, her survival chance might
diminish.
Lorietta: Okay, well, I will call them and inquire, how they came up with the diagnosis.
Patrik: Yes. I think you need to get the evidence.
Lorietta: Okay.
Patrik: If they are accurate and how did they diagnose it? Right. I’ll tell you how you can often diagnose it. In ARDS, they do a chest x-ray, now the chest x-ray is usually a complete white out. What that means is a healthy lung, you should see sort of black textures and you know it’s just a healthy lung. With ARDS,
it’s usually a complete white out the lungs in the chest X-ray, go from black to white.
Lorietta: I see.
Patrik: Because they’re infiltrated by infection.
Lorietta: Okay. Right. I’ll call up there and find out.
Patrik: I will send you more information about ARDS as well as ECMO.
Lorietta: ECMO, Okay.
Patrik: I’ll send you information, you can look it up then on our website.
Lorietta: Thank you.
Patrik: With the dialysis, you can make that argument that yes, she’s very sick, but what’s the point in not trying. The other question-
Lorietta: Yeah.
Patrik: That’s right. The other question, you would have seen in my emails. I keep asking some of the questions that I asked you that are the same over and over again, but it’s important. You need to keep asking if she’s on Inotropes or Vasopressin you need to because she may. .
.
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Lorietta: But they’re saying no because her blood pressure is normal. Goodness. That’s what they keep telling me.
Patrik: No, no, that’s good. That’s good. I just know from experience that can change very quickly.
Lorietta: Very quickly, okay.
Patrik: If she has ARDS or pneumonia, she could become septic. Do you know what I mean by sepsis?
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Lorietta: Yes, yes, yes. Sepsis.
Patrik: Right. The minute somebody goes into sepsis, their blood pressure drops and they need the Inotropes and the Vasopressin. Especially with her white cell count still so high. Again, this is a sign that she may become septic and then she will end up on Inotropes and Vasopressin. Now, why am I so pedantic about those Inotropes and Vasopressin’s? Number one, yes, it’s counteracting a low blood pressure but number two, the Inotropes and
Vasopressin’s, I can see that life support.
Lorietta: Okay.
Patrik: Right?
Lorietta: Well they keep telling me there’s no need and all of this. But I’m not sure.
Patrik: Well, look, it would be accurate if they tell you no. What I am saying is that you know, she’s on the ventilator at the moment. That’s one form of life support, right?
Lorietta: Okay.
Patrik: If she’s on Dialysis, which she’s not at the moment. But if she does go on Dialysis, that’s a second form of life support. Inotropes and Vasopressin are a third form of life support. So I gauge the level of sort of sickness if you will, I gauge it by the amount of life support a patient is getting.
Lorietta: I see. Okay. Okay. Right.
Patrik: At the moment your mother is in single organ failure. What that may mean. .
Lorietta: Okay.
Patrik: Well, no, that’s not accurate. She’s in double organ failure. The lungs are failing and the kidneys are failing Right. She’s in double organ failure. Now if they start her on Inotropes and Vasopressin, she would be in multi-organ failure because that’s a sign of heart failure as well.
Lorietta: Okay. Okay. And the Echocardiogram that will determine, give it some indication.
Patrik: Definitely would give some indication at the moment from what you’ve shared with me. And even when I spoke to the doctors, there was no indication that the heart was failing. But it would be now that she probably is in ARDS, there is a good sign that the issue is
within the lungs themselves and the heart is not effective at this point in time. The indications are there, you know, until you told me she’s potentially in ARDS. I was always thinking, is it a heart issue? Have they ruled that out?
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Lorietta: Okay. Well and they did a blood culture but they said that will take a few days to get the results.
Patrik: Yeah, it would take sort of 48, 72 hours and that could potentially show more growth of bacteria in the culture. But there’s no point in speculating. You’ve got to wait and see. Definitely keep pushing for the dialysis and the reason that’s important is, if she’s got ARDS her lungs are failing. And if they’re not dialyzing her, imagine the lungs are failing because of the ARDS and number two, she’s not making any urine, which means any
fluids that she can’t get rid of will accumulate in her lungs. That’s going from bad to worse.
Lorietta: And I thought the drip would help, but apparently it’s not.
Patrik: Which drip was that? The Albumin?
Lorietta: The Albumin? Yes.
Patrik: Look, the challenge in intensive care is, if things work, it’s not often one thing, it’s a combination of things. You know, it’s not only, you keep the Albumin and it’s got the magic fix. It’s often a combination of things that need to work.
Lorietta: I see.
Patrik: If the ARDS diagnosis is accurate, I am very concerned for sure. And if they’re not starting to Dialyse her, I would be even more concerned. I guess you, as the medical power of attorney and you as her advocate, you need to keep asking. And you can rationalise with them. You can say, look, if my mom is in ARDS and the kidneys are failing, you know, you’re adding on more fluids to an already failing lung.
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Lorietta: Okay, okay. And then the urine output was maybe 650 to 800 today.
Patrik: Right.
Lorietta: You know, by the time I got there, is that good? Within about an hour.
Patrik: Oh, within an hour?
Lorietta: Yes. Yes. When I got there, it was I think nothing all morning.
Patrik: Right. So they must have given her some Furosemide as a bonus and that must’ve worked. So you’re saying 650 within an hour?
Lorietta: Yes. It was amazing. Even the nurse had no explanation.
Patrik: Okay, well that’s good. But it really depends how much fluid, how much urine, she’s done over the last few days.
Lorietta: That makes sense.
Patrik: You know, if she’s making 650 in an hour, that’s great. But the question is, can she repeat that?
Lorietta: Absolutely. Okay. And then when I left, she emptied it and then she was producing some more urine and the nurse didn’t really have an explanation. From this morning, none, to producing urine.
Patrik: I think your main questions are diagnosis of ARDS, why no Dialysis and I can see, they’re saying she’s too frail. But you know, if she was on Inotropes and Vasopressin, I would agree with that. But because she’s not on Inotropes or Vasopressin, I believe she can tolerate the Dialysis.
Lorietta: Okay. Okay.
Patrik: I will put all of that in an email.
Lorietta: Okay.
Patrik: And then you can read it all up there, and then you can ask the questions and get back to me.
Lorietta: I will and I’ll look for your email as well.
Patrik: You should have it in the next 20 minutes.
Lorietta: Thank you so much.
Patrik: You’re very welcome.
Lorietta: Thank you. Thank you for everything. I’m so grateful.
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Patrik: You’re very welcome.
Lorietta: So you won’t be in the United States, within the next few weeks or so?
Patrik: Say again please.
Lorietta: You won’t be travelling to the United States any time soon?
Patrik: Not that I know of. I haven’t got it planned, can’t rule it out either because sometimes I may, but at the moment I haven’t got it planned.
Lorietta: No. Okay. Okay. Well thank you for everything and we’ll just keep you posted.
Patrik: Okay. Look out for the email.
Lorietta: I will. I will. And have a wonderful evening. What time is it there?
Patrik: Sunday morning here.
Lorietta: Sunday morning. Okay, well have a wonderful day.
Patrik: And you, thank you so much. I’ll shoot you an email. Take care.
Lorietta: Thank you, Patrik.
Patrik: Thank you. Bye-bye. Bye.
The 1:1 consulting session will continue in next week’s episode.
