Friday 19 / April / 2024
Muscat: A 74-year-old man was hospitalised due to multi-organ dysfunction syndrome on March 26.
He had developed vomiting and was admitted to a private hospital at Ruwi, where he was diagnosed with vancomycin-resistant enterococcus (VRE) growth in the patient’s blood and urine, and sepsis. Antibiotic resistance occurs when the bugs no longer respond to the antibiotics designed to kill them. Sepsis is a serious condition caused by your body’s extreme response to an infection.
He had returned to Oman, after having undergone chemotherapy via chemo port on February 2 and immunotherapy; the last chemo was completed on March 15 in Mumbai, India for gastrointestinal cancer. He was under treatment under an oncologist at Mumbai having undergone multiple cycles of chemotherapy and immune therapy.
The notable pre-existing condition was bowel resection, a surgery to remove a small part of your bowel and ureteric stent placement (a thin tube that's placed in your ureter to help drain urine from your kidney) in 2022.
As the sepsis progressed to multi-organ dysfunction syndrome his organs started shutting down and his kidneys stopped producing urine, he was shifted to our hospital for expert critical care and renal replacement therapy under Dr Mohammed Farooq Ahmed (Specialist Nephrologist) and Dr Dilip Abdul Khadar- Specialist Physician (Intensivist) who were the primary attending.
Its team of doctors received a tour state-of-the-art Isolation room ICU on March 26. He was attended to by Aster's multidisciplinary team of doctors at the ICU across all specialities. His sensory faculties deteriorated due to sepsis and related neurological complications, and a treatment plan was put into action — he was electively intubated, with ventilator support. Alternatively, a larger venous access was secured and an arterial line was inserted for invasive hemodynamic monitoring (IHM) that monitors heart function. Blood cultures were taken and he was started on appropriate antibiotics for his multi-drug-resistant bacteria grown in blood, which is available at Aster's ICU for reserved use.
His platelet count was 30,000 on arrival, due to sepsis and he was transfused with four random donor platelets. There was no urine output, and after his family was counselled and consent obtained, he was taken under the care of a nephrologist, who was the primary attending then. An ultrasound-guided left femoral dialysis catheter was inserted. On March 27, the patient underwent SLED (hemodialysis) in the isolation room ICU. He required support with medications to maintain his blood pressure, but he tolerated the renal replacement therapy.
The patient subsequently became conscious over the next few days, oriented and obeying commands. His kidney recovered and was producing urine. He could be weaned off the medications given to maintain his blood pressure in the normal range and from the ventilator support.
The patient had muscle weakness which was confirmed by the neurologist as critical illness neuropathy arising from his prolonged hospitalisation for chemotherapy in India and later in Oman. He could not feed actively. He could not cough and bring out sputum. He had respiratory distress and developed pneumonia. He had to be electively put back on ventilator support and his secretions from his lungs were sent for a test called ‘Bio fire’ which screens the secretions for bacteria viruses and fungus. Surprisingly it grew another multi-drug-resistant bacterium and the antibiotics were readjusted accordingly.
After counselling the family, the patient underwent an elective tracheostomy by Aster's ENT surgeons for faster weaning and better bronchial toileting of the secretions which he was not able to cough out by himself. The patient meanwhile developed Atrial Fibrillation, an irregular and often very rapid heart rhythm, which was addressed and corrected by Aster's cardiology team. He was started on feeds as advised by the dietician through the Ryle’s tube inserted via his nose to the stomach and he tolerated it well. Consequently, his improvement was fast. He could be weaned off sedation and ventilator support. He could cough out through the tracheostomy tube. He could breathe and be comfortable in room air, not requiring oxygen at all.
His chemo port was removed at the cath lab on the same floor by our Interventional radiologist. His ureteric stents were removed and replaced by the urologist in the OT. He was made to sit out on a chair and aggressive chest and limb physiotherapy continued. He was given high-calorie feeds after screening his entire electrolyte including phosphate levels. He was shifted to the room on April 9.
He had difficulty tolerating the Ryle’s tube put through his nose for feeding so the family suggested a PEG tube, a feeding tube placed through the skin of the abdominal wall and into the stomach, which was done immediately by the gastroenterology team. The feeding and nutrition were now better with the PEG tube in position.
He was rehabilitated in the room and subsequently discharged home on April 20 with a tracheostomy tube after arranging a home nurse and giving adequate training. A home physiotherapist was also arranged.
ICU care is a niche skill that requires a lot of insight, patience and timely decision-making. Critically ill patients can be brought out of danger gradually by offering them the best possible care while under treatment. However, the reality is that no team will be able to wipe away the tears from every patient and their family's eyes, no matter how hard they try. Nevertheless, trying earnestly is the responsibility of every team member involved. Early diagnosis and timely intervention and management are the keys to faster recovery.
It is vital to tide over one day at a time for critically ill patients. Counselling of the family by all doctors involved is very crucial. A multi-disciplinary approach is the key. The trust and confidence that the patient’s family has in the team taking care of the patient is essential. It is crucial and strengthens the conviction of the team attending to the patient that the family is supportive and trusts the team’s judgement. Aster was lucky to have a supportive family who stood with Aster and supported him in every decision-making, which enabled faster healing.
Aster Royal Hospital is blessed to have a robust team in place including doctors, nurses and paramedics who took special care of this patient and helped him to go home. The team included Dr Dilip Abdul Khadar – Specialist physician (Intensivist), Dr Mohammed Farooq Ahmed (Specialist Nephrologist), Dr Sadik Al Lawati- Consultant Nephrologist, Dr Narendra, Dr Muthumanikandan, Dr Binoy and Dr Lekha ( Dept of Anesthesia), Dr Subarendra Kumar (Senior ENT Consultant) and Dr Vidya Bhargavan (Specialist - ENT), Dr Mahmoud Al Hajiri- Consultant Interventional radiologist, Dr Hemanth- Dept of Urology, Dr Achint- Neurologist, Dr Fahad - Radiologist, Dr Sharique- Cardiologist, Dr Ashik Sainu- Consultant Gastroenterologist, Dr Dhwani Shah- Specialist Dermatologist, Dr Pranjal – Pathologist, Jisha-microbiology, a psychiatrist on call, Mariam Al Jabri- dietician, Ajith and the physiotherapy team, and the backbone of ICU care - ICU nurses and ICU duty doctors and ward nurses.
