Louis Guzzi, MD, Chief critical care medicine at Florida Hospital Waterman, talks about kidney failure and how they created their new protocol.
When people come into the hospital and they’re in the ICU, they’ve been through a critical, critical situation. What are the things that you and your colleagues are looking for?
LOUIS GUZZI: Most of our patients end up in the ICU by coming in through two ways: either they come through the emergency room, something’s happened to them at home. They’ve gotten ill. They’ve gotten sick. They notice they’re not quite right. Or they come from our floor where patients are here already in the hospital, and they came through the E.R., and they weren’t that sick and then they suddenly decompensate. One of the most common reasons patients end up in the ICU is either for sepsis, hypertension, volume depletion, unfortunately for the old people just the weak and woozy, they just can’t eat and drink enough to catch up. They end up showing up in the E.R. hypertensive, which means they have a low blood pressure, sometimes have an elevated heart rate and they’re very volume depleted. Just yesterday we had an older gentleman, very healthy guy from upstate Connecticut, who comes in severely dehydrated in acute renal failure, confused and disoriented. Those are all the pieces we’re looking at in a patient. We see that patient, we as critical care doctors or even our floor doctors jump on board to sort out what’s going on with them. Is this something acute? Is this because they’re septic infected, dehydrated, they just didn’t get enough of their medicines or something? Or is this something more chronic from an actual toxin that led them to be ill for whatever reason? So, we look at their vital signs. We look at the patient. We assess their mental status, not uncommon for somebody ordered to be sick and dehydrated and have a very confused state, and we think to ourselves what we should actually do to try to reverse the course of the injury we’re seeing.
What other body systems could be affected? Are the kidneys the prime target?
LOUIS GUZZI: No, it can be anywhere actually. It can be the brain, which we see a lot of people who are hypertensive and shocky who are confused, disoriented. We have a lady next door sweet as pie yesterday, didn’t know where she was, name of the hospital anything, today looked at me and said “Who are you?” I said I was with you yesterday for 20 minutes. She goes, well there you go. It’s not uncommon for somebody who’s dehydrated, disoriented, infected to be confused or have what we call an altered mental status, so the brain. The heart gets dry it gets volume depleted, it can overwork itself. It can actually overwork for the patient’s age. They get tachycardia. They can get hypertensive. The heart can have an effect. The lungs, sepsis can be pneumonia. They can have a shunt. They can be hypoxic. They can be breathing too fast and they can’t actually keep up because they’re under profused, they don’t have enough volume? People come in with very cold extremities, cold fingers, cold toes, everything because they’re shunting the blood from their extremities to their core system to maintain perfusion. If you think about the most important piece of all that, the brain, the heart, the kidneys and all this, everything is shunting blood to the core because it’s trying to maintain the vital organs. If your kidneys don’t get enough fluid, they actually start shutting down and try to retain every drop of fluid they can. So, you have a perfect storm. You have hypertension. You’re in shock. You have a lack of volume for some reason so you don’t profuse and then the kidneys at the same time are trying to retain everything they can. They’re not putting enough urine out, so they start shutting down as well, and they’re incredibly sensitive to these vagaries that happen when somebody’s sick.
Talk to me a little bit about the things that you and your colleagues are doing here to try to reverse the very serious complications.
LOUIS GUZZI: We’ve noticed that a lot of the times we as physicians, and unfortunately, I’ve been doing this 34 years, used to fly what I call blind. It’s always like a pilot flying in a snowstorm with no radar, no anything and just hoping he doesn’t hit anything. We know that certainly is not a good situation. So, what we really want is we want something called objective data. We want to know exactly what’s going on with you. When I came here ten years ago, we started in our heart program by actually monitoring your cardiac output what your heart does, your cardiac index, your systemic vascular resistance or how tight you are to squeeze blood to places, and then in some cases we measure your stroke volume value, meaning how much volume are you putting out per heartbeat to profuse you? I put it this way, if you and I would try to run a marathon, I wouldn’t do very well, but if you and I would try and run a marathon after about five miles our heart would be pumping very fast, we would be very short of breath and we probably really wouldn’t want to continue. That’s what your body’s trying to do when it’s going through shock. It’s trying to escalate its heart rate and output to try to maintain the perfusion while the shock state is ongoing. It’s exactly what we’re doing. But we have a patient here who’s sick, septic, seventy-five years old doing that, that’s a problem. What we want to do is we want to know what their volume status is. In the old days, we used to measure blood pressure and look at perfusion and everything. Nowadays, we use something called flow track where we actually can measure their cardiac output cardiac index, their systemic vascular resistance and their stroke volume. The cool part is we can measure it with an arterial line or just putting a little cuff on their finger and seeing how they do. That gives us an objective measurement of how your profusion is. If you would come in in shock, and we would say well let’s give you three liters of fluid and we do and you still don’t look too good, we would look at our numbers and say well her numbers say she’s still dry, she’s very tight, her SVRI is very tight, her output and index are up and she needs more volume. We might give you another two or three leaders to resuscitate you. When I say do this, I don’t say do this over two days or a day or even three hours I’m talking in that first hour you’re sitting there looking at us because as I always say time for the kidneys is really the money for the kidneys. I need to get those kidneys reprofused as soon as possible before they start shutting down. We do that as we try to resuscitate you. At the same time, we measure something called nephrocheck. It’s an early marker of your kidneys that say that they’re in trouble because the proximal and distal tubular are no longer participating and actually making cells divide and they start leaking these proteins. You may have heard him called biomarkers. That’s the big new word in medicine – biomarkers. Everything is biomarkers these days. It’s an early biomarker that says that your kidney’s at risk of going into renal failure. You need to do something now. So, we build a protocol around the flow track, all that volume I talked about, the biomarker for nephrocheck. Because we’re a nice, small, concise unit, we have everybody engaged. The nurses can order it. Somebody can come in and see the patient and say they order it, and they can order it without being because they see the patient going in the shock, the urine output dropping and get the test done and then we react to it by putting the protocol in place.
What is the danger when your kidneys start to fail?
LOUIS GUZZI: The dangers are many. First of all, you can become very acidic which means most of our drugs don’t work. Increases your respiratory rate can increase your chance of actually dying. Number two, your kidneys may not come back. If you’ve already got damaged kidneys because you happen to be seventy-five years old and you’ve taken drugs that may damage your kidneys, this may be the final death knell for them, and they may not come back. About 20 to 25 percent of kidneys don’t come back who go into something called ATN or acute tubular necrosis. They just don’t come back. It can increase your length of stay in the hospital significantly from two to three days for a little sepsis episode to two months because to dialyze you and do other things. You may need short term dialysis. We have to adjust your medications. The real thing is that it’s kind of an awful thing to have your kidneys shut down and go into this kind of process. There’s a lot of things that happen. I would say it’s the most painful thing you can go through is going to renal failure because your entire life changes at that moment, even simple vacations are no longer simple because you always got to find a place that has dialysis for you.
How common a problem or a side effect is it for people?
LOUIS GUZZI: Nationwide in most all comer hospitals renal failure or AKI, acute kidney insufficiency, in hospitalized patients is anywhere between 12 and 18 percent. To put it realistically, 1/5th of patients suffer some sort of A.K.I in the hospital and that’s all comers. If you take in patients who are having a coronary bypass grafting or cabbage surgery or heart surgery, patients that are having belly surgery that are very sick or in shock, it can be as high as 25 and 30 percent in those patient population.
You said for a while it was like you were flying blind. How did you and colleagues get from that point to realizing that you do these things – the flow track, the nephrocheck, the biomarkers and you’ve got something here that’s working?
LOUIS GUZZI: In the old days means to use something called a swan ganz catheter. It’s invasive. They put it in you. It measures your pressures. But having put probably thousands of those things in, the data was always very equivocal on what it meant. We really don’t know what the actual heart was doing. There was some things that weren’t great about it, so we decided when we saw a flow track, we used some variations of this device for years, that this might be a better way to go: less invasive, better information, updates itself every three seconds so we know exactly what’s going on with the patient, and we thought we could build something around it. That was our first step about nine years ago, and we started using that for resuscitation for shock, volume depletion, patients in hemorrhagic shock – take anybody in between. So, we started that there. Then three years ago we were lucky enough because one of our other docs said, well, this nephrocheck thing makes in another hospital. Why don’t you go see Dr. Guzzi out of Waterman? They’re smaller, they can maybe test this thing. We started building a protocol. And it’s funny, when you build a protocol you do a lot of hits and misses. You say this might work, this might not work, this might work. And I will tell you the beginning wasn’t so great. We weren’t so good at it because we knew what we were doing. We just didn’t know how far we should push it. We didn’t realize we could push this really far. We’d see positives but rather than an hour to resuscitate them it would take us a couple hours which is really not the right answer. But then everybody started getting engaged. We started seeing the nephrocheck test going in and becoming positive. And our lab became very aggressive in turning it around to us. And the nurses would call and say, listen, Mrs. Jones has a 2.8. She’s very positive. I’m going to institute the resuscitation protocol right now. We start with the volume, the albumin and pushing everything very quickly. And again very quickly to see if we can get her tank back up and peeing. She starts peeing and her pressures get better with the same information coming with the flow track, we’re good to go. If she doesn’t, we have to assess maybe there’s something else wrong. Maybe her heart’s not good. Maybe this is one of the patients we talked about that this is chronic and we’re actually not going to reverse her. Interesting, our rate here was about 9.8, 9.9 percent renal failure. We’re at 2.1 right now. In some of our populations below 2, which puts us right at the forefront of resuscitation, by simple protocol, driven by the medical staff not just the doctors. The nurses are a massive component of this. I cannot tell you how important they are in driving this protocol.
Because they identify the patients that might be the best fit?
LOUIS GUZZI: That’s correct. They identify the patients. They send the test out. Because we’re busy. We’re seeing 28, 30 patients we may not get the patient 18 until 5:00 this afternoon. Before I ever get to patient 18, they’ve already said we’ve got a problem. Let’s send the nephrocheck. Let’s look at the rest of the numbers. They don’t look good. Let’s go ahead and start the protocol. It’s a lot of times, they’re doing it before we even get in the room.
You mentioned some numbers – you’re down to…
LOUIS GUZZI: Two point one.
Is that patient population per year?
LOUIS GUZZI: That’s 2.1 in the past. Nine percent of our patients last year had some sort of AKI, acute kidney injury or renal failure. In the last year, it’s been 2.1 percent.
And you directly directly attribute that to this?
LOUIS GUZZI: Oh absolutely. Absolutely.
Is there any doubt in your mind that this is saving lives?
LOUIS GUZZI: Not only saving lives but changing lives. I like to think it’s twofold. Saving lives means our patients leave here better, more comfortable, but we’re changing lives. Because patients aren’t leaving here with kidney failure and all the ramifications that come with it. We’re shortening their length of stay in the hospital. We’re getting them back to normal and a normal lifestyle, where in the old days without all this component and everybody doing this, that patient might’ve gone into kidney failure, end up needing long term dialysis, and that’s a drain on the patient, their family, the resources, the national resources, because you got to pay for dialysis, and just think of a life changing event it is for the patient. I think we’re doing a really good job. We wrote this up as a protocol. We published it in critical care medicine this past June. It was accepted and published. It’s funny how many hospitals are either adopting it wholesale or as everybody does tweaking it a little bit to meet what they like. That’s OK because people are doing it and coming back saying this is just easy and a simple way of doing this and people are starting to get it.
To your knowledge how many other hospitals or institutions?
LOUIS GUZZI: I know of at least 20 to 25 that are already doing it, but there’s probably so many more.
And talk to me a little bit – because there is just like the Waterman protocol.
LOUIS GUZZI: How this all came about was that I sat in San Diego with what I would argue some of the smartest nephrologist critical care guys in the country and I was asked to chair a meeting to talk about renal replacement therapy, renal resuscitation, flow track, nephrocheck, all the devices. We sat in a room for two days and if you put 15 really smart people together, you have 15 really smart opinions, and everybody wants to be in their own box. If you’re the director of that opinion lab, you have to either let everybody talk or you have to guide the therapy. We started guiding the therapy. What we really found out was is that we all had a lot of common ground. We had to get rid of the onesies and go with the threesies and foursies, meaning what we all knew was important. But that wasn’t enough. We had the opportunity to go to Europe last year to Munich and meet with all the European guys that are considered the best at what they do. When you put yourself in a room with people that are thinking the same way, and I remind myself, in a socialized medicine situation where every dollar counts, right? That’s Europe. You suddenly get another set of opinions, and we showed them what we’d done five months before and actually had hard wired at that point. And they said wow this is great. They tweaked it. We got some ideas, which I love some of the ideas we got and we tweaked it a little bit, and we changed it around a little bit. We brought it back, and we wrote the whole resuscitation component again and I let my nurses, which are superstars. I let them tear it apart because I thought I had written the perfect resuscitation protocol. It came back covered in red with big X’s on it and don’t do this because we don’t understand this. I looked at it and I said, I was taking my intuitiveness and letting it drive a protocol rather than letting the protocol drive the protocol. When the nurses brought it back to me, a lot of very bright, good nurses came back and it’s funny, they all came back with almost the same comments. We said, you’re right. We need to fix this. So, we completely fixed it. We allow for reassessment in it. We allow you to assess again and again in it, which we see a lot of patients get better than get sick again. It really came out to be very, very strong. Recently presented it at a big meeting in New York City, and the overwhelming response from most of the big hospitals in New York was this seems so simple. Why aren’t we doing this? So it’s been great.
About how many patients do you treat every year?
LOUIS GUZZI: I think last year – last year we sent out 600 nephrochecks. We probably four hundred with the protocol.
You say you send out the nephrochecks?
LOUIS GUZZI: No, we do them here. We do them in-house. It takes about 45 minutes to get it back.
One technical question before I ask about Bonnie and John – you used the term early on perfusion. Again for our viewers, in layman’s terms…
LOUIS GUZZI: I tell people what perfusion is, the easiest way to think of profusion is squeeze your fingernail, watch it get white, and then watch it turn pink again. You’re perfusing. Your perfusing your bed, just like you perfuse your kidneys, your heart, your liver, your lung. It’s all about getting blood flow and perfusion there.
I wanted to ask you about Bonnie and John.
LOUIS GUZZI: Bonnie and John were a very super unique case, came in very sick acutely, very sick. Went into renal failure very quickly. We were struggling with that component of it, turned out to be multifactorial illness, some dehydration, some sepsis component of it, also something called atypical hemolytic syndrome, but all together a lot of disease process. Very quickly, we knew the biggest goal there was to save her kidneys. We sent the nephrocheck off. It was wildly positive. I think it was five and a half or something – instituted very aggressive resuscitation therapy right up front. Never really went into renal failure because we did that up front. On the back end of that, saving her kidneys and turning off what was causing this renal failure was not only dehydration, but it was sepsis and her breaking down actually components of her red cells. It’s a very complicated course. Bonnie and John only had this protocol, but they were also our first patients to get something called Solaris to turn off their atypical hemolytic uremic syndrome which turned off her whole process. It was absolutely amazing to see somebody go from Friday grey and not looking good to Monday smiling and saying I want out of here. It’s not just the renal component, which was huge in their case. It was also the other component of her illness. It was a lot of compendium of lot of pieces coming together to save her kidneys upfront and then turn off her hemolysis problem.
Bonnie tells me she does not recall anything from the time she hit the ground in the garden to her time here. So, John has been front row for all of this. Did you have conversations with John?
LOUIS GUZZI: I can’t tell you how many conversations I had with John. John was Bonnie’s best cheerleader. John realized there was something wildly wrong here, and Bonnie was deteriorating very rapidly, no question about it, deteriorated very rapidly and got very, very sick. We kept looking for an answer. Once we got her kidneys turned around, we had to turn off this hemolysis problem, which is a very rare disease. To be honest, six months ago, it wouldn’t have been turn offable. But now with the new drugs we have turned this process off, they get better. John was a big supporter. We made the decision once we got her kidneys better was to actually turn off this process as well. And it really worked. I just got a message from them today that she’s going on longterm therapy and is doing fantastic. It’s every eight weeks now, home. We’ve seen her once since then with a headache. That’s been her only problem. Kidneys are functioning normal. No renal failure. All the things we did to manage her lungs and everything out and back to living a normal, very productive life. So absolutely, total turnaround in somebody who, to be honest, two years ago probably wouldn’t have survived. And I’m sure John would tell you that.
Yes, he did. He’s amazed by watching.
LOUIS GUZZI: He was great with the nurses. I always say that there’s people that you realize really want to hear what you’re doing. We had very deep conversations every day with him about what was going on. It takes a village. It takes some of the best nursing care to keep her going. It takes a nephrologist to keep the plasma going. We also had other components that were very good there. A little bit of funny stories about John too is he became very engaged with the staff as well and was actually one of the biggest cheerleaders for Bonnie along the way. You just can’t say enough about having that kind of support. He also understood that we love Chick fil A. He would bring it in all the time for us. So, we love John for that all the time.
I want to make sure – Bonnie came in – was it a stroke?
LOUIS GUZZI: No, Bonnie came in with altered mental status as we talked about hypertensive and shockey. We didn’t know why. That’s our job is to sort all that out. But we have to treat all the organs and try to save them as we sort through that process.
Is there anything I didn’t ask you doctor?
LOUIS GUZZI: You didn’t really ask me where Waterman came from. We didn’t get there. We sidetracked So how did Waterman come about? Because when people ask me where I was or where I work at I always say Waterman, so it suddenly became the Waterman protocol for whatever reason. I just kind of said OK whatever. It kind of stuck with it.
I have one technical question. Flow track – you used here at the hospital for about nine years?
LOUIS GUZZI: We’ve used it since we started. I came here and took over the program nine years ago. Nephrocheck three years.
And it’s the combination of the two.
LOUIS GUZZI: I think the combination of two makes the big difference.
END OF INTERVIEW
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