Day +18, Wednesday, April 20th. Dad was transferred out of ICU back to the BMT (Blood & Marrow Transplant) floor.
WBC: 1.04 k/uL LOW H: 8.8 g/dL LOW P: 16 k/uL LOW BUN: 69 HIGH Cr: 3.4 HIGH Na+: 147 HIGH
Mentation: During the night, Dad was extremely restless and pulled at his various tubes and lines. A sitter was assigned to sit bedside. He became so restless that he had to be restrained. When Mom arrived in the morning, she was shocked and angered by the restraints and what had transpired overnight. Dad was mildly confused, bothered, and continued his attempts to remove the his tubes and lines.
Doctors wondered if Dad’s altered mentation was due to increased sodium or ICU delirium. Dr. Baluch, BMT infectious disease, changed how Zosyn was administered and also considered adjusting free water amounts via Dad’s tube feeds.
Blood. After multiple attempts, a PICC line was placed. Dad was officially declared engrafted with an absolute neutrophil count (ANC) of 1040. Dad was to receive neupogen for an additional day due to his recent sepsis. Due to the tip from the broken forceps during Dad’s central line catheter removal, the catheter site was monitored for new infection.
Graft versus host disease (GvHD). Dad continued to receive sirolimus via feeding tube. Acute GvHD assessment resulted in an overall grade of 0.
Skin = Stage 0
Liver = Stage 0
Gut = Stage 0
Mouth & Throat. Dad’s mouth continued to be dry. The nurse and Mom were regularly wetting his mouth with a green, water-saturated oral swab. Dad continued to have pain and thick secretions from mucositis, grade 1, and used magic mouthwash to treat.
Lungs. Dad no longer was on supplemental oxygen. His was breathing on his own. He continued to have a productive cough from the thick secretions resulting from the mucositis. Continued voriconazole and acycolovir.
Abdomen. In the wee hours of the morning, diarrhea was back, and a lot of it. Poor Dad had a rectal tube inserted. Ugh…how awful!
His tube feedings were discontinued due to the diarrhea since the doctors believed the diarrhea started the same time the tube feedings were initiated. Unfortunately, Dad continued asked for food and water. He was desperate for a popsicle and ice chips.
Speech therapy came by to test Dad’s ability to swallow properly. He was unsuccessful, and the feeding tube remained in place.
Kidneys. Dad had no dialysis. Dr. Chemaly, nephrology, was concerned about the rising BUN:creatine ratio and high sodium (Na+) level. Dr. Chemaly requested a renal function panel to determine free water amount.
WBC: 0.08 k/uL CRITICAL H: 7.4 g/dL LOW P: 18 k/uL LOW Cr: 3.9 HIGH Na+: 148 HIGH
Blood. All three lines (blue, red & white) in Dad’s central line catheter indicated Gram-negative bacteria. Continued minocycline for MRSA and atypical Gram-negative bacteria.
Dad continued to receive blood support (platelet and blood transfusions & neupogen shots) as needed.
Graft versus host disease (GvHD). Dad was unable to take sirolimus since he was restricted from all food and drink.
Mouth & Throat. Dad continued to have pain from mucositis and used magic mouthwash to treat.
Heart. The day before’s echo cardiogram confirmed no heart failure.
Lungs. Dad continued his liquid diet. Again, anytime he drank, he would go into a terrible coughing fit and would require use of an oral suction/vacuum. It was determined that Dad’s epiglottis was not closing properly to prevent food and drink from entering his larynx down to his lungs. The day before’s two chest X-rays showed developing aspiration pneumonia.
Dad had another X-ray taken of his chest. Continued supplemental oxygen. Ordered a nasal feeding tube, but the nurse, who specializes in feeding tube insertions, was unsuccessful in placing Dad’s tube after several attempts.
Abdomen. The day before’s abdomen X-ray showed mild improvement. Imodium was stopped. Dad was switched from Zosyn to meropenem, an ultra-broad spectrum antibiotic.
Kidneys. Nephrology discussed with us the possibility of Dad needing dialysis. The day before’s renal ultrasound showed swelling of Dad’s right kidney due to a possible obstruction. Repeated ultrasound. BK virus was finally confirmed as the source of blood in Dad’s urine. Continued IV fluids and monitored sodium levels. Nephrology also monitored potassium in Dad’s blood and identified Dad as having hypokalemia (deficiency of potassium in the bloodstream). Dad was considered anuric (not passing urine).
Legs. An ultrasound of Dad’s legs, taken the night before, confirmed no blood clots.
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.
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.
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.
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 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 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.
Mouth & Throat. Dad’s mouth continued to be dry. The nurse and Mom were regularly wetting his mouth with a green, water-saturated oral swab. Dad continued to have pain and thick secretions from mucositis, grade 1, and used magic mouthwash to treat.
Dad was moved to the ICU on the second floor.
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