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Mr. Rajesh Desai, a 45 yr old male was transferred to Apex Multispecialty Hospital, on 23/01/2020. Before getting referred to our hospital, he was treated at multiple various corporate hospitals across. Thane and Mulund & was on mechanical Ventilator for more than 45 days and had many failed attempts of extubation and hence was tracheostomised and continued to be on a mechanical ventilator. At the outside hospital, he also developed VAP( Ventilator associated pneumonia ) with Multi-Drug resistant Klebsiella pneumonia & MRSA (Methicillin resistant staphylococcus aureus) bacteria which was resistant to all carbapenems and beta-lactam antibiotics except colistin only. Also when we received the patient, he was in septic shock on Norad infusion and had a multiorgan failure. The patient had Renal shutdown outside and was on maintenance dialysis. Also, there was thrombocytopenia (PT count 90,000) and raised WBC counts. His 2decho was done outside and was found to have severe LV dysfunction, hence was shifted to Apex Multispecialty hospital Mulund under the care of Cardiologist Dr. Mayur Jain who is DM cardiology (Gold Medalist)for getting a Coronary angiography. His Angiography turned out to be normal and his LV dysfunction could only be explained due to cardiomyopathy secondary to alcohol or severe sepsis. Then the patient was shifted to ICU under the care of Dr.Mayur Jain & Intensive critical care treatment of the patient was done by Dr. Nitin Kumar Reddy who has vast experience in critical care and also recently finished his course training in DNB cardiology.Our first and foremost Goal was to treat sepsis, improve his blood pressure/tissue perfusion and early weaning off the ventilator as he already started developing critical illness neuropathy as he was on a ventilator for more than 45 days.
What we did differently which saved patient life.
- First, as soon as the patient was received to us a detailed evaluation of his blood reports and multiple antibiotics he received in various outside hospitals were reviewed. We reduced his number of antibiotics and used only rational combinations as per bacterial culture sensitivity reports.
- Coronary angiography was performed on the same day of admission to rule out the correctable cause and a possible reason for the inability to wean the patient off the ventilator considering recurrent LV failure secondary to ischemia as the patient had severe LV dysfunction. But to our surprise and to make thing even difficult for us his angiography was normal and the only another possible explanation for his severe LV dysfunction was cardiomyopathy secondary to severe sepsis/ alcoholic cardiomyopathy ( A condition in which the heart muscle becomes weak in spite of having normal circulation and difficult to treat)
- Post angiography we kept the patient in ICU for further treatment of his medical condition. We gave him two sessions of dialysis on consecutive days to clear off the dye and treat his uremia secondary to his Renal shutdown.
- Meticulous selection & calculation of each and every antibiotic dose was done as per creatinine clearance and also every time patient was given dialysis we made sure that post-dialysis patient received full loading dose of all those antibiotics which were dialyzable. Also the mode of administration of antibiotics was modified based on pharmacokinetics of each antibiotic to have maximum bioavailability. For eg., Drugs like Meropenem which has time dependent pharmacological action was given as an infusion over 3 hrs.
- Every day in morning treating consultant doctor had a detailed discussion with dietician to calculate is a total calorie and protein requirement and every day the fluid intake, feeds and calories given to the patient was monitored.
- Since the patient had developed respiratory muscles weakness due to long duration ventilator support, we got a dedicated physiotherapist for him who started him on passive bed exercises and breathing exercises to strengthen his respiratory muscles.
- Meticulous Nursing care was done like 3 hourly changing turning the patient in the bed and back care to prevent bedsores.
- During the course of treatment, we observed that since the patient had severe LV dysfunction (EF=20%) he was given less fluids but when we scanned his IVC (inferior vena cava) and found that it was completely collapsed which was suggestive of severe dehydration and we started to give him a lot of IV fluids to correct his dehydration and withheld his dialysis. Eventually after 6 liters of IV fluids infusion over a period of 2 days patient started pouring out urine and his vital parameters also started improving. Gradually his acidosis corrected, Norad infusion got weaned off and stopped, the patient became independent of dialysis and started pouring urine with iv diuretics.
- When the patient’s vitals were stabilizing, we started to wean the ventilator and we believed in early mobilization and made him out of bed to sit on a chair while being on the ventilator.
- Eventually patient was on T-Piece on 5 th day. After 24 hrs of T-piece we decannulated the tracheostomy of the patient and was maintaining good saturation and normal ABG even on room air.
- On 6 th day we shifted the patient to the room and started to mobilize him with walker and with support.
- On 8 th day patient could manage to get up and walked on his own without support and he his wbc counts got normalized, his platelet counts improved.
- On 10 th day we discharged the patient and now he comes to our opd for regular follow-ups and check-ups.
- Achieving this incredible feat of success in treating such difficult case wouldn’t have been possible without Dr. Mayur Jain, Dr. Nitin Kumar Reddy, Physiotherapist , Dietician ,ICU doctors ,Nursing staff and other supportive staffs who really worked very hard in making this patient well and giving him a new life to live when all his family member have lost hopes.