I had a patient on CVVH this weekend. CVVH is continuous dialysis – a conventional dialysis treatment takes around 4 hours and can remove about 4 kilograms of fluid (and waste products, etc) from someone. Sometimes patients are too unstable to tolerate this jarring treatment and require CVVH. It runs 24 hours a day, and depending on the patient’s condition, we can take off around 2 kilos per day.

My patient this weekend was pretty sick and required multiple blood transfusions, vasopressors (IV medications that support blood pressure), IV nutrition, and sedation. He was intubated on a ventilator. He was quite busy with all of this (I forgot to mention frequent labs, dressing changes, intense monitoring, and precise fluid calculations.)

He’d had a huge abdominal surgery a few days ago, was septic and had required a LOT of fluids to keep his blood pressure up immediately post-op. Several factors sent him into kidney failure, which put him on CVVH. All told, he gained about 50 pounds of fluid. Thus, every last centimeter of him was chock-full of edema. He could barely move. I’m sure every finger felt like it was anchored with a concrete cast.

He has achieved a level of sedation that we always strive for but rarely accomplish. We prefer the patient to be mostly pretty sleepy, but if I go to them and say their name, I want them to open their eyes and at least answer very basic questions (are you in pain, etc). Usually this is an impossibility – despite our best efforts, the patient is either over or undersedated. It’s difficult to reach that perfect plateau. An oversedated patient is difficult to assess neurologically. An undersedated patient is an agitated and restless mess, which typically results in an agitated and flustered nurse.

Throughout the night, I ask him if he’s doing okay, if he’s in pain. If his eyes are open, I tell him what I’m doing. He can’t talk but he does nod appropriately to my questions. At one point, I was straightening out his gown, and he just slightly bumped my hand. I looked at his face and saw him trying to talk. I started guessing the usual requests that intubated patients have – Pain? No. Mouth dry? No. Uncomfortable? No. (Whatever – hooked to 8 IV’s, a vent, a dialysis machine, in bed, with swollen eyeballs for heaven’s sake.)

Then he points to me and starts to mouth something. Like most of my colleagues, I am usually unable to read lips when those lips are surrounded by tape with a few tubes in the way. There have been times that I’ve put forth a LOT of energy trying to figure out what someone is trying to tell me, and after a lot of frustration and very shaky handwriting, I find out that they’re saying that they wish those soldiers out there would stop marching. In other words, the patient is partially sedated, disoriented, hallucinating, and I’ve just wasted 15 minutes.

But I digress. He’s pointing at me, and mouthing words, and I decide that he’s lucid enough to really want to tell me something pertinent. Finally I say, “Me? Something about me?” and he nods yes, then mouths something v e r y slowly. I think I understand, so I repeat, “Are you saying you think I’m number one?”

He put his hand down, smiled as best he could, and nodded. Wow. It doesn’t get any better than that.