Catastrophic

There are some events that are simply catastrophic, events I consider non-survivable. Even though sometimes we can tide patients through the acute phase, I worry that these disasters set the patient back so much that recovery is impossible. It's a terrifying realization, really, because sometimes you feel that you have a patient who has no hope for survival. Sometimes you just hope that your intuition is wrong.

A patient with alcohol related heart failure receives a left ventricular assist device. The LVAD is a continuous pump that assists the heart by sitting in the left ventricle and pushing blood out to the aorta. Post-operatively, these patients are incredibly tenuous because only the left heart has assistance; the right heart remains in failure. They often stay in the CVICU for weeks while we tend to the right heart and address all the usual ICU complications. These patients seem to develop more ICU-related morbidity than standard patients, probably due to their tenuous hemodynamics and implanted hardware. It often takes us weeks to wean epinephrine, dopamine, milrinone, vasopressin, inhaled nitric oxide. And during this time, we struggle with ICU delirium, pain management, pulmonary hypertension, infections, ileus, renal failure, and glucose management.

This patient with an LVAD has had steady progress for over a month. We've been actively diuresing him to offload his right heart, but an unfortunate side effect of drying him out is severe constipation. His stool has become a cement sludge, and though you wouldn't think bowel movements are all that important in the CVICU, this story taught me differently. He was being evaluated daily by general surgery and medical GI consultants and had received several colonoscopic decompressions. I'd never seen anyone that happy to get a colonoscopy; he didn't want any sedation and enjoyed watching his own stool be disimpacted. Every day, we made a little progress with getting his bowels moving, weaning his oxygen, titrating down his inotropic drips.

Then one day, I got called because of severe abdominal pain. When I saw him, I knew something bad was brewing, and in fact, I can remember the very thought: this is what's going to kill him. His abdomen had peritoneal signs, indicating that he had perforated his bowel. I got an abdominal X-ray and as I watched them position him for it, I knew what it would show. A rim of gas was seen in his belly. We called general surgery, and even though he was at incredibly high risk - 3 vasopressors and a fresh LVAD - they took him to the OR.

That first night after he got back tested all my anesthetic and critical care abilities. He had high abdominal pressures concerning for abdominal compartment syndrome. He was maximized on four vasopressors, two of them at continuous code doses. His ventilation was poor because all the irritaiton in the belly had caused swelling, making it hard for us to deliver deep breaths. And the surgeons weren't confident about their bowel resection; they said that his intestines fell apart in their hands as they operated (a result of his vasopressors). The biggest challenge was fluid management. After large bowel surgery, patients become very dehydrated, and so he got a substantial amount of blood product and fluids. However, his right heart could not tolerate that sort of load. If his right heart failed, he would die.

We sat at his bedside all night, pushing medications, starting paralysis, doing serial echocardiograms, managing continuous renal replacement therapy (he had gone into kidney failure during this). And we managed to tide him through the acute catastrophe. But with ischemic bowel, raging peritoneal infection, right heart failure, kidney failure, prolonged paralysis and steroids, minimal nutrition, and increased hemodynamic support, I worry that this catastrophic event set him back a whole lot, and likely too much. Now I am in a hard place because we are doing everything we can to save this guy, but deep in my heart, I feel that he will never realistically recover enough to make it out of the ICU. I hope fervently I am wrong, but after a few years in medicine, I realize there are some catastrophic events where modern medicine can weather someone through a little bit, but not enough.