This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from one of our readers

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 14)

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 another 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 15)

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, PART 10, PART 11, PART 12, PART 13 and PART 14

Robert continues with his mother’s situation below

Hi Patrik,

a few updates and questions:

1. The main issue right now is that platelets are still very low 24 in the latest blood count. I have not had a chance to talk to the doctor yet. They have said that they are going to hold off on giving her any platelets yet, because there’s a chance that the body is fighting the platelets and that sometimes trying to transfuse platelets only exacerbates the issue and causes the body to fight harder.  Does that make sense?  
    

2. They were able to do the “scope” to see if they could see what might be the cause of the bleeding we saw. They were able to find two small ulcerous areas. Nurse said that if they were going to find anything, that’s not a terrible thing to find as they can treat with Pepcid and they often self-heal.  (Also, the procedure itself went well and without incident.   They also found haemorrhoids in the rectal area.
    

3. Haemoglobin has improved a little bit and is 76 and staying stable.
    

4. <Blood pressure meds(=inotropes/vasopressors they’re keeping at a very low level (0.2) and she’s doing fine on that front. (They’re keeping them on, rather than taking them off completely, because she’s usually needed to have them back on at least just a little — so rather than bouncing on and off, they’re going to leave them on at a low level for now).
    

5. They are likely going to try feeding via the tube (vs. I.V.) tomorrow and see how she tolerates it.
    

6. White blood cell count went from about 20k to 17k. Hopefully it continues to trend downward.
    

7. Overall, she looks about the same as yesterday. Breathing rate is still about 24 and she looks comfortable and peaceful. They’re giving her a low dose of pain meds Fentanyl (0.25) continuously right now.
    

8. The fluid removal I had talked about earlier was near her spleen. It was a one time thing and they haven’t seen any since then. So, that doesn’t seem to be a concern for them.
    

9. They have been able to extract 1.7 litres of fluids via dialysis in the last day (and a litre the day before). She is still responding well to the dialysis. She looks less puffy than she did, and the nurse says she can see the difference throughout her body.
    

As always, all feedback and commentary appreciated.  As for the family, the last couple of days have been tougher than usual because of this new platelet thing.  We were hopeful that once on dialysis, as the infection was under control, she’d be able to get back on a positive trajectory.  That hasn’t happened yet, and it’s unclear what is causing the platelet issue.

Many thanks as always

Robert

Recommended:

• 1:1 email counselling and consulting with Patrik
   

• 1:1 phone and email counselling and consulting with Patrik

Hi Robert,

thanks for the update.

Please see my comments to your questions in red below.

1. The main issue right now is that platelets are still very low  24 in the latest CBC.  I have not had a chance to talk to the doctor yet.  They have said that they are going to hold off on giving her any platelets yet, because there’s a chance that the body is fighting the platelets and that sometimes trying to transfuse platelets only exacerbates the issue and causes the body to fight harder.  Does that make sense?> I have not heard of holding off Platelets because of chances the body fighting the Platelets. That would be new to me. Because they are in the dark about what’s causing the low Platelets, I strongly feel that they need to get a specialist involved, namely a Haematologist. If they can’t find the cause, I believe rather than holding off giving Platelets and potentially exacerbate the bleeding a specialist needs to find out what’s going on.
   
   Most Patients in ICU with low Platelet count are Haematology Patients or are Patients after multiple trauma where they lose massive amounts of bloods. Especially for Haematology Patients, a specialist tends to be involved and can direct any findings and then treatment to the team.
   
   
2. They were able to do the “scope” to see if they could see what might be the cause of the bleeding we saw.  They were able to find two small ulcerous areas.  Nurse said that if they were going to find anything, that’s not a terrible thing to find as they can treat with Pepcid and they often self-heal.  (Also, the procedure itself went well and without incident.   They also found haemorrhoids in the rectal area.> That’s exactly what I meant in one of my previous emails. The small ulcerous areas may well be a result from holding off nasogastric/enteral feeds. By giving Intravenous feeds(=TPN=Total parenteral nutrition) there is a much higher likelihood of gastric ulcers developing and especially with your mother’s recent history of gastric bleeding AND gastric perforation the protection of the gut flora should have priority through feeding.
   
   

   perfectly understand the need for IV nutrition/TPN immediately after surgery and it’s now been a week and therefore the protection of the gut/stomach flora should be given priority by recommencing enteral nutrition/nasogastric feeds to maintain a physiological stomach/gut flora.
    

   Yes, ulcers do often “self-heal” but even more so under physiological conditions(Feeds) plus the Pepcid.
    

   Are they still giving intravenous nutrition(=TPN)? If so do you know why they are not giving nasogastric feeds yet?
    

   could even start small, by giving 20 cc/hour and then gradually wean off the IV nutrition by increasing nasogastric feeds.
   
   

3. Haemoglobin has improved a little bit and is 76 and staying stable.> 76 is stable-ish. Not fantastic, especially since Haemoglobin binds oxygen in the blood. Anybody in ICU needing to be weaned off the ventilator should have a Haemoglobin> 80 at a bare minimum to support weaning off the ventilator
    

   Weaning off the ventilator is not priority yet, given that your mother is battling other major issues at the moment.
    

   Do you know

     
   1. when she had the last blood transfusion?
       

   2. if there are any more signs of current active bleeding?

    

4. blood pressure meds(=inotropes/vasopressors they’re keeping at a very low level (0.2) and she’s doing fine on that front.  (They’re keeping them on, rather than taking them off completely, because she’s usually needed to have them back on at least just a little — so rather than bouncing on and off, they’re going to leave them on at a low level for now).> That’s fine, inotropes/vasopressors for low blood pressure is nothing unusual in the face of Haemodialysis, fluid removal as well as what your mother has been through in recent weeks, including the active bleeding. I’m not too worried about it at this stage, especially in such low doses.
    

5. They are likely going to try feeding via the tube (vs. I.V.) tomorrow and see how she tolerates it. > fantastic news, for the reasons mentioned in 2.
    

6. White blood cell count went from about 20k to 17k. Hopefully it continues to trend downward.> It’s still fairly high, but even in non-infectious ICU Patients it can be fairly high and as long as her Inotropes/Vasopressors are down and her White cell count is coming down, I’m not too worried. It’s still wise to keep monitoring a “masked” temperature whilst on Dialysis, but I tend to agree that monitoring the white cell count is the best indicator to keep monitoring the infection
    

7. Overall, she looks about the same as yesterday.  Breathing rate is still about 24 and she looks comfortable and peaceful. They’re giving her a low dose of pain meds Fentanyl (0.25) continuously right now.> That’s seems an improvement compared to your emails from yesterday. Pain must be well controlled and a breathing rate of 24/minute is indicative of her comfort whilst “only” having a low dose of pain meds such as Fentanyl.
    

   I also feel that it’s very important for you and your family to know that in spite of all the challenges and setbacks you know that she’s comfortable. The minute you and your family feel that she’s going through too much struggle, pain and discomfort you may have to rethink the outcomes that you want to achieve from my perspective.
    

8. The fluid removal I had talked about earlier was near her spleen.  It was a onetime thing and they haven’t seen any since then. So, that doesn’t seem to be a concern for them.> I’m glad to her that. I was very concerned yesterday about the potential for liver failure with fluid accumulation in her abdomen that needed draining. If the fluids don’t come back then I take for face value that it was a one off and the problem has been resolved.
    

Recommended:
 

• PEACE OF MIND, CONTROL, POWER AND INFLUENCE EVEN IN THE MOST CHALLENGING OF CIRCUMSTANCES THAT YOU, YOUR FAMILY AND YOUR CRITICALLY ILL LOVED ONE COULD POSSIBLY FACE IN INTENSIVE CARE!
   

9. They have been able to extract 1.7 litters of fluids via dialysis in the last day (and a litre the day before).  She is still responding well to the dialysis.  She looks less puffy than she did, and the nurse says she can see the difference throughout her body.  >Great news and it’s good to hear that you and the team can visibly see that Dialysis makes a difference. Do you know if your mother is still making a little spontaneous Urine or have they taken the catheter out?
    

10. My big question (and theirs, I think) is around the platelets.  I don’t think they know what’s causing the low count. Not sure if the ulcerous areas would contribute to that.  Or the high level of fluids.  Or the earlier infection. Or something else.> I think they are all in the dark, including myself. Again, from my perspective they need to get the specialist in, the Haematologist. 

    
    

    The only other thing that I can think off is the Dialysis machine and the filter the blood is running through causing a “destruction” off the Platelets. This is very rare but it may be a reason why.
     

    Also, she may develop an autoimmune reaction of something causing the Platelets to drop as well as potentially having a reaction to any drugs been given.
     

    But that’s too much speculation on my end and hence the need for a specialist to look at. I hope they don’t wait until Monday to get that specialist in but move on this sooner than later!
     

11. As always, all feedback and commentary appreciated.  As for the family, the last couple of days have been tougher than usual because of this new platelet thing.  We were hopeful that once on dialysis, as the infection was under control, she’d be able to get back on a positive trajectory.  That hasn’t happened yet, and it’s unclear what is causing the platelet issue.> This is a very tough time for you and your family and I believe even though in the midst of this massive challenge you and your family have not given up hope!
     

    You and your family should be proud of what you are doing, by not giving up and supporting your mother through this challenge. Even though you may feel at times that your mother can’t hear or see you, most Patients coming out of Intensive Care don’t recall the details of their ICU stay, but can recall their loved ones being around, which often makes a big positive difference. So give you and the rest of your family a pad on your back for being so strong! It’s easy to lose sight and perspective during those highly emotionally charged situations!

     

    Therefore, keep doing what you are doing for now, your mother is alive fighting nasty and massive challenges. Hopefully they can get an answer and a solution for the Platelet problem, start feeding her and then get back on track with starting to wean her off the ventilator and then also starting to wean her off Dialysis.

     

    As for the Doctors and the nurses, what’s their situation, do you feel they are more positive or negative? Is there more talk about “withdrawing treatment”?