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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip and question answered today for one of our members. Actually, I want to show you again what you get if you have become part of our membership for families of critically ill patients at intensivecaresupport.org.

So, I’m just reading out one of our member’s questions and how we answer that so you can see what you get when you’re a member of our membership. So, one of our members says,

“I have several questions that I’ve been researching on my own in the last few days. We get about 60 seconds with these doctors in ICU and I pick and choose what I think are the most important questions and then I don’t trust them anyway. Would you be able to help me with some of those random questions?

As an update, my dad has been off the IV pressors and inotropes for about 48 hours now. His MAP (Mean Arterial Blood Pressure) has been in the 60s, which I don’t really like, because if just one thing changes, his MAP (Mean Arterial Blood Pressure) will go into the danger zone. Regardless, the doctors are already trying to get him to LTAC and planned discharge tomorrow. I really just think they are so careless with my dad, and it infuriates me. The LTAC (Long Term Acute Care) doesn’t have any private rooms available at the moment. So, my dad is going to go to the dreaded hospital step-down unit, likely tomorrow.

He’s taking what they call the maximum dose of midodrine, 30 milligrams every 6 hours. Just for your explanation watching this, midodrine is a vasopressor or inotrope. This is what he was taking in the days leading up to septic shock. He never needed to take midodrine regularly until this hospital visit when they said he had heart failure and did a midodrine, metoprolol, Lasix combination, then started the GDMT heart failure regime, and then had to stop the metoprolol and consistently increase the dose of midodrine until they let him go into septic shock. When he had dialysis today, his MAP went into the 50s. I just think this is so reckless and he shouldn’t be leaving the ICU until his blood pressure is better. Do you agree?”

Now, just as a side note here, if he’s going to a hospital step-down ICU with that much midodrine, that’s dangerous. I’ll tell you why, as some of you know, also running Intensive Care at Home and you can find out more information at intensivecareathome.com. Now, we have a client at home with Intensive Care at Home that’s ventilated, has a tracheostomy that’s also on midodrine. He needs an intensive care nurse, 24 hours a day.  Now, they want to send this man to a step-down ICU, doesn’t sound safe to me.

But again, the biggest challenge for families in intensive care is 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.

This is what we’re dealing with on a day-by-day basis, but you will see how we help this lady when we answer her questions.

Also, if they’re doing a combination of midodrine, metoprolol, Lasix, that’s a dangerous combination. You don’t really give metoprolol with midodrine because they’re antagonistic.
Metoprolol is lowering blood pressure. Midodrine is getting blood pressure up. That’s why it’s so important that you, as a family, question everything. You need to question everything, and you need to take full responsibility for what’s happening. Otherwise, you won’t be getting anywhere.

Now, continuing with the email from our member, “He got a “permacath” today, which I read about and asked them to confirm that it can be removed. Dad has been on dialysis for approximately 11 to 12 days, starting with CRRT. CRRT stands for Continuous Renal Replacement Therapy, also known as hemofiltration, and then doing regular dialysis for approximately the last week. Not every day and removing varying levels of fluids, each time based on blood pressure. Every day, he has been producing more and more urine. Monday was about 200 mls. Yesterday, it was 300 mls and today it was close to 400 mls. The nephrologist said this is a good sign and I agree this is a good sign.

They haven’t been trying him on spontaneous breathing trials. They turned off pressure support completely a few days ago to see if he could go back on the tracheostomy collar after not even weaning for over a week since the dialysis started. Again, I’m extremely infuriated by the incompetence. Why in the world would you just turn off the pressure support completely and see if we can do the tracheostomy collar?! He needs to wean!”, and I agree with that. It is a gradual process. It’s not just stopping everything, and “sprinting”. It is a term that is sometimes used in intensive care when you want to wean a patient off rapidly I have not seen that being a good approach and work.

“So, he needs to wean slowly, just like you have to wean off the pressors, slowly.” Again, our member is very correct here.

“I don’t understand what they’re doing, and the respiratory therapist agreed that it didn’t make sense. I’m actually eager to get to the LTAC in a way because these doctors are insane.

Dad has been talking, moving his limbs and his head a bit, and he even did math problems with me yesterday when I was trying to add up the output from his drainage bag and divide to see how many mls per hour he was putting out. Thank you, Lord!

Here are my random questions. I don’t think they’re random questions. Hypotension after septic shock, why is that still on midodrine? When will he be able to get off the midodrine? They didn’t echo two days ago but apparently there is no information as to his heart function until the cardiologist writes up the report. They only know that there is no endocarditis.

Dad’s lips have had bloody blisters all over them beginning a couple of days after septic shock. 23rd of July was the septic shock. Someone suggested it’s because he gained so much weight with fluid retention that his lips swelled and as he has lost some of the fluid weight, these blisters formed. Is that likely? Could it be something else that they’re missing?

Could the Eraxis anti-fungal antibiotic for the infection be causing the low blood pressure and kidney problems? It did really seem like it based on the website side effects listing. Maybe a contributing factor? They also started Cresemba last week.

Number four, is there an albumin supplement I can ask the doctors to give? I ask them constantly to give protein supplements like ProSource or ProStat but is there anything stronger?

Thank you as always.”

Here is my response, “Thank you for sharing this with us your dad’s current progress. Given your dad’s current situation, he remains in a vulnerable state, having recently experienced septic shock and with the discontinuation of inotropes just two days ago. Currently undergoing dialysis with unstable blood pressure adds to the complexity. Considering these factors, it’s not advisable that they transfer him to LTAC at this stage. Rushing his transfer might result in him returning to the ICU which we don’t want to happen and has happened before. It is important that they need to stabilize his condition first and address all concerns while all the experts are around. This approach will ensure a safe transition out of the ICU considering his complex medical history.

It’s good to note that he’s producing more urine by the day, which is a very positive sign. and you are right, spontaneous breathing trials/gradual weaning off the ventilator should always take place to monitor his tolerance.

On a brighter note, your dad’s ability to talk, move his limbs and head a bit, and even participate in math problems with you is truly remarkable.

Here are my answers to your questions below.

Number one, hypertension after septic shock, why is your dad still on midodrine? When will he be able to get off that? They did an echo (echocardiogram) two days ago but apparently there is no information as to his heart function until the cardiologist writes up the report. They only know that there is no endocarditis.

Well, midodrine is being given to your dad, particularly following his recovery from septic shock to continue improving his blood pressure/circulation and overall cardiovascular function. In addition, given that he’s on dialysis, that potentially lowers his blood pressure. Midodrine can help in maintaining a stable blood pressure levels for him. Otherwise, the decision to discontinue midodrine, especially in your dad’s case, depends on several factors which includes maintaining acceptable blood pressure levels with adequate tissue perfusion and his response to dialysis. It is also best to involve his cardiologist regarding this.

Number two, dad’s lips have bloody blisters all over them beginning a couple of days after the septic shock, 23rd of July was the septic shock. Someone suggested it’s because he gained so much weight with fluid retention that his lips swelled and as he has lost some of the fluid weight, these blisters formed. Is that likely? Could it be something else that they’re missing?

The presence of bloody blisters on your dad’s lips is a concern and the doctors need to thoroughly assess and examine these blisters taking into consideration his overall health, medical history, and any other relevant symptoms. Blisters may be caused by various factors including medication side effects, allergic reaction, skin irritation, or potential underlying condition.

Number three, could the Eraxis antifungal antibiotic for the infection be causing the low blood pressure and kidney problems? It didn’t really seem like it based on the website’s side effect listing. Maybe a contributing factor? They also started Cresemba last week.

Now, regarding his anti-fungal antibiotics, every individual’s response to medication can vary. So, there might be a possibility that these medications might cause low blood pressure and kidney problems for your dad. They should closely monitor him for these potential side effects and interactions and promptly manage them. Otherwise, this is where the benefit over risk comes into play.

Number four, is there an albumin supplement I can ask the doctors to give? I ask them constantly to give protein supplements like ProSource or ProStat, that but is there anything stronger?

Albumin is a protein that plays a crucial role in maintaining blood volume and transporting various substances throughout the body. Albumin supplements can be considered in specific cases, particularly for individuals with low albumin levels, which can result from factors like certain medical conditions or inadequate protein intake. However, the use of albumin supplements is typically determined based on your dad’s needs and medical history. Otherwise, treatment to address the underlying condition can improve albumin protein levels.

Both ProSource and ProStat are good options known for their protein content and potential benefits in enhancing protein intake. It is best to discuss this with the nutritionist to assess your dad’s nutritional status, albumin levels, and overall health to determine what supplements would be beneficial and appropriate for his condition.

I hope this information helps. As always, should there be any recent progress reports available, you can also send them to us so that we have a clinical insight based on the recent results of his blood works and any diagnostic exams done, doctors’ and nurse’s, documentation, ventilation settings, arterial blood gases, chest x-rays, ultrasounds, et cetera to determine his next course of care plan.

Thank you so much.

We continue to pray for your dad’s healing and recovery. Take care as always.”

Now, if you want the same level of attention and questions answered when you have a loved one in intensive care, go and check out our membership for families in intensive care at intensivecaresupport.org. There, you have access to me and my team, 24 hours a day, in a membership area and via email and we answer all questions intensive care related.

I also offer one-on-one consulting and advocacy over the phone, via Skype, via Zoom, via WhatsApp, Google Meet, whichever medium works best for you.

We also offer medical record reviews in real time if you want a medical record review in real time and the second opinion, please contact us as well. You can contact us at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions. We also offer medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are simply suspecting medical negligence.

Now, if you find value in those videos and if you like them, 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 and what questions and insights you have from this video, and share the video with your friends and families.

Thank you so much for watching.

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

Take care for now.