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
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?
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 with Severe ARDS? (Part 2)
This is a great case study and an excerpt from Luisa and the doctor discussing about her mom’s health progress in ICU.
Luisa has her 72-yr old mom on a weaning unit in the hospital, went into fast AF, went back into ICU after the fast AF (Atrial Fibrillation), 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 she has severe ARDS?
Go and check it out yourself here.
Part 1
Luisa: Okay, so we’re here. I hung up.
Dr. Sanchez: Hello.
Luisa: Yes. Do you hear me?
Dr. Sanchez: Yes, I can hear you. Chester, are you there?
Chester: Yes I am, doctor.
Dr. Sanchez: Okay. So I wanted to update you in regards to her condition.
Thankfully she didn’t require any vasopressors overnight, okay?
Luisa: Oh, that’s great. Mm-hmm (affirmative).
Dr. Sanchez: We’re going to try and take her off of the fentanyl. The NG tube that was in her nose and giving her feeds had come out, so I had replaced it and we confirmed it with an x-ray that it’s in the appropriate position.
Luisa: Okay. All right.
Dr. Sanchez: That being said, we went and looked at the final report of the CT scan again to figure out if she has any underlying cause for fevers.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: And it showed some cystic fluid collection, somewhere possibly in the vagina, possibly in the pelvis.
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Luisa: Mm.
Dr. Sanchez: Okay. If it’s in the vagina, it’s in the vagina it’s going to come out. But our concern is it’s not in the vagina and in the pelvis.
Luisa: Okay.
Dr. Sanchez: The CT scan’s not the best image to tell us where it is. The best test and we talked to our OB-GYN colleagues about this, is an ultrasound.
Luisa: Okay.
Dr. Sanchez: The issue is, this ultrasound needs to be done transvaginally.
Luisa: Oh. So it’s… okay. I understand. Mm-hmm (affirmative).
Dr. Sanchez: So, that’s why I’m calling with you guys. Part of the reason why I want to talk to you guys today is if you’d give us permission to do this test to evaluate exactly where it’s located. Whether it’s somewhere that’s going to pop and come out like the vagina or if it’s somewhere deeper in the tissues of the pelvis.
Luisa: No, absolutely. You can do whatever is needed. Mm-hmm (affirmative).
Chester: We approve of that.
Dr. Sanchez: Okay. The reason I’m bringing this up is because she unfortunately can’t give us the decision herself and Chester, you are her proxy in this sort of situation and you make decisions about this. And this is sort of a sensitive area and sensitive topic.
Luisa: No, yes, yes, yes.
Chester: I understand, Doc.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: So we’re going to be getting a transvaginal ultrasound, and the OB-GYN team as well might want to examine her later.
Luisa: Okay.
Dr. Sanchez: I’m going to ask of them to get consent from you before that happens, so they can explain what’s going to happen in a little bit of more detail.
Luisa: Okay. So is she still getting fever? Is that why we’re trying to figure out if this is the cause, because she still has fever today?
Dr. Sanchez: Absolutely. She’s still having fevers, but that’s expected with as severe of an infection she has. She has MRSA in the lungs, she has MRSA in the blood.
Luisa: Okay.
Dr. Sanchez: We repeated respiratory cultures yesterday. She has a high burden of infection. The thing is, we want to make sure it’s not causing abscesses or collections in the body.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: The CT scan didn’t show any evidence of that, so this is the only thing that may represent that.
Luisa: Mm-hmm (affirmative), okay.
Dr. Sanchez: Which is why Dr. David wanted to evaluate and potentially see if it’s in the pelvis itself or if it’s just fluid in the vagina. Okay?
Luisa: Okay. All right.
Dr. Sanchez: As for the blood, I mentioned the colon. She is not having bloody bowel movements. She did have a large soft to watery brown bowel movement yesterday night, this morning.
Luisa: Okay. And that’s okay, right? That consistency is not anything to be of concern, right?
Dr. Sanchez: It’s something to keep an eye on, especially because it could be related to what she’s been receiving in terms of medications and fluids and stuff through the tube. But if it persists, it’s something to keep an eye on. Okay?
Luisa: Okay.
Dr. Sanchez: The good news is her WBC count stabilised and normalised. She didn’t require any more transfusions. Her blood is stable.
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Luisa: Oh, perfect.
Dr. Sanchez: Her last haemoglobin was 8.6 and that’s only after two units.
Luisa: Oh wow. Okay.
Dr. Sanchez: Okay, so-
Luisa: So the two units she received yesterday, right?
Dr. Sanchez: Yes ma’am. And there hasn’t been any real drop where she needed more blood.
Luisa: Okay, perfect.
Dr. Sanchez: Okay, her platelets are 81,000 as well. Okay?
Luisa: Okay. Perfect.
Dr. Sanchez: That being said, because she has MRSA in the blood, we’re worried about it, God forbid, going to the heart or elsewhere or receding and causing abscesses. Regardless of whether or not she has infections elsewhere, she’s going to likely need prolonged antibiotics.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: Now we have a central line in her, but the central line can only stay for a few days before it needs to be taken out or swapped out because of risk of infection.
Luisa: Yes.
Dr. Sanchez: There is something interventional radiology could possibly do, like a peripherally inserted central line. It’s an IV line that’s in the arm, that goes to the heart, similar to a central line but it’s tunneled so it’s a lot more, sort of… It’s a long-term IV that can stay for a really long time. I want you to think of it like that. Only like a central line. So, the idea is it would give her a chance to get antibiotics long term
and for them to draw blood, and that way we don’t have to keep sticking her.
Right now, the plan is just, thankfully she’s off vasopressors, she might be transferred from the ICU soon.
Luisa: Oh wow, okay.
Dr. Sanchez: In the next few days, okay?
Luisa: Is it safe, do you think that it’s safe to take her out of ICU being…
Dr. Sanchez: So the level of care she is receiving right now is similar to the level of care she’d receive in the CPCU.
Luisa: Okay. Okay.
Dr. Sanchez: We just want to come up with a clear plan, or at least as clear of a plan as possible for the floor team before she heads out.
Luisa: Okay.
Dr. Sanchez: Okay?
Luisa: All right. And Doc, her ventilator, is she still pretty high level on the ventilator?
Dr. Sanchez: Yeah. Unfortunately her oxygen requirements are very high. So, they’re higher than usual and that can be very clearly explained by her worsening pneumonia.
Luisa: Is it at 100% or is it like high 80s?
Dr. Sanchez: It’s not at 100%. I believe it was 80% this morning or 90%. I believe it was 80.
Luisa: Okay. Yeah, that’s what we kind of figured it would be.
Dr. Sanchez: Yeah.
Luisa: So.
Dr. Sanchez: From what I understand is at one point she improved to the extent where they were capable of doing a tracheostomy on her, so that must have been a low percentage.
Luisa: Yes.
Dr. Sanchez: But unfortunately she’s having overlying pneumonia now, so her oxygen requirements have definitely gone up.
Luisa: But even if her oxygen requirements are up, being that she’s, it’s so high, wouldn’t it make sense to keep her in ICU, or is it just when you think that in the next few days-
Dr. Sanchez: So the same care she’s receiving here is the care she’d be receiving there, in terms of ventilatory support. Because she’s not intubated. She has a tracheostomy. So that’s a secure airway.
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Luisa: Okay.
Dr. Sanchez: I understand your concern. Her oxygen is going up. So doesn’t that mean she’s worse, doesn’t that mean she needs to be in ICU?
Luisa: Yeah.
Dr. Sanchez: With that being said, CPCU does have cardiac monitors. That’s how they were able to tell she had an abnormal heart rhythm to begin with.
Luisa: Mm.
Dr. Sanchez: And the pulmonary team and respiratory would be following her closely to see if there is any worsening or improvement. So that’s part of the benefit of her being in the CPCU. Similar to what happened on Friday. She deteriorated, we took her to ICU right away, right?
Luisa: Yes, mm-hmm (affirmative).
Dr. Sanchez: So-
Luisa: Yeah.
Dr. Sanchez: That’s why we like to keep the two units nearby. She’s definitely at risk of deteriorating if she leaves the ICU, but that’s why she’s nearby the ICU in case she truly needs it.
Luisa: Okay. From my understanding I know-
Dr. Sanchez: It’s not like she’s going to a floor bed or some other floor, right. She’s in a monitored bed. A unit specifically meant as a step down unit to handle patients with tracheostomies and ventilator support.
Luisa: Okay. And Doc, her glucose level. Because I know the day that she was transferred to the ICU she had a glucose level of 40 from when we spoke to Dr. Patel. Has it been increasing since then?
Dr. Sanchez: So she’s had two levels of low glucose earlier this morning. So we check her sugars frequently, four times a day. And earlier this morning it was down to 33. We had given her a shot of D50 which is a big syringe of glucose, to bring it up. She’s also getting fluids with glucose to help keep it at a high level. But despite the fluids with glucose, it went down, okay. That can be a sign-
Luisa: Do we know why that is?
Dr. Sanchez: Probably infection. And how ill she is, unfortunately.
Luisa: Okay.
Chester: That is truly low.
Luisa: Yeah, that’s very low.
Dr. Sanchez: Because she’s not getting any insulin, she’s not getting anything like that, right, that could be bringing the sugars down.
Luisa: Exactly.
Dr. Sanchez: So the only thing we’re doing is we’re just checking it and preventing it from going low. In another sort of situation, and other hospitals or floor situation where they weren’t checking glucose, that could have been catastrophic.
Luisa: Yes. And we agree with that. Yes. We closely monitor mom’s glucose levels.
When she’s at home with us we are always on top of it. And she’s never really been under 100, so knowing that she was at 40 on Monday and then even now at 33, it’s extremely concerning.
Dr. Sanchez: No, no, her last one was 135. So glucose changes minute to minute.
That’s why we keep an eye on it and keep monitoring it.
Luisa: Okay.
Dr. Sanchez: So she’s not ready by any stretch of the means to leave the hospital.
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Luisa: Okay.
Dr. Sanchez: With her current requirements. And she still needs a workup done.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: But she’s not unstable to the extent where she needs life-sustaining medications or a central line anymore.
Luisa: Okay.
Dr. Sanchez: And what we’re going to do is we’re going to try to get peripheral access before removing the central line.
Luisa: Okay. And then for the… I know you said her feeding tube kind of came out.
Dr. Sanchez: Mm-hmm (affirmative).
Luisa: Excuse me. Now that it’s back in place, has she started again with the regimen of the nutrition?
Dr. Sanchez: They haven’t started it yet. The X-ray just confirmed it. As soon as they bring the food up they can probably start her.
Luisa: Okay. Yeah that might be wise too, yeah.
Dr. Sanchez: This is the issue with the NG, I think they might have discussed with you guys about.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: Is that an NG is not a permanent solution. It’s very uncomfortable. I had to give her a little bit of fentanyl to make her a little more calm so I can put it in, otherwise she would have been fighting. And it’s also at high risk of coming out.
And if it comes out, it takes a skilled individual to put it back in, right?
Luisa: Yes.
Dr. Sanchez: So the PEG tube, the benefits of the PEG tube and why they want it is that it’s used for long-term feeding.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: And if she manages to get better later, then it can just be popped and then digested in the stomach and pooped out.
Luisa: Yeah, I think, yeah. We kind of discussed that as a family and being that she’s going through MRSA right now, right at this point I don’t feel like we feel comfortable with even putting her on a PEG. We’re just worried about having another procedure done and then the infection. So I think right now-
Dr. Sanchez: I understand. I understand. Right now it’s not an appropriate time.
And that’s very, very fair. What you’re saying is very, very fair. But ultimately it’s something to think about.
Luisa: Yes, yes. When she’s stable we’ll come back to it and we’ll think about it, yes.
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Dr. Sanchez: Do you have any more questions or concerns for me?
Luisa: Just one more. Just her kidney levels.
Dr. Sanchez: They are at .8.
Luisa: .8, okay.
Dr. Sanchez: Mm-hmm (affirmative).
Luisa: And then the X-rays. Did they take X-rays this morning to see.
Dr. Sanchez: Well they took an X-ray at midnight and we repeated an X-ray this morning because the tube was out and I had placed a new one.
Luisa: Okay, so it’s nothing about the lungs though. I know X-rays can be, you can’t really tell whether or not the lungs are getting worse or better, I know sometimes with X-rays, right?
Dr. Sanchez: Her lungs are definitely worse than what it was about a week ago.
Luisa: Yeah.
Dr. Sanchez: So her lungs do not look good on X-ray at all.
Luisa: Mm.
Dr. Sanchez: I don’t know what to say. I’m very sorry but they’re… Looks worse, especially on the left side.
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Luisa: Mm-hmm (affirmative).
Dr. Sanchez: But relatively unchanged since yesterday.
Luisa: Oh and so the last one. Remember yesterday you said that you would let us know about the blood, whether or not the MRSA was still growing? Was it still growing, or?
Dr. Sanchez: So far, the last cultures sent on the third show no growth.
Luisa: Okay. But we still have to worry about whether or not it’s incubating somewhere else, right?
Dr. Sanchez: Absolutely.
Luisa: Okay.
Dr. Sanchez: Because it’s not only in the blood, it’s in the lungs. There was some in the urine that may have been a contaminant or might be real, we’re not quite sure.
Luisa: Okay. All right. All right. Well thank you. Thank you, Doc. We truly appreciate everything.
Dr. Sanchez: Okay.
Luisa: And as long as-
Dr. Sanchez: One other thing… Sorry to interrupt. One of the things you guys had brought up was DIC, we sent the panel yesterday. It doesn’t look like it either.
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Luisa: Okay, perfect. Okay. So we… All right. The DIC, he sent the panel just to ensure. It didn’t look like it. Okay.
Luisa: Okay, so you think that once they start the feeding, you think it will help with her glucose level, or today?
Dr. Sanchez: I think the feeding there is going help with the glucose level. We’re going to still keep an eye on it and give her sugar as needed.
Luisa: Okay.
Dr. Sanchez: But she’s still profoundly ill. Thankfully she’s off the vasopressors.
We’re going to try to transition her to the CPCU again, but we need to get good access in her arm.
Luisa: Mm-hmm (affirmative).
Dr. Sanchez: If we can’t get a PICC line or a midline in, I’ll try to place a good peripheral IV that will last her a few days and maybe they can keep trying to place one and rediscussing.
Luisa: Okay.
Dr. Sanchez: Okay?
Luisa: Yeah, as long… Yep, sure. As long as the sonogram is used because I know her veins are very weak right now.
Dr. Sanchez: Yeah, absolutely. I’m going to be using the sono. No one’s going to be poking her but someone… because I look at her arm, it’s so swollen and the blood in the arm, oh my Lord.
Luisa: Yes. Yes. That’s what happened last time. Someone didn’t do it right and it was just three litres of blood. They gave her three units of blood, and it didn’t actually go to her because the line wasn’t right, so.
Dr. Sanchez: Yeah, unfortunately it can appear like it’s in position, especially because it’s running well, but her skin and soft tissue is so weak it just expands and takes all of that fluid.
Luisa: Yeah. Mm-hmm (affirmative). All right.
Dr. Sanchez: So I’ll do my best to insert a good one. It will hopefully last a few days.
Luisa: Yeah.
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Dr. Sanchez: But it definitely needs to be reinserted and kept in mind.
Luisa: Okay. All right.
Dr. Sanchez: But the ideal solution would be something as a long-term IV like a midline or a PICC line, which we’re going to try to discuss and see if she’s a candidate because of the bacteria in her blood.
Luisa: Yeah. All right, Doc. Well if anything, would you please call us and let us know? Like if she’s transferred… You don’t think she’s going to be transferred today, right?
Dr. Sanchez: No, not today.
Luisa: Okay. All right.
Dr. Sanchez: And just to confirm that you guys are okay with the transvaginal ultrasound, is that correct?
Luisa: Yes.
Chester: Yes.
Luisa: Yes.
Dr. Sanchez: Okay. Do you have any more questions or concerns? I didn’t hear much from you, Chester.
Chester: I don’t have any. She’s been asking all the questions. I was right next to you hearing everything.
Luisa: Yeah, we have a list here so we’re just going down the list, Doc.
Dr. Sanchez: Oh, you’re just going down the list. Okay.
Luisa: Yeah, yeah we’re all together.
Sam: This is Sam. We sit around the table and we just try to analyse what’s going on and just basically just ask questions. And we appreciate you taking the time out to call us and giving us all that information.
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Luisa: Yes.
Sam: We truly do. Thank you.
Dr. Sanchez: No problem. It is literally my job. Please don’t thank me for doing my job.
Luisa: Okay.
Chester: You’ve done a lot. You’ve done a lot.
Luisa: Yes, you’re doing a lot for us, so we appreciate it. Thank you.
Dr. Sanchez: Goodbye.
Luisa: Okay, bye bye.
Dr. Sanchez: Bye bye.
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