ICU and Pressors

Last week we admitted a patient to the ICU which recently built at the hospital. It was the first time I'd ever used Pressors in a Developing country (ie. anywhere other than the USA). (Pressors are medicine that you give through an IV drop by drop in order to keep the blood pressure up in the normal range so that blood can still get to the brain, kidneys, and heart (you vital organs needed to survive). People dieing from heart failure, infection, or blood loss will have blood pressures that get lower and lower until they die-- usually of an arrhythmia due to the heart not getting enough blood supply. In the US we're able to keep very sick people alive and allow them a chance to get better with Pressors). We we're caring for a 26 year old female who had end stage (meaning about to die, probably within 6-12 months) heart failure secondary to rhematic heart disease. Earlier that year the workers/staff in the hospital had raised enough money to send her to Tenwick (a larger mission hospital in Kenya) to have her heart valve (which was damaged by the rheumatic heart disease and causing her heart to fail because it was working extra hard pumping blood to make up for the valve) repaired--- unfortunately see was sent back without the surgery because it was too late and her heart was too damaged. During morning devotion Kyle was called and told that she had coded (her heart had stopped) and the nurses were doing CPR on her. I went with Kyle up to the hospital. The nurses had brought her back to life--- had a faint pulse (ie low BP) and was breathing. Kyle told them to shift her to the ICU. Then we went up to the pharmacy. Kyle had heard a rumour that they may have received some pressors--- though they weren't on formulary (ie the meds that a pharmacy aims to always have in stock). We searched the shelves and found a small box of 5-6 vials of dopamine. Down to the ICU we went where we sat down with pen, paper, and calculator trying to figure out if we mixed one vial into 500mL of IV fluids how many drops per minute the fluids needed to run at in order to give the minumum and maximum amount of medicine. A "drip" is a medicine given drop by drop. Drips for the most part are given only in ICU's in the US because they're labor intensive--- you can go up and down on the dose minute to minute. Drips in the US are easy because each medicine has an electronic box that you can program how many mg/min or mg/hr of a medicine you want and it will adminsister it. The dose of dopamine is between 1-50 mcg/kg/min. In developing countries you have to compress the IVF tubing just enough that however many drops per minute you want are released. Because the dose of many of these meds are so small and our set ups in developing countries aren't as precise as in the US, we have to dilute it first and then calculate from mcg/min to ml/min to drops/min. The goal BP needed to make sure adequate blood gets to the kidneys, brain, and heart is measured as a MAP of 60. MAP= mean arterial pressure. Meaning 1/3 of the time BP is equal to the systolic number and 2/3 of the time BP is equal to the diastolic number, so the MAP is [SBP + (2 x DBP)] / 3. For instance for a BP = 90/60, MAP = 70. The goal MAP is >60. So that was the target with our pressors. With max dose of dopamine she was maintaining MAP 40 - 60. Then we ran out of the dopamine. So we calculated a drip of epinephrine (adrenaline), which I maybe saw used once at JPS during med school, but they don't use it much in the US to my knowledge (I guess because they have better pressors. We used it anyways because she was going to die anyways if we didn't. And it was working pretty well initially anyways. The other major thing going on was she was in renal failure though. She was fluid overloaded due to the heart failure, but her kidneys weren't responding to Lasix (a "water pill", ie a diuretic) and she wasn't making urine in 3 days. She needed dialysis but her sister refused transport --- she probably would have died in route anyways (the next large hospital was 2 1/2 - 3 hrs away). Kyle had spoken to her about her faith over the last several years, and he talked with her again. Earlier she had asked him in Swahili if she was going to see the Lord today. Kyle responded, "Not yet." But now it looked like death was winning. He comforted her and prayed with her and her sister. Over their heads through the window a double rainbow decorated the sky we went out and looked at them. They were very strong. You could see the entire bow across the sky reaching from hilltop top hilltop. With the promise of the double rainbow like a banner through the window over her bed we left her --- and she went to be with the Lord that night.