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 Do I know if the ICU Team is Doing the Right Thing to Get My Mom Off 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, balloon pump
and is on ECMO. Juan asks if the ICU team has their own agenda that they don’t know whilst their mom is critically ill in the ICU.
Does the ICU Team Have an Agenda that We Don’t Know Whilst Our Mom is Critically Ill in the ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Juan here.”
Part 1
Part 2
Part 3
Part 4
Part 5
Part 6
Part 7
Patrik: Hey Juan, how are you?
Juan: I’m good, thank you. How are you Patrik?
Patrik: I’m very good, thank you.
Juan: There’s nothing else new.
Patrik: Okay, and what are they saying with the VA-ECMO coming out tomorrow?
Juan: I think that is the plan. So they are currently doing the procedure where they are moving the venous cannula to the arterial cannula line. I think that’s ongoing at the moment.
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Patrik: Why would they do that if they can take out VA-ECMO, why would they do such a procedure?
Juan: I think they were really concerned about the right leg.
Patrik: True.
Juan: Because it was swollen up quite a bit and it wasn’t settling down-
Patrik: Right. It’s still a question to me, why take ECMO out? Fair enough, that’s good and then the balloon pump is in, it still leaves the Milrinone and Dobutamine out of the picture.
Juan: Yeah we brought it up again and we’re going to bring it up one more time now. Once they complete this, so they were saying that they’re moving to a VAV tonight to remove the VA tomorrow.
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Patrik: Okay, and what about the balloon?
Juan: The balloon will still remain in for a little while.
Patrik: What does a little while mean?
Juan: I don’t know.
Patrik: Juan, does not make any sense to me having a balloon going and not using Milrinone and Dobutamine. It does not make any sense. I discussed this today with my team as well. And, anybody that’s on my team that’s looked after ECMO is saying the same that it does not make sense. You removing VA-ECMO, not using Dobutamine or Milrinone and keeping the balloon, but that does not make any sense whatsoever.
Juan: I don’t know. It seems just that here, they seem so confident about it, about the balloon.
Patrik: But can’t you see the infection risk? They might be confident about it and it might even work, but I do argue it’s putting your mom at risk.
Juan: So would you say that we should be removing the balloon pump?
Patrik: Absolutely.
Juan: And if they say that, her heart still needs the support?
Patrik: Well then I argue, I keep coming back, Juan to the ejection fraction of 30 to 35%. Okay, that is a good ejection fraction after what your mom’s been through, and it’s an ejection fraction that’s quite common after a heart attack or cardiac arrest.
Juan: So what do you think their reasoning is? If it is-
Patrik: I really don’t know. I have no idea what the reasoning is, I have never seen it. I could not tell you what the reasoning is, if I was you, I would want to know what the reasoning is.
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Juan: So given that they’re doing this moving of the cannula now, the moving of the venous cannula from the right to the left side.
Patrik: Yes.
Juan: Once that’s done and we speak with them, do you suggest that we, I mean, if the plan was to remove the arterial cannula tomorrow,
Juan: Do you suggest that we push the balloon pump to be coming off tomorrow?
Patrik: Well, no. What I would push for is, start the Dobutamine or the Milrinone.
Juan: Okay.
Patrik: Remove the balloon pump and then remove ECMO.
Juan: Okay, they mentioned some concern that the Dobutamine might like lower the BP.
Patrik: Yes it may initially, it may initially.
Juan: Okay.
Patrik: But then you could also add in a little bit of noradrenaline.
Juan: Okay.
Patrik: I still feel like… See here’s the other problem, blood pressure is also low because your mom’s hemoglobin is very low.
Juan: The hemoglobin’s low because she’s still on VA-ECMO.
Patrik: Correct, correct. It’s a vicious cycle.
Juan: It’s a loop, it’s a cycle, yeah.
Patrik: It’s a vicious cycle that I believe they can break.
Juan: Yeah.
Patrik: Look, I don’t.
Juan: How long between removing the balloon pump? How long after removing the balloon pump would they need to wait before removing the VA-ECMO?
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Patrik: Okay, let’s just say they remove the balloon pump now. Let’s just say they did that.
Juan: Okay?
Patrik: The question is what would happen to A) the VA ECMO and B) what would happen to then, would they need Milrinone or Dobutamine straight away? Here is another concern. So when I look at the ECMO machine from today assuming this is a picture from today-
Juan: Yeah it is.
Patrik: They increased the support compared to yesterday.
Juan: Yeah.
Patrik: Why is that? Why?
Kevin: They increased the support because there was a slight-
Juan: A fluctuation.
Kevin: There was slight fluctuation in the saturation.
Patrik: Yeah?
Kevin: She started waking up and fighting it and she was hyperventilating a bit and the blood pressure dropped a bit so-
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Patrik: Okay.
Kevin: So they increased it to compensate.
Juan: They’re planning to reduce it to-
Kevin: They’re planning to reduce it through the day tomorrow-
Patrik: Okay.
Kevin: Tonight. Sorry, tonight.
Patrik: Sure, okay, all right. Fair enough. The missing link to me is the Dobutamine and the Milrinone that is the missing link to me from my experience. And yes I agree that her blood pressure with the Dobutamine specifically might go down a little bit, but again the infection risk of having ECMO and balloon pump is just much higher than using the Dobutamine, potentially noradrenaline, and also topping up her low hemoglobin with the
blood transfusion. Is she still on dialysis?
Kevin: Yes, but they’ve not-
Patrik: They’re not using it, they’re not using it.
Kevin: They’re not using it.
Patrik: Yeah, fair enough.
Kevin: They did a blood transfusion today-
Patrik: Okay?
Kevin: … Because, the haemoglobin has fallen.
Patrik: Yeah, okay. I’m not saying that I have seen everything in ICU, that’s not what I’m saying. I think I’ve seen a lot, but I haven’t seen everything. It does not make any sense to me having that balloon pump in the mix without Dobutamine and Milrinone. And yes, blood pressure might go down a little bit, let’s use a little bit of noradrenaline then. Let’s use a blood transfusion to get hemoglobin up and maybe let’s use the dialysis
in case of fluid overload because of the blood transfusion.
Juan: And do you think it’s possible if after they remove the balloon pump today after they’ve gone and remove this venous cannula from the right to the left leg?
Patrik: Hard to say, when did they do the last echo of the heart?
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Juan: This morning.
Patrik: This morning, and that was 30 to 35% ejection fraction.
Juan: Right, yes.
Kevin: We can send you the video of the echo-
Juan: Echo.
Kevin: The echo.
Patrik: No need for it, I’m not a cardiologist. Yeah you could, I can see what contractility is there. I’m not a cardiologist, but it’s probably interesting to look at it for sure but… Okay I’ll just try to explain this to you. Let’s just say for argument sake, your mom’s heart attack had happened today. And she would be in a position with, after the heart attack, 25% of ejection fraction, they stented the LAD and let’s just rewind the time. Let’s go back to where it started.
Patrik: The first thing they would do is they would use the inotropes, they would use the Dobutamine and they would use the noradrenaline. That would be the first thing they would be doing. If that didn’t work, they would add in the balloon pump.
Kevin: Okay.
Patrik: If that didn’t work, they would go onto ECMO.
Kevin: Okay.
Patrik: They wouldn’t start the balloon without inotropes, no way.
Kevin: All right.
Patrik: So this is all… The cascade of treatment escalation, does not seem to be-
Juan: They’re going in a different-
Patrik: They’re going-
Kevin: Yeah.
Patrik: They’re turning it upside down from my experience, maybe there is something I just have never seen that..
Kevin: Okay.
Patrik: It doesn’t make any sense why.
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Juan: No sir I guess it’s worth… Yeah, I mean we have brought it up. We brought it up with two different doctors and I don’t know, they were… It’s not that they said no to the Dobutamine and Milrinone but it just wasn’t with as much urgency and even the balloon pump they were like, “No that’ll stay.” I don’t know. But yeah, we completely understand where you’re coming-
Patrik: Have you asked about the infection risk?
Kevin: Yes.
Patrik: And what are they saying about it?
Juan: Yeah they were going to take out the PA catheter today-
Patrik: Okay.
Juan: And then this happened, and then this took priority.
Patrik: Right and what are they saying with the infection risk specifically?
Kevin: They’re saying that there’s no less risk than there is from any of the other lines.
Patrik: Okay, all right. I dispute that. Yeah, again look, maybe there is something that I’m missing here, just-
Juan: Or maybe there’s something that they aren’t telling us, I don’t know.
Patrik: That’s what I’m fearing, there is something they’re not telling you and I don’t know what it is at the moment. Just trying to think… Is blood results today? Have you got them?
Kevin: The morning ones? Yes.
The 1:1 consulting session will continue in next week’s episode.
