Lung Is Not Functioning And Not Able To Pass Much Urine. What Treatment Should Be Done?

Hi,

Your granny seems to have septicemia with multi organ dysfunction.

Let me proceed system wise:

1. Respiratory system: She is on ventilator since 1 of her lung is not functioning well which I presume is pneumonitis and not both the lungs.
However, it would be of immense help if you could have mentioned what the doctor says the actual lung pathology is.
Since her oxygen saturation is low she would have to be on a ventilator till her respiratory system improves and the parameters on monitor shows satisfactory oxygen saturation coupled with a satisfactory ABG ( arterial blood gas ) report and a satisfactory X-ray chest film to consider further weaning off ventilator.

2. Hemodynamic system : Her blood pressure being on the lower side and considering she is on a ventilator and not passing enough urine so initial management with fluids ( fluid bolus) has to be very cautious as she might develop pulmonary edema ( which is congestion of lungs because of fluids) and further worsen oxygenation. Therefore, for the low pressure she might require inotropic support anytime. Inotropes are medications given by continuous IV infusion to support circulation. She would also require a central venous catheter and an arterial line for proper management.

3. Renal system: She is not passing enough urine. I suppose as she is on a ventilator they have already inserted Foley’s catheter. However, the management goes beyond this. If she is passing enough urine on catheter, it is good. But if she is not then seeing her renal function test report, she has to be adequately managed. For me without knowing those values it becomes little difficult to discuss the management line but still on a general basis, first (if feasible) fluids followed by diuretics whether as IV injection or continuous IV infusion are used. If there is a further deterioration in the urine output and seeing the renal function test report then the need for dialysis arises. Urine output is monitored on a closer basis on a per hour basis.

3. Cardiac system: She is a case of CAD (coronary artery disease), status post stenting. At present she has to undergo an ECG to look into the rate and rhythm function of the heart as well as she has to undergo a 2 dimensional echocardiography ( 2D Echo) to look into the pumping function of the heart and rule out any regional wall motion abnormality of the heart which might also lead to the low blood pressure.

4. Neurological system: The good thing is she is conscious. For a conscious patient at times because they do not tolerate the Endotracheal tube (the tube from the mouth connecting to the ventilator) and ventilator so they might have to be put on sedatives for proper ventilatory function.

5. Septicemia: Well septicemia is a broad diagnosis. It is the systemic inflammation (eg: fever and leucocytosis) in response to an infection. In her case as it is accompanied by hypotension (low blood pressure) and involvement of more than one vital organ so, it is 'sepsis with multi organ dysfunction'.

Brief management outline for sepsis:

1. For sepsis, the therapy is resuscitation with fluids and inotropic support to maintain the blood pressure.
2. IV antibiotics which is broad spectrum and usually preferred empiric therapy is a regimen consisting of gram negative organism coverage ( eg: Meropenem ) and gram positive organism coverage ( eg: vancomycin). However, 2 sets of blood cultures are sent prior to starting antibiotics. Depending upon the blood culture and sensitivity report, the antibiotics are further modified.
Anyways the first set of cultures are also sent from urine ( for culture and sensitivity ) and endotracheal tube aspirate ( for culture and sensitivity) to look into the focus of infection.
Also important would be antibiotic dose modification as per renal function.
3. IV steroids (sepsis dose) are recommended for patients especially the ones requiring inotropic support for blood pressure.
4. Apart from this, the supportive management with IV Proton pump inhibitors, IV paracetamol and other nebulizations would continue as in regular management of critical care patients. Renal supportive therapy as guided by the clinical condition and laboratory parameters would continue.
5. For adequate management of sepsis strict asepsis has to be followed in managing the endotracheal tube suctioning, all IV lines and catheter.

I suppose I have answered your question in detail. My sincere apologies for some of the medical terminologies I had to use but trust me they are used so that you can relate to what your treating Intensivist mentions in regular clinical updates about the patient.

If you have any further queries, I shall be happy to answer.

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Hi
Good to her that her vital parameters are improving.
High blood pressure can be easily managed with medications. Not to worry for that.
Again passing adequate urine is good news. As for the degree to which the kidneys are affected would be determined by the renal function test and structural view as per ultrasound.
For the lung, you would have to continue nebulization even after discharge.
As her oxygenation is low , you might have to arrange for Oxygenation at home. Oxygen cylinder and face mask would be required for that. Discuss with your treating doctor if he feels the need for the same.
Management at home would depend upon her clinical status.
If she is conscious and eating well by mouth then feeding should not be an issue.
Medications would have to be followed as per the advice on discharge.
If her kidneys are affected then you would have to skip fruits and high protein diet.
But also keep checking the renal function tests once in a month to find if there is a worsening of the renal parameters.
As for the diet, at the time of discharge just get in touch with the dietician in the hospital and show her all the reports so that she can plan the proper diet.
Well no need to get MRI done , its basically a clinical and laboratory guided diagnosis. Any need for further evaluation would be suggested by your treating doctor.
Thank you.

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