Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where
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This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question in this series of questions from our client Robert and the question last week was PART 11 of
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 11)
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 12)
You can find previous questions from this series of questions answered here
PART 1, PART 2, PART 3, PART 4, PART 5, PART 6, PART 7, PART 8, PART 9, and PART 10
Robert continues with his mother’s situation below
Hi Patrik,
here’s the latest update on our
end.
The insertion of the line for dialysis went without incident, and overall, my mom is responding to the dialysis well.
They estimate an extra 25-30 liters of fluid in her body, so
it’s going to take a while for them to get that processed and out.
Related article/video
The bp meds (inotropes/vasopressors) are either off completely or very low.
Yesterday, she had to be taken for a procedure to remove some fluid that they saw in the abdomen. The
procedure went well, they were able to get all the fluids out. They didn’t leave a tube in there to do future extraction. They’ve sent the fluids extracted for testing.
Currently, the issues are:
- Yesterday, she had a couple of episodes of bleeding in the morning. They monitored her throughout the day, and they believe it has subsided.
They are still seeing small amounts of blood through her nose tube, but it’s darker, so they think it’s from the original bleeding and there’s not likely new bleeding. But they’re still concerned.
- Her breathing rate has gone up (used to be 22-25 and now stays in the 35 range). They think it’s because she’s getting more and more awake. She’ll try to open her eyes every now and
then.
- When the breathing rate gets to about 45 or so and stays there for a bit, they give her a little bit of pain mediation (50cc of Propofol?) They say it’s fast acting (which it seems to be, because you can almost immediately see her breathing rate come down to 25). And, they saw it’s not long-lasting. They seem to be good with pain management.
- Her platelet count is very low (about 30). They say that it should be in the 100-150 range. Not sure what to do about that yet, causes could be kidney function issues. What’s your take?
- Her skin is super-super sensitive (they say it’s because of the excess of fluids). She is very easily bruised and has fluid seeming
out of her pores. Hope is that as dialysis does its job, this will get better. But it’s a little troubling to see.
- Neuro-response is not dramatically improved yet, but she does seem to be fluttering her eyes more in response to our voice, and is moving her mouth a little now, as if trying to say something. (She’s got a tracheostomy, so likely won’t be able to talk, but guessing it’s a good sign that she’s actually trying to move her mouth)
Related article/video:
- So far, most of the
decisions have been straight-forward (tracheostomy, dialysis, etc) — partly because she’s never seemed in any pain, and the doctors didn’t suspect any. Now that she starts to wake up, it seems she may be in pain at some points. So, family will likely find it harder to see. But, we have conviction and are hopeful that in a few days, we’ll start seeing some positive improvement.
That’s all I have for now. All
thoughts/feedback appreciated.
Kind Regards,
Robert
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Hi Robert,
I think that from your email overall there is some progress and also some setbacks. I will explain in detail from my perspective.
Please see my comments in red below.
I hope that helps Robert, please let
me know any changes and any other questions.
The insertion of the line for dialysis went without incident, and overall, my mom is responding to the dialysis well. > That’s what I expected, Dialysis treatment most of the time seems uncomplicated and straight forward.
They estimate an extra 25-30 liters of fluid in her body, so it’s going to take a while for them to get that processed and out. > 25-30 litres sounds like a lot of excess fluids, I’ve probably seen up to 10 litres. And yes, it will take a while for the
Dialysis to process the excess fluids.
The bp meds are either off completely or very low. > That’s a good sign, keep an eye on if they go back on or not. On the one hand being off BP meds (Inotropes/ Vasopressors) is a very good sign because it shows that her infection seems to reduced. One of the signs for severe infection usually is low blood pressure. Do you know what her other infection markers in the blood such as White cell count (WCC) are doing or also CRP? Does she still have a
temperature?
Yesterday, she had to be taken for a procedure to remove some fluids that they saw in the abdomen. The procedure sent well, they were able to get all the fluid out. They didn’t leave a tube in there to do future extraction. They’ve sent the fluids extracted for testing. > Why is she having fluids around her abdomen? The first thing that comes to mind is
that her liver might be impaired and she may have gone into some sort of liver failure. In one of my previous emails I have mentioned low Albumin levels as part of being very oedematous and “puffy”. If she’s having excess fluids in the
abdomen to the point where they need to drain the fluids, there may be something wrong with the liver, hence the excess fluid and most likely a low Albumin level. If I was you, I would try and find out what your mother’s liver function is and what her Albumin levels are. Do you also know if they have replaced Albumin via transfusions? It’s good that they sent the fluids for testing.
Recommended:
Currently, the issues are:
- Yesterday, she had a couple of episodes of bleeding in the morning. They monitored her throughout the day, and they believe it has subsided. They are still seeing small amounts of blood through her nose tube, but it’s darker, so they think it’s
from the original bleeding and there’s not likely new bleeding. But they’re still concerned. > If she’s bleeding, besides monitoring her Platelets as you’ve pointed out in 4) they will also need to monitor her Haemoglobin (Hb) levels. Haemoglobin levels are the red blood cells in the blood and they should be at least >80 in a critically ill Patient. Haemoglobin is the oxygen carrier in the blood, therefore especially with your mother still
being ventilated, having an adequate and physiological Haemoglobin is vital to get her weaned off the ventilator. Do you know if they have replaced some of the blood she’s losing with blood transfusions?
Also, what are they doing to stop the bleeding medically? Have they stopped Intra Venous nutrition/TPN and is she back on Nasogastric feeds into her stomach? The earlier she can have feeds through the Nasogastric tube the less the likelihood of gastric bleeding. This seems to be particularly important in view of the fact that she had a stomach perforation previously.
Also,
do you know if they are giving her a Pantoprazole infusion? Pantoprazole infusion is usually given whenever there is abdominal/stomach bleeding. It’s a proton pump inhibitor designed to slow down acid production in the stomach to lower her PH levels and hence reduce the risk of bleeding.
- Her breathing rate has gone up (used to be 22-25 and now stays in the 35 range). They
think it’s because she’s getting more and more awake. She’ll try to open her eyes every now and then. > If breathing rate stays >35 on a regular basis it’s certainly as concern and it’s a sign of discomfort. It’s often pain, but it can also be a sign that she’s getting more awake and that she can’t make sense of her situation/environment as yet.It would also be good to know what her Arterial blood gases show?
- When the breathing rate gets to about 45 or so and stays there for a bit, they give her a
little bit of pain mediation (50cc of Propofol?) They say it’s fast acting (which it seems to be, because you can almost immediately see her breathing rate come down to 25). And, they saw it’s not long-lasting. They seem to be good with pain management. > It’s probably Propofol (Diprivan) they are giving to reduce her breathing rate. Propofol (Diprivan) is a sedative and not an Opiate (=pain medication). Therefore Propofol (Diprivan) is only sedating her and is not giving her pain relief. Yes, Propofol acts very quickly and is not long-lasting and it will get her breathing rate down in the short term. But it does concern me if she’s in pain and
they are trying to treat it with Propofol (Diprivan) and not with adequate pain relief. Do you know if they are giving her adequate pain relief in the form of Morphine or Fentanyl. Both, Morphine and Fentanyl are strong opiates and would be appropriate to manage pain in a
situation like this.
- Her platelet count is very low (about 30). They say that it should be in the 100-150 range. Not sure what to do about that yet, causes could be kidney function issues. What’s your take?> This could be caused by kidney issues, but it could also be a cause of liver issues. Abnormal blood coagulation is usually a sign that the liver may
be failing or that something else is going on in the blood.
Low Platelets therefore could be a sign of the liver failing but sometimes it can also be a sign that when the blood is getting filtered through the Dialysis machine that some Platelets might get destroyed.
Do you know if they have replaced her Platelets by giving her Platelet
transfusions?
I would be curious to know what her INR is. INR is the Prothrombin time and is an indicator how well her blood is clotting. Again from the information you have shared, she may need some blood transfusions, either red blood cells to replace Haemoglobin and/or Platelets or even FFP’s (=Fresh frozen plasma) if her INR is too high and is causing the bleeding.
There is also the chance that the bleeding is caused by a leaking blood vessel, potentially from the surgery she’s had a few days back.
- Her skin is super-super sensitive (they say it’s because of the excess of fluids). She is very easily bruised and has fluid seeming out of her pores. Hope is that as dialysis does its job, this will get better. But it’s a
little troubling to see. > Yes, skin would be super-sensitive after having so much excess fluids on board. Make sure she’s getting good pressure area care so that skin is not breaking down and potentially leave her vulnerable for a skin infection. She should also be on a special care bed and on a special air mattress to prevent any pressure sores.
- Neuro-response is not dramatically improved yet, but she does seem to be fluttering her eyes more in response to our voice, and is moving her mouth a little now, as if trying to say something. (She’s got a trach, so likely won’t be able to talk, but guessing it’s a good sign that she’s actually trying to move her mouth) > That is encouraging, and every little step she’s taking I believe
helps. If she’s in kidney and potentially liver failure, she may need more time to “wake up” as her body is still severely weakened and she’s still “battling” on many
fronts.
Recommended:
- So far, most of the decisions have been straight-forward (trach, dialysis, etc) — partly because she’s never seemed in any pain, and the doctors didn’t suspect any. Now that she starts to wake up, it
seems she may be in pain at some points. So, family will likely find it harder to see. But, we have conviction and are hopeful that in a few days, we’ll start seeing some positive improvement. > Yes, agree that most decisions to this point have been straight forward, even though your mother doesn’t seem to make big gains at the moment. Trying to manage pain with Propofol (Diprivan) appears to be inappropriate from
my perspective and I would really try and find out what else they are doing to manage pain. Pain management in ICU is a real issue but they should be able to get a handle on it with all the resources that they have.
Of course, you as a family will find it very hard to see your mother being in pain and also not progress as quickly as you would like her to.
I think it’s great that you are keeping the faith for positive improvements in a few days! That’s the way to go, you never know what’s going to happen, but staying positive is important!
With all the information that you have given me, here is my quick summary what I consider to be really important at this stage
- Is there potential for liver failure with excess fluids around the abdomen that needed to be drained? Also another sign for the potential for live failure could be the bleeding and the low Platelets and I also believe low Albumin levels?
- Dialysis will take off some fluids over the days to come
- Adequate pain management is necessary to keep her comfortable, I.e. Morphine or Fentanyl
- Management of abdominal/stomach bleed? > Pantoprazole infusion? Blood transfusions
- Management of low Platelets > Platelet transfusion to help stop the
bleeding
Wishing you and your family all the best!
