My name is Patrik Hutzel from intensivecarehotline.com, and this is another quick tip for families in intensive care.

Here at intensivecarehotline.com, 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 best care and treatment, even if you’re not a doctor or a nurse in intensive care.

Today I have a question from Jennifer who’s asking about her mother’s hemoglobin dropping into the sevens and white cell count rising despite treatment in ICU.

So, the email from Jennifer reads,

“Hi Patrik,

My mother’s kidney function appears to have improved. They gave her three IV doses of albumin since yesterday. However, her hemoglobin is trending lower and now in the sevens, and her white blood cell count is trending upward. Mom is on continuous tube feeding and tolerating that well, but why is her blood hemoglobin going down? What are the possible causes? Also, blood and other specimens were taken from Mom yesterday and sent to the laboratory for investigations. Antibiotic medications have been started as well, but why do the white blood cell count continue to rise? What causes them to rise? After how many hours will the treatment take effect? Also, she still remains ventilated with tracheostomy and makes no progress. Thank you.

– Jennifer.”

Jennifer, thank you so much for your question. I’m really glad you reached out because what you’re describing with your mom is concerning and needs immediate attention and advocacy. Let me break this down for you so you can understand what’s happening and what you need to do next.

So why is your mom’s hemoglobin dropping despite treatment?

First of all, it’s excellent news that your mom’s kidney function is improving with the albumin treatment. That’s a very positive sign. However, the dropping hemoglobin into the sevens is concerning and needs investigation and potentially is correlated to the albumin that she’s had. I will explain in a minute why because here are the possible causes for hemoglobin dropping in ICU.

1.  Ongoing bleeding. This is the most common cause in ICU patients.
Your mom could be bleeding from the gastrointestinal tract, stomach or bowel bleeding. She could be bleeding from tracheostomy site or from any other surgical sites if she had recent procedures. She might also have internal bleeding that’s not immediately visible.

2.  Frequent blood tests. ICU patients often have multiple blood tests daily, and this phlebotomy can cause what we call anemia of blood loss over time.

3. Hemolysis. This is when red blood cells break down faster than normal, which can happen due to infections, certain medications, mechanical factors like if she’s on certain types of support equipment.

4.  Dilution effect. This is where the albumin comes in. The albumin and IV fluids your mom have been receiving can dilute the blood, making hemoglobin appear lower.

5.  Bone marrow suppression. Critical illness, infections, and certain medications can suppress the bone marrow’s ability to produce new red blood cells, and

6.  Nutritional deficiencies. Despite tube feeding, deficiencies in iron, vitamin B, or folate can affect hemoglobin production as well.

Now, regarding the rising white blood cell count, this is equally concerning, and here’s what could be happening.

1.  The antibiotics haven’t had enough time. Antibiotics typically need 24 to 72 hours to show significant effect. If the cultures just came back yesterday and antibiotics were started, you may not see improvement yet.

2.  It might be the wrong antibiotic. The bacteria causing the infection might be resistant to the current antibiotic regimen. This is why getting culture results is critical.

3. Undrained infection. There could be an abscess or collection of infection that antibiotics alone can’t reach. It may need drainage.

4.  New or secondary infection. Your mom could have developed a new infection in addition to the original one. Patients in ICU are extremely prone to developing new infections because they’re often immunocompromised and with doctors and nurses going from patient to patient, they could carry infections around despite all the precautions and hand washing and hand hygiene they’re doing.

5.  There could be a non-infectious cause. White blood cells can rise due to medications like steroids, stress response from critical illness, blood clots, and tissue damage.

6.  C. diff (Clostridium difficile) or other hospital acquired infections. ICU patients are at risk for hospital acquired infections like I mentioned a minute ago, like Clostridium difficile, also known as C. diff.

So, what do you need to do right now? Jennifer, here’s what’s critical.

Get complete access to all medical records. You need full access to all medical records immediately. This includes complete blood count, CBC trends, all other blood results, culture results and sensitivities, imaging reports, CT scans, MRI scans, X-rays, etc., all the vital signs and ventilator settings, medication list, input and output records like fluid balance, doctor’s progress notes, nurses’ progress notes, physio and so forth. Get everything, leave no stone unturned. And we can help you understand whether you have access to all medical records. Sometimes we’re finding hospitals are trying to withhold information, but we can, we will find that out for you. Without these records, it’s impossible to provide specific guidance.

Also, you need a consulting call with myself or the intensivecarehotline.com team urgently. During this call, we review all the medical records, we’ll prepare specific questions for the ICU team, we’ll help you advocate effectively, we can potentially join a family meeting with the ICU team and yourself to question and clarify treatment plans. This is exactly what we do. We question and advocate on your behalf when you don’t have the medical knowledge to do so.

Also, questions to ask the ICU team today about the dropping hemoglobin. Is there evidence of bleeding? If so, where? Has a stool test been done for blood? Are you checking for hemolysis? What is the reticulocyte count? Shows if bone marrow is producing new red blood cells. At what hemoglobin level will you transfuse? What’s the trend over the past week?

If hemoglobin remains low, will my mom be able to wean off the ventilator? Because if hemoglobin is low, oxygen will have a hard time connecting to the red blood cells carrying oxygen around the body because there’s not enough of them. So that’s why normalizing hemoglobin levels will also help with ventilation weaning.

Let’s now also talk about rising white cell counts. What are these specific culture results? Are the current antibiotics covering the identified organisms? Is there antibiotic resistance? Are you looking for undrained collections or abscesses? What imaging has been done? Have they ruled out C. diff? What’s the plan if the white cell count doesn’t improve in the next 24 to 48 hours?

Also, about the ventilator and the tracheostomy. What are the current ventilator settings? What’s preventing weaning? What’s the weaning plan? Is she making any spontaneous breathing efforts? What’s the long-term plan if she can’t wean? Are they mobilizing her? Are they doing physical therapy? And like I said, are they making sure hemoglobin is trending upwards so she can wean off the ventilator more effectively with a higher hemoglobin level?

To answer your specific questions about antibiotics. Antibiotics typically take 24 to 72 hours to show effect, but it depends on whether the right antibiotic is being used, the severity of the infection, your mom’s immune response, whether there’s source control, draining infections. If the white blood cell count continues rising after 48 to 72 hours of appropriate antibiotics, this is a red flag that needs immediate investigation.

Let’s also now look at long-term ventilation and Intensive Care at Home because you mentioned your mom has or is still ventilated and tracheostomy dependent. And you mentioned, Jennifer, that your mom makes no progress on the vent weaning with tracheostomy. This is very concerning and you need to start thinking about long-term options potentially. If your mom requires long-term ventilation, either invasive with a tracheostomy or non-invasive and can’t be weaned off the ventilator, or if she needs the tracheostomy without a ventilator long-term, you need to know about intensivecareathome.com and you can go to Intensive Care at Home’s website.

Intensive Care at Home is a long-term option that can keep your mom out of ICU predictably and permanently, provides ventilation support at home, invasive or non-invasive, managed tracheostomy care at home, provide palliative care at home if that’s the direction you choose, gives you and your mom and your family dignity, privacy, and quality of life outside of ICU. Because this is absolutely critical, because prolonged ICU stays lead to hospital acquired infections which may be happening right now, deconditioning and muscle wasting, ICU delirium, ICU psychosis, poor quality of life, enormous costs. We’re talking about five thousand to ten thousand dollars per bed day, whereas Intensive Care at Home gives you 24-hour intensive care nursing at home to replicate an ICU bed at home and to keep your mom at home predictably and permanently. And that is at the cost of 50% of the ICU bed roughly, right, so health insurance and government funding bodies have an interest in this proposal because they’re cutting the cost by 50%.

The bottom line, Jennifer, is that your mom’s situation is serious. The dropping hemoglobin and rising white cell count suggests possible ongoing bleeding, possible inadequate infection control, need for immediate investigation and treatment adjustment. You cannot wait. You need to get access to all medical records, get on a consulting call with myself immediately. Go and book it at intensivecarehotline.com, call me on one of the numbers on the top of our website, aggressive advocacy and questioning of the ICU team, investigations into both the anemia and the infection.

I have worked in critical care nursing for 25 years in three 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. You can verify that on our testimonial section at intensivecarehotline.com. 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 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. 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. 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 if in case you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care, and you can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly. 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 the membership, you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded. All of that will help you to improve your life instantly, make informed decisions, have peace of mind, control, power and influence, making sure your loved one gets best care and treatment always.

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

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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 for now.