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
How Can My Critically Ill Mom Wean Off From ECMO in the ICU?
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 post COVID in ICU with a
tracheostomy, IABP, and is on ECMO. Juan is asking how he will know if his mom is getting better with ECMO.
My Mom is Post-COVID in ICU and How Do I Know if She is Getting Better with ECMO?
Juan: The VA-ECMO because that just took everyone by surprise. And then I guess weaning her…
Kevin: It’s also because she picked up some bugs in there. Some fungal infections, some…
Kevin: A bunch of things. ICU induced bugs or whatever.
Patrik: Right. That was my next question. Does she have an infection besides the COVID?
Kevin: So now everything seems to have settled, but when she desaturated right before they put her on the ECMO, she had about two or three bugs, fungal bugs. And had heavy congestion and things of that sort.
Patrik: Right. Okay. Coming to the COVID or coming to the lung infection as such, does she have tracheostomy?
Kevin: Yes, she has a tracheostomy.
Patrik: How long ago has she had the tracheostomy?
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Kevin: About 17 days. Over two and a half weeks or three weeks maybe.
Patrik: Okay. Okay.
Kevin: Between two and three weeks. Around two and a half weeks probably.
Patrik: Okay.
Kevin: Because after 10 days, they didn’t want to leave the endotracheal tube in her mouth anymore, so they did the tracheostomy.
Patrik: And that was after she had gone on ECMO.
Kevin: No, prior to ECMO.
Patrik: Oh, that’s interesting. Okay. That’s interesting. Okay, good. I’m glad she’s got one, one way or another. What I am a little bit concerned about is, you’ve sent me the pictures of the infusions. I can’t see it in detail but he’s on Midazolam and on Fentanyl.
Kevin: And Atracurium.
Patrik: Oh my goodness. Right.
Kevin: So Atracurium is her paralytic because every time they try dropping it, she start fighting it and fighting the ventilator.
Patrik: That’s not good. Okay. You haven’t sent me-
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Kevin: Having said that, even though she’s on this right now, she wakes up and she’s fighting all these sedatives and the paralytic. She’s moving her head. She’s nodding, her tongue is coming in and out. She’s responding to us when we talk to her, basically.
Patrik: I was just about-
Kevin: … despite being on her-
Patrik: Right. So you can actually visit her and you can see her.
Kevin: Oh yes. We’re fortunate to be able to go as much as we want a couple of times. And because she came into the hospital with a very high CT value of COVID. And after four days or five days, they moved her out of the COVID ICU, into the regular ICU, because
they did the test again and there was no COVID left.
Patrik: Right. So you would argue she’s COVID free at the moment?
Kevin: Oh yes, because there’s no active viral replication going on. Also, when she came in, she didn’t have a fever, she didn’t have any of the major COVID symptoms.
Patrik: COVID symptoms. I see.
Kevin: Apart from breathlessness.
Juan: But they said that the breathlessness is also because of the heart attack.
Patrik: I was-
Juan: an extensive damage to the lungs.
Patrik: Yes. I was just about to say. So the breathlessness could have been part of the heart attack.
Juan: Yeah. So we were initially quite concerned that they would focus more on treating her for COVID and sort of ignore the heart issues because as I mentioned to you in my message, it was a week where she forgot completely to take her heart medication.
Patrik: Yes.
Juan: Everyone was so focused on the COVID. We’d just been realized that it went seven days without her blood panels and then she had the heart attack.
Patrik: Right. Right. Okay. But now they’re basically saying that she’s got pulmonary fibrosis. Is that what they’re saying?
Juan: Yes. They’re saying that’s one of the major issues. Obviously, they’re seeing her as a post COVID, post pneumonia, heart attack, other infectious, post kind of all of these issues combined. And they say that the pulmonary fibrosis and the heart scarring are definitely the issues, but
her heart seems to be performing better and they’re more concerned about the lungs.
Patrik: Yes. Now they are more concerned about the lungs. I get it. Yeah. Yeah. Okay.
Kevin: Also the heart is completely offloaded right now because she’s on ECMO and her IABP or intra-aortic balloon pump.
Patrik: Yeah. I guess the heart and the lungs should be completely offloaded at the moment.
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Juan: Yeah. Yeah.
Patrik: Which is-
Juan: They also inserted PA catheter or pulmonary artery catheter a few days ago, maybe six days ago.
Patrik: Right.
Juan: So that’s in her as well.
Patrik: Right. Okay. This is why I asked you earlier about her weight. So when you’re sending me the picture of the ECMO, it looks like her cardiac output is around 5.1 liters per minute.
Juan: Right.
Patrik: Right?
Juan: Yes.
Patrik: And if they’re trying to reduce ECMO or VA-ECMO, her cardiac output should remain stable.
Kevin: They haven’t tried to wean off the ECMO, since before they put in the IABP. Because before they put in the IABP, they were trying to wean her off, and then the blood pressure would drop and the saturation.
Patrik: Yeah, I see. I see.
Kevin: Because she had come down to 2.4, 2.5 of the liters per minute, prior to putting in the IABP. But because the blood pressure was dropping and slight saturation was dropping, they added in the IABP. And since then, the blood pressure, as I said, has been on the higher side, but they’ve not tried moving any weaning since they added the IABP, they just want her to remain stable and for the lung situation to improve.
Patrik: Yeah.
Kevin: They haven’t tried any weaning in the past two days.
Patrik: I see. I see. With the atracurium. How long has she been on that for?
Juan: Since the beginning. I mean-
Patrik: Oh my goodness.
Juan: All three have been on from the beginning at different levels.
Patrik: Sure.
Juan: That’s been on since the beginning, and that’s been one of our concerns. I mean, in all fairness, they have tried to wean some of this off, but she desaturates or her BP… Yeah, it’s been tough.
Patrik: Right. Yeah, I can see that.
Juan: She has a bit of the hyper nature. Generally, she’s not a relaxed person at all, so she does get very hyper and agitated and-
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Patrik: Sure.
Juan: Whenever they do drop the sedation. I think another thing was, we had been told that there was an option to use Dexmed instead of one of the sedatives, but that’s just something that’s been floating around but no decision has been made on that.
Patrik: Right. Okay. Hang on. Are you talking about Dexamethasone in terms of steroids, or are you talking about-
Kevin: Dexmedetomidine.
Juan: No. Dexmedetomidine as the sedative.
Patrik: Precedex. Yeah. Okay. I would be very surprised if they’re using Precedex whilst she’s on atracurium. Even I can see in the pictures, it says 4 mgs an hour of Midazolam. That’s not a lot when she’s on atracurium, but it is what it is. I assume its 4 mgs an hour from what I can gather from the picture. Yeah. Right. And Fentanyl, do you know how much Fentanyl? It’s not quite clear.
Juan: Four.
Patrik: Four as well.
Juan: That’s four as well.
Patrik: Okay.
Juan: five.
Patrik: Right.
Juan: Atracurium was at 8 at one point, and then in the last few days it’s been dropped.
Patrik: Right. Is she being fed through a nasal gastric tube?
Juan: Yes.
Patrik: And she’s-
Juan: In the middle, about a week ago, she had a bout of diarrhea and she wasn’t tolerating her feeds, so they had to drop the protein intake. But now they’ve opted again. She’s at about 1.4 to 1.5.
Kevin: 5 grams per kilo of body weight.
Patrik: Right. Okay. And she’s absorbing her feeds?
Kevin: Oh yeah. Yeah. Yeah. Yeah, she’s absorbing her feeds well now.
Patrik: Okay. I mean, it’s important in any situation, but it’s even more important given that she’s on Atracurium.
Kevin: Right. Her albumin is quite low-
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Patrik: Yes, I saw that. I saw that. Well, that leads me to the blood transfusions, which she obviously didn’t tolerate all that well.
Kevin: Right.
Patrik: How low did her hemoglobin drop?
Kevin: 6.5, 6.6.
Patrik: Oh my goodness.
Patrik: How long ago-
Kevin: A couple of days ago. About four days ago.
Patrik: Why do they think hemoglobin has dropped so low?
Kevin: It’s because she’s on so many machines and the heparin and everything.
Patrik: Yeah. Makes sense. Makes sense.
Kevin: And because she’s been so unwell for so long now.
Juan: But now that they’ve offloaded so much fluid, her hemoglobin is looking up a bit as well.
Patrik: Well, in the blood gas it’s 8.1.
Juan: Yeah.
Patrik: Which is okay, given the situation she’s in, but it could be higher of course. But then there’s the issue about the tolerance of the blood transfusion of course. Okay. So the reason I’m asking about absorbing feeds is simply, if she’s on atracurium, that’s and can be an issue about absorbing feeds because that’s paralyzing agents, and it’s also paralyzing the digestive tract.
Juan: Okay.
Patrik: That’s why I’m asking. But if they’re saying she’s absorbing feeds, well, I guess that’s given then.
Juan: Yeah, she’s absorbing the feeds right now I guess.
Patrik: Okay. And she’s opening bowels. There’s no issue there.
Michelle: Every two or three days.
Juan: Every couple of days.
Patrik: Good, good, good.
Juan: She had two or three days where she didn’t, then I think she did again.
Michelle: Every two or three days she passes the stool.
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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. Okay. 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.
The 1:1 consulting session will continue in next week’s episode.
