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
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 his mom can prevent further kidney failure in the ICU.
My Mom is in ICU for 4 Weeks Now & How Can She Prevent Further Kidney Failure in the ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Juan here.”
Patrik: So, therefore, air/oxygen needs to be humidified. That filter is doing some of that, but it’s not as good as a humidifier. I will send you a picture of a humidifier. It might not be as important at the moment because she’s on VV ECMO. I still think, especially with your mom’s condition, I actually think this might make a difference.
Juan: So, a humidifier is another attachment like that, that can be used-
Patrik: No, it’s not an attachment. I’ll send you a picture so you know what I’m talking about. The ventilator needs to run through a humidifier so that the inhaled air/oxygen is actually humidified.
Juan: We just looked up a picture. So, it’s a little device that which gets attached to the ventilator.
Patrik: Very much so. I have to send it to you.
Juan: Okay. Yeah. I’m going to send a picture as well.
Patrik: Look, there are others… this is just one of the most common ones. There are others too but I see it every now and again and it’s just a big red flag to me. Yeah, that’s one. That’s the one that you sent. That’s what I’m talking about.
Patrik: And enlarge that picture… it suggests it should be at 37 degrees. Right. Yeah, I worked in ICU when the filters went away to the humidifiers. In the early days, when I started in ICU, it was only the filters. And then, I actually did witness the humidifiers coming in 20 years ago. I would argue it was almost like a small revolution.
Juan: Okay. So, we can probably organize this..
Patrik: I would hope so. And also, if for whatever reason they can’t provide a humidifier, I would argue they need to change the filter every day.
Patrik: Nothing replaces a humidifier even if they change the filter every day.
Juan: Got it.
Patrik: If they’ve been using this filter for God knows how long, they would make all sorts of rationalizations no question.
Juan: Like what kind of rationalizations.
Patrik: Yeah. The rationalizations would be around that it’s as good as the humidifier, if not better. And I question that. But anyway, let’s see what they say I guess.
Patrik: Coming back to the kidneys. Are they talking about dialysis?
Juan: We could just purchase one and give it to them and tell them to use it, right?
Patrik: Not necessarily because they would need different circuits most likely.
Patrik: Most likely they would need different ventilator circuits. So, it’s a case of do they have the circuits that go with the humidifier.
Juan: And if they don’t?
Patrik: I’ll tell you what to do if they don’t. You should probably contact Fisher and Paykel directly.
Patrik: I probably even have a contact for you I know actually when dealing with Fisher and Paykel. Yeah, and I actually know a guy here from Melbourne that used to work for Fisher and Paykel.
Juan: Oh, that would be amazing. Could you please send us the contact anyway?
Patrik: Ask them first. Maybe, for whatever reason, I’ll tell you sometimes the filters are being used. The filters might be used temporarily when you go for a CT scan. But that is just for a couple of hours maybe and then you go back on the humidifier.
Juan: Well, she’s been using that for about 40 plus days now or so.
Juan: Yeah. Okay.
Patrik: But coming to the kidneys, are they talking about dialysis?
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Juan: They’ve not mentioned anything. We’re going to talk to them now.
Juan: But honestly, I believe that if we stop the Ganciclovir, then her kidney damage will stop. She did not have kidney damage before this.
Patrik: Look, the Ganciclovir might contribute to kidney failure and it might be very hard to pin down what’s leading to kidney failure. A lot of patients in ICU go into kidney failure.
Juan: Okay, fair enough.
Patrik: It’s not unique to having Ganciclovir. It can be the Ganciclovir I’m not disputing that, but it’s often a combination of a number of things.
Juan: Okay, fair enough.
Patrik: Your mom would have been hypotensive many, many times. Sustained hypotension leads…
Juan: …can affect the kidney.
Patrik: Yeah. It leads to poor perfusion of the kidneys which leads, inevitably, to kidney failure.
Patrik: Plus all the medications she’s been on for many weeks. So, it’s a combination.
Juan: Okay. So, with dialysis… you were mentioning?
Patrik: Yes. If her kidney function is not improving, they need to start dialysis. Even though she might be making urine which it sounds like she does, judging the color of her face, she’s not get rid of the toxins.
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Juan: Okay. Is dialysis the preferred option?
Patrik: Say that again?
Juan: As in, do we want to push the dialysis. Is that what we want to do?
Patrik: I think I would ask them.
Juan: Okay. We would ask them if there’s something they can suggest or how do they plan to manage the kidney. Just ask them that. Like, what are they planning to do about it.
Patrik: Yep, absolutely, I would.
Juan: Can I ask you, Patrik, about the steroid you’ve mentioned. These are steroids and antibiotics as well. So, what about that?
Patrik: So, a lot of patients in lung failure have steroids as part of the treatment course. Now, it should be time limited, but I understand your mom has been on steroids now for quite some time.
Juan: What role exactly do the steroids play in the whole thing?
Patrik: I think steroids are… on the one hand they’re immuno-suppressants. On the other hand, they’re also protecting the lungs.
Patrik: I can’t tell you the exact interaction. What I will tell you it’s a common treatment option for lung failure patients. It’s also anti-inflammatory.
Patrik: It’s anti-inflammatory and it’s shown that it’s giving good outcomes for patients in ARDS. However, it should be time limited.
Juan: Considering she’s been on them for so long, what, in her case, do you think? Like, what should be the time limit? Have we already crossed that?
Patrik: I have seen patients in lung failure that are on VV ECMO stay on it until they come off VV ECMO. As long as she keeps improving you wouldn’t change that. The steroids are a catch 22. You need them when you need them but you want to get rid of them as quickly as you can.
Juan: Okay. Which steroids is she on right now? She’s on Methylprednisolone, hydrocortisone… I’ll just check. I’m just trying to look at her medicine sheet. She is on…
Juan: Hydrocortisone. So, maybe we can reduce it at least.
Patrik: I’ve just sent you an article for a little bit more insight around wide steroids in lung failure.
Juan: Sure. So, I give her hydrocortisone which other ones are steroids?
Patrik: Methylprednisolone, hydrocortisone, dexamethasone, prednisolone. They’re the most common ones.
Juan: I don’t think she’s on Medrol Dose Pack. Is she still on Medrol Dose Pack? (methylpred?) I think that’s…
Kevin: No, it’s only hydrocortisone.
Juan: It’s only hydrocortisone. So, we know we can talk about reducing the hydrocortisone dosages.
Patrik: Well, I think you can ask but there might be some benefits from that.
Juan: So, we’ll just ask them before we start reducing the hydrocortisone.
Patrik: Very much so.
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Juan: I hope that if this improvement continues and she continues to improve by tomorrow, then they’ll be more likely. Or they might just be like you’re jumping the gun, we’ve just seen baby steps. Like, calm down. We need to cool it.
Patrik: And I think that’s what it is. Yes, we are seeing baby steps. With cortisol, or with steroids, it’s also a case of you want to reduce it gradually.
Juan: Right. So if she’s on 50, four times a day, then we can just see maybe how she…
Patrik: …half it. Again, it’s a gradual weaning process.
Patrik: What are they telling you are the next steps?
Juan: They haven’t mention anything really I think. Today’s the first day after a few days that we’re seeing some stability and improvement. So, I think this evening when we talk to them is when we can talk about next steps because we’re seeing some improvements. Before this it was, sort of, damage control.
Juan: Let’s hope she stabilizes. We couldn’t really talk beyond that. I think even now they’ll be a bit cautiously optimistic… okay. Let’s see if she’s the same tomorrow because she’s been different every day.
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Patrik: Yeah. Very much so.
Juan: So, I think, logically speaking, the next steps as if it was going in a bad direction. Then it was all of this stuff where they were jumping around saying VA, transplant… it was a backup plan. If things are improving then it means reduce the meds, reduce ventilator support, VV flow support. And then, take off the VV and then take of the ventilator. I think, logically, that what’s they always indicated would be the steps if she’s improving.
Patrik: Yeah. Agreed.
Patrik: Well, so far it’s been one of the better days where there seems to be some improvement. She might need some dialysis.
Patrik: She might need some dialysis. Yeah, that’s all I can say. I wouldn’t be too worried if she does need dialysis. Yes, it’s another intervention but I’ve seen so many patients on dialysis in ICU.
Juan: Patrik, you’ve mentioned that we’ll ask them how they plan to manage the kidneys. How would you manage her kidneys if this was in your control? Like, what should we be hoping for them to do?
Patrik: So, you would’ve seen that in the short term to increase her urine output there’s a number or things you can do. A, you can give Lasix which they’ve done, I believe, yesterday. When you sent the medication chart earlier I couldn’t see any Lasix there, but that certainly would be the first thing you would do in the short term give Lasix. The other thing you would do is…
Juan: They have done that, yes.
Patrik: If blood pressure is low, you could increase inotropes like noradrenaline or vasopressin to maintain a good blood pressure. And perfuse the kidneys which seems to be the case because her blood pressure in the picture you’ve sent is around 140/90.
Patrik: Okay. And then, you could also, depending on her fluid status, you could also give fluids which they’ve probably done when they’re giving her a unit of blood.
Patrik: Okay, so you can do that. No guarantee that any of it is working, but it looks like some of it is working.
Patrik: Okay. The problem with that is, you might have seen that in her laboratory, in her pathology, her urea and creatinine are going up.
Patrik: So, once she’s making urine for now, if urea and creatinine not going up, the quality of her urine is poor.
Juan: Correct. Yeah.
Patrik: And that’s the issue. And if the quality of the urine is poor, she will, inevitably, go into kidney failure if they don’t start dialysing her.
Juan: Okay, understood.
Patrik: Well, that’s-
Juan: What’s the difference between a hemofilter and the dialysis? Does the hemofilter simply just take off fluid and the kidney itself like the dialysis helps improve the quality of the urine, is that correct?
Patrik: Very much so. So if you’re doing dialysis, you’re pretty much replacing the function.
Juan: So, what the kidney does itself?
Juan: Whereas the hemofilter just takes out fluid in general? It doesn’t do what the kidney does.
Patrik: Very much so.
Patrik: When I look at her magnesium levels, it’s a clear sign that she’s going into kidney failure.
Juan: Okay. How long do we have usually before things get worse?
Patrik: Probably depends on her potassium as well. Potassium might be next going up… it seems to be holding. It probably shows in her potassium next. How much time? Look, if her urea and creatinine is still going up tomorrow, I don’t think they would have any time to waste.
Patrik: I’m sure they will be discussing it already.
Juan: So, from the medication that she’s taking, if we know that it is usually a combination of multiple medications that could be contributing to the kidney failure, what would be top of the list to look at reducing? Is it the steroids? Is it the antivirals? Like, what is really that needs to be reduced first?
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Patrik: I’ll tell you what I would do. I wouldn’t reduce anything. I would be probably starting dialysis because her lungs are improving slowly… so something must be working.
Patrik: I would not jeopardize at the moment the improvement in the lungs by taking any of the medications off. What I would do is start dialysis.
Juan: Do the dialysis, okay, fine. So, we’ll talk to them about that.
Patrik: I’m just looking at the medication list again. I mean, don’t get me wrong, she’s on tons of medications.
Juan: Yeah, she really is.
Patrik: She is. There is so much room for side effects in there. It is what it is.
Juan: I’ll let you look at the list and then I’ll ask you another question.
Patrik: Yeah, I’m just looking at the list.
Juan: Yeah, go ahead.
Patrik: I don’t think there’s anything that they can just take off.
Juan: Maybe just tapering things, or thinking about when they will stop tapering things. That all.
Patrik: Was she on lots of medications at home?
Patrik: Right. So this is all induced-
Juan: In general, she’s someone who used homeopathy her whole life.
Juan: Yeah, that’s-
Patrik: It’s far away from homeopathy with this mix of medications.
Juan: Yeah. I just mean that she’s not someone who used antibiotics regularly. Yes, she was on her blood thinners but that’s pretty much literally. Yeah, it’s not something she’s done much of. She was on statins, blood thinners, and blood pressure medications. Yeah, that’s been all. Aside from that not much else. I don’t think mom really used anything. She doesn’t use… not like Azithromycin. Nothing really else, like, in general. So, this has been her first experience with all of this.
Patrik: It is like this, we keep saying it’s one day at the time. It looks like there is some improvement now and she needs to maintain that overnight and reassess tomorrow.
Juan: Sure. Patrik, you mentioned… the last point in your message earlier said, “Do they think they are treating the diaphragm/ lungs with the antibiotics?” Can you elaborate on that, please?
Patrik: Yeah, absolutely. So, let’s just say someone is diagnosed with a pneumonia.
Patrik: The first thing they should be doing is to take a sputum sample and find out what bacteria is growing. While they’re waiting for that result, which should come back within 24-48 hours, they should be starting a broad-spectrum antibiotic. Once the result is back, they should be starting the antibiotic that’s working for a particular bacteria they’ve identified.
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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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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