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 last week was
My 68 year old mother is in ICU with gastric perforation and she’s not “waking up” after the surgery! Will she need a tracheostomy?
(PART 1)
You can check out last week’s episode by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer the next question from our client Robert, which are excerpts from email counselling and consulting sessions with me and the question this week is
My 68 year old mother is in ICU with gastric perforation and she’s not “waking up” after the surgery! Will she need a tracheostomy? (PART 2)
Robert describes his mother’s situation as follows.
Hi Patrik,
thank you for your response and for your insightful and thoughtful answers.
My first question today is: My Mother basically has been “under” for about 7 days now and has not woken up. The MRI and EEG shows no issues (so there hasn’t been any brain damage). How
common is this?
She’s got some factors that are likely extending her time unconscious, including age and the fact that she’s known to take a while to get over sedation. In Brazil it took her 4 days to get over the sedation and finally open her eyes and be able to
sit up.
Related:
My second question is: Today she took another step backwards. She’s not responsive at all anymore. What do we need to expect next from your experience?
My next question for today is: The Doctors have talked about extubating her and turning off the ventilator (this was yesterday when she was doing a little better). Their claim is that it’s better to get her off the ventilator and reduce chances of infection. They are also talking about a tracheostomy. I think one of your web pages advised waiting until the patient has “woken up” before extubating and taking the ventilator off. Given the context above, do you think that still
applies?
My next question is: If they do extubate and they do turn the ventilator off, and for some reason she’s not able to breathe on her own, how quickly does a tracheostomy need to be done?
And my last question for today is: What discretion does the family have in terms of how long the hospital waits for her to “wake up”. Is there some point at which they just “give up” and cease life
support?
Many thanks
Robert
Recommended:
Hi Robert,
Thank you for the update and thank you for sending your questions through.
Let’s look at your first question:
“My Mother basically has been “under” for about 7 days now and has not woken up. The MRI and EEG shows no
issues (so there hasn’t been any brain damage). How common is this?
She’s got some factors that are likely extending her time unconscious, including age and the fact that she’s known to take a while to get over sedation. In Brazil it took her 4 days to get over the sedation and finally open her eyes and be able to sit up.”
Here is my answer :
7 days and not “waking up” is nothing in Intensive Care terms. Not after major abdominal surgery with sepsis and not after what your Mother has been through in recent weeks.
I know how frightening and scary it is for families in Intensive Care to watch their loved ones go through this and I know how helpless and frustrated you must
feel for watching your mother going through this.
I’m so glad they have done the MRI and EEG to rule out brain damage, therefore this delay in “waking up” is very common.
Again, it would be very good to know what sedatives and opiates(=pain killers) your mother is on.
Furthermore, this massive event to your mother’s body and system with the critical illness will cause a delay in “waking up” too, because
her body will need time to rest and heal.
You are describing that it took your mother 4 days to “get over” the sedation in Brazil.
This is nothing in the bigger scheme of things and sometimes critically ill Patients in Intensive Care can be in an induced coma for many weeks and yet they can still “wake up”.
Therefore time, patience, positivity, nurturing and getting perspective around critical illness, sepsis and induced coma are important to deal with the frustrations of it all.
Keep also looking at the Ebook you’ve purchased, most of the information and timelines around “waking up” will be in there
Your second question is
“Today she took another step backwards. She’s not responsive at all anymore. What do we need to expect next from your
experience?”
Again, abdominal surgery and sepsis can be very challenging. It’s not uncommon that as you have described, Patients have various forms of Antibiotics and yet they still don’t get the sepsis under control.
We have been working with a client since November last year who was in ICU for abdominal sepsis and the infection is still not clear but the client’s family member has finally
after 7 weeks come off life support and out of ICU, therefore again, patience can sometimes be one of your biggest assets in all of this.
And again, the combination of sepsis with low blood pressure and the sedatives, opiates would be causing your mother to not respond.
Your third question for today is:
“The Doctors have talked about extubating her and turning off the ventilator (this was yesterday when she was doing a little better). Their claim is that it’s better to get her off the ventilator and reduce chances of infection. They are also talking about a tracheostomy. I think one of your web pages advised waiting until the patient has “woken up” before extubating and taking the ventilator off. Given the context above, do you think that still applies?”
I know your mother has gone backwards before you wrote this question. However, getting her off the ventilator rather sooner than later should always be the goal,
therefore a clear “yes” to extubating her as soon as clinically possible.
Getting your mother off the ventilator is reducing chances of another infection as length of time on a ventilator is simply increasing the chances of a chest infection/Pneumonia.
A tracheostomy is
definitely an option if your mother can’t come off the ventilator and I will explain to you in detail in a moment why.
A Patient in Intensive Care definitely needs to be awake before the breathing tube can be removed, no question. If they are not awake they can’t maintain a safe airway.
But it should always be the primary goal to extubate as quickly as possible for the reasons
mentioned.
Your next question for today is
“If they do extubate and they do turn the ventilator off, and for some reason she’s not able to breathe on her own, how quickly does a tracheostomy need to be done?”
If for whatever reason your mother can be extubated and is unable to breathe on
her own, she will need to be re-intubated(=breathing tube back in the throat) and then they can do the tracheostomy within in the next 24-48 hours.
Sometimes I do believe it is good to have a “trial” extubation first because then one can be sure that a tracheostomy is the right next step.
A tracheostomy in this day and age is a quick 30 minute procedure for an experienced Intensive Care specialist or surgeon and it can be done in ICU. (unless they expect
complications)
A tracheostomy will give your mother time to “wake up” in their own time because as soon as a tracheostomy has been done, pretty much all sedatives can be ceased and Opiates can often be reduced as a tracheostomy usually is not
painful.
It’s also a lot easier to wean a Patient of a ventilator with tracheostomy compared to a breathing tube, especially in prolonged critical illness.
Please check out these articles/videos here as it relates to your questions around tracheostomy
And your last question for today is:
“What discretion does the family have in terms of how long the hospital waits for her to “wake up”. Is there some point at which they just “give up” and cease life support?”
If your mother doesn’t “wake up” there will be a point where discussions need to be had around “how long is too long” to “wake up”.
But then the next step is to
do a tracheostomy first to give her the time to “wake up” in her own time.
At this point in time with everything that has happened there is nothing that I haven’t seen or haven’t witnessed before.
Yes, your mother is in a critical condition, no doubt about it and yes, she could deteriorate as well as take her time to “wake up” however the point to “give up” is from my perspective a long time away, even though she remains on multiple forms of life support such as mechanical ventilation and Inotropes/Vasopressors.
It’s the nature of Intensive Care and Critical illness, there are often differing views about what might be “in the best interest” of a critically ill Patient and their family.
We can certainly help you to get best, standard and prolonged treatment for your mother should the Intensive Care team be of the
view that is contrary to your and your family’s wishes.
We can help you position your mother’s diagnosis, prognosis, as well as her care and her treatment should the Intensive Care team be of a differing view and wanting to cease life support prematurely.
Every hospital/ICU as well as every state has policies, guidelines around when and in what circumstances life support can be withdrawn and
who can make those decisions.
Again we can help with that if it came to this point.
As for now, especially with abdominal sepsis, one of the next issues/complications that may occur if your mother continues to be septic is acute kidney failure and then there is a high likelihood for your mother needing Haemodialysis, but hopefully she’ll just
improve.
It sounds to me like she has a very supportive family who is prepared to go the extra mile.
Again we can help you with advocating for your mother if she deteriorates if the ICU team is having conflicting views with your views.
For now, from everything that you are describing, your mother is in a “normal” situation for Intensive
Care/Critical Care terms given her current clinical picture and circumstances with the information that you have given me and I think that everything that should have happened thus far has happened.
I hope this helps Robert, please let me know if you have any other questions or if you need more clarification.
