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 in ICU for 4 Weeks Now & How Can She Prevent Further Kidney Failure in the ICU?
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 asks why he needs to be demanding and be in control when talking to the doctors of his critically ill mom in the ICU.
Why Do I Need to be Demanding & Be in Control When Talking to the Doctors Whilst My Mom is Critically Ill in the ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Juan here.”
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 its 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.
Juan: Yeah.
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.
Juan: Okay.
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Patrik: So, what do I mean by that? So, the antibiotics she’s on at the moment should be specific to a bacteria they found.
Juan: So far, as we understand, that’s, sort of, what they’ve been doing because they gave some bacteria broad-spectrum for a Gram-negative or a Gram-positive. And then, they’ve been trying to narrow it down which is why they decided on Ganciclovir, for example. That’s why it has been narrowed down on the three meds they’re giving her… Elores. Is Elores specific or is it more general?
Patrik: It must be specific. When I say broad- spectrum you narrow it down to what you think is the most likely one you will be finding.
Juan: Patrik, because, obviously, she’s severely immunocompromised. They keep explaining to us how you find all sorts of things in every single human body. It’s when you’re severely immunocompromised like if you have HIV, then these bacteria start to manifest and that’s when you display symptoms. So if someone’s severely immunocompromised, wouldn’t you find multiple specific bacteria? And then, would it be better to go with multiple specific meds for those specific.
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Patrik: No.
Juan: Am I getting it wrong?
Patrik: Yeah. Look, most of the time you find one. That’s not to say there isn’t another one. Most of the time you find one. And then, you should narrow it down to what you’re finding. However, in your mom’s case, it hasn’t been narrowed down to one and I’ll tell you why. They’re talking about a CMV (cytomegalovirus). They’re talking about a fungus. And there talking about bacterial growth as well. So she’s got antifungal, she’s got the Ganciclovir and she’s got antibiotics. So she’s got everything in the mix. Now, again, not saying that I haven’t seen this before, and the more complex a situation is, the more likely it is that you’re treating the fungus, and the bacteria, and the virus, which is exactly what’s happening in your mom’s situation. But to answer your question, the more specific the better.
Juan: So, in broad-spectrum…
Patrik: No, no. You can find that out very simply. You can ask them have they identified bacterial growth. That’s all you need to ask them.
Juan: Okay. And then, based on their response, if they say yeah… if they say no, then?
Patrik: Well, then, if they say no ask them why are they giving those specific antibiotics. You know, what’s the reason?
Juan: Okay. With the fungus they’re saying that they know its Candida. With the Ganciclovir they’re saying they know it’s CMV (cytomegalovirus). So, I guess the bacterial one is the question, right?
Patrik: Correct. You would think that if they can be so specific with…
Juan: …the other two then why not for this one.
Patrik: … the other two then they should be very specific with the bacteria as well.
Juan: Oh, they’re also giving her Targocid. I sent you…
Patrik: Targocid?
Juan: Targocid. I just resent them.
Patrik: Hang on, just give me a second. Targocid? Just need another name for that if I think it is what it is. Just give me a second.
Juan: Teicoplanin.
Patrik: Oh, okay. Just give me a second.
Juan: Sure. Take your time.
Patrik: Well, it is Teicoplanin. Yeah. Teicoplanin is an antibiotic used in the prevention and treatment of serious infections. Well, again, ask them what prompted them to give the Teicoplanin.
Juan: They said they had to cover Gram-positive.
Patrik: Okay.
Juan: They had to cover most of the Gram-positive bacteria.
Patrik: Sure. Gram-positive is fairly broad it’s not very targeted.
Juan: I’m sorry. I just want to be prepared for that conversation because usually with them showing up and we don’t know where to take it further. Why Elores and why Targocid? And then, they say to cover any Gram-positive bacteria. Then we say, well, why aren’t you narrowing it down to something more specific?
Patrik: Yep.
Juan: Is that where we want to get to in the conversation?
Patrik: Yeah. Ask them why they can’t narrow it down any more specific.
Juan: And if they do narrow it down further…
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Patrik: Well, maybe they’re waiting for a result. It could be as simple that they’re waiting for a result.
Juan: The Elores has been going on for quite a while now. It’s been going on for ages as far as I remember.
Patrik: Has it? Okay.
Juan: We’ve been talking about it for a long time.
Patrik: Okay.
Juan: I’ll double check since when. Do you know when she was put on VV ECMO? Sorry, just a second. Weeks to a month? So they restarted Elores 8 days ago.
Patrik: Right. Again, ask them why. Have they done a culture check?
Juan: Okay. And if the answer is no, and they haven’t been able to identify it, and they’re not sure and they say just to be safe. Then, should we be pushing to identify it or stop it?
Patrik: That’s a good question. What I could not see in your pictures today… I couldn’t see a white cell count, or have I missed that.
Juan: The WBC count was down to about 4.7 so she was going down.
Patrik: That could be a sign that antifungals, antivirals, and antibiotics are working. The question is which one is working. So, let’s just say for arguments’ sake, they would stop all of it and white cell count would rise and it would spike a temperature. Why would that-
Juan: We wouldn’t know which one is…
Patrik: Correct.
Juan: The WBC count started dropping the day before yesterday.
Patrik: Right. I don’t think they would be risking taking any of that off at the moment because she’s improving.
Juan: If it’s at the expense of other things then…
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Patrik: It often is at the expense of something else. You’re giving the antibiotics, you’re giving the antivirals, you’re giving the antifungals, and that might contribute to kidney failure. It’s probably not the only thing, but it’s probably contributing to kidney failure. So, there’s always, unfortunately… your mom, probably for many weeks, has probably been the sickest, or one of the sickest people, in that hospital.
Juan: Right.
Patrik: Right.
Juan: They have to weigh up what…
Patrik: Have to weigh up.
Juan: So, okay, fine. This is a good conversation to have tomorrow if we continue to see improvement. And we can see where we can make some changes that make everyone feel comfortable. One other question, Patrik. Sorry, I’m just going to go back up to your message. You mentioned Midazolam still going besides the introduction of ..
Patrik: Yes. So, here is my concern there. Midazolam is a benzodiazepine.
Juan: Yeah.
Patrik: Exactly, that’s my concern. Why would you replace one with the other?
Juan: Yeah.
Patrik: That’s probably my concern now.
Juan: Correct.
Patrik: I can tell you that as much as I don’t like the benzodiazepines, as long as she’s on Atracurium, she will need some form of heavy sedation.
Juan Yeah, I think we realize… we know that.
Patrik Right.
Juan: Our main concern there is for her lungs to improve enough to get off the ventilator. Okay, anything else. Oh, yeah. Patrik, in the two images I sent you with the reports on the Ganciclovir, from what I can understand from what I’ve read about the viral load using the PCR test, identifying symptoms, and then trying to analyze the viral load in the body. It sounds similar to how PCR in SARS-COV-2 work, am I correct?
Patrik: Say that again. It sounds similar to…
Juan: How SARS-COV-2, COVID, and PCR test works. Right? You have cycles, you have a viral load, and then you try to correlate that with symptoms?
Patrik: Yes.
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Juan: And that makes sense of that to see how sick…
Patrik: Yes. That’s my…
Juan: So, I’m trying to understand from these two reports on… I’ve understood a fair amount about the PCR in terms of SARS-COV-2. That you have a 25 cycle threshold and above that it starts becoming less and less relevant. It can start indicating a milder infection, or whatever. So, what’s the correlating number for the CMV (cytomegalovirus)?
Patrik: Oh, I see.
Juan: What does the 52,000 mean? What does the 4,000 mean?
Patrik: So, you can probably Google that. Just quickly type into Google CMV (cytomegalovirus) DNA. Just give me a second… CMV (cytomegalovirus)? Just looking up your paper there where it gives any numbers.
Juan: Yeah, I tried looking… when I was figuring this out I just couldn’t pinpoint exactly. So, I thought I’d quickly check with you.
Patrik: No, it’s not clear to me. It’s not in that research paper and I’m just looking it up.
Juan: The doctor, I don’t think they know really either. They said we may have to talk to the infectious disease expert and get back to us.
Patrik: Oh, I’ve got it… hang on. I think I’ve got it just give me a second.
Juan: Sure.
Patrik: Yeah, there is something… I just sent this to you. You would have to make sense out of those numbers. This is very deep stuff. If the doctors don’t know it, I wouldn’t know it either. I would have to Google it myself.
Juan: That’s okay.
Patrik: I have to send it to you.
Juan: Okay. We’ll take a look at this and just understand as well. Anything else?
Patrik: I believe they can’t tell you at the moment why she’s improving. I don’t think they can tell you.
Juan: No, they can’t.
Patrik: It’s a case of… they’re throwing everything at her lungs at the moment and something is working.
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Juan: That’s what I was mentioning earlier when they put her on VV ECMO and they thought that it was a very difficult situations. The next two days they did say to us, “well, we’re just throwing the kitchen sink at her.”
Patrik: Very much so. So, that’s what they are doing and with some affect. They couldn’t tell you which one is working. If you knew which one is working you might could…
Juan: …and you could focus on that.
Patrik: Correct. And you might also be in a better position to manage kidney failure potentially.
Juan: Then I mean, I guess, it’s a process of continuing elimination and reducing certain things.
Patrik: Correct.
Juan: Yeah. That is how, logically, try to figure out what’s going on.
Patrik: It’s a process of elimination and that needs to be what you could ask there. You can ask for a pathology input… infectious disease and pathology input.
Juan: What does that mean?
Patrik: When you have an infectious patient, even in ICU, you usually get infectious disease involved. They should be the one recommending antibiotics and antivirals whatever. I don’t know how it works.
Juan: To be honest with you, Patrik, the infectious diseases expert seems like the kind of person whose solution is let’s just throw everything. And then, it doesn’t matter which one is working..
Patrik: Correct.
Juan: To be honest with you, that’s just the sense we’ve got right now.
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Patrik: Oh, yeah. There’s nothing new there, and that’s what you do in situations like that. Now, it’s a case of, okay, something’s working what we can eliminate. And that can be very difficult to find.
Juan: Maybe we start tapering the one that seems to have the highest risk of damaging other things and just see how that does.
Patrik: I don’t think they would risk that.
Juan: No?
Patrik: And I’ll tell you why they wouldn’t risk that. In looking at it from a hierarchy point of view, and I know that’ll sound horrible what I’m going to say now, but you can’t sacrifice the kidneys for the lung.
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Juan: Yeah, I know. I get it. We’ve understood that from all the conversations. I get where, and why, and what… that very strong hierarchy that they have to maintain to make very tough decisions. I understand that sort of the guide book and rule book that they follow. Okay…
Patrik: Because dialysis is much easier than VV ECMO much easier.
Juan: So when they say weigh the risks and the pros and cons, and see what’s manageable… what can be supported. It’s the easier one to support.
Patrik: That ECMO needs to come out.
Juan: Yeah. Okay. I think even we have that priority in that sense.
Patrik: I would replace dialysis with ECMO at the drop of a hat.
Juan: How long can you do dialysis for? Like, for an example…
Patrik: There’s people with dialysis living in the community.
Juan: So even if we have to hypothetically do dialysis for a few days, or for a week, and then this is improving, and then we stop the dialysis, that’s okay?
Patrik: Absolutely.
Patrik: Many patients in ICU go on dialysis temporarily and they go back home eventually and don’t need dialysis. Now, there is no guarantee for that of course. The bigger problem is lung failure not kidney failure at the moment. Both are very problematic don’t get me wrong, but if you want to choose one over the other you would choose kidney failure and not lung failure.
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Kevin: Got it. Also, Patrik, in the article you just sent us about the PCR CMV. It says the conditions as heparinized specimen.
Patrik: Yep, sure. Well, that’s not only for CMV that goes for anything.
Kevin: Would that alter the results by any chance.
Patrik: It would potentially give inaccurate results. I wouldn’t worry about that because it’s got everything to do with how you take a sample. It’s got nothing to do with she’s on Heparin at the moment. It’s got everything to do with what syringes they’re using when they take a sample. That shouldn’t be a focus at the moment.
Juan: Okay. I think that’s all our questions. Is there anything else?
Patrik: Not that I can think of. There’s definitely been some improvement. There’s no question about that. The x-ray clearly shows there is improvement. The reduction in Noradrenaline shows there is improvement. They have to reassess tomorrow morning?
Juan: Yeah. We’ll have this entire conversation with all the points that we just discuss. I think this evening we’re going to have that chat. And I’ll take it from there. And then see tomorrow, of course, how she’s doing.
Patrik: All right. Any other questions?
Juan: No. I think it for now, Patrik.
Patrik: Okay. All right. Let’s see how it go and reassess tomorrow, or if you need anything later just reach out.
Juan: Yeah. We’ll continue to share any kind of updates on the chats then you’ll have the updates.
Patrik: Okay. Wonderful.
Juan: Okay. Thank you, Patrik.
Patrik: Okay. Thank you so much. All the best for now. Thank you, bye.
Juan: Thank you. Bye.
The 1:1 consulting session will continue in next week’s episode.
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
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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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- 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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