Why Would the ICU Doctor Want to Do a Tracheostomy & PEG for My Dad When He is Improving in the ICU?
Published: Tue, 10/24/23
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
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, Iyah, as part of my 1:1
consulting and advocacy service! Iyah and her siblings are in a family meeting with the doctor and a nurse to discuss their dad’s condition. She is asking why the ICU doctor wants to do a tracheostomy & PEG on their dad when he is improving in the ICU.
Ron: So, he had gram-positive cocci, and now, we know there’s something in there. That’s all we know. Now, they’re trying to grow it.
Iyah: Okay.
Dr. Shelby: So, it could be new, it could be recurrent that was not fully treated the first time. It’s hard to say for sure.
Iyah: Okay.
Patrik:
Can I just ask you? So that’s in the blood or…
Ron: Yes, he had positive blood-
Patrik: Right.
Ron: Yeah.
Patrik: Okay.
Dr. Shelby: And he also had
worsening kidney function. So, he needed dialysis, which was started, I think, last week.
Iyah: No, not just last week. That was like… Oh, yeah, actually, he’s only been here for two weeks.
Nurse Ron: Yeah.
Patrik: No, wait. I want to say it was a Monday.
Dr. Shelby: The dates aren’t really crucial for this discussion though. The gist of it.
Iyah: Okay.
Nurse Ron:
Yeah. We just needed a ballpark.
Dr. Shelby: So, he needed dialysis. Two days ago, they needed dialysis, but his blood pressure was way too low. And it’s not safe to do dialysis, so they weren’t able to do it.
Nurse Ron: Right.
Dr. Shelby: Today, his pressures have improved some. He’s no longer on vasopressors, meds that raise blood pressure artificially. So, the plan is to do some dialysis today. And have you guys heard from any of the nephrologists,
kind of what their thoughts are about what your dad’s long-term needs might be for dialysis?
Iyah: I spoke to Dr. Gerry, his actual nephrologist, two days in a row yesterday and the day before. He’s very gloomy about dad’s condition. He says
it’s a double whammy, needing dialysis, needing ventilation. And he wants his suffering to stop, and that’s not where my mind is going. So, I was asking, I was mentioning about his oxygen settings, looking for improvements. And he, at one point, mentioned he needs 100% oxygen, and I corrected him, telling him it’s 50%. So, he stood up to go look at the oxygen settings, and he said, “Wow, that is encouraging. He is at 50%.” So, he has a very gloomy outlook, and I really did not appreciate that.
But he didn’t really say what his thoughts are other than, “Let’s end his suffering.” And I didn’t appreciate that.
Nurse Ron: Well, he would rather be gloomy to be honest with you than say, “Well, it could be okay,” you know what I mean?
Doctors need to be upfront so that you have accurate information.
Dr. Shelby: Well, that’s right, let me kind of share what I can glean in terms of positives or negatives and things that we’re looking at to help try to weigh what the
future may be like for him.
Iyah: Yeah.
Dr. Shelby: So, I’ll start with the positive things. I saw today that his FiO2, the oxygen saturation was down to 40% from 50%.
Nurse Ron: At the average of 40. Some of our patients have to be 30.
Iyah: So that’s very encouraging
then.
Nurse Ron: Because they get too much on.
Iyah: Okay.
Dr. Shelby: That’s it this morning. So, let’s see how he does and tolerates that.
Iyah: Oh. And also, his PEEP went down.
Dr.
Shelby: Also, the eight. They both went down.
Iyah: Yes.
Dr. Shelby: They’re both moving in a good direction. That’s encouraging. We’ll see kind of how that pans out, if he tires out, if his labs will look more normal.
Iyah: Yeah.
Dr. Shelby: But that is an encouraging sign that maybe his lungs are starting to improve. His white count’s gone down a little bit. I think it was down to 7. something
today. So, it’s back down to a normal range for the white blood cell count. That’s also encouraging.
Iyah: That’s good.
Dr. Shelby: And then things that worry me a little bit.
Iyah: Hang on one sec, sorry. The
arterial blood gas, that made some improvements, is that what you were saying earlier, Ron? The oxygen to CO2, it looked a little improved, but may not.
Nurse Ron: Was I saying that yesterday?
Iyah: This morning when I saw
you.
Dr. Shelby: The pH was lower though. It was a little more acidotic.
Nurse Ron: Yeah.
Dr. Shelby: He may have been retaining some CO2, potentially.
Patrik: Well, can I just ask? What ventilation settings is he on? Is he in a controlled mode? Is he on pressure support?
Nurse Ron: I don’t remember. I never pay attention to that, his respiratory.
Patrik: Well, I think that’s important.
Nurse Ron: Yeah, yeah. So, the thing about having a lower white count-
Patrik: Hang on, hang on. Can you just please answer my question? Because that’s an important question.
Nurse Ron: I don’t know. We’re not in his room, and we don’t have access to that.
Iyah: We’ll get back to you after the meeting, once we’re back in his room.
Nurse Ron: Yeah. We’ll let you know. So white blood count can go low, because they’re getting used up from trying to
fight the bacteria. So being low can be good, but sometimes it can be bad. I just want you to be aware of that.
Because remember, I told you his secretions, he has a lot more now, and now they’re blood tinged. So, he’s got some pretty irritated bronchial
tissue.
Iyah: Yeah.
Dr. Shelby: He’s still been on the vent a lot more time than we would think he would need to be, given the severity of infection.
Iyah: 17 days.
Dr. Shelby: We don’t know if the diastolic heart failure is causing him to have more fluid buildup and more irritation or inflammation, or whether just being immune suppressed for a long time, or whether it’s being weakened over time and just all that his body has gone through over the years. But for whatever reason, he has been on this for a long time, needing a lot of support, and that is concerning. We’re seeing signs sometimes of improvement, but we don’t know how this will play out in the long run too. So definitely,
it’s one day at a time right now.
Liza: So, I have a question. What if we did more dialysis on him? Would that improve over fluid?
Dr. Shelby: It can, and that’s kind of what they’ve been aiming for. On some days, he’s had too low blood pressure, so they couldn’t do it. But today, he’s good enough where they can do it again. So, they’re going to try to do some more dialysis. But it’s definitely give and take.
Liza: Right. From my understanding through my research, I feel that a fluid overload is because his kidney isn’t filtering, and I feel that it’s his kidney that is the main problem.
Dr. Shelby: It’s a part of it. He’s also getting IV fluids, and when your body is in sepsis, or in and out of sepsis, and
having trouble maintaining fluid balance, the fluid can go to different places. And the pressure and strain of being on ventilator also puts stress on the body too. So, kidneys are a big part of it, but there’s other factors that are probably contributing as well.
Nurse Ron: So, what she was telling you is, yes, we want to do dialysis, but he was too sick to do dialysis.
Iyah: Low blood pressure, right?
Liza: Right. I understand.
Nurse
Ron: Yeah.
Iyah: And also, he hasn’t had urine output through the catheter at all for like a week and a half.
Dr. Shelby: So obvious question that I would love to have nephrology answer, if they know, which they may not know, is what are the chances of his kidney function improving, versus what are the odds that he’ll now need dialysis indefinitely?
Iyah: I’m curious why a nephrologist cannot be in this meeting at this time.
Dr. Shelby: They cannot always attend. They have to attend to other
patients.
Iyah: I’m curious about questions that we may have, why were they not brought word forth to them?
Nurse Ron: Well, we don’t actually have nephrologists that stay in the hospital and only treat hospital patients. They all have clinics, and they all have patient appointments.
Iyah: Yeah.
Nurse Ron: So, we can’t always reach them.
Patrik: It’s still not unreasonable to ask for a nephrologist to be here. I mean, this is potentially a life-or-death decision.
Iyah: Yeah.
Patrik: I don’t think it’s unreasonable to ask for a nephrologist.
Dr. Shelby: Yeah. Well, every hospital works a little bit differently.
Patrik: Sure.
Dr. Shelby: In this hospital, I’ve never seen them in these meetings.
Patrik: That doesn’t change my point of view, that it’s not unreasonable.
Dr.
Shelby: No, of course not. It’s very reasonable.
Iyah: And I can also see, why not have the questions prepared for them to answer to bring to the
meeting beforehand.
Nurse Ron: Well, and we know his outlook. If Dr. Gerry said, “Let him be out of misery,” then he thinks it’s not good.
Iyah: That’s an opinion without basing off of other things.
Dr.
Shelby: Well, all I can tell you is what we can work with today if that’s okay.
Iyah: That’s what we got, yeah.
Dr. Shelby: Yeah. So, the big question is, what are the odds that he may improve and what if he doesn’t? And obviously, if he improves, that’s simple.
He improves, he gets better. There’s really, I think, a range of scenarios of what might happen. So, I’m going to go through what is the most favorable to the least favorable.
Iyah:
Yeah.
Dr. Shelby: And these are all, again, unknowns right now, but these are kind of the realities that we may encounter.
Iyah: Yeah.
Dr. Shelby: But I would say the most favorable outcome is
that he resolves whatever effects are going on his lungs. He gets off the ventilator, he gets off from dialysis, and he recovers to as close baseline as possible. I worry that he’s in the hospital on the ventilator for several weeks, his body will get very weakened. And some patients are not able to recover back to baseline strength after going through that long of a serious illness. So, there’s a good chance that if he improves in all these ways, he may still not be healthy enough to be able to
live at home again. He may need to be in a higher level of care, potentially.
Michael: Do patients like my dad that are in the same health condition that he is, do they usually make it to the point where they can swallow? Is that a high percentage?
Iyah: I
think we just jumped quite a bit from what you just said, Doctor Shelby, because you were saying favorable outcomes.
Michael: Well, these are my questions.
Iyah: That jumped quite a bit. I’d like to go gradually.
Michael: I just have a few questions. You’ve talked most of the time. Can I just ask a question?
Iyah: I know. But I’d like to go gradually.
Dr. Shelby: So, asking about what setting that would be in?
Michael: Yeah. Yeah.
Dr. Shelby: If he were to leave the hospital in need of being on a feeding tube and on a tracheostomy, which is a possibility, then he would end up going to another long-term care facility. And over there, they would be there for weeks or months, and they would be able to wean him from those things. Or he would be on them permanently, which could also be an option.
Nurse Ron: And there’s really no way to predict. Everybody is so different. We never know how his body, if his body can heal, just how bad, how weak he is kind of thing. So, it is nearly impossible to predict how long it would be before he could eat, if he gets well enough to actually eat.
Michael: Yeah.
Dr. Shelby: But I think in the best case, he’s still probably going to need 24-hour care going forward, unless there’s a miraculous level of recovery. But that seems less realistic than what would probably happen, what usually happens. So that might be with a 24-hour home caregiver, if he’s healthy enough for that, or in a long-term care facility. And that’s the best-case scenario that we’re looking at.
If he does not improve in the next week or so, that means he’ll be on a ventilator for close to three weeks. And at that point, if someone still is on a ventilator, then families have to decide, “Do we continue with this path, or do we not?”
Patrik: Okay.
Dr. Shelby: And
if they do, then that’s when they do the tracheostomy and the feeding tube. Because at that point, you can’t have the tube in for so long without just causing damage to the throat.
Iyah: I noticed you gestured the feeding tube to the stomach. I understand that there’s also a feeding tube to the nasal.
Dr. Shelby: Ones that would be used for more long-term planning, they go through the stomach, because the NGT can’t be kept in for more than a few weeks as well, without causing deterioration of the inner septum.
Iyah: Wouldn’t the goal of a tracheostomy be to get them to improve and to have it as temporary?
Dr. Shelby: Yes, but if you need it for more than a week or two, then nasogastric tube is not a viable option.
Iyah: Right. And if that were the case, then you would need to do the stomach. So why not start with the less permanent first?
Dr. Shelby: They do these both together. Because if someone’s-
Nurse Ron: They’re not permanent.
Iyah: No, I’m talking about the nasal tube compared to the stomach tube.
Nurse Ron: It’s the same. We’re up against the exact same problem as the trach through the throat. The
tube through the throat, the tube in the nose and down through the throat is at risk of rubbing, making a little infection there, making huge open holes, sores, infections. So, we have to get them out and put them in an area that has stronger walls to hold and not get wounds rubbed into them. So, in the stomach, that’s used to having acid in there, it’s not going to make this big, huge abscess as easily as something, a tube down through your nose. So that’s why they always put a trach and a
feeding tube in the same surgery. You want to get everything out of here.
Iyah: Out of the nose.
Nurse Ron: … out of the nose and out of the mouth. Yes.
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