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Quick Tip for Families in Intensive Care: My Dad Went Back into ICU with Pneumonia & a Weak Heart Needing Vasopressors & Inotropes, Can He Improve?

Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So, today I have a couple of emails from one of the clients that we worked with recently. I just want to show you how we help our clients and their families so that you know what you get if you want to work with us one-on-one and also, I advise you on what to look for in intensive care in the meantime just by reading out this email. So, you’re going to win one way or another.

So, here’s an email.

“Hi Patrik,

I just received a call from my mother saying she received an alert from the hospital ICU letting my mom know they moved my father to the cardiac ICU, and they think he needs more specialized services.

The ICU told her he was having trouble breathing so they are ventilating him now via the tracheostomy again. He’s bringing up lots of phlegm and they think this is the best thing for him to have him back in ICU. I feel like we’ve taken a step back and I’m very nervous. Can you advise on if you think this is the route we should be taking? Or what other questions we should be asking them tomorrow to verify the information?

I also talked to his nurse. She remembered my dad from when he was last in ICU. He became hypoxic and the respiratory and cardiac surgery team was called in. They moved him from his tracheostomy where he was breathing spontaneously into a ventilator and like I said, he’s now back in the cardiac ICU. They gave him a small dose of Levophed or norepinephrine and he’s back to baseline. They are not sedating him, he’s fully awake and he’s doing fine. They feel like they can move him back to the midodrine soon and wean off the Levophed/norepinephrine. I will call the nurse after the change of shift tomorrow and give everyone an update.”

So, in this situation, we’re also looking at the online chart to verify everything that our client is saying. We have access to the medical records so that we can verify that what the client is saying is accurate.

Here is what we found online and just to give you some context here, this particular client was in cardiac failure, had a very poor ejection fraction. He was on the ward with a tracheostomy or on the hospital floor, but then had to go back with another setback because of his cardiac failure into ICU, ended up on Levophed, and ended up back on the ventilator.

So, here’s what we found in the medical records. As you’ve mentioned, they moved him back to the cardiac ICU due to respiratory failure which is a good step to manage his complex medical issues well and stabilize his respiratory and cardiac function. He has been placed on the ventilator and started on a low dose vasopressor, Levophed/norepinephrine to improve his blood pressure and they are considering possibly switching him back to the midodrine. Midodrine is also a vasopressor that’s given in tablet form, whereas the Levophed/norepinephrine is given intravenously.

However, it is important for them to repeat his echocardiogram of the heart, also known as ultrasound, to further assess his heart function and determine the next steps and determine his ejection fraction. Ejection fraction means the contractility of the heart also known as the pump function of the heart. His most recent TTE (transthoracic echocardiogram) on the 27/3/2024 showed the ejection fraction of only 20-25% despite a maximum dose of Midodrine at the time (10 mg every six hours, which is 40 mg per day) which is a fair amount by the way. He may need Milrinone to improve his cardiac output as he has severely reduced heart pumping capacity with the ejection fraction only 20 to 25% and also to decrease vascular resistance, which can help improve heart flow, help reduce pulmonary pressures, and alleviate symptoms of congestion which affects his respiratory function.

Notes from the doctor on the 4/9/24, your dad is lethargic with lots of secretions. They sent sputum sample for analysis on the 4/9/24 pending result. They repeated the CT head on the 4/10/24 which showed no evidence of acute intracranial hemorrhage, discrete mass, or definite acute infarction. Microvascular disease and volume loss with chronic infarcts involving the right cerebellum. Neuro to address this for potential stroke.

Additionally, they have done arterial blood gases to check his oxygenation on the 4/10/24 while he was on the trach mask 100% of oxygen and showed respiratory acidosis which means there is accumulation of carbon dioxide, also known as CO2, in his blood causing altered mental state and impaired oxygenation/ventilation. They then shifted him to the ventilator to support his breathing and for CO2 clearance, on high ventilator settings of volume control mode, FiO2 of 100%, PEEP of 10, ventilation rate/breathing rate 20 breaths per minute. His repeat arterial blood gas on the 4/10/2024 few hours later improved. His PO2 (partial pressure of oxygen) on the recent blood gas showed very high (233.2). His FiO2 via the ventilator is on 100%. They should now try to gradually decrease the FiO2 on his ventilator and monitor his tolerance. They can repeat the arterial blood gas to monitor progress and to determine the need to modify further his ventilation settings. They also need to suction him on time (before taking any blood gases) and as necessary to prevent the accumulation of secretions blocking his airway.

The chest X ray on the 4/10/24 also showed cardiomegaly which means the heart is enlarged and it is also unchanged compared to the previous x-ray. Sternal sutures and mediastinal clips again noted. Tracheostomy tubes seem in satisfactory position. The lungs are mildly hypo aerated. Small bilateral effusions with superimposed patchy bibasilar atelectasis versus infiltrate. Parenchymal opacity more marked on the left than right. Probable mild volume overload. His white cell count also continues to increase. As we previously advised, infectious disease team and the doctors need to further investigate for any underlying additional infection. To address this as it might need to restart appropriate empiric antibiotics. So, the chest x-ray really suggests that there is some form of chest infection potentially developing into a pneumonia.

Furthermore, his hemoglobin level is low. I have seen that he had blood typing and screening and potential for packed red blood cell transfusion to improve the levels. They also need to take note of his increasing platelet count. This needs hematologist input. So, when someone is on 100% of oxygen and they have a low hemoglobin, there’s also a good chance that with a unit of blood, that oxygen requirements on the ventilator can go down.

His sodium level is increased which means he could be dehydrated, and to continue correcting it with free water flushes. Also, his potassium level is elevated, and they need to correct this on time. His high potassium levels may cause life-threatening cardiac arrhythmias, muscle weakness, or paralysis and worst-case scenario, death, if left untreated. They can correct and manage his hyperkalemia/increased potassium levels with any of the following: salbutamol nebs, sodium bicarbonate, calcium gluconate, polystyrene sulfonate, insulin/glucose, Veltassa/Lokelma, also with Resonium. If initial conservative treatments are not effective, he may need dialysis or hemofiltration to correct persistent increased potassium levels.

So, that is the situation there and eventually the gentleman came out of ICU. I can say that much, it was a long road for him, but eventually the gentleman came out of ICU. Also, what they were doing in ICU as well to increase his cardiac function, they gave him a dose of levosimendan. Levosimendan, again, increases the contractility of the heart and it increases the pump function of the heart, so does dobutamine and milrinone which are from memory, he’s had as well.

So, it’s really important that when you have a family member in a similar situation, that you really understand all the ins and outs, and that you get that second opinion so that you’re not flying blind. After all, this is a once in a lifetime situation when you have a loved one critically ill in intensive care that you can’t afford to get wrong.

Also, 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 exactly what this family was dealing with, and we could handhold them through everything that was happening in the process.

This was also a family we helped to go from LTAC/ long term acute care facility back to ICU with our advocacy. So, if you are stuck in LTAC in the U.S. and you want to go back to ICU, we can help you with the advocacy. We can make the clinical case; we can look at everything and make the clinical case for going back to ICU, which is part of our consulting and advocacy.

I have worked in critical care for nearly 25 years in three different countries where I also worked as a nurse manager for over 5 years. I’ve been consulting and advocating for families in intensive care all over the world since 2013 here at intensivecarehotline.com. We have saved many lives with our consulting and advocacy. You can verify that on our testimonial section at intensivecarehotline.com. You can also verify it when you go to our podcast section at intensivecarehotline.com and you can watch some client interviews there.

Because we get so many questions for families in intensive care every day, that’s why we created a membership for families of critically ill patients in intensive care so that we can help as many as families in intensive care as quickly as possible. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related in there. You also have exclusive access to 21 eBooks and 21 videos that I’ve personally written and recorded, sharing all my 2.5 decades worth of critical care nursing experience. Sharing it with you so that you can make informed decisions, you have peace of mind, control, power, and influence so that your loved one gets best care and treatment.

All of that you get at intensivecarehotline.com if you click on the membership link or you go to intensivecaresupport.org directly and there you can get access to the membership.

Now, I also do one-on-one consulting and advocacy over the phone, Zoom, WhatsApp, Skype, whichever medium works best for you. I talk to you and your families directly. I talk to doctors and nurses directly. I handhold you through the process when you have a loved one in intensive care, and once again, I’ll make sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment. Once again, I handhold you through the process and it’s a process you can’t afford to get wrong when you have a loved one critically ill in intensive care. When I talk to the doctors and nurses as well, I ask them 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.

Now, 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 if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or send an email to [email protected].

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, and comment below what you want to see next, what questions and insights you have.

I also do a weekly YouTube live where I answer your questions live on the show and you will get notification for the YouTube live if you subscribe to my YouTube channel, or if you are a subscriber to our email newsletter at intensivecarehotline.com.

Also, if you want your email done very quickly, make a small donation to the super chat button here on YouTube. Or if you just want to make a small donation to support our work, the more videos we can do, the more families we can help in intensive care. It’s a win-win situation.

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 for now.

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