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 frequently asked question from our readers and the question in the last episode was
When to give TPN (Total parenteral nutrition) in Intensive Care?
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 continue answering the next question from one of my clients Emma, which are excerpts from 1:1 phone and email counselling and
consulting sessions with me and the question this week is
My sister is in ICU on a balloon pump and ventilated after cardiac surgery! The ICU doctors want to stop treatment against our wishes and let her die, what should we do? (PART 14)
You can also access previous episodes in this series of questions here PART1, PART2, PART 3, PART 4, PART 5, PART 6, PART 7, PART 8, PART 9, PART 10, PART 11, PART 12 and PART 13 by clicking on the relevant links.
In this
series of 1:1 phone and email consulting and advocacy sessions with my client Emma you’ll get real in-depth knowledge about cardiac failure in Intensive Care, how it works, the treatment and therapy options, how to wean somebody off the ventilator and most importantly, you’ll discover how to not take “no” for an answer and get strong advocacy.
You’ll witness how I can lead Emma in going from the Intensive Care team trying to coerce her and her family to agree to a “withdrawal of treatment” as being “in the best interest” for her sister to challenge that and the Intensive Care team having to do everything within their power to safe her sister’s life and turning the dynamics upside down in Emma’s favour.
That’s what happens when you have the right advice from a professional who knows Intensive Care inside out and who knows how to manage the dynamics
and who can take the fear away of being intimidated by the Intensive Care team!
Enjoy this consulting and advocacy session!
Emma: Hello.
Patrik: Hi, Vicki. It’s Patrik here. How are you?
Emma: I’m good. How are
you?
Patrik: Really good. Thank you. How has your day been?
Emma: Oh, it’s been touch and go today… With my sister, they changed the sedation to … It’s dexa-something.
Patrik: Oh, yep. Dexmedetomidine?
Emma: Yes. They did change that. They tried to do a spontaneous extubation. It didn’t work. That was earlier this morning before I got there. They said her blood pressure dropped low so she had to put her on vasopressin, she said 0.8, and she added norepinephrine, but the
vasopressin, when I left there at 5:30 today, she had took it back down to the 0.04 something and now they’re trying to get …
They had norepinephrine on 7, so they’re trying to wean her down. They said they couldn’t do …
The CRRT? They’re doing filtering. They couldn’t pull fluids because her blood pressure was dropping.
Patrik: Yeah.
Emma: So, when I left there it was … the blood pressure was like 104/30-something number and he said that’s going to try to take the norepinephrine down.
Patrik: Yeah, yeah.
Emma: I asked … Huh?
Patrik: Yeah. I’m just looking at your emails. Thank you for sending through the pictures. I do believe that there’s enough … Maybe carry on for now. Carry on.
Keep talking, because then you’ve told me
everything that’s happened, then I’ll put in perspective for you. Keep talking.
Emma: Okay. They changed the vent, she said. They said … The doctor said to VSP because they’re saying with that rate … with that setting that she could breathing on her own. They wanted … They tried … When they tried to extubate her they said she’s weak and she can’t … She’s able to breathe on her own but she’s so weak, so they said that she’s going to try to start physiotherapy on her upper body-
Patrik: Great.
Emma: On her muscles. I asked her what if the estimation fell and she said that they may have to,
after another week or so when she’s not on it, they may have to just try to tracheostomise her and she didn’t answer the question if it failed or not.
Patrik: Right. Well, was that the first time you have heard of a tracheostomy?
Was the first time that’s been mentioned?
Emma: Yes.
Patrik: Okay, so do you know what it
means?
Emma: It’s where…I see a lot of patients with…I had an aunt with one in her neck.
Patrik: Right.
Emma: It was a trach?
Patrik: Yep. Okay. You have seen it. It’s something we can discuss down the
line. It’s not the most urgent thing we need to discuss for now, okay? What else has happened?
Emma: This was at like 8:00 tonight, my daughter, she told me that they’re going to start trying to decrease the norepinephrine because they had to go up from the four to seven or eight, and well, eight, and now it’s at seven, so the nurse is going to try to decrease that. And they said when her blood gets where she can get
stable, then they’ll start back pulling from the dialysis. I’m not sure what that it is.
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Patrik: Yeah. I’ll talk about that in a moment. Anything else? How awake is your sister?
Emma: Oh, she’s very awake. She’s responding-
Patrik: Okay, good.
Emma: The doctor came and said that they know now that when my sister get upset, she tends to block people out, and I told her she need to stop that, but they know her habits now of doing that. But she’s responding. She can’t talk, but she’s nodding her head, shaking her head no, moving her head, and then look like she’s trying to move her hands and
feet.
Patrik: Okay, that’s good, that’s good.
Emma: She’s alert.
Patrik: That’s good. That’s good news. Okay. So, with the blood pressure drop and the increase in the vasopressin and norepinephrine, they have been obviously filtering the blood with a CRRT, and as you said in
your email, they stopped pulling fluids because her blood pressure dropped, you gotta think about this from your perspective, right? If you, for example, stopped drinking, your blood pressure would drop as well. Okay? So, because they are aggressively removing fluids, right, her blood pressure dropped? Why are they removing fluids? Number one, they are removing fluids because she’s got chronic kidney failure. That’s number one. And number two, with a weak heart, you always wan to off-load fluids
because a weak heart and too many fluids in the body means that the heart will be struggling of pumping those fluids around.
Okay?
Emma: Okay.
Patrik: So those are the two reasons why they are aggressively removing fluids.
Now, if they are
aggressively removing fluids, that brings the blood pressure down, and I can see it in the pictures you sent. I’ll illustrate that you. In one of the pictures, the blood pressure is 104/38, right?
Emma: Right.
Patrik: I’m now worried about…the 104 is good. The 38 suggests she’s dry, she’s clinically dry. It means they are removing too many fluids.
Okay?
Emma: Okay.
Patrik: And that’s one of the reasons why they had to increase the norepinephrine and the vasopressin, right? So, the challenge is, not to overload her with fluids because of the weakness of the heart, that’s one challenge; but she also would need to get off the inotropes and the vasopressors, the vasopressin and the norepinephrine. But, at the same time, getting her extubated is more important. Right? So, here is how this all works together. If she has too many fluids on board and the heart can’t pump around the fluids, the first organ that’s affected are the lungs. Okay?
Emma: Mm-hmm (affirmative)
Patrik: Any fluid that builds up in the body, usually pushed into the lungs. And if there are fluids in the lungs, she can’t get extubated.
Emma: Okay.
Patrik: That’s one thing. I’d much rather have her
being dry and they manage it with the inotropes and the vasopressors, rather than having her fluid overloaded, especially in the lungs, and then they can’t extubate her. That’s number one.
Emma: Okay.
Patrik: I’m not too worried at the moment that they have to increase the norepinephrine and the vasopressin, because that’s probably, it’s a result of her
being dry, as well as the heart being weak. It’s hard for me to say from here, which one is the one that’s more prominent, but, it’s a combination of the both.
Being clinically dry and fluid over…and the heart being weak.
I do like that they’ve changed her from the propofol to the dexmedetomidine. I like that. Do you think she’s been more awake since?
Emma: Oh yeah. A lot more. A lot more awake.
Patrik: Good. Is she agitated?
Emma: They said initially this morning when they did, she
was, but she’s calm now. She’s interacting with the family very well.
Patrik: Good. Is she trying to pull out her tube?
Emma: Not yet, but she’s biting on her tube.
Patrik: Okay. Okay. Do you think she’s comfortable on the tube?
Emma: No, I know she don’t want that tube.
Patrik: Okay. Okay. No, no, of course not. Okay. Have they stopped the fentanyl as well, do you know?
Emma: Have they…oh yes, they stopped that, but they give it through a syringe and push it in her IV. It’s not in the machine anymore
where-
Patrik: Okay.
Emma: It automatically goes in.
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Patrik: Okay. That’s good. That’s good. I like that. Okay. Of course, she’s not breathing enough yet, I understand that. That’s a concern for sure. Hopefully with the dexmedetomidine, hopefully she will be more awake tomorrow. You know, she’s stagnating at the moment. She’s not moving forward, but that’s okay. They…it’s often two steps forward, one step back, and you’ve gotta wait.
You gotta sit
and wait and see what happens next. You gotta wait for another day. It’s stagnating, but they are doing the right things by taking her off the propofol, giving the dexmedetomidine, I believe it’s the right thing to do as long as she’s not agitated. Tomorrow, they will reassess tomorrow.
I said to you yesterday that I wanna hear from them, what they’re doing, if the extubation fails. Now, given that they mentioned-
Emma: Mm-hmm (affirmative)
Patrik: Given that they mentioned the tracheostomy, that was the answer I wanted to hear. That was the answer-
Emma: Oh, okay.
Patrik: That’s the backup plan.
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Emma: Okay.
Patrik: That was the answer I wanted to hear. Who said that, the doctor or the nurse?
Emma: The doctor.
Patrik: Good. Good, good, good. I like that. That was the backup plan I wanted to hear from them.
Emma: Okay.
Patrik: That’s good. We don’t need to go any further with that at the moment.
The tracheostomy will come up if she can’t be taken off the ventilator. That’s going to be the next step. That’s too early to talk about that in detail.
Emma: Okay.
Patrik: Are you in the hospital at the moment?
Emma: No, I’m at home at the moment.
Patrik: Okay. What’s your feeling about the doctors and the nurses? Are they positive, are they the same, what’s your feeling about them?
Emma: The doctor was very positive. She came in and….I’ve never had this response. Actually, she came in the room, she came to me, and I was kind of shocked when she explained everything with the VSP, even with the setting on that, she said
that’s better for her. They changed it from…because on the screen was a little lung, and I noticed it had went out and so she explained that.
And I told her, I said “Well, we’re in it for the long haul.”
Patrik: Yeah.
Emma: The doctors are not being negative.
Patrik: Okay.
Emma: At all.
Patrik: Good. Good. That’s good. I like that, because they were very negative when you first contacted me.
Emma: They were. They were very..
Patrik: That’s good. That’s good. I mean, we don’t know the outcome, but being negative is not going to help anyone. It’s not going to help anyone. From that perspective, I know it feels like and eternity for you, but, with a weak heart, coming off the ventilator can be a challenge.
Emma: Mm-hmm (affirmative)
Patrik: They are doing all the right things and their trying. Give them until tomorrow, see what happens, and then we can take it from there. Have they asked for anymore meetings?
Emma: Not yet, they haven’t said anything.
Patrik: Okay. Okay. If they are friendly, ask them all sorts of questions. Now, if
you think they are engaging and they are positive, ask them. Ask them.
Emma: Okay.
Patrik: Because now that, they’ve changed, and now that they’re more engaging, now that they’re friendlier and positive, you know, you can be, too.
Look, I’m always advocating to work with people, always. If you can
make friends, great. If you can’t, obviously, in the early stages when we started working together, the situation was different. But it’s changed relatively quickly. If they are friendly to you, you can be friendly, too. Of course.
Emma: Okay.
Patrik: As long as we think they are doing all the right things, and I will tell you whether they are or
they aren’t, but at this stage-
Emma: Okay.
Patrik: I think they are. Now, the other question that I have is, do you know whether your sister has ever had an atrial fibrillation? Have you heard of that?
Atrial fibrillation or A-flutter?
Emma: No, I haven’t…I don’t know if…I’ve heard, but I don’t really know what it is.
Patrik: Okay.
Emma: She’s never mentioned that she had it.
Patrik: Okay. Or have you heard of A-
Emma: I’m sorry, go ahead.
Patrik: Or have you heard of a-fib? A-fib?
Emma: A-fib? Her machine, that monitor, kept saying it was v-tach and they said that it was wrong, because the numbers didn’t match, or something was wrong with the machine or something they kept saying. I’ve heard of it, but she’s never
mentioned if she had it or not. I know on the machine, they said the PVC, that they said she do have, that was true when it registered PVC, but the v-tech was not true, the nurse said. I don’t understand why they didn’t change the monitor out if it wasn’t reflecting the true thing, so-
Patrik: Okay.
Emma: No, I don’t know what those
are.
Patrik: Okay. The reason I’m asking, from the pictures that you sent, I’m pretty certain she’s not in a-fib. I’m pretty certain. But, the reason I’m asking is, a lot of patients with those conditions, especially with a weak heart, they are in a-fib.
But as far as I can see, she’s not. The PVCs (Premature ventricular contractions) I’m not surprised by. The reality
is, she’s on the dialysis machine, when they remove fluids her potassium would be dropping. I’m not getting too medical, but the more you understand, the better it is.
Emma: Mm-hmm (affirmative)
Patrik: When they remove fluids with a dialysis machine, her potassium levels in the blood go down. When the potassium level is down, the patients can have PVCs. So I’m pretty certain they will be giving her potassium, but you also have to be careful with not replacing too much. The v-tach, I’m not too worried, because the v-tach means it’s a regular rhythm. A-fib is not regular, and as I said, as far as I can see from the pictures you’ve sent me, she’s in
a regular rhythm, she’s not in a-fib, and that’s important to know. It’s very important to know that she’s in a regular rhythm. The PVCs (Premature ventricular contractions), they can manage. I’m not too worried about it.
