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
My Mom is on ECMO Support for 25 days in ICU & Now She Has a Blood Clot in Her Lungs! Help!
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 now on VV- ECMO. Juan is asking how much longer can his critically ill mom be on ECMO in the ICU.
How Much Longer Can my Critically Ill Mom Be on ECMO in the ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Juan here.”
Juan: Yeah.
Kevin: They are changing the arterial and the radial line I think about an hour ago.
Patrik: Right. Right.
Kevin: They will do the 2D echo and they’re going to do whatever other tests that you suggested as well. We’ll maybe ask them for those then we’ll get back to you and see.
Patrik: Yeah. Absolutely. All right.
Juan: Okay. Thank you, Patrik.
Patrik: Let me know what you need next. Thank you so much.
Kevin: Thank you.
Patrik: Thank you.
Juan: All right.
Patrik: Bye.
Juan: Bye.
Patrik: Bye.
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Patrik: Hi, Juan!
Juan: Hi, Patrik. Sorry about that earlier.
Patrik: That’s okay.
Juan: Okay. We met the doctor who’s handling the ECMO. Essentially she told us that they’re definitely happier than they were this morning, and that she seems to be stabilizing. And they’re slowly going lower… they’ve removed the vasopressin altogether and they’re going to keep lowering the Noradrenaline as well. We asked her about the Midazolam, and the Morphine discussion, as we had had, and she did say, yes, Midazolam does tend to drop the blood pressure. And they were quite confident that Morphine does the sedation job as well, that they wanted to do that… Yeah, what else did they say?
Kevin: They said it’s dynamic, and if they see her maybe starting to wake up or something, then they give her a bolus of Morphine. So they’re keeping the sedative effects of it on as well.
Patrik: Sure. And the Cisatracurium is still going, is it?
Juan: Yes.
Kevin: At three.
Juan: At three.
Patrik: Sure. If-
Kevin: We were trying to see what we could do for the Cisatracurium… or what other paralytic agent could be used or… So I think that discussion is still ongoing. We’re going to just try and see if we can move it around or get something else, probably..
Patrik: They all have the same effect, they all have the same effect. I’m a bit surprised that she’s saying they’re happy… The blood gas doesn’t look good to me. That’s very-
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Juan: I don’t think she meant happy. I think she meant happier than this morning. They thought that that event would continue to deteriorate and lead to something worse. So in that sense, she was like, “We’re glad that that’s not happening.” And as her hemodynamics improve, and her blood gases improve, then they can look at titrating the VV ECMO.
Patrik: Right, the numbers… I am probably a little bit numbers-driven. I look at the numbers and I worry and I look at… I can totally see why they’re not giving her Midazolam and I can see why they say what they’re saying with the Morphine. I just need you to be mindful of that it’s probably not best practice, that’s all.
Juan: Okay. So maybe by tomorrow, if she holds through the night and things are looking better and we see the ABG improve, then we can raise that again with the-
Patrik: I would.
Juan: The other doctor who’s actually in charge of the sedation.
Patrik: Yeah, absolutely.
Juan: Yeah, But we did bring it up with her as well, earlier today and she said a similar thing and then we raised it with this doctor and she said a similar thing, so it’s in their mind, we have raised it. So we’ll continue to just bring it up.
Patrik: Yeah, yeah. And why… So you mentioned that they’ve reduced the Noradrenaline. Why are they doing that? What’s their reasoning behind that?
Kevin: She was on no inotropes before, so they want to get back to that level, essentially.
Patrik: Okay, and they’re not worried that ejection fraction is down at the moment?
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Juan: It’s up to 32, thirty-
Kevin: It’s the same, so when she got admitted it was at 20, and now… When they did the last level, before removing the VA, it was at 32, 35, and it remains the same.
Patrik: Okay, okay. So, a little bit better.
Juan: And I guess after removing IABP and the ECMO, they wanted to see if her BP holds and now it’s holding. So I guess they want to slowly reduce it. They said very slowly, but…
Patrik: Fair enough.
Kevin: They said they probably want to keep the Noradrenaline on tonight, and then maybe start try treating her from tomorrow and see how it goes.
Patrik: Right, sure, sure. I’m a little-
Juan: In general also they have said that my mom, and her incidents and her turnarounds.. It’s all quite unique and that it’s not just… She doesn’t just follow regular patterns-
Patrik: Yeah, I agree.
Juan: I think they do have to go a little bit out of the box and they keep it very dynamic, which is why they don’t commit to anything for too long.
Patrik: Yes, I agree. I can see that she’s out of the box. I can see that she’s not behaving like what probably most people that worked with ECMO patients have seen. I agree with that.
Juan: Yeah.
Patrik: And I guess the other uniqueness about the situation, I believe, is that she has been on ECMO for a very long time, a very long time… Where my concern is how much longer can she be on ECMO?
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Juan: Yeah, yeah. I think that’s definitely on their mind as well. They have been… Even with VA and with VV, they’ve been trying to get her off it for quite a while now. I think obviously today, had this weekend not gone the way it had, they were thinking maybe today they’d be able to start thinking about removing it. On Saturday night, it sounded like that’s what they were aiming for. But let’s see. Let’s see, I guess, because this weekend went the way it did and then this morning happened, but now she seems to be doing better. She’s looking better, as well. Her face was looking pale and just more unwell from Friday afternoon to yesterday and this morning, but then this afternoon onwards, she’s definitely looking brighter. She’s looking a little bit more… She just looks less unwell.
Patrik: Okay good. That’s good to know.
Juan: Yeah, I think they’re being cautiously optimistic, and so are we. Because in the morning, her ABG did peaked up, and then, yeah… So maybe we’ll just see how she holds through the night and then talk to them about that.
Patrik: Yes, yeah, agreed. They need to make some form of progress with the ECMO.
Juan: Yeah, agreed. Agreed.
Patrik: Or at least, for now, not go backwards.
Juan: Yeah. Yeah, this morning they even thought about it. This was a heart incident, then maybe going back to VA ECMO… And you know, there were all sorts of conversations flying around, but then all of that disappeared because it all just settled.
Patrik: Absolutely.
Juan: Yeah.
Patrik: It’s definitely touch and go at the moment.
Juan: It is touch and go. Yeah, I know, yeah. So I guess the points to bring up is the Midazolam, sedation, paralytics conversation regularly. Bring up the plan for VV ECMO when we’re planning to get it off. How, if not, then what? What’s the timeline, what are our plans, what are our options? Yeah, I guess those are the two main points.
Patrik: I think so, I think so.
Juan: Okay, okay. We’ll have that discussion tonight later when we talk to the doctors again and then again tomorrow, seeing how she holds up through the night.
Patrik: Yeah, absolutely.
Juan: Okay, thank you, Patrik.
Kevin: Thank you.
Patrik: Pleasure, pleasure. All the best for now.
Juan: Thank you, we’ll keep you posted. Bye.
Patrik: Thank you, bye-bye. Bye.
Patrik: Hi Juan, how are you?
Juan: Hi Patrik, I’m fine.
Patrik: I’m very well, thank you. Can you hear me?
Juan: Yes, I can hear you.
Patrik: That’s good. How’s your mom?
Juan: Mom is all right. And she’s stable right now. The saturation has improved. She’s at about 95%. And brought FIO2 down to 55%.
Patrik: On ECMO or on the ventilator?
Juan: On the ventilator.
Patrik: That’s really good.
Juan: So that’s good. She has a leaky tracheostomy. They said that about 60% leakage is going on. So they’re going to change that, most likely. That had come up as a concern once or twice in this course. I think now they’re just going to change..
Patrik: Do you know what size tracheostomy she has?
Juan: No, but I can find out.
Kevin: They’re trying to make it eight, if I’m not wrong.
Patrik: If she has a leak and if they want to try and make it eight, she probably has an 8.5 or a nine. Might be slightly too big. Yeah, that’s all right.
Juan: So that’s happening. And I think that last night didn’t tolerate her feed. When she aspirated, it came back out. The same thing happened today. They’re going to stop the feeds for a day. They started lightly. It could have been the Morphine that could be causing that. They also said maybe it could be the magnesium as well, but they said, yeah the Morphine as a possibility.
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Patrik: My first guess about her not absorbing feed is the Cisatracurium. Because basically what happens when someone is paralyzed, the gastrointestinal tract is paralyzed too.
Kevin: Yeah, that’s what they said, that the paralysis now is paralyzing everything.
Patrik: Correct.
Juan: Yeah. So we’ve gone off Cisatracurium anyway. They’re on Atracurium, but I think they were saying about-
Kevin: Yeah, but better Atracurium as they say.
Juan: No, but they said today about the tapering of the Atracurium as well.
Kevin: Yeah. They’re going to try and taper that off and stop the Atracurium. Maybe introduce a small dose of Midazolam.
Juan: And potentially they’re exploring those other two tranquillizers.
Patrik: Yeah, Quetiapine and Olanzapine.
Juan: They’re going to bring in the neurologist and see what options they have. But yeah that’s being discussed. But they’re reducing the Morphine, they’re taking off the Atracurium, and thinking of introducing a low dose of Midazolam and then they’re going to see what to do about it.
Patrik: Okay. So when I looked at the ECG, the ECG looks unremarkable. But what are they saying, have you asked them?
Kevin: They said it’s fine.
Juan: Yes. But the EEG and the ECG are unremarkable.
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Patrik: Okay, great. But the troponin seems to be elevated. And whilst I agree that after CPR, troponin goes up. Even though someone might not have had a heart attack I think they need to follow up, because it looks elevated to me. And I do believe-
Juan: Yeah, they’re doing another one tomorrow.
Patrik: Okay, great. Is there a cardiologist involved still?
Juan: Yes.
Patrik: Okay, great. What are they saying, why has the gas improved? What have they done to have-
Juan: They’ve not addressed it.
Patrik: So it’s basically an improvement in and of herself.
Juan: Yeah. We believe that the ozone has contributed to it. But other than that, they’ve not remarked on it. They’ve just not said anything.
Patrik: Right, okay.
Juan: That has a difficulty also, because it’s a little more out there. But we can push for it. They said there’s no harm done if it helps create that. So they aren’t commenting on any other reason why that mom’s gas improved. But if it’s helping, it’s helping, great. We’re happy with that.
Patrik: Absolutely. It could also be a combination of the antivirals and antifungals working.
Juan: Sure. Although the Ganciclovir seems to have had some negative impacts. Definitely it’s affecting kidney function.
Patrik: Oh, definitely. I was about to come to that.
Juan: Yeah. So they’re going to try and reduce that, and we’re waiting for the CMV (cytomegalovirus) report to come back. And depending on the report, then we’ll see what to do about it.
Patrik: Yeah, okay. So coming to the kidney function, yes the Ganciclovir definitely might’ve impacted low blood pressure, it might’ve impacted on the kidneys. Many patients in ICU go into a temporary, sometimes permanent, kidney failure. You asked what BUN stands for. BUN is basically the blood urea nitrogen levels. It’s basically the urea levels. It’s going up, and it basically means the kidneys can’t excrete urea. The creatinine is still within a normal range. But obviously the biggest sign is her not producing enough urine. And whilst she might be responding to the furosemide or the Lasix, which is great, the Lasix can also damage the kidneys in the long run and creatinine might go up just by them using Lasix. But it’s certainly a good short term therapy.
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Patrik: Yeah, good short-term solution. Now, you’ve also seen that magnesium is very high. That’s probably as a result of kidney failure as well. It is critically important that they keep her lungs dry in particular. So they will have to manage that with Lasix in the short term, potentially with the hemofilter/dialysis in the long run.
Patrik: The other thing that I’ve noticed is her albumin levels are fairly… Hang on. Is that… yeah, they’re fairly low.
Juan: Yeah.
Patrik: When was the last blood she had?
Kevin: Yesterday.
Juan: She got it, yeah yesterday.
Patrik: One unit, two units?
Kevin: One unit.
Juan: One unit, half and half. They did it over eight hours.
Patrik: What do you mean by half and half?
Juan: So they did half a full unit over four hours-
Kevin: 150cc over four hours, and then 150cc also. Full unit of blood over eight hours, because they had diagnosed TACO (Transfusion Associated Circulatory Overload) last time. So they infused it slowly.
Patrik: Yeah, that makes sense. It’s also, especially with kidney failure, you don’t want to fluid overload someone. Yes she needs the blood, but you definitely want to give it slowly. With albumin being low, have they given albumin?
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Juan: No… or maybe they gave one? No.
Kevin: They gave one, but that’s when they were confused of whether the blood transfusion or the albumin caused the TRALI (Transfusion-Related Acute Lung Injury) reaction.
Juan: But then now we know it TACO, and we know it was probably the blood. We can ask them if we’re planning to give… No, we’re not planning to give albumin. No.
Patrik: Right. Is your mom very edematous?
Juan: Meaning does she have edema?
Patrik: Yeah.
Juan: Yeah, she does. It settled down last week, and now that seems to be a bit more again.
Patrik: Right, okay. Because one way to manage edema is potentially to give a little bit of albumin. The problem is that if you’re giving albumin, hemoglobin gets diluted. The more fluids she gets that is not red blood cells, hemoglobin might drop. But on the other hand, she needs albumin.
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Patrik: That leads me to her liver function. Her liver function is slowly going down as well. I don’t know whether you’ve noticed that.
Juan: Mm-hmm.
Patrik: Are they saying something about that?
Juan: No, they didn’t really say, but we know that Ganciclovir can also affect liver function.
Patrik: Oh definitely.
Juan: And the Polymyxin as well was stopped a few days ago, but that could have some after-effects too.
Patrik: Yeah. You mentioned in your text earlier about there’s a little bit of bleeding from the lines. Her aPTT seems fine, her platelets seem fine, a little bit low, but not too low. So I’m wondering where the bleed is coming from. Are they saying anything?
Juan: Not really. They said they’ll keep an eye on it, I guess because of the heparin
Kevin: This bleeding was a problem every time they did some kind of new procedure, whether they removed the catheter or they put in a new catheter, there was bleeding issues for her.
Patrik: I see. Okay, there’s nothing new there. The other thing is CRP levels…
Juan: It’s gone up.
Patrik: It’s gone up. And white cell count is normal.
Juan: It’s going down in size.
Patrik: Yeah. It doesn’t quite add up to me. Usually CRP and white cell counts often go hand in hand. If they’re going up, they’re going up, and if they’re going down, they’re going-
Juan: I think one of them also mentioned that CRP is kind of a non-specific indicator in some ways. So it could be multifactorial.
Patrik Oh for sure. Look, it could definitely be multifactorial. The most important thing at the moment is that her blood gas is improving. That is the most important thing. There are definitely other issues with liver, kidneys. It almost looks like the moment like you can’t have an improvement with one organ without impacting on the other. That’s certainly a concern. With the Quetiapine and Olanzapine, yes definitely get a neurologist involved there. It’s damned if you do, damned if you don’t. The Midazolam-
The 1:1 consulting session will continue in next week’s episode.
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- How to ask the doctors and the nurses the right questions
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- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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