by Jena | Apr 17, 2016 | Atrial Fibrillation, Graft-versus-host-disease (GvHD), Infectious Disease, Sepsis, Sirolimus, Stem Cell Transplant, Tobramycin, Vancomycin, Zosyn |
Dad has declined dramatically.
Day +12, Thursday, April 14th.
WBC: <0.01 k/uL CRITICAL H: 7.0 g/dL LOW P: 21 k/uL LOW
Blood. Everyday, Dad’s 3 lumens (blue, red & white) of his central line catheter are tested. The day’s initial blue line test indicated Gram-negative bacteria. Dad was given tobramycin, an antibiotic, to treat. Further testing on the blue line resulted in Dr. Baluch, BMT infectious disease, stopping vancomysin and starting minocycline, another broad spectrum antibiotic.
Dad continued to receive blood support (platelet and blood transfusions & neupogen shots) as needed. Set targets for hemoglobin (H > 8) and platelets (P > 20).
Graft versus host disease (GvHD). Dad continued to take sirolimus to prevent GvHD.
Mouth & Throat. Dad continued to have pain from mucositis. Used magic mouthwash and oxycodone to treat.
Heart. Continued oral Amiodarone to manage atrial fibrillation.
Lungs. Dad had another X-ray of his chest. Continued supplemental oxygen.
Dad was still on a liquid diet. Anytime he drank, he would go into a terrible coughing fit and would require use of an oral suction/vacuum.
Abdomen. Dad continued with Imodium to treat diarrhea. He had another X-ray of his abdomen taken. Dad continued to receive Zosyn as broad spectrum antibiotic.
Kidneys. Creatine (Cr) is the most widely used marker of kidney function in patients undergoing stem cell transplant. Measure of creatine provides an estimation of renal function allows for following trends in renal function. We have learned that acute and chronic kidney disease are common following stem cell transplant and can lead to long-term effects. Stem-cell-transplant-associated kidney injury are often due to a variety of factors including conditioning chemotherapy and sepsis.
Nephrology (kidney doctors) was consulted. Dr. Khimani, inservice Blood & Marrow Transplant (BMT), noted that Dad’s urine output decreased in the prior 24 hours with increased creatine (Cr: 2.3 HIGH). Dad’s sodium also continued to increase (Na: 150 HIGH), which was noted as hypernatremia. Dad continued to receive fluids and have his sodium levels monitored. Dad had a renal ultrasound. Dad was having acute renal failure. He was in septic shock (widespread infection causing organ failure and dangerously low blood pressure) and cardiogenic shock (his heart was unable to pump enough blood to his organs to meet his body’s needs).
Dad was moved to intensive care status. Dr. Baluch, BMT infectious disease, believed that Dad should be transferred out of the BMT unit on the third floor to the intensive care unit (ICU) on the second floor.
by Jena | Apr 17, 2016 | Atrial Fibrillation, BK virus, Epstein-Barr virus (EBV), Folotyn, Ileus, Infectious Disease, Lasix, MRSA, Rituximab, Stem Cell Transplant, Vancomycin, Zosyn |
Catching you up from last Saturday to Wednesday…
Day +7, Saturday, April 9th.
WBC: 0.03 k/uL CRITICAL H: 7.3 g/dL LOW P: 16 k/uL LOW
Dad had continued to go in and out of atrial fibrillation. By the evening, his heart was in normal sinus rhythm (NSR). Dad felt that his abdomen had improved.
Dad noticed increasing throat pain with swallowing. Oral mucositis (mouth sores) can be extremely painful and can result in an inability to eat, speak, or swallow. Last summer, when Dad had received Folotyn (pralatrexate) chemotherapy, he had suffered from oral mucositis. Dad had used magic mouthwash to get some relief. Magic mouthwash is the term given to a solution used to treat oral mucositis.
Abdominal fluid retention improved slightly. Dad had an abdominal X-ray taken.
His diarrhea remained improved. He remained fever free. He remained on 2 L/min oxygen.
MRSA was confirmed on April 6th once Staphylococcus was identified on April 5th.
Day +8, Sunday, April 10th.
WBC: 0.01 k/uL CRITICAL H: 7.3 g/dL LOW P: 13 k/uL LOW
Report from the day before’s abdominal X-ray showed mildly prominent loops in his small intestine, which possibly represented ileus or enteritis. Ileus is the inability of the intestine to contract normally and move waste out of the body. Enteritis is inflammation of the intestine usually accompanied with diarrhea. Dad’s diet was downgraded to clear liquids. His abdominal swelling was improved, yet he continued to receive lasix, a diuretic, to address the fluid retention.
Dad had an X-ray of his chest taken. He was breathing on his own.
Dad switched to an oral amiodarone to manage his atrial fibrillation.
He continued to be monitored for EBV (Epstein-Barr virus), which is more commonly known as mononucleosis or “mono.” Most people will be infected with EBV in their lifetime and will not have any symptoms since it is controlled by a healthy immune system. Yet, when someone has a weakened immune system, the EBV infection can get out of control.
Day +9, Monday, April 11th.
WBC: 0.04 k/uL CRITICAL H: 8.2 g/dL LOW P: 5 k/uL CRIT
The prior day’s chest X-ray suggested inflammation in Dad’s lungs versus fluid overload. Dad’s respiratory culture showed both “gram-positive” and “gram-negative.” These are terms used to classify bacteria into two groups. Usually, gram-positive bacteria are helpful, and gram-negative are the ones that cause illness.
Dad’s atrial fibrillation continued to be addressed with the oral amiodarone. He continued to receive lasix, a diuretic, to address the fluid retention. Dad remained on a clear liquid diet.
The blood in Dad’s urine was suspected to be the BK virus and adenovirus. For most, the BK virus has no consequences since it remains latent, but it can be reactivated during post stem cell transplant when immunosuppressed.
Dad was too tired to work with physical therapy.
Day +10, Tuesday, April 12th.
WBC: 0.02 k/uL CRITICAL H: 8.2 g/dL LOW P: 7 k/uL CRIT
Dad started to choke/cough when eating ice or drinking liquids. Yet, Dad said that his cough had improved and was no longer producing sputum, which is a mixture of saliva and mucus. Respiratory culture from the day before likely indicated MRSA.
Dad’s sodium was high at 148 mmol/L..
Day +11, Wednesday, April 13th.
WBC: 0.01 k/uL CRITICAL H: 8.0 g/dL LOW P: 12 k/uL LOW
Dad continued to be monitored for EBV. Based upon the latest EBV test results, Dr. Ayala, Dad’s primary BMT doctor, was consulted. It was determined that Dad would receive an infusion of rituximab. Rituximab is used to treat EBV post stem cell transplant. Since Dad experienced rigors, fatigue and mild confusion in the morning, the rituximab treatment was postponed.
Dad complained of further pain in his mouth and throat. Dad continued to take oxycodone and magic mouthwash to provide relief from the mucositis. Two X-rays were taken (chest and abdomen). Dad restarted supplemental oxygen.
His cultures indicated MRSA. Dad was started on two new antibiotics, vancomycin and Zosyn (piperacillin/tazobactam). Vancomycin is used to treat infection of the intestines. Zosyn is the combination of two penicillins.
Dad experienced an abnormal heart rate last night, which was resolved with metoprolol. Dad’s atrial fibrillation continued to be addressed with the oral amiodarone. He continued to receive lasix, a diuretic, to address the fluid retention. Dad remained on a clear liquid diet. Dad had a foley catheter placed since he was at a high fall risk. Dad was given Imodium to treat his diarrhea.
Adenovirus was ruled out as the cause of blood in Dad’s urine. BK virus was still a possibility. Set a goal to maintain Dad’s platelets at 20.
Dad’s sodium was high again at 147 mmol/L. Dr. Baluch, BMT infectious disease, noted that Dad’s T. bilirubin was mildly elevated and wanted to monitor trend.
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