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 15)

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 16)

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, PART 14, and PART 15

Robert continues with his mother’s situation below

Hi Patrik,

Overall, the day ended on a neutral-to-positive note.

1. Their plan is to do a platelet transfusion if the count drops below 20.  The ICU attending has the same theory that you had, that it’s possible that the platelets are being impacted by the dialysis.  He also thinks it could be a by-product of the recent infections and antibiotics.
   
   

2. Nothing new has shown up in the cultures.
   
   

3. Her blood pressure has been stable enough that they’re going to attempt taking her off the vasopressors/inotropes tomorrow and see how she does.
   
   

4. Her breathing has improved such that they are going to try and reduce the ventilator support provided (which is at 50% oxygen, 12 Pressure support and +10 PEEP right now and her breathing rate was 20-24 for most of the night tonight.
   
   

5. Given that enough time has passed and that she tolerated the G.I.(=gastro-intestinal) procedure fine today, they’re going to test the feeding tube tomorrow. The doctor tonight has the same position as you: There is benefit to getting her back on the feeding tube vs. the Intravenous feeding(=TPN=total parenteral nutrition)
   
   

6. Both the doctor and I witnessed my mom trying to move her lips a little bit today, as if trying to mouth some words (couldn’t make out what she was saying). The doctor said that since it was not sustained, it’s not an “official” neuro-status improvement marker, but unofficially, it’s a good sign.
   
   

7. Nurse (very experienced) noted that her mental status seemed “lighter” today (i.e. less like she was on sedatives).  Unofficial, but this is the third night in a row she’s worked the night shift with my mom, so she can make a relative comparison.
   
   

8. Doctors seemed more positive today than I’ve seen them in the last few days.  Certainly not out of the woods yet, but I’ll take that.
   
   

9. Your point on getting a haematology expert on the case is a good one.  We’ll bring it up tomorrow.  Based on past experience, it’s unlikely they’ll be able to do things before Monday.  Things slow down on the weekend for the “special” teams (like infectious disease).

They’re running a FBC(=Full blood count) every 6 hours so we’ll get a sense for how the platelet count number is moving over the course of the night.

That’s all I have for now.

Many thanks

Rob

Recommended:

• 1:1 email counselling and consulting with Patrik
  
  

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

Hi Rob,

Thanks for your update, please see my comments and answers to your questions in red below!

Overall, the day ended on a neutral-to-positive note.

> Your and your family’s positive attitude is so important and I can’t stress this enough. Positivity, patience and persistence is often half of the battle! Even if the outcome is not what you had hoped for, it still helps to stay positive! If I was in your position, no matter how difficult the situation appears to be, staying positive in the face of adversity is going to be important and helps you and your family, no matter the outcome!

1. Their plan is to do a platelet transfusion if the count drops below 20.  The ICU attending has the same theory that you had, that it’s possible that the platelets are being impacted by the dialysis.  He also thinks it could be a by-product of the recent infections and antibiotics. > I don’t quite get why they are waiting for the Platelet count to go so low before transfusing. The risk for bleeding remains high. The only positive is that the Dialysis machine is less likely to “clot”. In many cases the Dialysis machine filters can clot frequently and cause a lot of disruption during the process because the filters need to be changed frequently when the blood is too thick or simply not thin enough.
   
   

2. Nothing new has shown up in the cultures. > encouraging!
   
   

3. Her blood pressure has been stable enough that they’re going to attempt taking her off the vasopressors/inotropes tomorrow and see how she does. > Good news, although I wouldn’t be too worried if they continue going at a low rate. As long as they keep removing fluids in high doses often inotropes/vasopressors are needed to support a low blood pressure cause by aggressively removing fluids!
   
   

4. Her breathing has improved such that they are going to try and reduce the ventilator support provided (which is at 50% oxygen, 12 Pressure support and +10 PEEP right now and her breathing rate was 20-24 for most of the night tonight. > 50% Oxygen is still a fair bit, it should be less than 35% in order to consider ventilation weaning. Pressure support 12 mmHg and PEEP +10 are fairly normal settings for a Patient like your mother to be ventilated, there is nothing unusual there. 20-24 breaths/minute is a good rate and it shows she’s comfortable. Any breathing rate >30/min would be of concern and it could be a sign of discomfort and pain. On the other hand, a respiratory/breathing rate <10/ min could be a sign of her being too sleepy and too sedated.
   
   

5. Given that enough time has passed and that she tolerated the G.I.(=Gastro-Intestinal) procedure fine today, they’re going to test the feeding tube tomorrow. The doctor tonight has the same position as you: There is benefit to getting her back on the feeding tube vs. the I.V. feeding(=TPN=Total parenteral nutrition) > The sooner the better from my perspective
   
   

6. Both the doctor and I witnessed my mom trying to move her lips a little bit today, as if trying to mouth some words (couldn’t make out what she was saying). The doctor said that since it was not sustained, it’s not an “official” neuro-status improvement marker, but unofficially, it’s a good sign. > I do believe that families are much better at assessing what their loved ones are doing when “waking up” than Intensive Care teams. ICU teams tend to be too busy taking care of all the other stuff that needs to managed whereas a family at the bedside has more time to look at what their loved ones are doing in detail. You witnessing and interpreting I believe is a good thing. You know your mother and if you feel she’s doing more than yesterday or in recent days, keep looking for that!
   
   

7. Nurse (very experienced) noted that her mental status seemed “lighter” today (i.e. less like she was on sedatives).  Unofficial, but this is the third night in a row she’s worked the night shift with my mom, so she can make a relative comparison. > Another sign that she’s slowly moving in the direction of “waking up”!
   
   

8. Doctors seemed more positive today than I’ve seen them in the last few days.  Certainly not out of the woods yet, but I’ll take that. > Doctors being positive is a great sign and it’s often a missing ingredient when we work with clients 1:1. They often hire us because of so much negativity! I’m glad to hear that!
   
   

9. Your point on getting a haematology expert on the case is a good one.  We’ll bring it up tomorrow.  Based on past experience, it’s unlikely they’ll be able to do things before Monday.  Things slow down on the weekend for the “special” teams (like infectious disease). > If ICU can’t find what’s happening in regards to the Platelets, they need to seek specialist advice!

They’re running a CBC every 6 hours so we’ll get a sense for how the platelet count number is moving over the course of the night. > Another sign that they are keeping a very close eye on what’s happening, which shows their commitment!