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 Laura as part of my 1:1 consulting and advocacy service! Laura’s mother is in the ICU for Septic Shock and is asking if her mum’s high level of Blood Urea Nitrogen (BUN) a sign of deterioration.
My Mom is in the ICU for Septic Shock. Will My Mum’s BUN (Blood Urea Nitrogen) Level Return Back to Normal?
Urea/BUN is off the rails too. What are the kidneys doing generally speaking?
Is she making urine at all? Is the Bumex working?
What are her fluid balances doing? Fluid balance is what is going in in a 24-hour period and what’s coming out over a 24-hour period.
If her fluid balance is positive by multiple litres over many days, she is oedematous as you described.
Low Albumin, low HB and high Bilirubin won’t help with oedema. Oedema can be reduced by giving Albumin and increasing Urine output with either diuretics such as Bumex or Lasix or with haemodialysis.
I hope this helps! Keep asking the right questions and keep them on their toes. You are making progress!
Give yourself a tap on your back for being so strong and persistent!
Right now, she’s on BUMEX-1mcg,
Vancomycin 2500 mg, Levophed 15mcg. Urine output is a little lower today. But still making some. Nephrostomy bag has some output too.
Hi. Well they did an ultrasound of her abdomen and Dr. Charles said that the liver is failing due to mass pressing on it. Maybe it’s bulky lymph nodes? Looks like there’s flow of biliary duct, however he said there may not be blood flow?
They’re putting a feeding tube now in stomach through nose. BUMEX infusion. Urine -Less than 20 cc an hour today I believe she said. Yesterday and the day before was more.
I have had a look at the reports.
A couple of concerns here
- a) has an ERCP been done as suggested in the report?
- b) has the result from the biopsy come back?
- c) it says “necrosis” in the report, however it doesn’t actually specify the location of the necrosis. One way or another necrosis usually means “dead tissue” and it means a massive source of infection often leading to sepsis.
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The only procedure GI doctor did was endoscopy for bile stent and needle biopsy of lymph nodes. I believe the enlarged lymph nodes in the abdomen have necrotic material. The biopsy came back inconclusive as it wasn’t a large enough sample. (GI doctor said probably lymphoma in the bulky nodes and there was a spot or two on the colon as well-metastatic)
I spoke with the GI who did the procedure and that’s what he said right after the procedure.
Today the second opinion doctor, Dr. Charles did an ultrasound of her abdomen and preliminarily said looks like a mass pressing on her liver, and it’s failing. Bilirubin levels 18. Maybe it’s the lymph nodes or sludgy gallbladder.
Hi Patrik. Last thing I heard last night was that Dr. Charles had ultrasound of abdomen and then said that though he didn’t have radiologist report yet, that it looks like liver is falling as mass is pressing on it. There is some flow of bile but that perhaps it wasn’t getting blood flow due to the mass pressing on it and it’s failing. As I researched liver failure, it seems as that is true. She had high bilirubin levels 18 yesterday and she has her right-hand flapping gestures. Yellow skin. I’m thinking this is the end for her. Maybe it’s time to let go.
Well I talked to GI and they’re going to look at CT scan to see if stent is in place. The GI and Dr. Charles the second opinion doctor both say that most likely that the liver has tumours, metastasized in there and that is causing the liver to fail. That explains the climbing bilirubin. They will do a CT scan of the liver, as the ultrasound isn’t as good to see in there. It sounds like the liver may be failing due to tumors in it that has spread. So anyway, it may be time for her to go. We are Christians so I know she will go to heaven. We’re kinda at the end of the road looks like. We will see.
Agree that CT scan is necessary to see the full extent of what’s exactly happening.
Liver failure extremely difficult to control.
The necrosis is also an ongoing source of infection. If she can’t come off the Levophed in the next few days, it is most likely incompatible with life.
It really depends how you as a family and your Mom want to approach end of life, in a fighting spirit or by withdrawing life support.
Don’t feel like you need to make a decision. Think about it.
In the meantime, your Mom’s body might make the decision.
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Well, we got the CT scan of liver and without contrast, Dr. Charles and GI Dr. Bernard looked at it and said the biliary stent is in good placement, but that it’s the bulky lymph nodes/mass that’s pressing on liver, or liver inside could have tumors that’s making it fail. Bilirubin at 18. Creatinine 3.6.
Mom is still on breathing tube. She’s weak so they’re keeping her on until we decide. Breathing with pressure support during the day, full support at night Levo-14, BUMEX 1 mg, IVF and KCL 20 MEQ/L.
They put feeding tube last night, but even with little bit, she can’t digest.
I don’t know if home hospice is good choice. We live 10-12-minute drive away, and I think that in ambulance they only have oxygen, not pressor med. I bought a used hospital bed like these here, a few weeks ago.
She’s in liver failure. I was reading about it. It isn’t painful they say, they go into deeper sleep. We may decide to forego supports tomorrow. We don’t know for sure. It looks like it may be her time. With our Christian faith, we have hope of eternal life. Thank you for everything. We fought a good fight. With your help also. I’ll keep in touch.
Look out for lactate results as well as blood coagulation results such as
Platelets, Haemoglobin, INR, APTT, If, lactate is rising fast your mom has full blown sepsis.
Lactate result is in arterial blood gases.
If coagulation results are off it’s a sign the liver is failing.
Furthermore Laura, if they want to make your mom “comfortable”, this could be perceived as euthanasia.
Involuntary euthanasia is illegal and a lot of it will depend on your and your mom’s belief system in how you want to approach this.
It seems new that she needs full ventilation support overnight. I can’t remember you saying something to that effect. Are they sedating her overnight?
Home hospice an unlikely choice, just simply because they can’t do the Levophed and ventilation at home.
As soon as both are removed, it’s likely that the removal of life support is incompatible with life.
Whatever you decide will be the right decision. I would be curious to know what you do next.
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Right now, she’s on BUMEX-1mcg,
Vancomycin 2500 mg, Levophed 15mcg
Urine output is a little lower today. But still making some. Nephrostomy bag has some output too.
Bumex infusion or several times per day?
Vancomycin is causing kidney failure as side effect, but they probably have no other option.
How much urine is she making in a 24-hour period?
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Well I went ahead and spoke with Dr. Charles, the second opinion doctor. Actually, I feel pretty good talking with him because he said some things that might buy us time, etc.
- He’s independent, please see business card below
- He said we can order an ultrasound of abdomen. I think to check flow of mesh stent /bilirubin. Bilirubin-17 level
- He said she may be a candidate for transfer to LTAC, but we would have to state, “LIMITED CODE”, meaning no chest compressions.
- He said no tracheotomy until she’s off pressers
- Creatinine- 3.38. WBC-28
- Right kidney is ok left kidney has stone in ureter, I guess. -not obstructing
- Said TPN is not safe right now because of bilirubin level?
That’s good overall.
It’ll buy you time.
I will address some points shortly.
Well they did an ultrasound of her abdomen and Dr. Charles said that the liver is failing due to mass pressing on it. Maybe it’s bulky lymph nodes? Looks like there’s flow of biliary duct, however he said there may not be blood flow?
They’re putting a feeding tube now in stomach through nose.
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This is way overdue.
I didn’t ask if she had a feeding tube, I just assumed. 99% of ventilated patients in ICU have a feeding tube for either feeding or to drain bile.
You could claim medical negligence. I also recommend you ask for the medical records to keep them on their toes. Look out for lactate results as well as blood coagulation results such as
Platelets, Haemoglobin, INR, APTT
If lactate is rising fast your mom has full blown sepsis.
Lactate result is in arterial blood gases.
If coagulation results are off it’s a sign the liver maybe failing.
Ok understood Laura.
If the mass is pressing on the liver and the bile duct and the stent isn’t working an ERCP might help.
Or potentially abdominal surgery.
The vancomycin is just trying to keep the infection at bay but will be unable to cure it because of the primary infection source either being necrotic tissue or a tumour/ metastasis.
Nevertheless, is a withdrawal of treatment inappropriate and they will need to keep trying.
I still believe Dr. Charles will need to get a second GI specialist involved.
BUMEX infusion has been started.
Urine -Less than 20 cc an hour today I believe she said. Yesterday and the day before was more.
20cc per hour is minimal urine output.
How many fluids is she getting in perc24 hours?
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It’s Laura. We’re still here in ICU. I just had this thought. We kind of agreed to do comfort measures soon, with morphine, taking out breathing tube and Levophed 14 mcg. They’re not doing bloodwork daily anymore. We’re on modified code, no chest compressions. If I request bloodwork, with bilirubin levels etc, will they show how much time my mom has when she comes off supports? I was thinking maybe take her home on hospice rather than die in ICU. Most all people here say let her die here but today she seems more awake. What do you think? Thank you.
It’ll be reasonably difficult to predict.
However, I do believe by extubating your Mom and giving her Morphine and then ceasing Levophed, it’s almost incompatible with life. Her blood pressure is low in the picture you sent and that’s on a lot of support.
Blood results won’t necessarily indicate how much time your Mom has left.
Arterial blood gases will, with oxygen and CO2 levels as well as lactate levels.
Have you asked them about their thoughts getting your Mom home?
They are taking blood, today’s levels are 15 bilirubin, down from 18, creatine 3.9. BUN 81. Thx. And yes, I asked them. The nephrologist said probably not about hospice at home. Nurse said maybe we can start process by first taking out breathing tube, having comfort care in standby. Morphine, and see how it goes with maybe oxygen support. Maybe they would give my mom a chance to speak or interact then see what happens and how to proceed. What do I think? Thanks so much.
Levophed 14 and a low blood pressure according to the monitor and removal of ventilation is normally incompatible with life.
It would help if you could also send me a recent blood gas result.
It’s Laura. With having the second opinion Dr. Charles given us the evidence and Dr. Bernard, the GI, we see with ultrasound and CT without contrast that my mom’s liver is being pressed on my bulky lymphoma nodes pressing on liver. While bile stent is in place and there’s some flow, it looks like liver is failing. Perhaps tumors inside liver or just with masses pressing on it- no blood flow. It’s failing. So, with that in mind, the ICU Dr. Chris offered a hospice custom plan for Monday, where we extubate my mom, keeping Levophed while in ambulance transport 10 minutes to my mom’s home where I have hospital bed. She will most likely pass quickly at home. This was important to some family members to get her home.
Thank you Laura, for the update.
If it is important for your Mom and your family to have your Mom pass away at home, then you should follow through on that plan. I’m all for home care. Are they offering you a nurse as well for home care?
It’s Laura. Well it looks like my mom’s body is giving out and soon we’re gonna let her go. She is a woman of God and I know where she’s going! I just want to say thank you so much for your help!! It was what we needed! God bless you in your efforts to help families know their rights because it bought us time to get things on our terms, and to be heard here in ICU!! Thank you
Laura and family.
You’re very welcome Laura.
Is your Mom home or still in hospital?
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See how you go, she might be too unwell to go home as long as she’s ventilated and on Levophed.
She’s in ICU. We had planned to get her home tomorrow but we’re still in hospital.
It’s Laura. My mom passed today around 1:30. Thank you Patrik for your help! God bless you for helping families with loved ones in ICU!! Take care!
Ok thank you for letting me know Laura.
I’m very sorry to hear about your loss.
Did she pass away at home or in ICU?
This is very sad news and I send you and your family my best wishes and condolences!
I wish you and your family all the best for now and a happy new year.
If you don’t mind, I would like to follow up in a couple of weeks once the dust has settled.
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
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
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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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