Thank you for your query at DoctorSpring.com
To give a clear answer- I would like to know if a pre op evaluation was done, including a chest x ray, echo and lung function test. I think you might have done x ray and echo, while it must be difficult to get a Pft done. Do you have any idea what the pre op status was?
How was she before the surgery? Was the surgery a general anesthesia type or spinal? What was the duration of surgery? And did they have a DVT pump during surgery?
Count of 24000 can be part of stress response, or purely infection. So does she have other signs of infection like fever, increased heart rate, increased respiratory rate, altered consciousness? Was a procal ordered?
Problems she is facing are old age, RA, ? RA Lung, malignancy, and now ? sepsis.
The fact that she has respiratory acidosis tells that the demand of body on respiratory system is high, and she cannot cope with it and her muscles are failing.
I didn't understand why the x ray was hazy. Was it because of RA associated lung disease, or pneumonia or does she have a cardiac failure also? A such high Bp, with difficult to wean from bipap / cpap usually it's secondary to cardiac issues too. ( occult cardiac failure)
Bipap / cpap traditionally are thought to fail when blood pH falls less than 7.20, and a pH of 7 is far low than what we expect.
As she is DNR , I do think she does not have an airway assistance, nor are you going to do a tracheotomy to aspirate the secretions. So she is in additional chance for developing an aspiration pneumonia and the inability to cough, plus a bipap / cpap is making the risk worse.
As each day in ICU progresses, she is also prone for increased muscle fatigue because of improper diet, and increased demand at this time.
So all said and done, I do believe she is not going to make it. I do suggest his quality palliative care. A DNR consent should mean only a do not intubate and she should get the very best treatment otherwise including adequate diet, sedation and pain management.
I also will never be optimistic, as there are other problems also that can be expected. Such as pulmonary embolism along with a long list of problems she already has.
As for now, to me, her prognosis is guarded and grave.
Feel free to ask any questions
Patient replied :
Thank you - I really appreciate your candor. It is needed at this time. She passed the echo with no issues showing. No pulmonary function test and the X-ray was "hazy" then as well. It was not hazy when she entered the hospital. She has never had a fever since entering hospital.
When the respiratory incident happened her oh dropped to 7 and last night dropped to 7.28.
She has literally slept the entire day today although she woke up briefly twice to ask me a question. I feel like that is not normal and indicates something more.
Thanks for appreciation.
An echo being normal pre op cannot equate that her cardiac status is normal. It might imply that her cardiac status is normal in the absence of stress. Also diastolic heart failure, common in this age will be missed unless specifically liked out for.
Altered sensorium is not a good sign, however it needs to be attributed to the situation. If she answered correctly to your questions, it's OK and she may be sleeping because of medicines.
Not being able to correct the pH back to 7.3 is also bit bad.