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Quick Tip for Families in Intensive Care: Is it Too Early for My Dad to Go to Step-Down ICU? He has a Tracheostomy & Compromised Ejection Fraction.

Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

Today’s tip is about another question answered for one of our members in our membership for families of critically ill patients in intensive care, which you can find at intensivecarehotline.com on our membership link or at intensivecaresupport.org.

If you want to have your questions answered by myself or by my team in our membership area, click on the link and sign up for our membership for families of critically ill patients in intensive care.

Now, also if you like my videos, subscribe to my YouTube channel, click the like button, click the notification bell, share the video with your friends and families, and comment below what video you want to see next.

Now, let’s go to our member who is asking questions and who has her father in intensive care. And she writes,

 

Hi Patrik and Team,

Thanks for your last email.

I read the email to dad. I just transferred my dad to the step-down ICU this morning after a week in the ICU. We are waiting for a bed at the LTAC to open, but we really don’t want that. Dad’s urine output is still decent – It seems to vary day to day, the nephrologist said. I asked him if it’s because of dad’s sodium being high and him being dehydrated and he said he has asked them to do some kind of test to determine the fluid volume. He’s getting dialysis today, but no fluid will be removed, just a blood cleaning.

Dad’s been off the vasopressor and the inotropes for three days but still has the maximum dose of midodrine. We asked the ICU several times to wean the midodrine before going to the step-down ICU, but they couldn’t.

Dad’s cardiac output and ejection fraction have improved greatly. I have attached the last two echocardiograms. One was the transesophageal ultrasound. So, I don’t really understand why his blood pressure is still low. They aren’t growing anything in any of the cultures. Is he still healing from the septic shock? He did 8 hours on the pressure support ventilation yesterday, 15 pressure support, 5 PEEP, 30% of oxygen. I know my dad can work back to the trach collar once we get this low blood pressure issue figured out.

I feel like dad is getting better every day because his kidney function is getting better. His heart numbers look better. He’s doing the pressure support trials, but his blood pressure is still low which makes us and the doctor’s nervous and he’s still feeling very tired, resting most of the days.

Thank you so much for your email and for keeping us updated on your dad’s current condition.

 

Here is our reply.

As you mentioned, your dad has recently been moved to the step-down ICU following a week in ICU. We strongly recommend against rushing his transfer to LTAC.

Obviously, this is a client in the U.S. LTACs only really exist in the U.S. LTAC stands for long-term acute care facility. And many ICUs want to send patients to LTAC.

We strongly advise against it simply because LTAC are not even the better version of nursing homecare. There is very substandard, dangerous and people die if they go to LTAC. They do not get off ventilators. Very few LTAC have the skill to wean patients that come from ICU off the ventilator and the tracheostomy.

So, we strongly recommend against rushing your dad into LTAC until significant issues have been fully addressed in the ICU, especially since his vasopressors have just been off three days back and are currently on the maximum prescribed dose of midodrine. Midodrine is also a vasopressor.

You mentioned that his urine output is still decent. It’s important that they closely monitor his fluid intake and output, do regular weight checks, and perform routine blood tests to assess his fluid status and measure the amount of waste products such as creatinine and BUN (Blood Urea and Nitrogen), and other related tests to help assess the effectiveness of the dialysis treatment.

I have seen the result of his echocardiogram and you’re right that there has been an improvement in his ejection fraction. However, his most recent echo done only the 17th of August still indicates a reduced ejection fraction calculated at around 41%. Now, for reference, the normal ejection fraction typically falls within the range of 50% to 70%. Thus, midodrine helps in addressing the issues associated with his decreased ejection fraction and symptomatic low blood pressure.

Now, for anyone who’s wondering what ejection fraction is, it basically makes reference to the contractility of the heart, how strong the heart can beat and can pump.

In addition, your dad is currently on dialysis treatment and low blood pressure is a common issue that can occur during dialysis or ultrafiltration. Dialysis removes excess fluids from the body, which can sometimes lead to rapid changes in blood volume. This can cause a drop in blood pressure, especially if the fluid removal is too aggressive. Slowing down the rate at which fluid removal is happening can help prevent drops in blood pressure.

To add in terms of his low blood pressure, they may also need to check his hemoglobin levels to see if it is within his acceptable range. Anemia is a condition characterized by a decreased number of red blood cells or a decreased ability of these cells to carry oxygen. Severe anemia can lead to low blood pressure because there aren’t enough red blood cells to deliver oxygen to the body’s tissue. In such cases, a blood transfusion can help by increasing the number of red blood cells, especially if his hemoglobin falls below 7 and improving oxygen delivery, which can, in turn, help stabilize blood pressure.

Furthermore, adequate hydration can help maintain acceptable blood pressure.

Complete recovery from septic shock can take a long time depending upon the severity of the infection and how the sepsis has been managed.

He did 8 hours on pressure support yesterday which is good and requires minimal ventilator settings with FIO2 (inspired oxygen) of 30%, PEEP of 5. We hope he continues to improve and be weaned off back to the trach collar.

Please see the details below from the ultrasound results you sent.

Transthoracic echocardiogram examination on the 17th of August.

Indication: heart failure, evaluate ejection fraction, left ventricular outflow tract velocity time integral

Biplane left ventricular ejection fraction is calculated at 41%.

Global hypokinesis is present. Hypokinesis once again refers to the contractility of the heart being reduced.

Mild Mitral Regurgitation

Trileaflet Aortic Valve

Mild or aortic regurgitation is present.

Aortic leaflets exhibit calcification.

The tricuspid regurgitant velocity is 274 centimeters per second.

Limited study performed to evaluate ejection fraction.

 

Transesophageal echocardiogram examination (TEE) on the 8th of August

Indication: endocarditis

Blood pressure: 100/50

Heart rate: 88

 

Conclusions:

Severely reduced systolic left ventricular function.

Ejection fraction evaluated by visual assessment.

There is global hypokinesis with regional wall motion variation.

Normal size, right ventricle

Right ventricular systolic function is normal.

Mild mitral regurgitation.

The calculated stroke volume is 44 mls per beat. The stroke volume index is 22 mls per square meter.

Trileaflet aortic valve.

Mild aortic regurgitation is present.

There is severe aortic stenosis. The findings are consistent with low flow gradient aortic stenosis. Consider cardiology evaluation or dobutamine stress echo test to assess the aortic valve if clinically appropriate.

No valvular vegetations identified.

Bubble study negative for intrapulmonary and intracardiac shunt

Stroke volume 65 mls

Cardiac output 5.9 liters per minute.

 

We always pray for your dad’s continued healing and recovery.

Keep us posted.

Take care.

 

So that’s the question answered for one of our members.

Now, if you want to have your questions answered when you have a loved one in intensive care, become a member of our membership for critically ill patients in intensive care at intensivecarehotline.com.

Click on the membership area on the website or go to intensivecaresupport.org directly and get access to the membership there. In the membership area, you have access to me and my team 24 hours via email and we answer all questions intensive care related.

And I also offer one on one consulting advocacy over the phone, via Skype, via Zoom, via WhatsApp, whichever medium works best for you. And I ask all the questions to the intensive care team you haven’t even considered asking, but you must ask so that you can get peace of mind, control, power and influence and so that you can make informed decisions.

I also represent you in family meetings with intensive care teams once again, so that you can make informed decisions, get peace of mind, control, power, and influence. I would not go into a family meeting without an advocate there and without clinical representation which I can give you. I have worked in intensive care for over 20 years in three different countries.

I have worked as a nurse manager in intensive care for over five years. I have been consulting and advocating for families in intensive care all over the world here at intensivecarehotline.com for over 10 years, getting massive results for our clients as is evidenced in our case studies and our testimonials.

We also offer medical record reviews in real time so that you can get a second opinion in real time. We also offer medical record reviews after intensive care if you have unanswered questions, if you need closure or if you are suspecting medical negligence.

Like I always say, the biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights and they don’t know how to manage doctors and nurses in intensive care. That’s exactly what we do here at intensivecarehotline.com. Making sure you make informed decisions, get peace of mind, control, power, and influence.

Now if you like my video, subscribe to my YouTube channel for regular updates for families in intensive care, click the like button, click the notification bell. Comment below what you want to see next or what questions and insights you have from this video and share the video with your friends and families.

Thanks for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days.

Take care for now.