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If you want to know what it looks like when your loved one goes to LTAC and then bounces back into ICU, stay tuned. I’ve got news for you.

Hi, my name is Patrik Hutzel from intensivecarehotline.com, and I have another quick tip for families in intensive care today.

So, we’ve been working with a client a while ago who had their loved one in LTAC (Long-Term Acute Care) when they first signed up. The client is in the U.S., obviously. When the client was in LTAC, when we looked at the notes and the medical records, we said, “Look, your mom should have never gone to LTAC in the first place because she simply wasn’t fit and well enough to go to LTAC.” 

As you’ve heard me say before on this channel, LTACs are not even the better version of a nursing home. So, think about this. Your loved one is in ICU, ends up with a tracheostomy and the PEG (Percutaneous Endoscopic Gastrostomy) often, then goes to LTAC. That’s a critically ill patient that is extremely vulnerable going to a nursing home. This is sheer and utter madness, and it needs to stop. But it’s also up to you to stop it. It all comes down to taking full responsibility for what is happening and putting a stop to it because it can be stopped. We have helped so many families in intensive care over the years to avoid a transfer and an admission to LTAC so that their loved ones can get best care and treatment.

So, let’s look at the situation in more detail when our client’s mother bounced back into ICU after a short LTAC admission. I should say it was only a few days which, again, confirms what we’re always saying is that most patients go from ICU to LTAC prematurely, and they should never go in the first place. Look at the online reviews of LTACs, that will tell you everything you need to hear.

So, this is a report from the client, sent in an email:

“4 pm blood results. First hemodialysis was from 11:25 am to 1 pm. Some good results after the first session:

BUN (Blood Urea Nitrogen) went down from 137 to 98 mg/dl
Creatinine Serum / plasma went down a full point.
Estimated GFR went up 4 ml from 10 to 14
Potassium serum went up 0.2

Vitals stayed steady during and after.

This is the thing. Most patients in LTAC cannot get dialysis or hemofiltration. So, the first thing, when the client went back to the ICU, was to do dialysis and hemofiltration, and kidney function improved straight away.

Then, the client continues:

With ventilator settings the same as before dialysis, her SPO2 went up from 92 to 95 and then down to 93 at 6:30 pm.

Hemodialysis – Did only 1 1/2 hours today. Tomorrow – 2 hours. Usually do 3 days in a row, then every other day or 3 days a week. Pure ultra filtration on 4th day, then hemodialysis again on 5th day. What they do each time is based on her lab results. All went well. Vitals stayed close to same before and after. Heart rate – 81, Blood pressure – 126/48. Mom is 130 lbs and her pre hospital weight was probably around 110.

I think she’s allergic to latex so they can’t give her albumin to help speed up getting rid of fluid part of the dialysis. We believe the past allergy to latex thought is when years ago, she actually had a reaction to the adhesive on a patch.

I’ve certainly done my research and there’s nothing suggesting that a latex allergy is a contraindication to an albumin infusion. If albumin is low, it can cause a lot of harm including fluid retention, including third-spacing when excess fluids are stored in the tissues and can’t be going back into the vascular system, which is why albumin needs to be given in a situation like that. So, it seems to be like they’re making up stuff not to treat your mother.

So, then email continues,

Ventilator settings: 

(Day 2 after readmission to ICU from LTAC) Wednesday 65% of FiO2, Thursday 60% of FiO2, on Friday 65% of FiO2, 11th Saturday 80% FiO2, 12th Sunday 80% FiO2 – PEEP 8 every day in this ICU, now it’s sitting at 10. Maybe the FiO2 can start being turned down soon with dialysis helping to remove fluid from the lungs. My mom sounded very wheezy. Last week at the LTAC, we had 4 great weaning days on the ventilator, CPAP, and tracheostomy at 40% or maybe lower FiO2 and then 10 pressure support over PEEP 5, then 3 bad days with shaking before transferring back to ER and ICU where she is now on ventilator and is on full support at 80% FiO2 with PEEP of 10.

Bear in mind, this lady had a full-blown pneumonia now.

Then, he continues:

She’s on propofol for several days because she has been fidgety.

Now, the plan according to ICU now is monitor hemoglobin and hematocrit, continue supportive care, continue diuretics, continue with the sputum cultures, continue Linezolid and Cefepime which are antibiotics, and vasopressors as needed to maintain mean arterial pressure greater than 65.

So, this is actually important, maintaining a mean arterial pressure greater than 65. If the main arterial blood pressure is less than 65, there’s a high chance that vital organs are not perfused with enough blood and oxygen. This is particularly important for the kidneys, especially since our client’s mother is already in kidney failure. It’s going to be really important to continue maintaining that mean arterial pressure. If it can’t be achieved with just organically, his mother needs to be started on vasopressors or inotropes, and she most likely will be started when she’s on dialysis because that will most likely decrease the blood pressure.

When we looked at the medical reports for this particular client, yes, she was on norepinephrine on and off to maintain the MAP or mean arterial pressure over 65 ml/Hg. 

Hemoglobin was also trending down. It is now at 7.2. 

Normally, a blood transfusion should be given if hemoglobin is less than 7. Also, when someone is on dialysis, there’s a much higher chance that hemoglobin will drop further and that the blood transfusion needs to be given.

Furthermore, the chest X ray says there are interstitial and patchy airspace infiltrates throughout the lungs. Lung volumes are diminished. Moderate bilateral pleural effusions. No pneumothorax. No acute bony or soft tissue abnormality. 

We talked about the hemoglobin.

White cell count is 30.5 which is very high up from 24.7.

Normal white cell count is between 4 and 7, so that suggests a significant infection which means they need to do sputum sample, urine sample, as well as pathology test. They need to check the bloods for an infection as well. 

All other blood results are fine besides the kidney markers, BUN is 134, creatinine is 3.68 and GFR is 11.

So, it’s just another sign that you can’t have your loved one going into LTAC and you should reach out to us if you think your loved one is at the brink of going to LTAC. And one last word, do not give consent to a PEG tube. I’ve talked about not giving consent to a PEG tube for years and why you shouldn’t give consent to a PEG tube. That will be your backstop of your loved one not going to LTAC in a nutshell. But I’ve done plenty of videos about why not giving consent to a PEG tube when your loved one is in intensive care. Again, this is unique for our clients in the U.S. because LTACs don’t exist in other countries.

Lastly, the client’s arterial blood gas on 80% of oxygen, PCO2 – 43.2, PO2 – 70, pH – 7.37, which is just about normal.

But bear in mind, this is on 80% of FiO2 with a volume of 300 which is too low for this lady, even her weight. So, they need to free up lung capacity by clearing pneumonia, by doing some suctioning, maybe by draining secretions with either physical therapy, chest percussions, but also maybe with head down nebulizers and so forth. That would be the way forward, but the bottom line is to never ever go into LTAC.

I’ve worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. We have saved many lives with our consulting and advocacy. You can verify that on our testimonial section at intensivecarehotline.com. You can also verify it on our intensivecarehotline.com podcast section if you go to intensivecarehotline.com if you click on our podcast section. We have done some client interviews there.

Over the years, we have helped hundreds, if not thousands, of members and clients, which is why we created a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com If you click on the membership link or if you go to intensivecaresupport.org directly. In the membership, 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 there. In the membership, you also get exclusive access to 21 eBooks and 21 videos that I’ve personally written and recorded, sharing all my 2.5 decades worth of ICU and critical care nursing experience with you, making sure you make informed decisions, have peace of mind, control, power, and influence so that your loved one gets best care and treatment always.

I also do one-on-one consulting and advocacy over the phone, Zoom, WhatsApp, Skype, whichever medium works best for you. I will talk to you and your families directly. I will handhold you through this once in a lifetime situation that you can’t afford to get wrong. I also talk to doctors and nurses directly. When I talk to them directly, I ask all the questions that you haven’t even considered asking.

I also represent you in family meetings with intensive care teams.

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

All of that you get 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.

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Thank you so much for watching.

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

Take care for now.