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 makingfast, 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

 

 

How to have Control & Power Over the ICU team So that My Critically Ill Mom will Get the Best Care and Treatment?

 

 

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 Tom, as part of my 1:1 consulting and advocacy service!  Tom’s mom is on a ventilator in the ICU. Tom is asking how he will know if the ICU team is doing the right thing to help his mom come off the ventilator in ICU.

 

 

How Will I Know if the ICU Team is Doing the Right Thing to Help My Mom Come off the Ventilator in ICU?

 

 

“You can also check out previous 1:1 consulting and advocacy sessions with me and Tom here.”

 

 

Part 1

 

Part 2

 

Part 3 

 

Part 4

 

Part 5

 

Part 6

 

Part 7

 

 

Patrik:  Yeah, no. So I see a lot of progress. Right? Even if she can’t tolerate the CPAP trials yet, I mean, she’s doing that. You know, it’s… you’ve got to start somewhere. And I can see why she’s not tolerating them yet because she was in a coma for so long. Right? So her breathing muscles should be severely weakened. But that’s why I’m so pleased to hear that they’re standing her up, that they’re talking about sitting her in a chair. That’s how you strengthen breathing muscles.

 

 

Ronald:  Mm-hmm (affirmative).

 

 

Patrik:  Right? So, from what you’re sharing, that they’re doing the right things.

 

 

Ronald:  Okay.

 

 

Patrik:   So this is how you wean a patient off the ventilator. There’s nothing new in that patients don’t tolerate the CPAP initially, there’s nothing new there. You know? It’s just part of-

 

 

Ronald:  Okay, there’s nothing alarming about that-

 

 

Patrik:  No, no.

 

 

Ronald:  Okay. 

 

 

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Patrik:   No. Alarming would be if they weren’t trying, that would be alarming. The most alarming thing would be them denying her the CPAP trials. That would be the most alarming thing. And if they..

 

 

Ronald:  What about?

 

 

Patrik:  … if they weren’t mobilizing her, that would be alarming.

 

 

Ronald:  How do you, what’s your threshold for the patient not wanting to? Because my mom, she’s doing that, but as of one hour, she said, “No, no more. No more.” And it’s like, “What? We asked her to do more, is that too much?”

 

 

Patrik:  Yeah, normal. Normal. Very normal. You know, like you mentioned, she’s just waking up, her brain is recognizing on what’s happening and what’s happened, you know? She would go through a normal… what’s the word… I wouldn’t say depression, but she needs to come to terms with what’s happening, and a need to familiarize herself with what situation she is in.

 

 

Ronald:  Okay.

 

 

Patrik:   So nothing what you’ve shared with me so far is a surprise. The most important message that I’m getting from this is, they’re trying.

 

 

Ronald:  Yeah.

 

 

Patrik:   That is the most important message that I’m getting from this. And a week ago, well, they needed to get rid of sedation, they’ve done that. She wouldn’t be standing if she was on sedation.

 

 

Ronald:   Okay, yeah.

 

 

Suggested links:

 

• What’s The Difference Between An Induced Coma And Sedation?
   

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• HOW LONG DOES IT TAKE TO WAKE UP AFTER AN INDUCED COMA?

 

 

Patrik:    So I’m seeing a lot of positives here. I just want to quickly comment about the pressure support.

 

 

Patrik:   So, coming to the pressure support that you mentioned, you said initially 6 over 22? What did you say? Tell me..

 

 

Ronald:   The lady is writing as they do the pressure number up top and..

 

 

Patrik:   Yeah.

 

 

Ronald:   ..on the bottom.

 

 

Patrik:   Yeah, yeah.

 

 

Ronald:  So it’s 28 over 6 yesterday, today, 22 over 10.

 

 

Patrik:   All right. Let’s give you some insights there. So, the 6 over 28, it means the PEEP (positive end expiratory pressure) is 6 and the pressure support is 28. And 10 over 22 means the PEEP is 10 and pressure support is 22. Now, both numbers are not great numbers. Both suggest there’s a lot of support still.

 

 

Ronald:  Okay.

 

 

Patrik:  But again, it’s a start. You know, in order for her to come off the ventilator, I’ll tell you what needs to happen. The PEEP needs to be less than 8. And the pressure support needs to be less than 10.

 

 

Ronald:   Okay.

 

 

Patrik:   That’s the time when they can, that’s the time when they can consider taking her off the ventilator. However, that’s not the only variable. So let’s just say she’s breathing on PEEP of 6 and pressure support of 10. There’s other things that need to be looked at as well. For example, arterial blood gases need to be assessed, carbon dioxide needs to be assessed. Oxygen levels in the blood need to be assessed.

 

 

Suggested links:

 

• HOW LONG SHOULD A PATIENT BE ON A VENTILATOR BEFORE HAVING A TRACHEOSTOMY?
   

• What are the reasons for not being able to come off the ventilator/respirator?

 

 

Patrik:    Tidal volumes, i.e., how big are the breaths she’s taking on the ventilator.

 

 

Ronald:    Okay.

 

 

Patrik:   And also, how fast is she breathing? If she’s breathing with a rate of 40 per minute, that’s too fast. If she’s breathing with a rate of 15 per minute, that would be normal. So there’s a number of things that need to be looked at. But I can tell you, by you telling me that they’re doing, they’re doing all the right things.

 

 

Ronald:   Okay.

 

 

Patrik:   They’re doing all the right things, which is very, very important. So she’s on the right track, even though she’s still on a lot of support, and even though she’s probably now, you probably need to give her a few days until she comes to terms with the situation she’s in, and then work from there. And it’s probably going to be baby steps.

 

 

Ronald:   Yeah.

 

 

Patrik:  Right? But..

 

 

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Patrik:   And it’s often two steps forward, one step back. So just because, you will see some setbacks potentially, don’t be discouraged.

 

 

Ronald:  Meaning some days she’ll need more support even though she decreased other days?

 

 

Patrik:   Absolutely, absolutely. Two steps forward, one step back. So, and just quickly moving away from the ventilator for a moment, I just want to quickly focus on the report.

 

 

Ronald:  Okay.

 

 

Patrik:  I have obviously noticed the IVC (Inferior vena cava) filter, which makes sense in light of the tracheostomy bleed.

 

 

Ronald:  Yeah.

 

 

Patrik:   They needed to reduce her anti-coagulation to stop the bleed, but she’s also at risk of thrombosis because she’s immobile. So putting in an IVC filter makes sense. That is on top of, did you see that she most likely had a heart attack?

 

 

Ronald:  Yeah, when she was admitted? Is that what happened?

 

 

Patrik:  Well, it’s not clear when, but it’s clearly documented non-STEMI (non-ST-Elevation Myocardial Infarction). And that is the medical term for a heart attack.

 

 

Ronald:   Yeah, they told us that, well, they explained to me, I mean, yes. Something to the extent of, like, the heart was producing an enzyme, and that’s what if it produces enough of it, it meets the definition of a heart attack.

 

 

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Patrik:   Correct.

 

 

Ronald:  … and she was on the threshold.

 

 

Patrik:  Correct.

 

 

Ronald:  So, they explained to me that, regarding her admission. Like somewhere between the first day and maybe like the second or third? So I interpreted that as, like, okay, when she would come in, I actually just took it for face value she was on the verge of that when she admitted herself.

 

 

Patrik:  Okay. You see, that part wasn’t clear to me when, but it was..

 

 

Ronald:   Yeah, only because of the timing when they explained it to me. I went to visit her 5 days after she was admitted, and they had already explained that part to me. So that..

 

 

Patrik:  Right, I see.

 

 

Ronald:  … for sure it happened in those first 4 to 5 days, I would say first 5 days. And some, at least or at minimum, it occurred between the first 5 days because they explained to me in person.

 

 

Patrik:  I see. So, okay, so for you it wasn’t a surprise that it was documented there.

 

 

Ronald:   Well, I don’t even know where it is, where it says it, but they explained it to me. Because I was like, “What do you mean she had a heart attack?” I really was like, “What does that mean?” I was freaking out. And then they’re like, “Well, it’s because of this enzyme when the heart’s not getting oxygen,” and then so she’s like, “She was on the verge. She has enough of this enzyme that the heart, it’s not good for the heart to produce in these stressful times.”

 

 

Ronald:   And so she just said it was on the border of being considered a heart attack.

 

 

Patrik:  Right.

 

 

Ronald:  But are you saying that it’s not medically documented as an actual heart attack?

 

 

Patrik: I would say so. If you look at the report at the second page, second page on the report, it says, “Number 9, elevated troponin, non-STEMI or NSTEMI, likely demand ischemia resolved.” Can you see that?

 

 

Ronald:  Which report? Like what day is that?

 

 

Patrik:   The one from today.

 

 

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Ronald:  Oh, okay. Let me, I’m looking at 2 days ago. Let me go down to that one. Oh, okay, yeah, that, oh yes.

 

 

Ronald:  Okay. Number 9, yes. Oh okay, that’s the enzyme, right? Troponin?

 

 

Patrik:  Yeah, troponin is the enzyme, and non-STEMI is one medical term for the heart attack.

 

 

Ronald:   Okay.

 

 

Patrik:   So, but here is something else, and that was in the report from yesterday, not from today’s. In the report from yesterday it says, “LVEF 30 to 35%.” So basically what that means is… And I don’t want to get too medical here but I think it’s important for you to understand… LVEF 30 to 35% means, left ventricle ejection fraction is 30 to 35%. So what that means is, they’ve done an ultrasound of the heart. And they’ve measured the contractility of the heart, how strong is the heart beating.

 

 

Patrik:   And the..

 

 

Ronald:   Okay.

 

 

Patrik:   … ejection fraction is the medical term for contractility of the heart, and that ejection fraction was down a fair bit, which is another indicator that she had a heart attack.

 

 

Ronald:   Okay.

 

 

Patrik:  But it’s..

 

 

Ronald:  … they feel like..

 

 

Patrik:   … it’s gone up.

 

 

Ronald:  … and what line?

 

 

Patrik:  That was in yesterday’s report. I have to look up yesterday’s report, just give me a second.

 

 

Ronald:  Oh, okay.

 

 

Patrik:  But it would have been on the first couple of pages as well, the way it’s structured. So..

 

 

Ronald:  Okay, but that’s… I’ll look at them, I’ll refer to it, but can you just repeat? So you’re saying that that ultrasound that they did measures how strong her heart is beating.

 

 

Patrik:   Correct.

 

 

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Ronald:  … and what did you say? Combo, con..

 

 

Patrik:   Contractility.

 

 

Ronald:  … contractility?

 

 

Patrik:  … contractility, yes. Correct.

 

 

Ronald:   And then if it’s below a certain number, it’s considered… well, oh..

 

 

Patrik:  Well, in..

 

 

Ronald:   … say that part again for me?

 

 

Patrik:  Yeah, yeah. If it’s below a certain threshold.  It’s almost an evidence that she had a heart attack. Unless she would have been diagnosed with, let’s just say, with a cardiomyopathy which is not the case. Then you would have to diagnose is it one or the other. But because there’s no other cardiac history. It’s pretty much a confirmation that she had a heart attack.

 

 

Ronald:  Wow. Okay.

 

 

Patrik:   Right?

 

 

Ronald:   Okay, I imagine that changes her vulnerability then.

 

 

Patrik:   Very, very much. So it changes her level of vulnerability. It changes, it helps with your argument that she needs to stay in ICU.

 

 

Ronald:    Oh, my God.

 

 

The 1:1 consulting session will continue in next week’s episode.

 

 

• Email counselling/consulting with Patrik
   

• One on One phone/ Skype counselling/consulting with Patrik