MUSCAT : A pleasant 74-year-old man was hospitalized due to multi organ dysfunction syndrome on 26/03/2023. He had developed vomiting and was admitted at 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 02/02/2023 and immunotherapy; last chemo completed on 15/03/2023 at 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 sent 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 for renal replacement therapy under Dr. Mohammed Farooq Ahmed (Specialist Nephrologist) and Dr. Dilip Abdul Khadar- Specialist Physician (Intensivist) who were the primary attending.

Our team of doctors received him at our state-of-the-art Isolation room ICU on 26/03/2023. He was attended to by our multidisciplinary team of doctors at the ICU across all specialties. 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 our 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, consent obtained, he was taken under the care of our Nephrologist, who was the primary attending at that point of time. An ultrasound guided left femoral dialysis catheter was inserted. On 27/03/2023, the patient underwent SLED (hemodialysis) in our 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 was obeying commands. His kidneys 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 our neurologist as critical illness neuropathy arising from his prolonged hospitalization 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 lung were sent for a test called ‘Bio fire’ which screens the secretions for bacteria virus and fungus. Surprisingly it grew another multi drug resistant bacteria and the antibiotics were readjusted accordingly.

After counselling the family, the patient underwent an elective tracheostomy by our 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 our cardiology team. He was started on feeds as advised by our dietician through the Ryle’s tube inserted via his nose to 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 on room air, not requiring oxygen at all.

His chemo port was removed at our cath lab on the same floor by our Interventional radiologist. His ureteric stents were removed and replaced by our 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 all his electrolyte including phosphate levels. He was shifted to the room on 09/04/23.

He had difficulty tolerating the Ryle’s tube put through nose for feeding so the family suggested for a PEG tube, a feeding tube placed through the skin of the abdominal wall and into the stomach, which was done immediately by our 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 20/04/23 with 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 of 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’s and their families’ eyes, not matter how hard they try. Nevertheless, to try earnestly is the responsibility of every team member involved. Early diagnosis and timely intervention and management is the key 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. 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 the patient that the family is supportive and trusts the team’s judgement. We were lucky here to have a supportive family who stood with us and supported us in every decision making, which enabled faster healing.

We are blessed at Aster Royal Hospital 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 , Ms. Jisha-microbiology, our psychiatrist on call, Ms. Mariam Al Jabri- dietician, Mr. Ajith & the physiotherapy team, and the back bone of ICU care- our ICU nurses and ICU duty doctors– to whom we owe everything, and most importantly, to our ward nurses.