That One Last Thing

Part of critical care fellowship is learning how to handle the extremes of a disease. When someone's oxygenation is so bad that you've maximized your ventilator, what do you do? When someone's blood pressure is refractory to every drip you can think of, what do you order? When a patient's on every antibiotic you can think of but you still think they have an infection, what do you add?

On my VA rotation, a patient was transferred from another hospital for consideration of heart transplant. He had advanced end stage heart failure and received continuous inotropic infusions as an outpatient to support his heart. His weak heart was dependent on constant medications to give it enough squeeze to keep him alive. When he arrived at our facility, his numbers looked awful. His liver and kidneys were starting to be injured. We put in a pulmonary artery catheter to figure out his cardiac output and systemic vascular resistance. No matter how carefully we titrated his dobutamine and milrinone, we could not find the sweet spot where his heart and all his other organs could be supported. While everyone perseverated on his medications - whether to add epinephrine or vasopressin, whether diuresis would help or not - I knew that no drug could fix this problem. I called the cardiac surgeon and had them come over to place an intra-aortic balloon pump. This mechanical device didn't have the side effects of blood pressure medications and could keep his kidneys, liver, and brain perfused by mechanically assisting the heart. It was that one last thing that could keep him alive while we waited for a heart transplant.

Yesterday, in the medical ICU, I had a patient with life-threatening acute respiratory distress syndrome - a widespread inflammation of the lungs. I was on maximum ventilator settings with delivered oxygen of 100% and an end-expiratory pressure of 14. There was very little I could do with the breathing to machine to deliver more oxygen to the patient. As a resident, we are taught to adjust the delivered oxygen and end-expiratory pressure, but what do you do when you have nowhere to go? I added inhaled epoprostenol, a medication that dilated pulmonary blood vessels, and paralyzed the patient to prevent disharmony with the ventilator. It only helped marginally, but it's that one last thing, the thing few people recognize, that might make the difference.