Saturday, February 06, 2016

Peaceful Friday

Slightly recovered my sleep patterns by having a nap for about two hours in the morning.

This evening I had a whole bath, not just a pretendy wipe down. The careers would no doubt have been horrified if they had seen me get out of the bath by myself with the usual technique of grabbing the bar with my left hand and levering myself up to the rim of the bath and sliding over to the board. I felt totally clean for the first time in weeks.

Tomorrow is the big day when Bhante circumnavigated the M25 and comes off of the Orpington turn, meeting Lyulph at the renovated graveyard and then coming on for a visit at Flodden Road.

Thursday, February 04, 2016

Yesterday in King's

Most of the day at King’s from 10.00 to 16.00. The transport department had been asked to provide oxygen but tried to pretend he had said it wasn’t needed.

Kidney function bad, deteriorated a little but not to the extent that it required action. Haematologist had not seen the complete blood results but enough to tell us there had been further deterioration over the 5 days since our last visit. “Leukaemia is taking off”, she said. She made arrangements for me to have a blood transfusion next Tuesday. I only had a magnesium infusion through the wonderful PICC line which allows most transfers of fluids to be made via a semi-permanent line in the arm. The only medication suggested was hydroxycarbomide, but that was of doubtful benefit, so we agreed not to bother with it.

First half of last night went well, but after midnight, Stripey the cat kept jumping up on the bed and trying to sleep on my feet which is fine in the daytime but not at night. As he makes a habit of it, I need to find a solution that allows me to have a peaceful sleep without cats jumping up and down on my feet. The whole point of getting out of hospital was to have a peaceful sick room environment, and after midnight, this is not it!

Discharge Summary:

Lord Avebury, an 87 year old gentleman with known myeloproliferative disorder,  presented with deteriorating renal function. Prior to admission he had suffered from nausea and vomiting for 2 weeks and diarrhoea for 7 days. Creatinine was 293 on admission from a baseline of -110 in December and he was clinically dehydrated. During the admission his renal function improved (creatinine) and he was clinically well.

Lord Avebury has previously required bilateral renal artery stenting for stenosis. Repeat renal artery Dopplers demonstrated in-stent re-stenosis (severe on the right, moderate on the left). His case was extensively discussed during the radiology MDM and it was decided that repeat angioplasty and stenting would give long-term benefit. The improvement of his renal function allowed this procedure to be organised as an elective case and was therefore not possible to be completed during this admission. It will therefore be re-scheduled as a routine outpatient procedure.

During his admission he required multiple transfusions of platelets and blood for his transfusion dependent myeloproliferative disease. Hb was 83 and platelet count 22 at discharge. Regular transfusion will continue to be required after discharge and this will be arranged under the care of the haematology team. To support the provision of blood products a PICC line has been inserted.

Sat 30 Jan 2016

Monday, February 01, 2016

Acute Myeloid Leukaemia

This is my discharge notice from King's College Hospital on January 29:

Lord Avebury was admitted as an emergency on 19th January 2016. Following outpatient blood tests which showed an acutely raised creatinine of 250, he was admitted for IV fluids which resulted in the sum improvement in his renal function. He was due to have an outpatient renal artery angiogram +/- stent on 21st January to treat the underlying cause of the acute kidney injury, so this was performed as an inpatient. Due to his low platelet count, (due to the underlying diagnosis of myeloproliferative disorder) and deranged clotting results Lord Avebury was given platelet transfusions and Fresh Frozen Plasma to minimise the risk of bleeding during or post the procedure. Following this, Lord Avebury suffered from chest tightness, shortness of breath and his oxygen saturations deteriorated. He also spiked a temperature. He was treated for sepsis with IV Meropenem and for fluid overload with diuretics. ITU outreach team reviewed him regularly. Lord Avebury had a very high troponin during the above events and though this was thought at first to be secondary to an acute myocardial infarction, it is more likely to be related to acute heart strain post-stenting of the renal arteries and fluid overload. An echocardiogram showed no new regional wall motion abnormalities, moderate tricuspid and normal left ventricular systolic function. Lord Avebury also had some haemoptysis so the clopidogrel was discontinued (aspirin continued due to the new indwelling stents) and a course of vitamin K was given to correct his clotting. His haemoptysis settled. His oxygen requirements were gradually weaned from Optiflow. However, he still required some oxygen to maintain saturations above 94% (he had no evidence of CO2 retention during admission). As he was still spiking temperatures, antibiotics Clarithromycin and Teicoplanin were added in. Blood films taken during admission were suggestive that the myeloproliferative disorder has transformed to acute myeloid Leukaemia. This will be managed supportively. As Lord Avebury was clinically stable, he was discharged from Davidson ward. He is already known to St Christopher’s Hospice who will kindly review his needs in the community. He will be seen regularly in HOP for blood transfusions as required.

Main diagnosis: acute kidney injury, transfusion associated cardiac overload, sepsis (likely chest source) transformation of myelofibrosis to acute myeloid leukaemia.

Thursday, January 28, 2016

Good News

Eric is coming home tomorrow, Friday.

Wednesday, January 27, 2016

Back in hospital again

Eric was readnitted to King's College Hospital on Tuesday 19 January. Two days later Mr Wilkins performed an angioplasty on both renal arteries, as he did most successfully two years ago.   This time, various problems arose post-op. Eric appeared to have had a reaction to the units of blood he was given.  Also, his body, particularly his chest, became overloaded with fluids.  He developed an infection.  All these symtoms are being treated and Eric is beginning to recover, albeit slowly. However, as background to this, Eric's myelofibrosis is now starting to develop into leukaemia.

The family are  having talks with the palliative care team ar KCH to arrange for Eric to come home soon and be treated at home.  Lindsay.

Saturday, January 16, 2016

Hospittal Discharge Notification

Reason for admission

Patient admitted with deterioration in renal function. Known myoloproliferative disorder, requiring platelet and blood transfusions. Previous bilateral renal artery stenting. with rehydratng. Found to be dehydrated following period of loose stool and renal function improved with  rehydration. (creatinine 300 < 14 and downtrending at discharge). Repeat renal artery dopplers demonstrated in-stent re-stenosis severe on left side, moderate on left) and after disccussion in  our rediology MDM, it was decided that repeat angioplasty/stenting would be beneficial in the long term. This was scheduled as a non-acute procedure due to recovering renal functiion - unfortunately it was not possible to perform this as an in-patient, and it will be re-rescheduled in a routine out-patient setting. His discharge Hb was 83. We have inserted a PICC line to facilitate future blood product infusion. He will be followed up by the haematology doctors next week (date to be confirmed) and we will see him in renal outpatients on the 28th January.

Note: I have an appointment scheduled with Professor H at Guy's on Monday Jan 18 at 14.45., and     we also have Dyno-Rod coming in the morning -similar problem.

Friday, January 15, 2016

Home, surprisingly

Eric unexpectedly sent home today.  Renal doctors decided that Eric's kidney function had improved greatly, due to rehydration and two units of blood.  We are all delighted to have him home, particularly Stripey the cat who won't leave his side. The doctors say they will carry out the procedure to clear his renal arteries on another date, possibly when things quieten down - they seemed to be dealing with a large number of emergency procedures this week.  Lindsay