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
What Questions Should You Be Asking If You Have A Loved One In Intensive Care?
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 feature another case study with one of our clients and the case study this week is
CASE STUDY: Have They Moved my Mom out of ICU Too Quickly, she went on Fast AF (Atrial Fibrillation) and Now She Has Severe ARDS?
This is another great case study and an excerpt from Luisa and the doctor discussing about her mom’s health progress in ICU.
Luisa’s mom ended up in ICU with COVID, with pre medical history of Diabetes Mellitus Type 2, cannot come off the ventilator so she ended up with a tracheostomy. She was then transferred to stepdown unit but readmitted back to ICU because of multiple episodes of fast AF (atrial fibrillation) managed by cardioversions and amiodarone.
She has low BP so they started her with inotropes, inserted central line and arterial line. Her hemoglobin went low as well. She’s had blood transfusions and so hemoglobin improved. They were suspecting DIC due to drop in hemoglobin but it is not confirmed.
She has been given with high doses of Fentanyl which they weaned down drastically which Luisa doubted as the cause of the fast AF.
Luisa’s mom went back to ICU after the fast AF and diagnosed with severe ARDS.
Luisa is asking if the ICU team has moved her mom out of ICU too quickly, she went on fast AF and now with severe ARDS?
Go and check it out yourself here.
Luisa: Hello.
Dr. Sanchez: Hi.
Luisa: Hi. How are you? Dr.Sanchez?
Dr. Sanchez: Yes, ma’am.
Luisa: Hi, it’s Luisa. How are you?
Dr. Sanchez: I’m all right.
Luisa: I was just going to see if you got the results for the CT scans that you had taken before earlier.
Dr. Sanchez: I just want to confirm, because what I have documented is Mr. Chester is a health care proxy. Is he near you by any chance?
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Luisa: Chester’s upstairs. I can three-way him if you want because we live in the same house. I’m downstairs from him.
Dr. Sanchez: I’d appreciate it because if he gives me the okay, I’ll give you the information. I just don’t… Yes. I just want to confirm that before-
Luisa: Okay. Hold on. Let me just… I’m going to three-way him and give me one second.
Dr. Sanchez: No problem.
Luisa: Actually, my other brother’s calling him to come down. Hold on. Sorry about that. All right. He’s coming. He’s on his way downstairs. I’m sorry. Chester is the proxy, but if anything I will call in because it’s easier for one of us to call in as opposed to everybody trying to call in, and then I’ll just relate all the information that you provide to the rest of my siblings.
Dr. Sanchez: I understand.
Luisa: We don’t want to inundate, too many calls. All right. He’s here. Hold on. Chester’s right here. Hold on.
Dr. Sanchez: I understand.
Chester: Hello?
Dr. Sanchez: Hello? Mr. Chester?
Chester: Yes, hello. How are you doing?
Dr. Sanchez: I’m all right. I just wanted to confirm, cause I have you documented as the healthcare proxy. Usually that means that you’re the person I’ll be getting in touch with to avoid confusion than talking with multiple people and misunderstanding. Do you want me to talk to your sister and divulge that information? Or do you want me to talk to you?
Chester: You can speak to her. I’ll be right next to her. So I won’t leave. I’m right next to her.
Dr. Sanchez: Okay. So I can speak to both of you in regards to you condition, everything. Is that right?
Chester: Yes, that’s correct.
Dr. Sanchez: Okay. But what I don’t want to happen is I update you one day, I update her one day, and there might be some sort of miscommunication or misunderstanding.
Chester: You’re only going to talk to me and Luisa. That’d be perfect.
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Dr. Sanchez: Okay. I understand. But moving forward, I’d like to update one of you so that there’s no misunderstanding or confusion about what’s going on.
Luisa: No. Understandable. Yes. I totally agree with that. If anything, I’m actually staying at the house with them, if something has happened with mom. I live pretty far, but I’m saying over here, so it’s best to communicate with me primarily and I can always include Chester and everyone else if needed. The only time you would really need to contact Chester is if you need his approval.
Dr. Sanchez: Decisions. I understand. I got it. Okay. So in terms of the CT scan, the CT scan report came back and thankfully didn’t show any evidence of strokes or bleeds.
Luisa: Perfect.
Dr. Sanchez: So whatever’s going on in regards to the CT scan, doesn’t seem to be something that is as large as a stroke or something that is reversible or catastrophic as a bleed in the brain. Okay?
Luisa: Okay.
Dr. Sanchez: But that being said, her mental status may be due to all the other things. Her prolonged ICU stay, the sepsis she’s having with the bacteria growing in her blood and her lungs. It could be, as your other sibling had mentioned, related to the sedation, but that is the last thing that we need to blame. The other things are much, much more common and reasonable and more important to being managed at this point. Okay?
Luisa: Okay.
Dr. Sanchez: The CT of the chest shows really, really horrible pneumonia, unfortunately. So it seems like it’s progressed particularly in the left lower side in comparison to her prior imaging and showing a picture of pneumonia affecting both lungs. So it’s not just the left lung
that’s affected, although the left lung is predominately affected. That’s probably why her oxygen requirements have been increasing.
Dr. Sanchez: The CT of the abdomen showed some findings. Some of them are chronic and need to be addressed in an inpatient setting. One of the things that showed, though, was an enlarged gallbladder, but no evidence of a gallbladder infection.
Luisa: That’s her urine bladder, right? No?
Dr. Sanchez: No. Sorry. Her gallbladder. So where bile is stored before it goes into the small intestines.
Luisa: Okay. Got it.
Dr. Sanchez: If you’ve ever heard about gallstones, gallstones are notorious for affecting the bladder and causing infections there. But that doesn’t seem like that’s the case based on CT imaging. Okay?
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Luisa: Okay.
Dr. Sanchez: It did show some numerous findings, but the most pertinent ones are that there is material in the colon suggestive of potential blood, but she’s not actually bleeding right now. So it might have been tube feeds, it might’ve been some contrast she had taken, or it might be blood remaining in the colon and she’s on the verge of having a bleed. Okay?
Luisa: Okay.
Dr. Sanchez: That being said, we’ve been monitoring her blood levels and she only got one transfusion. Her hemoglobin went from four to 7.5, which is suggestive that the four is probably an incorrect, inappropriate, wrong value. Okay?
Luisa: Yes.
Dr. Sanchez: She is definitely at risk of having bleeds from her colon because of the diverticulosis that she has, and what we’re doing is we’re avoiding things that can make her bleed, like aspirin, anticoagulation, and heparin. So we’re just trying to prevent clots from forming in her legs by doing sequential compression devices. Okay?
Luisa: Okay. Yes.
Dr. Sanchez: She also did undergo an ultrasound here today and it showed no evidence of clots in the upper and lower extremities.
Luisa: Okay. That’s good news.
Dr. Sanchez: Okay?
Luisa: Yes.
Dr. Sanchez: That being said, she’s still profoundly ill. There are findings on these CT scans that can be addressed as an outpatient, or followed up in an outpatient setting, should we reach that point. Okay?
Luisa: Yes. Does she still have a fever today?
Dr. Sanchez: She still had a fever earlier this morning, which is what prompted us to change the antibiotics.
Luisa: Okay. Since this morning has it reoccurred or is it just low grade or…?
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Dr. Sanchez: I’m honestly not too sure about that. I know it improved, but I don’t know if it had recurred as of yet.
Luisa: And for her bowel, I know yesterday she had diarrhea. Does she still have diarrhea or did it stop?
Dr. Sanchez: No, she’s not having diarrhea right now. I think it might’ve been because of the sedation and fentanyl that she was on so that in itself can slow down the colon.
Luisa: Okay. Got it. And her kidneys are okay with the levels? That’s the first thing I know…
Dr. Sanchez: Her kidney function are stable, but she’s definitely at risk for them worsening, which is why when we did the CT scan we did it without contrast.
Luisa: Yes. I recall you saying that before. Her feeding tube. Is she still on the same nutrition that she was on prior or…?
Dr. Sanchez: Initially we had held it for the CT scan, but now she’s resumed on it because her pressor requirements are low to none. So it’s safe to be feeding her at this point. When her vasopressor requirements are very high, that can cause some issues with the gut,
some poor absorption, and even something like bowel necrosis, but thankfully her requirements are so low that we can feed her. So yes, she’s receiving feeds right now to help aid in her recovery.
Luisa: Okay. That’s good. And her heart rate? Is it okay? I know earlier today you said it was stable.
Dr. Sanchez: It’s not in an abnormal rhythm and the Amiodarone infusion she’s getting here is helping control that.
Luisa: Okay. That’s perfect. Okay. And is the cardiologist involved with everything that’s been going on or is it just the ICU team?
Dr. Sanchez: It’s just primarily the ICU team. Usually we call cardiology only for particular interventions, like stents for heart attacks. Otherwise, these things are very much managed in an ICU setting by the intensivist.
Luisa: Okay. And the same goes with her haemoglobin, right? A hematologist is not involved or anything like with the MRSA?
Dr. Sanchez: Generally the ICU is a closed ICU. We will appreciate their input, but we’ll usually call them in case they can offer an intervention that we think is appropriate. Okay?
Luisa: All right. That sounds good.
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Dr. Sanchez: In her case the hematologist-oncologist actually dropped a note and primarily said to treat the underlying infection and they believe this is all related to infection, the low platelets, and so on and so forth. And what’s it called to treat supportively,
which means if the hemoglobin is low, to transfuse as needed. If platelets are low, to transfuse as needed.
Luisa: No, it’s understandable. For the MRSA. One question I did have, when we were told that she had MRSA, I was trying to look up, how can we basically find a level of MRSA in the blood? Can we see whether or not it’s improving? Are there tests that can be done for this?
Dr. Sanchez: So what we’re doing is we did blood cultures, we do blood cultures. There were multiple sets of blood cultures, separated from different dates, all showing MRSA. Now the last set of blood culture we had just drawn has not grown it as of yet, but they have not
been finalized. Okay?
Luisa: Okay.
Dr. Sanchez: So if they stop growing in the blood, that is better news, but that doesn’t change the fact that she’s profoundly ill and it’s probably still growing in her sputum and all of the other things that are wrong. But if it stops growing into the blood that
means there is some sort of antibiotic response to what we’re giving her.
Luisa: So that would be primarily the vancomycin, right?
Dr. Sanchez: Again, we changed the antibiotics. She’s currently on daptomycin and ceftaroline.
Luisa: Oh, okay. I got it mixed up because it does sound the same as the other one.
Dr. Sanchez: Yes. So the person in charge of the antibiotics for this is a doctor named Dr. Rome. He Is also the intensivist taking care of her. He is one of the experts in drug-resistant organisms we have in the United Kingdom. So his decision was the decision that was made to change the medications.
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Luisa: Okay. I’m glad we have someone like him on board, as well as you. I just have three more questions, and I don’t need to keep you any more further. I know for the C-reactive protein, when I was talking to my cousin Daniel earlier, he said that these are the things that we should ask you as well. Like the C-reactive protein level.
Dr. Sanchez: No, it wouldn’t change management. C-reactive protein level would be important in cases of COVID who come in with COVID. It’s important maybe as outpatients to see a sort of trend, but we already know she has a bacterial infection. We already know what’s going on. Trending it is not really appropriate. It wouldn’t change what we’re doing in her case. It might throw people off. The numbers are getting better, but she’s clinically
getting worse. Her vasopressor requirements are going up and so on and so forth. So they’re not very reliable.
Luisa: Okay. And the… How do you pronounce this one? The fibrinogen. I think it’s F-I-B-R-I-N-O-G-E-N.
Dr. Sanchez: Fibrinogen?
Luisa: There you go. I’m sorry.
Dr. Sanchez: Her last one, when it was drawn, was seen and evaluated by the hematologist-oncologist. It was normal. Now we are sending another one with her next set of labs and we’ll hopefully find out by the morning what it is.
Luisa: Okay, perfect. And then the last one, the last one, doc. Yesterday, when we spoke to Dr. Ferdie, I think his name was, he said he was going to take a tracheostomy culture. Did he do that?
Dr. Sanchez: We took a respiratory culture. I don’t know if he means that as the same thing. So her last fibrinogen was 766. That’s actually very high. And that is completely the opposite of when we think of Disseminated Intravascular Coagulation (DIC). DIC would be very low.
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Luisa: So that’s how you, okay. All right. So that makes sense. Okay. All right. Well, thank you so much. Thank you so much for your time.
Dr. Sanchez: Again, I want you to focus on her overall clinical picture. The medicine where we’re going to focus on, these are the debates, what we spend a lot of time during rounds talking about. I understand you are concerned and want to know all of these specifics and I’ll be happy to provide it, but I just want you to think about her and think about her current situation is in the ICU, sedated, profoundly ill, and that we’re going to do what
we can to treat her. If there’s anything emergent that happens, I’ll do my best to update you. Okay?
Luisa: Yes. Please. Thank you very much. And we believe that you guys will do everything possible for our mom. So we truly appreciate everything that you guys are doing.
Dr. Sanchez: I understand. All right.
Chester: Thank you, doc. I appreciate it, doc. Thank you so much.
Luisa: Thank you very much.
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Dr. Sanchez: No problem. Thank you guys.
Chester: Take care. Have a good day.
Luisa: Have a good night. Bye-bye.
Dr. Sanchez: Bye-bye.
Kind Regards
