My name is 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, control, power, and influence, making sure your loved one always gets the best care and treatment, even if you’re not a doctor or a nurse in intensive care.

In today’s video and blog article, I want to address a question from one of our clients, Heather, about her father, who has a tracheostomy, he’s on the ventilator in ICU, and is having repeated episodes of low blood pressure requiring norepinephrine or noradrenaline.

Let me read out Heather’s question. She says,

“Hi Patrik,

Over the last two days, my father has had repeated episodes of very low blood pressure requiring norepinephrine and noradrenaline. His arms were cold during these episodes and he had more PVCs (Premature Ventricular Contractions) and bigeminy than usual. The night nurse also had to restart the norepinephrine. His other vitals look okay, but no recent arterial blood gas has been done. He’s still ventilated with a tracheostomy. He’s also not tolerating the tube feeds and was found to have two stomach ulcers on his endoscopy, so they started IV Protonix, which is also known as pantoprazole. Because they removed the IV in the right arm, which has a known DVT, which stands for deep vein thrombosis, he now only has the PICC (Peripherally Inserted Central Catheter) line and one IV in the lower arm in his left lower arm, and blood pressure readings are being taken from his forearm which they say may affect accuracy. I am worried these repeated hypotensive episodes could mean he’s progressing towards septic shock even though he’s been stable for so long. Based on this update, Patrik, what should I be asking the team right now, and how urgent is this situation in your opinion?”

From Heather.

Heather, thank you for reaching out. Let’s look at how to best understand your father’s situation. I can hear your concern in your message, and rightfully so. When you’re seeing repeated episodes of hypotension requiring vasopressor/inotrope support like norepinephrine or noradrenaline, or other inotropes would be epinephrine, adrenaline, dobutamine, dopamine, milrinone, phenylephrine, vasopressin, and so forth, and especially after your father has been relatively stable, it’s absolutely natural to worry about deterioration and the possibility of septic shock.

Let me break this down for you. What do these symptoms actually mean? The combination of symptoms you’re describing – the repeated hypotensive episodes, cold extremities, increased PVCs and bigeminy, and the need to restart norepinephrine multiple times – these are all concerning signs that warrant immediate attention and thorough investigations.

Here’s what could be happening. Septic shock is certainly on the differential diagnosis, especially with the repeated need for vasopressor and inotrope support. However, it’s important to note that there are other potential causes for recurring hypotension in ICU patients with a tracheostomy on the ventilator, and those other issues could be hypovolemia. Your father might be very dry. He might be dehydrated. That could be another reason why he’s having low blood pressure. You should also be asking, does he have a temperature that would show potentially signs that he’s moving towards septic shock? What’s his white cell count like? What’s his CRP (C-reactive protein) like? Those are other things you need to look for.

The stomach ulcers they found on endoscopy could be contributing to the problem as well. If there’s any bleeding from these ulcers, even if it’s occult or hidden bleeding, this could lead to hypovolemia and hypotension. Hypovolemia again, dehydration. The fact that he’s not tolerating tube feeds and required endoscopy suggests significant gastrointestinal issues, and if he’s bleeding and they’re stopping the nasogastric tube or the PEG (Percutaneous Endoscopic Gastrostomy) tube feeds, he would be even more dehydrated.

The DVT in the right arm is another concern. While you mentioned they removed the IV from that arm, the presence of a known DVT raises questions about his anticoagulation status and whether there could be any complication from the clot itself. He’s probably on anticoagulation such as enoxaparin or heparin, and therefore the risk for a GI bleed or a stomach bleed is even higher, so everything links to each other in a situation like that.

The measurement accuracy issue with blood pressure readings from the forearm is actually significant. Blood pressure readings can be less accurate when taken from the forearm compared from the upper arm, and this could potentially mean his blood pressure might even be lower than what’s being recorded, or conversely that some readings are artificially low. The best way to deal with that is to put in an arterial line, because that would be the most accurate reading in a situation like that.

The other question here is, with the bleed from his stomach, what’s his hemoglobin like, and does he potentially need a blood transfusion? Would that bring up his blood pressure? And then there might be no need for norepinephrine.

Critical questions you should be asking the ICU team right now, especially about the hypotensive episodes: What is the working diagnosis for these repeated hypotensive episodes? Have they done all the investigations to find out? What’s his hemoglobin like? Is he dehydrated? Is he moving towards septic shock? Does he have a temperature, high or low? What’s his white cell count like? What are his CRP markers like? Is he developing a chest infection? What does his sputum look like? Is it yellow? Is it smelly? Does it look infected? Does he have a UTI or urinary tract infection? Does he need a catheter change? Have they done a full septic screen, including taking bloods? That includes blood cultures, urine cultures, and respiratory cultures, sputum sample. What are his lactate levels and are they trending up or down? Lactate is another very good indicator. If lactate keeps going up, that’s another good indicator that he might be moving towards septic shock. What does his white blood cell count look like and is there a shift? What does his CRP markers look like, and is there a shift? Are they seeing any new infiltrates on the chest X-ray that could suggest pneumonia? What is his procalcitonin level if they’re checking it?

As I have been saying here for a very long time, the biggest challenge for families in intensive care is that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask, they don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care.

Let’s talk about the gastrointestinal bleeding again. Could the stomach ulcers be causing occult bleeding contributing to hypovolemia and dehydration? What’s his hemoglobin level trending at, and does he need blood transfusions? I can guarantee you that if his hemoglobin is below 7 and he’s getting one or two blood transfusions, his norepinephrine needs will lower, potentially be eliminated altogether. Are they doing regular hemoglobin checks to monitor for ongoing bleeding? Is the Protonix/pantoprazole infusion adequately controlling the ulcers and the bleed, or does he need additional interventions?

Let’s look at his cardiovascular status. Why are the PVCs, which stands for premature ventricular contractions, and bigeminy increasing? Is this related to electrolyte imbalances such as high or low potassium, hypovolemia? Or is his calcium low, or is it cardiac ischemia, or is it the hypotension itself? Has he had a recent echocardiogram/ultrasound to assess cardiac function? Could this be cardiogenic shock rather than, or in addition to, septic shock? What are his troponin levels? Have they checked them?

Let’s look at his fluid status. What is his fluid balance over the last 24 to 48 hours? Is he fluid overloaded, euvolemic, or hypovolemic? Are they using any objective measurements like ultrasound to assess his volume status?

About medication management, what is the dose of norepinephrine he’s requiring during these episodes? Are they considering adding a second vasopressor, such as epinephrine, phenylephrine, vasopressin, dobutamine, dopamine, milrinone? Could any of his medications be contributing to hypotension? Have you looked at the list of medications?

Let’s look at the PICC line and IV access. Is the PICC line functioning properly and in a good position? Are they getting accurate central venous pressure readings if the PICC has that capability? Should they consider placing a central line on the other side for better medication delivery and monitoring? These are all very important questions.

About blood pressure monitoring, can they place an arterial line for more accurate continuous blood pressure monitoring, given the measurement issues with the forearm readings? This would also allow for easier arterial blood gas sampling, which you noted hasn’t been done recently.

Coming back to your other question, how urgent is this situation? In my opinion, Heather, this is an urgent situation that requires immediate attention, because anytime you have repeated hypotensive episodes requiring escalated vasopressor and inotrope support, this represents hemodynamic instability that needs to be thoroughly investigated and aggressively managed. However, urgent doesn’t necessarily mean immediately life-threatening. It means the ICU team needs to be actively investigating the cause right now and implementing appropriate treatment. The fact that he’s been stable for so long and is now having these episodes suggests something has changed, and identifying that change is critical.

The key here is getting to the root cause quickly. Is it septic shock, hypovolemic shock from bleeding ulcers, cardiogenic shock, a combination? Each requires different management strategies.

The importance of having access to all medical records. Heather, this is exactly the type of situation where you need access to all medical records immediately. It becomes absolutely crucial. You need to see the trends, not just today’s numbers, but how things have been changing over the past days and weeks. Looking at lab trends, vital sign trends, medication changes, fluid balance charts, and ventilator settings over time can reveal patterns that might not be obvious from a single day’s report and might not be obvious to non-ICU professionals. You have the right to request and review all of these records immediately, and I strongly encourage you to do so and share them with us so we can give you that crucial second opinion.

When you have all the medical records in front of you, you can see the complete picture of what’s happening with your father. This empowers you to ask better questions and advocate more effectively. And this is exactly the type of complex ICU situation where a consulting call with myself can make a tremendous difference. We review all medical records with you, we help you understand what’s happening, and work with you to prepare specific questions for the ICU team.

During a consulting call, we review the complete medical records and identify concerning trends, help you understand the differential diagnosis, prepare you for a family meeting with the ICU team, clarify the plan and prognosis, teach you how to question and advocate effectively, give you specific talking points to ensure all your concerns are addressed. We can also facilitate communication between you and the ICU team to ensure everyone is on the same page about your father’s condition and the path forward. You don’t have to navigate this alone. Having an experienced ICU nurse consultant like myself in your corner who helps you interpret what’s happening and helps you advocate will reduce your stress and improve outcomes.

What if he stays on the ventilator? Heather, you mentioned your father already has a tracheostomy on the ventilator. While we’re obviously hoping he’ll improve and eventually wean from ventilation support, it’s also wise to think about long-term options. If your father continues to require ventilation support long-term or tracheostomy support long-term, you should know about intensivecareathome.com. It’s a long-term option that can help your father, can help to keep your father out of ICU predictably and permanently while still receiving the ventilator support and ICU nursing level care he needs. Many families don’t realize that patients with a tracheostomy on a ventilator can potentially be cared for at home with proper support. This will provide a better quality of life for you and your father, more family time in a comfortable environment, reduced risk of hospital-acquired infections, lower overall healthcare costs, greater dignity and comfort.

At Intensive Care at Home.com, we help you explore whether this option is feasible for your father’s situation and guide you through the process of transitioning from ICU to home ventilation care with tracheostomy if appropriate. Even if he doesn’t need long-term ventilation but he needs a tracheostomy, knowing this option exists can give you peace of mind and help with care planning discussions.

Here’s what I recommend you do right now. Request a family meeting today. Given the repeated hypotensive episodes, you need to speak directly with the ICU team as soon as possible. Request all medical records. Get copies of labs, vital signs, notes, imaging reports, medication records, everything. Leave no stone unturned from his time since admission. Inquire about arterial line placement. This would give more accurate blood pressure monitoring and easier arterial blood gas sampling. Ask specifically about the septic workup. Make sure they’ve done comprehensive cultures and are looking for a source of infection. And book a consulting call with myself so we can help you review everything and prepare you for discussions with the ICU team.

Heather, I know this is a frightening time. Seeing your father experience these repeated episodes after he’s been stable is understandably worrying. The questions I’ve outlined above will help you to get clarity from the ICU team about what’s happening and what the plan is.

Contact me at intensivecarehotline.com for a consulting call. Call us on one of the numbers on the top of our website or send us an email to [email protected], or book a time with me on the website by clicking on the Book Appointment button.

I have worked in critical care nursing for 25 years in 3 different countries where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy, because of our insights, and you can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast section where we have done client interviews. Because our advice is absolutely life-changing.

The biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask, they don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. That’s why we help you to improve your life instantly, making sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets the best care and treatment always. That’s why you can join a growing number of members and clients that we have helped over the years, saving their loved ones’ lives.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. And I talk to you and your families directly. I handhold you through this once-in-a-lifetime situation that you simply cannot afford to get wrong. And when I talk to families directly, I also talk to doctors and nurses directly, asking all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. 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, in case you have unanswered questions, if you need closure or if you are suspecting medical negligence.

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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.