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Hi My Name Is Selam . I Want To Get

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Posted on Fri, 29 Jan 2021
Question: Hi my name is selam . I want to get medical advice for my father. He is in ICU for COVID in XXXXXXX The doctor text me his situation as follows .
Admission diagnosis: Severe COVID19 ARDS with superimposed bacterial infection
+Rt.side hemiparesis 2ry to ?ischemic stroke
+STEMI
+Septic/cardiogenic shock
+AKI(non oligouric)
+Rt.lower limb(popliteal) DVT
Currently,he is on
Meropenem and vancomycin
Aspirin 81mg po daily
Atrovastatin 80mg po daily
Heparin 17500IU SC BID
Dexamethasone 6mg IV daily
On sedation and NG feeding
Mechanical vent:
FiO2=80%. PEEP =10
Pinsp =15
ABG
PH=7.225 PO2=82 PCO2=42.5. HCO3=16.5 lac=2.25 Na=144 Cl =114


Renal:
Cr=4.29 BUN=96

Liver function:normal
ECG:

ST segment elevation on lead 2,3 and aVF

Cardiac enzymes:
Troponin=26,422
Bedside echo:RWMA on the inferior wall
EF is estimated >40%
Plan:to start metoprolol and enalapril once hemodynamics is maintained
And renal function improved for enalapril
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Follow up: Dr. Ilir Sharka (0 minute later)
Hi my name is selam . I want to get medical advice for my father. He is in ICU for COVID in XXXXXXX The doctor text me his situation as follows .
Admission diagnosis: Severe COVID19 ARDS with superimposed bacterial infection
+Rt.side hemiparesis 2ry to ?ischemic stroke
+STEMI
+Septic/cardiogenic shock
+AKI(non oligouric)
+Rt.lower limb(popliteal) DVT
Currently,he is on
Meropenem and vancomycin
Aspirin 81mg po daily
Atrovastatin 80mg po daily
Heparin 17500IU SC BID
Dexamethasone 6mg IV daily
On sedation and NG feeding
Mechanical vent:
FiO2=80%. PEEP =10
Pinsp =15
ABG
PH=7.225 PO2=82 PCO2=42.5. HCO3=16.5 lac=2.25 Na=144 Cl =114


Renal:
Cr=4.29 BUN=96

Liver function:normal
ECG:

ST segment elevation on lead 2,3 and aVF

Cardiac enzymes:
Troponin=26,422
Bedside echo:RWMA on the inferior wall
EF is estimated >40%
Plan:to start metoprolol and enalapril once hemodynamics is maintained
And renal function improved for enalapril
doctor
Answered by Dr. Ilir Sharka (1 hour later)
Brief Answer:
My opinion as follows:

Detailed Answer:
Hello Selam,

Welcome to Ask a Doctor servise!

I passed carefully through your father's medical report and would explain that his situation seems to be really serious.

These ECG changes coupled with the increased Troponin levels indicate a possible myocardial infarction or myocarditis. Anyway, we can not come into conclusions only based on these findings. When his situation will be more stable, with a good respiration, free from the respiratory devices, a coronary angiogram will be necessary in order to investigate on possible coronary artery disease.

I agree with his medication. Blood thinners (heparin and aspirin) that he is taking are really necessary to prevent future stroke or myocardial infarction.

Regarding the stroke, it will be necessary an evaluation by CT scan in order to distinguish between a possible ischemic stroke or a brain hemorrhage, and this is really necessary in order to judge on the continuation of blood thinners.

I agree also with the antibiotics, which include a broad spectrum of bacteria.

Hope to have been helpful!

I remain at your disposal for any further questions whenever you need!

Kind regards,

Dr. Ilir Sharka, Cardiologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Ilir Sharka (0 minute later)
Brief Answer:
My opinion as follows:

Detailed Answer:
Hello Selam,

Welcome to Ask a Doctor servise!

I passed carefully through your father's medical report and would explain that his situation seems to be really serious.

These ECG changes coupled with the increased Troponin levels indicate a possible myocardial infarction or myocarditis. Anyway, we can not come into conclusions only based on these findings. When his situation will be more stable, with a good respiration, free from the respiratory devices, a coronary angiogram will be necessary in order to investigate on possible coronary artery disease.

I agree with his medication. Blood thinners (heparin and aspirin) that he is taking are really necessary to prevent future stroke or myocardial infarction.

Regarding the stroke, it will be necessary an evaluation by CT scan in order to distinguish between a possible ischemic stroke or a brain hemorrhage, and this is really necessary in order to judge on the continuation of blood thinners.

I agree also with the antibiotics, which include a broad spectrum of bacteria.

Hope to have been helpful!

I remain at your disposal for any further questions whenever you need!

Kind regards,

Dr. Ilir Sharka, Cardiologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (11 minutes later)
“Regarding the stroke, it will be necessary an evaluation by CT scan in order to distinguish between a possible ischemic stroke or a brain hemorrhage, and this is really necessary in order to judge on the continuation of blood thinners”
Is it possible to have CT scan while he is intubation
Currently he is in mechanical ventilation.
2. Is his stork very bad
3. How about his oxygen levels? And his kidneys?
4. Any other suggestions? And do you think it’s possible for him to get better since his situation is very bad ?
Thanks you so much for your support!
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Follow up: Dr. Ilir Sharka (0 minute later)
“Regarding the stroke, it will be necessary an evaluation by CT scan in order to distinguish between a possible ischemic stroke or a brain hemorrhage, and this is really necessary in order to judge on the continuation of blood thinners”
Is it possible to have CT scan while he is intubation
Currently he is in mechanical ventilation.
2. Is his stork very bad
3. How about his oxygen levels? And his kidneys?
4. Any other suggestions? And do you think it’s possible for him to get better since his situation is very bad ?
Thanks you so much for your support!
doctor
Answered by Dr. Ilir Sharka (1 hour later)
Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again!

Let me explain that a CT scan could be possible even on mechanical ventilation once a portable ventilator is available for transfer to the radiology department.

It would be necessary to review your father's CT scan in order to conclude of the severity of the neurological condition and underlying therapy.

His clinical conditions seem to be very compromise with acidosis (from ABG) which needs to be promptly corrected by the medical staff and acute renal dysfunction due to several concomitant disorders (acidosis, viral infection, hemodynamic instability, etc.)

The ongoing hours are crucial for correcting the above parameters and defining the prognosis.
Special attention should be paid to respiratory mechanics and the appropriate ventilatory regimen.

You should discuss with the attending ICU physician on the above mentioned issues.

In case of any further questions, feel free to ask me again.

Regards,

Dr. Iliri




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Ilir Sharka (0 minute later)
Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again!

Let me explain that a CT scan could be possible even on mechanical ventilation once a portable ventilator is available for transfer to the radiology department.

It would be necessary to review your father's CT scan in order to conclude of the severity of the neurological condition and underlying therapy.

His clinical conditions seem to be very compromise with acidosis (from ABG) which needs to be promptly corrected by the medical staff and acute renal dysfunction due to several concomitant disorders (acidosis, viral infection, hemodynamic instability, etc.)

The ongoing hours are crucial for correcting the above parameters and defining the prognosis.
Special attention should be paid to respiratory mechanics and the appropriate ventilatory regimen.

You should discuss with the attending ICU physician on the above mentioned issues.

In case of any further questions, feel free to ask me again.

Regards,

Dr. Iliri




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (40 hours later)
Hello there

I just spoke to his doctor today. He told me his kidneys are failing, his potassium is very high and and he is still in septic shock. But his respiration is a little better. Please advise me what need to be done and what is this all mean ?
Thank you !
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Follow up: Dr. Ilir Sharka (0 minute later)
Hello there

I just spoke to his doctor today. He told me his kidneys are failing, his potassium is very high and and he is still in septic shock. But his respiration is a little better. Please advise me what need to be done and what is this all mean ?
Thank you !
doctor
Answered by Dr. Ilir Sharka (2 hours later)
Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello again!

His situation seems to be serious and high potassium levels can trigger a cardiac arrhythmia. You should know that potassium plasma levels increase during kidney failure, as potassium is not excreted properly in the urine.

For this reason, ultrafiltration and hemodialysis should be considered in order to lower potassium levels and creatinine and blood urea nitrogen plasma levels (which are increased in case of kidney failure).

You should discuss with his doctor on this possible treatment option.

Hope you will find this information helpful!

Let me know in case of further uncertainties!

Regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Ilir Sharka (0 minute later)
Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello again!

His situation seems to be serious and high potassium levels can trigger a cardiac arrhythmia. You should know that potassium plasma levels increase during kidney failure, as potassium is not excreted properly in the urine.

For this reason, ultrafiltration and hemodialysis should be considered in order to lower potassium levels and creatinine and blood urea nitrogen plasma levels (which are increased in case of kidney failure).

You should discuss with his doctor on this possible treatment option.

Hope you will find this information helpful!

Let me know in case of further uncertainties!

Regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (18 minutes later)
His doctor just gave me his today information

AKI was there but he is producing urine so far.
Today ABG
PH 7.2 PCO2 39 HCO3. 17.3
Cl. 119. Lac 2.0

His vasopressor requirement is decreasing from 0.5mcg/kg/min to 0.1mcg/kg/min

Ventilator

V-AC. Mode
FIO2. 75%. PEEP. 10


he may deteriorate at any time. So far,he has no new development

We have portable ventilator and we will figure out by tomorrow. I will evaluate him and see what is the best possible thing we can do for him.
Atleast,there is no urge for RRT(dialysis)

What is all this means? Any recommendations?
Thanks a lot!
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Follow up: Dr. Ilir Sharka (0 minute later)
His doctor just gave me his today information

AKI was there but he is producing urine so far.
Today ABG
PH 7.2 PCO2 39 HCO3. 17.3
Cl. 119. Lac 2.0

His vasopressor requirement is decreasing from 0.5mcg/kg/min to 0.1mcg/kg/min

Ventilator

V-AC. Mode
FIO2. 75%. PEEP. 10


he may deteriorate at any time. So far,he has no new development

We have portable ventilator and we will figure out by tomorrow. I will evaluate him and see what is the best possible thing we can do for him.
Atleast,there is no urge for RRT(dialysis)

What is all this means? Any recommendations?
Thanks a lot!
doctor
Answered by Dr. Ilir Sharka (29 minutes later)
Brief Answer:
Opinion as follows:

Detailed Answer:
AKI could be due to hemodynamic compromise in the settings of acute heart failure/shock. In such case the best strategy would be to optimize hemodynamic support.

From the other side, metabolic acidosis (pH 7.2) would decrease vasopressor drug effectiveness and sodium bicarbonate would be required for correction.

Acidosis should be corrected as soon as possible as it has detrimental effects.

If no renal replacement therapy (RRT) is used then there are other strategies to correct elevated potassium levels, like insulin, loop diuretics, calcium.

A comprehensive evaluation of the actual cardiac function and vascular resistances should be performed.

Let me know in case of any further questions.

Kind regards,

Dr, Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Ilir Sharka (0 minute later)
Brief Answer:
Opinion as follows:

Detailed Answer:
AKI could be due to hemodynamic compromise in the settings of acute heart failure/shock. In such case the best strategy would be to optimize hemodynamic support.

From the other side, metabolic acidosis (pH 7.2) would decrease vasopressor drug effectiveness and sodium bicarbonate would be required for correction.

Acidosis should be corrected as soon as possible as it has detrimental effects.

If no renal replacement therapy (RRT) is used then there are other strategies to correct elevated potassium levels, like insulin, loop diuretics, calcium.

A comprehensive evaluation of the actual cardiac function and vascular resistances should be performed.

Let me know in case of any further questions.

Kind regards,

Dr, Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (13 hours later)
His today conditions

Vent support is also not high

Renal: k+ is 5.1 , metabolic acidosis with concomitant resp acidosis

Urine output 800ml/24hrs
NaHCO3 is not available in the country and contraindicated for him since his Na is 160 and on hypernatraemic management.

Anyway,I will evaluate him and see what we can do more

What I am saying is Adrenaline requirement is coming down (from 0.5 to 0.2 mcg/kg/min)
default
Follow up: Dr. Ilir Sharka (0 minute later)
His today conditions

Vent support is also not high

Renal: k+ is 5.1 , metabolic acidosis with concomitant resp acidosis

Urine output 800ml/24hrs
NaHCO3 is not available in the country and contraindicated for him since his Na is 160 and on hypernatraemic management.

Anyway,I will evaluate him and see what we can do more

What I am saying is Adrenaline requirement is coming down (from 0.5 to 0.2 mcg/kg/min)
default
Follow up: Dr. Ilir Sharka (4 minutes later)
GCS is 6 T ?
default
Follow up: Dr. Ilir Sharka (0 minute later)
GCS is 6 T ?
doctor
Answered by Dr. Ilir Sharka (11 hours later)
Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello again!

Thank you for the additional information!

His situation seems to be still serious. The GCS 6 means that he is still unconscious (medium degree coma), but with a lot of reflexes and spontaneous movements. It could be related to the stroke or to the septic shock , but there are still chances of improvement.

The high Natrium levels could be related to dehydration, which is usually the main cause of hypernatremia.

For this reason, it is necessary increase his fluid intake, in order to help reduce natrium levels and also increase the diuresis. Of course the fluid administration should be evaluated along with the diuresis (the quantity of fluids excreted with urine).

It is also necessary evaluate the cardiac output by means of a cardiac ultrasound.

Regarding Adrenaline, I would suggest Dobutamine instead, which can help improve the kidney blood flow too, but I don't know if this drug is available in their hospital.

Hope you will find this answer helpful!

Please let me know in case of further questions!

I would be glad to assist you further!

Wishing all the best,

Dr. Iliri




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Ilir Sharka (0 minute later)
Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello again!

Thank you for the additional information!

His situation seems to be still serious. The GCS 6 means that he is still unconscious (medium degree coma), but with a lot of reflexes and spontaneous movements. It could be related to the stroke or to the septic shock , but there are still chances of improvement.

The high Natrium levels could be related to dehydration, which is usually the main cause of hypernatremia.

For this reason, it is necessary increase his fluid intake, in order to help reduce natrium levels and also increase the diuresis. Of course the fluid administration should be evaluated along with the diuresis (the quantity of fluids excreted with urine).

It is also necessary evaluate the cardiac output by means of a cardiac ultrasound.

Regarding Adrenaline, I would suggest Dobutamine instead, which can help improve the kidney blood flow too, but I don't know if this drug is available in their hospital.

Hope you will find this answer helpful!

Please let me know in case of further questions!

I would be glad to assist you further!

Wishing all the best,

Dr. Iliri



Note: For further queries related to coronary artery disease and prevention, click here.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
Answered by
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Dr. Ilir Sharka

Cardiologist

Practicing since :2001

Answered : 9541 Questions

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Hi My Name Is Selam . I Want To Get

Hi my name is selam . I want to get medical advice for my father. He is in ICU for COVID in XXXXXXX The doctor text me his situation as follows . Admission diagnosis: Severe COVID19 ARDS with superimposed bacterial infection +Rt.side hemiparesis 2ry to ?ischemic stroke +STEMI +Septic/cardiogenic shock +AKI(non oligouric) +Rt.lower limb(popliteal) DVT Currently,he is on Meropenem and vancomycin Aspirin 81mg po daily Atrovastatin 80mg po daily Heparin 17500IU SC BID Dexamethasone 6mg IV daily On sedation and NG feeding Mechanical vent: FiO2=80%. PEEP =10 Pinsp =15 ABG PH=7.225 PO2=82 PCO2=42.5. HCO3=16.5 lac=2.25 Na=144 Cl =114 Renal: Cr=4.29 BUN=96 Liver function:normal ECG: ST segment elevation on lead 2,3 and aVF Cardiac enzymes: Troponin=26,422 Bedside echo:RWMA on the inferior wall EF is estimated >40% Plan:to start metoprolol and enalapril once hemodynamics is maintained And renal function improved for enalapril