Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in
Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
Your Questions Answered Live: How to Stop the ICU Team From Withdrawing Life Support Without Your Consent?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Richard, as part of my 1:1 consulting and advocacy service! Richard’s dad is with a breathing tube and on a
ventilator in the ICU. Richard is asking how the consulting & advocacy service at Intensive Care Hotline can help his critically ill dad in ICU to get the best care & treatment to survive.
How Can Your Consulting & Advocacy Service at Intensive Care Hotline Help My Critically Ill Dad in ICU Get the Best Care & Treatment to Survive?
Hi Patrik,
I have gone across your website and I have seen how you have helped families with their loved ones inside the intensive care and so I thought of availing your consulting and advocacy service.
My dad is inside the ICU now and I need help in understanding ICU process. I need better assistance with ICU, ideas about ventilation durations, your thoughts about the weaning trial errors after 10 days, tracheostomy possibilities pros and cons, life choices and best quality of life.
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Here are the questions I have in mind and also a brief overview of my dad’s condition with a couple of recent conversations with the ICU doctor and the team:
- What questions should I ask? During family meetings, what are the clinical questions to ask? How do I manage doctors and nurses?
- What are they doing? What are they not doing to get him off the ventilator? What options are there for treatment and for care regarding ARDS to assist with extubation? What are the competing interests?
- What are the 5 tips to peace of mind, control, manage doctor and nurses, what’s behind the scenes? What are the cheat sheets and/or shortcuts you can provide to me when dealing with this ICU challenge?
- What is the agenda, behind the scenes?
- Is testing needed now for my dad versus over 13 days rare yeast, still no antibiotic drive specific?
- What is the agenda behind my dad’s prognosis and diagnosis? What should I be looking for when it comes to ARDS? My dad arrived with sepsis pneumonia, now ARDS? There’s no proning now, his oxygen is okay per ICU. Do they need to prone my dad now? How about Nitric Oxide and Flolan not given, per his doctor, it
doesn’t show it works.
- Also, there is no fluid removal via haemofiltration given, and Lovenox 40 mg given daily.
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- My dad is having tachycardia when sedation was turned off. Can we use Esmolol for his fast breathing or is the issue due to lungs?
- ECMO also was not done, other hospitals have it. His fast breathing could also be triggered from pain, stress, medication, sedatives, not sufficient to manage my dad’s fear?
- Can we use Dexmedetomidine while extubating? Are there other medications besides current fentanyl and propofol that might help wean him off the ventilator? Can Ativan possibly help? How about Ritalin or methylphenidate?
- For his FiO2 (Fraction of Inspired Oxygen), what are they doing, and not doing to extubate properly? Is the issue of the lungs are full of fluid, and they need more assistance with oxygen?
- How to prevent tracheostomy? What have we all done to eliminate trach? While on trach will he still need sedation? Not sending dad out to LTAC Can he stay in ICU? My dad needs ICU nurses not the ones from LTAC, most of them have no ICU skills. The correct environment where my dad belongs is in the Intensive care.
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For additional information, they have discontinued Vancomycin. The chest x-ray is clearer. His white cell count went up. The FiO2 is high again. He is positive for gram positive cocci, his antibiotics were changed to Zyvox 600 mg tablet twice a day, and Meropenem is continued daily.
I also want to ask if how long can you stay on ventilator with ARDS in addition to already on ventilator?
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Patrik, I am also sending you these information about my last few calls with the ICU nurses and his doctor:
PER NURSE:
He is currently with sedation meds. His ventilator setting is with FiO2 of 70% and PEEP of 14. He has antibiotics Meropenem 1 gm IV every 8 hrs and Zyvox 600 mg tablet two times daily. He has a PEG tube. They have given steroid solumedrol. His white cell count is 24,
going down again. His creatinine is 0.5, liver is good, urine output is good. Labs as a healthy person per nurse.
PER DOCTOR:
His FiO2 is at 85%, titrate few hours, levels go up. He has low tidal volume – 450 with no proning because his oxygen is good per doctor. They have not given nitric oxide nor flolan. The other doctor stated no benefit in ARDS. Arterial blood gases on the third week is on the acidotic
side, then with little improvement a few days after. He was given steroid solumedrol daily. He is on sedation infusion. They are giving feeds of 55 mls per PEG tube. His white cell count is down to 21.5. He is on antibiotics Meropenem 1 gm IV every 8 hrs and Zyvox 600 mg tablet twice daily via PEG tube. He has blood pressure meds as needed. They have given Lasix and also she is on Lovenox 40 mg daily. Medications are given, creatinine is normal, liver and kidneys are good. He has no fluid
removal via hemofiltration. Range of motion being done for my dad. I asked the nurse how often but I can’t get an answer. He has bowel movement.
These are all the information for now Patrik. Looking forward to get on a call with you with the doctors and nurses.
Appreciate your advice.
Regards,
Richard
Hi Richard,
It’s Patrik here from Intensive Care Hotline. I just thought I’ll quickly record this voice message for you, and I’ll read out the answers to your questions.
You’re asking, “What questions should I ask? During family meetings, what are the clinical questions to ask? I really believe that the best way to deal with this is for you and for me to get on a call. I can point you towards a blog post where we’ve documented the questions that families should ask, but that’s a one-sided thing. The advantage of you and I talking to the doctor, is simply that I can ask counter-questions straight away. I’ll send you the link to the
blog post anyway, but I do believe the shortcut is for you and me to talk to the doctor directly.
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How do you manage doctors and nurses? Well, one way to manage doctors and nurses is really to get more demanding, because it sounds to me like many families at the moment, especially with COVID restrictions and what-not, they’re trying to dictate terms. And it’s up to you to turn
that around. It’s up to you to demand what you want, and probably change the way you approach things in terms of your expectations.
What you will also see, again, I believe it also comes down to the two of us getting on a call to them so you can see or hear how I manage them. And I think I can get you independent… managing them and getting better outcomes.
You then asking, “What are they doing? What are they not doing to get him off the ventilator?” Well, I wouldn’t know that at the moment without having talked to them. It would be very advantageous to know ventilator settings, to know arterial blood gases, to know chest x-ray results, and also to find out again, what are they doing? What are they not doing? Are they doing physical therapy? Are they mobilizing him? And the list goes on.
You’re asking, “What options are there for treatment and for care regarding ARDS to assist with extubation?” The options are steroids, for example. Steroids is one option. Also, things such as Epoprostenol, also known as a Flolan nebulizer, potentially nitric oxide, potentially Sildenafil or Viagra tablets. And also prone position, high frequency oscillation ventilation, but also ECMO. Again, we can discuss that in more detail when we get on a call.
“What are the competing interests?” Well, the competing interest for an ICU is always to manage their worst case scenario. What’s their worst case scenario? Worst case scenario for any ICU is to look after a patient indefinitely, with an uncertain outcome. And that is probably the situation your dad is in. It’s also a case of, if they feel like your dad is not a good financial money-maker for them, they will try and limit his stay in ICU in whatever way they deem
to be appropriate. There’s too many interests way beyond the clinical care in ICU. And your dad is in the midst of it like many other patients.
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Another question you have is, “What are the 5 tips to peace of mind, control, manage doctors and nurses, what’s behind the scenes?” What’s behind the scenes is really, again, their interests and their interests only. A number of patients in ICU, how many patients do they have knocking at their ICU beds? Do they have enough staffing resources? It’s one thing to have beds, potentially even empty beds. What if they don’t have staff? No use for those empty beds
without staff. Peace of mind? I think you are on your way to peace of mind, because you are now getting control. You are taking control. You are asking the right questions. And that also brings me back, how do you manage doctors and nurses? Well, you manage them by starting to ask the right questions. And that, in and of itself, you’ll probably see that the dynamics will change in your favor. I do expect resistance when you start asking the right questions. I do expect resistance, but it’s just
a matter of keeping going with it and keep asking the right questions.
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You’re asking, “What are cheat sheets and/or shortcuts I can provide you with when dealing with this ICU challenge?” What is the agenda behind the scenes? Well, again, I talked about the agenda from the intensive care team’s point of view. And also what’s happening there behind the scenes. Again, for example, if they have surgery lined up, and your dad is occupying that bed, and they can’t operate, they will have the surgeons jumping up and down. And that will put
pressure on your dad’s ICU bed, unfortunately.
You are talking about, “Is testing needed now for your dad versus 13-day rare yeast, still no antibiotic drive specific.” I’m not sure what you are referring to. What I will tell you is this, if someone has an infection, they need to test for yeast. They need to test for bacteria. They need to test for virus, and then they can counteract that with antibiotics, antivirals, and so forth.
The agenda behind your dad’s prognosis and diagnosis. I always argue that ICU teams are only telling families only half of the story, and that’s probably the case in your dad’s situation. Again, I do believe let’s get on a call with the doctors, and let’s ask questions. You will see, I believe, a whole different world will open up for you.
You are asking, “What should I be looking for when it comes to ARDS? My dad arrived with sepsis pneumonia, and now ARDS.” What you should be looking for there really is how do they treat the ARDS? Again, as I mentioned before, steroids, potentially nitric oxide, Epoprostenol nebulizers, Sildenafil/Viagra, prone
position, high frequency oscillation ventilation, ECMO as a next step.
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Well, I know you’re saying in your email, “How about nitric oxide and Flolan not given, per doctor, it doesn’t show it works.” I disagree with that. I’ve seen it work. I’ve seen it in the units that I’ve worked at, being used many times.
You’re saying, “There is no fluid removal via hemodiafiltration. Given Lovenox 40 mg given daily.” Yeah, I don’t know why they’re not removing fluids via the hemodialysis or hemofiltration. Would need to talk to the doctors about that.
Then you’re saying, your dad is having tachycardia when sedation was turned off. “Can we use Esmolol for his fast breathing, or is the issue due to lungs? ECMO also was not done, other hospitals have it.” For his tachycardia, can he have Esmolol?” I would argue no Esmolol, because it would probably get his blood pressure right down. But again, I would need to know what medications he is on.
Let’s look at ECMO, Richard. ECMO is an option for ARDS if no other treatment options work. Again, I don’t know enough whether your dad would qualify for ECMO. That’s why I’m saying we need to talk to the doctors.
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Fast breathing could also be triggered from pain and I definitely need more information about your dad’s situation why he might have pain. Definitely agree with stress.
About Dexmedetomidine, yup, it’s worth giving a try. From my experience it doesn’t work most of the time, but it’s worth giving a try. In some patients it works. Also about Ativan, yeah, possibly good to mix it in. But for Methylphenidate, I’m not sure about that. But Ativan for managing anxiety, absolutely yes.
You’re saying, “For his FiO2 (Fraction of Inspired Oxygen), what are they doing, and not doing to extubate properly? Is the issue of the lungs are full of fluid, and they need more assistance with oxygen? Again, I wouldn’t know whether the lungs are wet or not. Would need to talk to the doctors in regards to that.
You’re asking, “How to prevent tracheostomy? What have we all done to eliminate the tracheostomy? While on tracheostomy, will he still need sedation?” I would argue that once he’s on the tracheostomy, he can probably come off sedation, unless he needs proning. Alternatives to tracheostomy is really to wean him off the ventilator in the first place. And again, I would need to talk to them to find out what have they done? What have they not done? If he ends up with
a trach, I would argue I can help you keeping your dad in ICU instead of going to LTAC.
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You say, they discontinued Vancomycin, his chest x-ray is clearer, and white cell count went high. FiO2 (Fraction of Inspired Oxygen) is high again. Gram positive cocci changed to Zyvox 600 mg day two, and Meropenem continued once daily.” Yes Richard, we will clarify that to the doctors.
“How long can he stay on a ventilator with ARDS in addition to already on the ventilator?” It depends Richard. It depends on, can they prone him? Can they do ECMO? Depends on all of that. How long he can stay on it? I would say three-to-four weeks.
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You also mentioned your last few calls with the ICU nurses and his doctor a few days ago. I have seen all of that.
So let me know Richard when you want to talk and when we can talk to the doctors so I can start helping you with your loved one inside the ICU. Remember, the biggest challenge for families inside intensive care is that they don’t know what they don’t know. They don’t know how to manage the doctors and nurses.
Let me know what time you are available for a call. My number again is 415-915-0090. Thank you.
The 1:1 consulting session will continue in next week’s episode.
