-
Dad Back in the Hospital Again
My 82-year-old father developed a UTI which turned out to be staph and yeast. He was admitted to the hospital on January 19 to receive IV antibiotics over the course of 10 days. An infectious disease specialist was called in and she brought out the BIG guns: vancomyacin. They also had him on IV diflucan (which I didn’t even know existed in that form.) Unfourtunately, when all this happened, I was half way around the world in Africa and had to rely on my brother for info via email.
Dad’s output was severely reduced and one kidney was swollen. They changed his stents which had slipped out of his kidneys. His blood pressure was elevated and his ankles, hands and abdomen were really swollen. He was put on Lasix. He was dismissed from the hospital last Thursday with a picc line and orders for home health care to continue to administer Zossan and the Vanco for an additional 14 days. Home health care taught Mom how to do the injections through the picc line. All was going well until his blood pressure became VERY elevated: in the 280 range on the top number. He called his GP (and only gets to see the PA) and she started experimenting (my word) with different drugs in different doses. Didn’t work.
Dad started having chest pain last night and it became severe enough that he went to the GP’s office this morning. They asked if he had a cardiologist and Dad remembered the name of one he had 20 years ago. So, the GP sent him to the ER of a hospital where the cardiologist had privileges. However, neither his local uro nor the GP have privileges at this hospital!!! So now we have to start over with all new doctors telling the story again.
My brother has called a kidney specialist who will hopefully see Dad tomorrow. His output is severely reduced from what it has been in the past and his feet and ankles and hands and abdomen are swollen again. At the hospital where he is now, he does not have a urologist consulting on the case. I think we should get him to a different hospital. Needless to say, he is down and depressed and has about given up on getting past all this. I got back in town this evening and found out that he was back in the hospital. I can start asking questions of all the doctors and nurses starting tomorrow.
Is it unusual for a person to be on vancomycin for almost a month? Home health care took his blood a few days ago and the vanco levels were off the charts. The lab suggested that the doctor review the dosage. His potassium levels are low, red blood count low, glucose low, creatinine high, albumin low, all of which indicate kidney problems to me. I think it could even be congestive heart failure due to fluids collecting around his heart that his causing his chest pains but nobody has suggested that yet.
Things were going so well until he got that darned UTI. Hopefully, we will know more tomorrow and maybe I can get him to a decent hospital. I am praying that his heart and kidney are not damaged.
-
13 Replies
-
Dad was released from that joke they call a hospital yesterday. The night before he was to be dismissed, he was supposed to get some anti-fungal medicine by IV. Since he was to administer this IV medicine to himself at home, it was important to see if he had any adverse reaction to this new med while he was in the hospital so they could deal with any reactions.
The next day at the hospital, I was on the phone with the Home Health nurse discussing the medicine that Dad was to get at home. I walked over to the IV pole to verify the name on the medicine hanging there and I noticed two things: First, the medicine was still there! The night nurse (don’t get me started about her!) did not ever release the clamp to start the IV. Second, it was not the medicine that the doctor had ordered! The pharmacy had substituted a different drug since they did not carry the drug the doctor prescribed. I specifically asked the doctor to prescribe a certain anti-fungal that I had been researching. She agreed, then the hospital substituted a different drug!! So, if Home Health was going to provide the drug that was prescribed, we wouldn’t know if Dad could tolerate it since he did not get the prescribed drug while in the hospital. Talk about a mess! I was furious! Not only was Dad now behind one day in his medication, it was not even the medication the doctor ordered!
Dad was dressed and ready to go when I discovered the meds had not been given. The doctor wanted him to have the first dose in the hospital, so that meant that they had to call the doctor (at 4pm) to ask her what she wanted them to do. The doctor ended up just prescribing what they had in the hospital for Dad to take at home. So, Dad is not getting the medicine the ID doctor wanted him to have simply because the hospital did not carry the drug. Home Health had access to the proper drug. Why didn’t the hospital???
The Home Health nurse came today to “train” Dad on how to mix and administer the drug to himself via IV. I can’t believe they would expect an 82-year-old man to give himself IV drugs! He even has his own pole now. I’m still unclear as to why the home health nurse does not come each day and give Dad the medicine. It takes an hour for it to be given and he has to be on this medicine for 4 weeks at $2500 per week. Yikes! However, before he was giving himself Zosyn 3 times a day and Vancomycin once a day. My Dad is amazing!
He has a yeast infection and my thought is that the yeast have colonized his ureteral stents and formed a biofilm that the meds can’t penetrate. He just had his stents changed out about 10 days ago, but I think he should get them changed again in case the yeast has taken up residence on the stents. He has been on IV Diflucan for about 2 weeks with no results. Once they stopped the blood thinner (Lovenox) and aspirin, Dad’s bleeding seemed to stop. The dose of Lovenox they had him on was astronomical! His blood pressure is still high in spite of the 13 meds he takes twice a day.
The nephrologist has him on fluid restriction of 2000cc per day (about 67 ounces) which is much less than he usually drinks. He has dry mouth, most likely as a side effect of all the meds he’s taking. I worry that he will become dehydrated. His output is reduced but so is his input. He is on oral Lasix, but so far he has not noticed that it has had any effect. He does not have to empty his pouch nearly as often as he did before the fluid restriction was implemented. His feet and ankles are swelling a little again. I am going to ask him to put the TED hose back on.
I’m glad he is home and not at the mercy of others to finally bring him his meds or anything else for that matter. Needless to say, we have added yet another hospital to the “don’t go” list!
-
Harley…why not take your dad to UTSW emergency room? Your uro is probably there anyway. Have you made any contact with him at all…….? Tell him you’re coming and bring his discharge papers…………Lord what a mess.
Pat -
The saga continues. Dad has been bleeding into his pouch for about 5 days now. The internist who is the lead doc on Dad’s case here called a urologist last Friday to come in. Turns out that this urologist DOES NOT SEE PATIENTS ON WEEKENDS!! To make matters worse, he didn’t show up today either (Monday). The internist (who I think is an idiot) said he is going to release Dad tomorrow, bleeding and high blood pressure notwithstanding, and that Dad should go see his own uro. Unbelievable!
His blood pressure is still not controlled and the nephrologist is sending him home with about 13 different meds to take twice a day for his blood pressure. He also wants Dad to limit his daily fluids to about 64 oz. He usually drinks much more than that as someone once told him to “drink lots of water since he has a urostomy”! Luckily, the chest pains that put him in this place have never occurred again.
The infectious disease doctor finally visited (only her second visit in a week!) and said she thought Dad had been released last week. Huh? I would think she could come up with a better excuse than that for failing to see her patient or even check on him. She did discontinue the Zosyn and Vanco but said the yeast is not responding to Diflucan. I had been doing some research about yeast infections, so I suggested a drug and she is changing Dad to that one. Downside is that it is an IV drug that, she says, Dad will have to take for 4 weeks. Guess he will be keeping his picc line for a while longer and give the new drug to himself!
I can’t tell you how many reservations I have about his release with the bleeding and high blood pressure. However, none of his urologists have privileges at this place, so I guess it is just as well. He just told me he doesn’t feel any better than when he got here and that he feels “crummy.” I’m hoping getting off the heavy duty antibiotics will help him feel better.
He had severe pain in his left kidney area early this morning so they did a CT scan of abdomen and pelvis and found nothing that could be causing bleeding or pain. They did see some fluid under the lungs which the kidney doc says most likely was left from when Dad had so much adema and will reabsorb when dad starts moving around again and breathing deeper. There was some hardening of the arteries noted on the scan.
The uro he is seeing tomorrow when he is released from the hospital is the one who, according to my brother, told Dad that if Dad were in just a little worse condition (when he was admitted to the hospital in the middle of January with an infection), he would not treat him and would just let Dad “expire.” Can you believe that??!! He said that to my Dad! I want to get Dad back to Dallas to UT Southwestern to see his uro there, but Dad thinks it is an inconvenience on the family to drive the 30 miles to Dallas. Doesn’t matter if he can get better care with a better doctor there. He thinks it is too much trouble for us. The UTSW doc is only in the office one day a week so it would mean another week or more of bleeding before he could be seen.
I misspelled the name of that drug. It is Imdur and is used to treat angina. He is off the Lovenox and aspirin and on two new drugs to treat gout. It is clonidine that he is taking for bp but he didn’t get it today because his heart rate was below 60. So many of the drugs he is taking for bp lower the heart rate so what do they expect?! He now has headaches and a cough, also noted side effects of many of the meds he is taking.
It will certainly be good to get out of this hospital.
-
Well his systolic pressure is coming down which is good and the diastolic is within normal now………pulse rate not terrific……and my lord so many drugs…….and i wonder what they’re shooting into his belly? aah i know the Lovenox…. you would not give aspirin along with another blood thinner……i really have to sort this out…….I know what my gut reaction would be but i want to confer with a few of my fellow pharmacists first just to watch their jaws drop.
Pathttp://www.drugs.com/drug_interactions.php
just check the bottom of page…check interactions
Do not know what Emidura is..thats a new one ..sure of the spelling?
Also i noticed that you mentioned Clonodine which i hope they’re not giving him as thats a drug for painkiller withdrawal..some drugs sound so much alike…i’ve seen the slipups all the time when doctors call in drugs…i hope the drug they’re giving him is Clonidine which is another for hypertension. -
These are the BP drugs I know about. Dad says the guy on call for the nephrologist today changed the dosage on some of them. I’m very concerned as Dad’s pressure they just took was 143/76 which is down about 40 points just during the day shift! His pulse rate has dropped to 49 and he is dozing and lethargic. The night nurse has put a call into the cardiologist (not really the one who prescribed or changed doses of the meds). The nephrologist is the one she should call, in my opinion. At least she had the common sense to call the doctor instead of just pushing the meds. And, she was going to draw blood for a Vanco trough and could not get blood from the picc lines! That’s why you are supposed to flush with both saline and heparin!! DUH! Still no word from the ID doc. To the best of my knowledge, she has not even called to check on him. Inexcusable, especially considering renal function, vanco and Dad’s age.
Here are the BP meds: (not sure if the names are generic or brand)
Lopressor – 25mg x3
Lotensen – 20mg x 2
Hydralazine – 25mg x 2
Tekturna – 300mg x1
Clonodine – .2mg x 3
Emidura – 120mg x 2
Norvasc – 10mg x 1Also daily:
Lasix – 40mg x 3
Lovenox injection x 2
Zosyn – 3 x daily
Vancomycin – 1 gram daily
Diflucan IV – 1 x daily
Aspirin (not sure why since he is getting blood thinner shot)
Gout medicine (in case leg pain experienced today was gout)
Prilosec – 1 x daily
Potassium – 2 x daily by mouthHe also has had 3 bags of IV iron, one bag of potassium and one bag of magnesium. Also, 2 units of blood which only raised hemo by 1 point.
The cardiologist just called back and stopped the Lopressor that the nephrologist had doubled this morning. Apparently Lopressor slows heart rate. Yikes! One doc negates what another one did just this morning. Scary, isn’t it? Does the right hand not know what the left hand is doing? Apparently not. If Dad gets out of here without any more damage it will be a miracle!
I have emailed his uro at UT Southwestern regarding all this and am awaiting a reply.
I’m not sure about input/output charting. They told me to keep a list of how much he drinks during a shift. He is not drinking much and his output has decreased but at least the urine is not blood tinged at this moment. I plan to bring a measuring cup up here tomorrow. He is allowed 2000ccs so that’s equal to about 2 of the water pitchers here or one pitcher and one 36 oz. bottle of Gatorade. I suppose they are measuring output.
I keep asking why he is still getting antibiotics when no bacteria shows up and his white count is normal. The docs who do show up tell me I have to talk to the ID who never shows up. Frustrating. I asked the internist today if Dad could take probiotics to help put some good bacteria back into Dad’s gut.
I think we may have lucked out and actually got a really good nurse tonight. She seems very competent and experienced. We’ll see what tomorrow brings on the medication merry-go-round.
-
Harley……..aaaaaaaaargh……what are the blood pressure drugs they are giving him…….get the names and dosages of everything.
Lasix (furosemide) and vancomycin (Moderate Drug-Drug)MONITOR: Increased adverse effects are possible when glycopeptide antibiotics are administered concomitantly with other potentially nephrotoxic and neurotoxic drugs.
MANAGEMENT: If these drugs must be used together, renal function, auditory and vestibular function, and serum drug concentrations should be monitored.
I think they’re causing most of the problems.
Pat -
Oh My.
My suggestion at this point would be to get a notebook and write down everything you have questions about.
Some things I would want to know are..1) Why is dad on Vanco? What is the diagnosis?
2) A list of all the drugs they have been giving him. Take this list to your local pharmacy and ask the pharmacist to review them with you. Ask for a printed page of the drug…The data bases they use at the pharmacy will also flag any possible interactions with other drugs.
Having this printed material can help educate you when the docs start throwing medication names around and you will have them to refer to.3) If the blood pressure machine is unable to record a BP of 190/80 (which I have never heard of) request that they take his BP the “old fashioned way”. The thought of an uncalibrated or faulty BP machine should be reported and I would make sure that it is.
4) How soon can I get my dad transferred out of here and to a hospital where his doc has privledges? Make phone calls as soon as tomorrow to get that ball rolling. Does his regular Uro answer his own call? If so he would be a great person to start with.
5) I would watch the fluid restriction chart like a hawk. Make sure everyone is charting correctly and is aware of any outside fluids he is getting (gatorade). I have seen some sloppy In/Out charting done. If it is not accurately done the use of certain medications is useless. Remember 1 ounce = 30 CC’s. Make sure everyone is using the same standard of measurement.
I could go on and on but those are the most important things I would focus on. This of course is just my opinion. I have been an active patient advocate for my husband and also have worked with families to help them be the best advocate they can be.
Good luck!
Age 53 Currently
Bladder Cancer Diagnosis October 2006 T1G3
2011 Finally made it 6 month between Cystos
8/22/2011 Cysto in the OR
(BCG and BCG Maintenance over the years)
Graduated to yearly Cystos
Tumor found at first one year Cysto – TURBT 4/26/2013
Kidney pain – CT scan 5/1/2013
Wow! What great info even though it scares the crap out of me since none of that is being done or taken into account in my Dad’s case. The ID has been to see him ONE time in the week he has been here. In the meantime, they have him on one gram of the vanco daily. They seem to always draw the blood shortly after the vanco has been given which, in my opinion, skews the results. Seems to me the blood draw should be about 30 minutes before his next dose. I’m for firing the current ID and finding someone who is willing to be more on top of things. This is serious stuff that requires more than a one time visit and the same dosage all the time.
The nuclear kidney scan to check for renal artery blockage came back “inconclusive” which we were told occurs about 20% of the time. The kidney doctor who is trying to get the BP adjusted left town for the weekend (of course!) so nothing is going to change regarding the 7 blood pressure meds he is being given twice a day that haven’t lowered the pressure at all! This morning it was 190/80. It has been so high that the little machine they wheel in to take the BP is not able to take it! The kidney guy said there were only 2 more BP meds known to man and if Dad’s pressure did not come down soon, he would add those to the mix!
The kidney doc increased the lasix to 40mg 3x daily. Not a big deal since Dad can hook up to a big night bag but the lasix also damages the kidneys by making them work harder not to mention washing out the sodium and potassium. Dad is currently on fluid restriction but even with that and the lasix, his hands, feet, ankles, abdomen and face are still greatly swollen. Not sure what it is going to take to get the fluids out of him. He is hardly drinking anything, which I keep telling him is not the thing to do. I brought him some Gatorade to drink (with the neph’s permission.) My fear is that he will become dehydrated on top of everything else.
The internist is a “hospitalist” and has been Dad’s doctor for almost a week now. Imagine my surprise when I asked him about the blood in Dad’s urine and he tells me that “it’s not unusual to see blood with a Foley catheter.”!! He didn’t even know Dad had a urostomy! The guy taking his call today also said the blood was due to a Foley and when I told him that was impossible because there was no Foley and that Dad has a urostomy, he said “Is that the thing that comes out the back?”!! This is an internist practicing in a big city hospital!! Plus, there are so few American doctors here, it is difficult to understand anything any of them (or the nurses) say.
We’re having a little controversy about flushing Dad’s Picc line. The policy at this hospital seems to be not to flush with heparin. Home health care taught him to flush with saline first and heparin at the end. One “nurse” tried to get away with flushing the line with IV saline when Dad is on fluid restriction. I had to go to the charge nurse about that one. None of the “nurses” flush before using a line and some don’t flush the line after using it. It is SOOO frustrating. If you ask them to clean their hands before touching you, they get mad. Please, Dad already has an infection. We don’t need another.
Dad developed a pain in the area of his Achilles tendon and it became severe and started moving up his leg. The on-call ordered a scan to check for a clot. No clot, so it is most likely tendonitis. He now has yet another pill to take for inflammation!
It’s the strangest thing. At times Dad’s urine is the color of raspberry tea. Then the foley bag is emptied and the next urine that comes out is the pale yellow color of straw. He has received IV iron 3 times now and the magnesium was dark or maybe it was the potassium. There have been so many drugs it is hard to keep them straight! He even got a shot of Procrit today even though they are giving him a blood thinner shot in the stomach twice a day. Not sure what that’s all about.
This whole experience brings back so many bad memories of impossible-to- reach doctors and uncaring, lazy nurses and techs who never come when you call. There has been one really competent nurse here so far who was a joy to have take care of you. Unfortunately, we changed floors and I have yet to find such a nurse on this floor. Too bad. To some, it is just a job.
I think there is still yeast in his urine. After a lot of days on Diflucan, maybe they need to try a different yeast drug. Call me crazy. We need to get out of here and into a place where Dad’s regular docs have privileges. The internist today said he was going to have to bring in a urologist because of blood in the urine. Great! That will be uro #4!
Pat you are always such a wealth of information it’s amazing. Do you think harleygirl’s dad has Methicillin-resistant Staphylococcus Epidermidis (MRSE)?
If so I would think the ID doc should have said that. But then again if the doc only works two days a week it wouldn’t suprise me if she didn’t.
We were very lucky to have the most dedicated ID doctor ever. Probably the most dedicated doctor period. He stayed on top of my husband’s treatments daily. He always popped into the infusion center even on Saturday and Sunday mornings to keep an eye on everything.
Pat you also have refreshed my memory of the importantce of the speed of which the Vanco had to administered. I know it was 4 hours a day and it set as so for a reason.
Harley here is some info and I hope it helps.
Monitoring parameters
Careful observation for signs of drug toxicity is imperative.The following patient parameters should be monitored during vancomycin therapy:
Vancomycin peak and trough levels
Obtain at steady-state (approximately four half lives) and then weekly during therapy.
BUN and serum creatinine
Measure every two days, or every day in unstable renal function.
Weight
Weigh patient every two to seven days.
Urine output
Measure and monitor urine output daily.
Baseline and weekly audiograms.
Check for signs of phlebitis daily.http://www.rxkinetics.com/pktutorial/2_5.html
I suggest the ID doc me more involved and if she can’t commit to doing so I would be looking for someone who could.
Let us know how the tests they are running come back. I’m intertesed in knowing.
Pamela
Age 53 Currently
Bladder Cancer Diagnosis October 2006 T1G3
2011 Finally made it 6 month between Cystos
8/22/2011 Cysto in the OR
(BCG and BCG Maintenance over the years)
Graduated to yearly Cystos
Tumor found at first one year Cysto – TURBT 4/26/2013
Kidney pain – CT scan 5/1/2013Harley….sounds like physician russian roulette to me.
Vancomycin is resistant to staph epidermis and yeast.
Also dosage in the older patient needs to be reduced especially if there is renal involment but they haven’t checked that?? It also has to be administered very slowly over 60 mins.
Patients with Impaired Renal Function and Elderly PatientsDosage adjustment must be made in patients with impaired renal function. In premature infants and the elderly, greater dosage reductions than expected may be necessary because of decreased renal function. Measurement of Vancomycin serum concentrations can be helpful in optimizing therapy, especially in seriously ill patients with changing renal function. Vancomycin serum concentrations can be determined by use of microbiologic assay, radioimmunoassay, fluorescence polarization immunoassay, fluorescence immunoassay, or high-pressure liquid chromatography.
If creatinine clearance can be measured or estimated accurately, the dosage for most patients with renal impairment can be calculated using the following table. The dosage of Vancomycin hydrochloride per day in mg is about 15 times the glomerular filtration rate in mL/min:
DOSAGE TABLE FOR Vancomycin
IN PATIENTS WITH IMPAIRED RENAL FUNCTION
(Adapted from Moellering et al)4
Creatinine Clearance
Vancomycin DosemL/min
mg/24 h100
154590
139080
123570
108060
92550
77040
62030
46520
31010
155The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.
see this article on staph epidermis and yeast.
http://jmm.sgmjournals.org/cgi/content/short/51/4/344I just don’t know what to say…to even send your father home and expect your mother to administer Vancomycin ?? What is that?
Pat
Thanks for the replies.
The infectious disease doc says it is not MRSA but that it is staph epidermis and yeast. I’m not sure what the difference is between MRSA and staph epidermis since MRSA is on the epidermis, but what do I know?
Dad was administering the vanco along with Zosyn to himself after Home Health Care showed him how. They were checking the trough and found last Sunday that the vanco levels were way too high. In the hospital, they seem to take random draws to check the troughs and the level is still showing to be too high. They can not reach the infectious disease doctor as she only works 2 days a week (??!) so he has not had any vancomycin for two days now in the hospital.
His blood pressure is elevated and they currently have him on 6 drugs to try to bring it down. Yep, that’s SIX! He had a nuclear stress test and echocardiogram, both of which were normal. So it is not the heart causing the chest pain. The next place to look is the kidneys and he is having a nuclear scan with doppler there tomorrow morning to determine if perhaps the renal arteries are blocked. If that is the case, he will need stents.
I think the doctors are just throwing stuff up against the wall to see what sticks when it comes to giving meds. It is amazing how much they DON’T know about the human body! His IV pole looks like a clothesline with Monday’s wash hung on it. There are so many bags: potassium, magnesium, iron, antiobiotics, diflucan, blood (2 units) to name a few. He gets a shot in the belly each day with a blood thinner and more pills to take by mouth than you can count.
He is sick of being in the hospital and sick of being ignored by nurses and techs when he rings the call button. That “someone” who they say will be there “shortly” usually never shows up. There are no private rooms in this hospital and the roommate thing is a whole new experience for us.
Not sure where they are going to look if the kidneys don’t prove helpful in diagnosis. They are running out of body parts to test!
A month on Vancomycin is not unheard of. My husband had 6 weeks of IV Vanco 4 hours a day 7 days a week. He went to the hospitals infusion center everyday. They should be keeping an eye on his trough levels and this should be done at least once a week.
Am I correct to assume that his infection is a Methicillin resistant infection?Take Care
Pamela
Age 53 Currently
Bladder Cancer Diagnosis October 2006 T1G3
2011 Finally made it 6 month between Cystos
8/22/2011 Cysto in the OR
(BCG and BCG Maintenance over the years)
Graduated to yearly Cystos
Tumor found at first one year Cysto – TURBT 4/26/2013
Kidney pain – CT scan 5/1/2013
Harley
I am so sorry. It is a lot to handle. I hope we can give you some comfort. Thank goodness you have a sibling to help you.Prayers for your father.
Ta Grade 1
6 TURBS
15 BCG
dx Jan 07Sign In to reply.
