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 Post-COVID in ICU and How Do I Know if She is Getting Better with ECMO?
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 Juan, as part of my 1:1 consulting and advocacy service! Juan’s mom is with a tracheostomy, IABP, and is
on ECMO. Juan is asking how to have power and control over the ICU team whilst his mom is critically ill in ICU.
How to Have Power and Control Over the ICU Team Whilst My Mom Is Critically ill in ICU?
Patrik: Yeah. Okay. Good, good, good, good. Yeah. Okay. The biggest issue that I can see at the moment is, so if her ejection fraction is 35 that was on or off the balloon?
Juan: This was done few days ago. So off the balloon I guess.
Michelle: For sure.
Juan: Off the balloon.
Patrik: Okay.
Patrik: Okay. You see the problem is, they might be able to take her off the VA-ECMO, but they also should be able to take the balloon out.
Juan: Yeah.
Patrik: That’s the problem. What I’ve seen over the years is, they often add in a little bit of Dobutamine or Dopamine or Milrinone, which is an inotrope, but it’s not like vasopressin or noradrenaline. The Dobutamine and the Milrinone specifically are inotropes that increase the
contractility of the heart, which is more or less the pump function. And if you can maximize the pump function of the heart, your ejection fraction usually goes up. And you should be able to reduce ECMO. You should be able to reduce the support from a balloon pump. Now, again, the novelty for me in this situation is I have not seen ECMO and balloon pump. I have not seen that. That’s a novelty for me. That’s also a concern for me. That’s not to say it ain’t going to work, but it’s just a
combination I haven’t seen yet.
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Juan: Right.
Patrik: And I’m wondering about the severity of your mom’s heart failure.
Juan: On the cardiologist who did this, she was overall been quite vocal about how weak her heart is, to be honest.
Patrik: Right. Yeah.
Juan: We were told it’s quite a dire situation. Yeah. I think their opinion was that she has a very weak heart. I mean, it might be improving now, but I think that they were very concerned-
Patrik: Right. No surprises there. No surprises there. Okay. How often do you-
Juan: Sorry. I just wanted to mention that because she’s on all of these machines, they’ve not been able to do any CT scans on her since the ECMO came on, since the VA-ECMO came on. So they’ve only have to rely on all of these other things, including chest x-rays and sonographies and things to figure out what’s going on with her. But there’s not been any way to do any CT scans, so even that information is a bit limited.
Patrik: Right. Okay. And just remind me. Just remind me one more thing. So before she went on VA-ECMO, there was no VV-ECMO. She went on VA straight away.
Juan: Yeah.
Patrik: Okay. Have they mentioned a lung transplant or a heart transplant as an option?
Juan: The other day they just laid out a roadmap for us. They told us that the first option would be to put in this IABP. If that doesn’t work, then they could consider an Impella heart pump. If that doesn’t work, they said that then our last resort would be to consider heart or
lung transplant, but they just laid that out, put it on the table saying that we’d hope that the balloon pump works and we won’t need to get that, but if we need to get that, that’s bad, but there’s a whole bunch of issues with transplant symptoms of even getting organs especially with COVID and everything else,
all the other issues that come with transplant. So that would be a very last case scenario.
Patrik: Very much so. And the reality is that an Impella would lead to… The Impella is usually a bridge to a heart transplant. I don’t know whether they-
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Juan: Okay.
Patrik: I don’t know whether they explained.
Juan: No, they didn’t mention.
Patrik: Right, right. The other issue is this, let’s just say even if a heart or a lung transplant are an option, the longer your mom stays in an induced coma and stays on the atracurium, the lower the chances a transplant will succeed.
Juan: Right. Right.
Patrik: Right. So that is sort of an issue. How experienced are they in this place, in this ICU with ECMO and balloon pumps?
Juan: They’re quite experienced.
Patrik: Okay.
Juan: They’re some of the best in the country.
Patrik: Okay.
Juan: So in that sense, she is getting the best level of care.
Patrik: Yeah.
Juan: We’ve been consulting various doctors around the world as well, and in the country. I mean, generally speaking, they’ve all sort of been like, “This is what we would recommend and she’s getting the best care and there’s not that much more that they would be able to add. That’s sort of the situation. I guess my question is that, do you feel like the balloon pump may not do the work of what they’re expecting it to do to be able to get
off the ECMO, was-
Patrik: Great question. Great question. So let’s just say, the best case scenario is to remove ECMO and balloon pump. Okay. That obviously would be the best case scenario. Let’s just say they go about it to go from VA-ECMO to the balloon pump. I have not seen that. And it sounds to me like this is a last ditch effort, without being negative, but I have not seen it the other way around. The other challenge that you have with ECMO or with
balloon pump is you have a very high infection risk because of the lines. You also mentioned earlier, she’s got a PA catheter in. Does she still have the PA catheter?
Juan: Yes.
Patrik: She does.
Juan: Yeah.
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Patrik: Okay. Do you know her cardiac output or her cardiac index?
Michelle: From the PA catheter?
Patrik: Yes.
Michelle: It’s there on one of the photos we’ve shared. Just look at it.
Patrik: Oh, okay. Hang on. Hang on.
Patrik: Hang on. I’m just looking…
Michelle: It’s the yellow-
Patrik: Oh, yes. Yeah, yeah. Sure. Yeah. No, I can see it now. I can see it now. Her CO2. That’s her CO2 and heart rate. Hang on. Just looking at it now. Just give me a second.
Michelle: It’s on the dragger.
Patrik: Oh, yes. Yes. Yes. Hang on. Yeah. Hang on. There it is. Yeah, but that’s just showing the PA pressures, which are… Oh yeah, here it is, 4.6. Okay, 4.6. I can’t see her cardiac index, but if you’re telling me she’s 92 kilos, I would argue that her cardiac output is a little bit low, considering the level of support she’s on. That’s a sign. That’s a sign that the support can’t really be removed any further. So if you were to remove
VA-ECMO… So for a 70 kilo person, you should be having around five liters per minute in cardiac output. Your mom is 92 kilos, right?
Juan: Right.
Patrik: So you’re talking about 70 mls per kilo. 70 times 90 is… What is that? That’s around 80. That’s 56. Is that right? Five. No-
Michelle: 630.
Patrik: 630. You can see why I’m concerned that once she’s on VA-ECMO, and once she’s on the balloon, and her cardiac output is 4.6, it’s too low. So what you could be looking at is, again, ask them, can they add in a little bit of Dobutamine or Milrinone.
Juan: Sorry. Could you-
Patrik: I’ll text that to you. I’ll text that to you.
Juan: Okay. Sure.
Patrik: Okay. And see what they say. I’ll just text this to you now. That would be one thing that might help.
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Juan: Okay.
Patrik: That’s certainly something that I’ve seen.
Juan: So you believe this would help in them being able to improve the cardiac output.
Patrik: Very much so. Very much so.
Juan: Okay.
Patrik: Just going back. With the cardiac output, or with the PA catheter, how many days has it been in?
Juan: About five or six days with the PA catheter.
Patrik: Right. The problem there is as well. The problem there is that it can’t stay in forever, huge infection risk. Huge infection risk.
Juan: So we can ask them when they plan to remove it.
Patrik: Very much so. The other thing is, with VA-ECMO, once her cardiac output is 4.6 at the moment, once you take ECMO off or you wean it off, hopefully her cardiac output will come up. But again, that’s part of the weaning study.
Juan: Right. So we can ask them about the weaning study.
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Patrik: I think you need to. What I can see, which I believe is a good thing. She seems to be in a regular sinus rhythm. Do you know what a sinus rhythm means?
Juan: I don’t. Do you guys know? No. None of us do.
Patrik: Okay. So the heart should be beating in a regular rhythm ideally. And that seems to be the case in your mom’s situation. A normal heart rhythm is called a sinus rhythm.
Juan: Okay.
Patrik: Okay.
Juan: Does that mean no arrhythmia?
Patrik: No arrhythmia. Exactly. That’s what it means. Especially since your mom had a heart attack in the past, do you know whether your mom had irregular heart rhythms in the past?
Juan: No, we don’t know.
Patrik: You don’t know. Okay. It looks to me like she’s in a sinus rhythm by all accounts. Which-
Juan: They just mentioned to us that she has no arrhythmia-
Patrik: Good. There is-
Juan: She actually had a doppler. If I’m not mistaken, they did that this morning to just check that her blood flow was all right and that there were no clots. That just came to my mind.
Patrik: Yeah. No. No, that’s important.
Juan: And there weren’t any clots. Yeah.
Patrik: That’s important. The only concern that I have is, when I look at the blood gas, and her potassium is 3.1. Okay. That’s fairly low. And I can see in the pictures that she’s on a potassium infusion. That’s great. If they’re not managing potassium well, she is at
risk of going into an irregular heart rhythm. It’s just a case of monitoring.
Juan: Okay. Okay.
Patrik: Okay. So you then ask in your texts or in your email, you ask about nutrition. Oh, hang on. Before we go to nutrition, what happened with the kidneys? Why did they start dialysis?
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Juan: So she had a lot of third spacing. She was really bloated and there was fluid around the lungs, and there was just a lot of fluids. They believed that was putting a lot of pressure on the heart. It was affecting the beating, and they needed to get the fluid out. So in order to do that, they added the hemofilter and yesterday she passed about three liters of urine. And through the hemofilter, they took out about six liters. And they
said today they were hoping that they would remove another 500ml, but they would wash the sodium. They were assuming that she would pass in another one, one and a half liters on her own as well.
Patrik: Right. And obviously, she’s on Lasix. I can see that.
Juan: Is she currently on Lasix?
Patrik: Well-
Juan: They give it sometimes. Yeah, they give it occasionally.
Patrik: It’s part of the medication list that you sent through.
Juan: Yeah. Yeah.
Patrik: Okay. The third spacing could be part of the low albumin. Right?
Juan: Yeah.
Patrik: The question is, are they replacing albumin?
Juan: No. Earlier they said that they were considering it. They’ve done it once. She didn’t react well to it I think. So they were kind of avoiding that again. And then they have to do a blood transfusion, so they did the blood transfusion. They said that they generally don’t supplement the albumin otherwise, but now that she’s increased her protein intake, they hope slowly that will have an impact.
Patrik: Right. Right. Because the third spacing is probably a combination of fluid overload and albumin being low. It would be good if you had blood results as well.
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Juan: So we got her latest blood report at 8:00 this evening. The hemoglobin was at 7.5. Her platelets were at 144,000 and her WBC count was 10.
Patrik: Okay. That’s all right.
Juan: Her CRP in the morning today was at 2.3.
Patrik: Okay. And sodium?
Juan: Sodium in the blood was 155 this evening. Yeah, so they want to manage that as well.
Patrik: Right. What do they want to do with that? Do they want to give her some water?
Juan: No, I think that they’re a little wary of water since they’re trying to offload water.
Patrik: Exactly. Exactly.
Juan: I don’t know what they were planning to do. They said they were going to talk about.
The 1:1 consulting session will continue in next week’s episode.
