ICU Medley

The bread and butter of the ICU stays the same. Patients after extensive surgeries remain intubated because of fluid shifts or concerns for swelling. I come in the morning, put them on a spontaneous breathing trial, extubate them by lunch, and send them out of the intensive care unit. Other patients have a much longer duration of respiratory failure; intubated for seizures or COPD or altered mental status, these patients are usually older and weaker, without significant reserve. I spend the week exercising their respiratory muscles, making very slow progress as they wean from the ventilator bit by bit. We have our post-cardiac surgery patients, our heart failures, our heart attacks, and our strokes. Although these are straightforward, occasionally, competing interests arise. For example, a patient with a mechanical heart valve on anticoagulation undergoes abdominal surgery. His anticoagulation is held before surgery and resumed post-operatively because with that mechanical valve, he is at high risk for strokes. Unfortunately, he bleeds into his abdomen, requiring a middle-of-the-night emergent laparotomy. Now, how do we decide when to restart anticoagulation? How much risk are we willing to take with regard to strokes or further bleeding? Often, there's no right answer, so both surgeon and cardiologist decide to "keep a close eye on him in the ICU." Along the same lines, GI bleeds tend to come to the unit, even if they are hemodynamically stable; the hospitalists are quite conservative and send them to critical care "just to watch the patient."

Of course, septic shock is the most common admission to the intensive care unit. One of the more interesting cases was a morbidly obese patient presenting with an infected kidney stone. He was anticoagulated for atrial fibrillation. When he came in, he was in septic shock, requiring large fluid boluses and vasopressors. He went to interventional radiology for placement of a nephrostomy tube. Unfortunately, his body habitus made the procedure technically difficult and with his anticoagulation, he had significant bleeding around the kidney. He received a massive transfusion protocol. When he returned to the intensive care unit, now intubated, he had a mixed picture of septic and hemorrhagic (or hypovolemic) shock. His ventilator settings were now very challenging given his body habitus and the fluid shifts he experienced. As a result of his shock, his kidneys stopped functioning and he required continuous renal replacement therapy. The critical care involved a delicate management of his fluids, titration of his vasopressors, decisions around transfusions, and weaning of the ventilator. What started as the oh-so-common "urosepsis" became a real multiorgan system failure. A week later, though, he was on his way to rehab, doing well, off dialysis, and back in good spirits.