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 was
My Brother Has COPD And Went Into Cardiac Arrest. Does He Need To Have An Immediate Lung Transplant Because Of Minimal Lung Function?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my Jim as part of my 1:1 consulting and advocacy service! Jim’s
brother is in the ICU after a cardiac bypass, unfortunately had a cardiac arrest and is asking why it takes long for his recovery.
My Brother had Bypass and Cardiac Arrest in ICU. Can he Recovery?
Hi Patrik,
Brother, 82 yrs. old, had triple by-pass cardiac surgery along with his carotid artery cleaned and cardiac ablation (all procedures done at once). The surgery was performed on 12 July. The next day they had to go back in because there was abnormal (excessive) bleeding. There
were no problems found with anything from the surgery (i.e. no missed sutures, etc.), but they did suction off the excess blood. His bleeding did slow down in a couple of days and they thought it may have been caused because the blood was not clotting normally because of his liver not functioning fully due to his slight cirrhosis caused by
Hep C (which he is in the middle of treatment for as well).
He opened eyes around 13 July and slowly became aware of his daughter though of course was still sedated and groggy.
He was extubated on 14 July and he showed good signs of a sharp mind and he could slightly talk. He still had mobility issues but could move his arms and slightly move his toes. He was extremely weak and he was having problems coughing up sputum.
They had to intubate him again on 18 July and it was suspected that pneumonia was the possible cause. They immediately started treating him with a broad spectrum antibiotic. Days
later, the cultures came back positive.
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He was extubated again on 21 July. He was still exhibiting signs of weakness and could still only move his arms, wiggle toes, and slightly resist pushing against his feet. His swelling was coming down but on 24 or 25 July they ended up tapping his lungs to drain fluids (about 800 mL). At this point he was still having
problems spitting up sputum on his own.
On 26 July around 11 PM he crashed and was down for about 4-5 minutes. Chest compressions started within 1 minute. He was intubated again. On 28 July they installed a pacemaker and the outcome was very good. His heart rhythm and blood pressure completely stabilized. He is now down to almost no meds and they are now talking
about a trach and PEG and then off to LTAC. Today he showed very good results from his trial extubation. Has been in trial since 09:15 and the ventilator has hardly had to help him. They of course will turn it back to full strength tonight so he can sleep and will resume trials again in the morning. No matter what though, they still want to trach him. I would
imagine this would be a precautionary step. They don’t want to have to re-intubate him again but want to have the trach available in the event his breathing becomes troubled (I’m guessing on this one). The PEG I’m not really sure about, but my guess is because the difficulties caused from the ETT tube may delay him eating by mouth and also because the pneumonia was probably caused by aspiration and the possibility of it happening again with food and water by mouth is
high.
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His wife (my sister) has been and will be very active in his care in CICU, LTAC, Skilled Nursing and when he comes home. I am also active as much as I can be and play a more supportive role in keeping her spirits up and not letting her fall into negative thoughts, thus keeping her energy positive for her husband who can be a very negative person. Thankfully (in this case), he is very selfish and loves himself enough to fight hard to get better. My other role is to
research the things the medical people are saying, suggesting, and doing to make sure the right things are being done. My sister has too much stress already and doesn’t have the time and energy to do this part as well. So, I am her research department.
Your website has a lot of great information and resources. Thank you for having it out there.
Yours Respectfully,
Jim
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Dear Jim,
Thank you for sharing your brother’s situation and thank you for your kind words.
From what you are sharing I have the following concerns.
- Tracheostomy can be done if all other avenues for extubation have failed. What do I mean by that?
The worst case scenario for any ICU is to have their beds occupied with long-term patients. ICU beds are in high demand, hence they know they can fill their beds with the next patient waiting and usually the longer a patient stays in ICU, the less money they are making.
Therefore, a tracheostomy and getting your brother off to LTAC may well be self-serving. From my experience, as soon as a tracheostomy is done patients get transferred within <48 hours.
Especially with everything he has been through, I question that he’s ready for LTAC.
Furthermore, especially with all the weaning trials you are describing, I believe he’s close to coming off the ventilator and the breathing tube.
You are correct to point out that your brother might have had the pneumonia from aspiration, however he was on and off the ventilator for a long time and ventilator associated pneumonia could have also been a cause.
Also, a tracheostomy is often not a pre-cautionary step but rather a vehicle to get patients out of ICU quickly, especially in the US.
Also, here is an article/video
Here are articles and videos that will help you in your research if a tracheostomy will be the right thing to do or not
Also Jim, I would be very happy to speak to you and give you some more tips and strategies to get your brother off the ventilator, either book a free call here or give me a call on 415-915-0090 and we can discuss.
I would also be very happy to talk to the doctors and nurses and find out what’s really happening and find out if they are doing all the right things in order to get your brother off the ventilator.
Kind Regards
Patrik
Patrik,
I would like to have you talk with my sister. Her husband has been on the trach now since 26 July and he is still in the cardiac ICU. They did not ship him straight off to LTAC. He is now ready to go to LTAC and will probably be transferred this coming Wednesday. We have visited the facility and are for the most part pleased with what we saw, observed, and our numerous questions that were answered. As she was extremely involved with his care in ICU, she will
continue to be extremely involved at the LTAC facility.
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Lately, she has been a little bit doubtful about her husband making a full recovery. By full I mean coming home, walking, and living life the way he did before the surgery. His regular cardiac doctor and the cardiac surgeon who performed the surgery both have told her that he will make a full recovery. They are very confident that he will and one (his regular cardiac Dr.) even gave him a 90% chance of full recovery. I was not there when they told her this and I
would have asked them to define what they mean by a full recovery. Their definition and ours could have been different. But, I still think that their confidence says a lot to him getting to our definition. The problem with her right now is the “doom & gloom” mentality of the ICU staff that is throwing her confidence off. They never seem to be overly optimistic and this is playing into her doubtfulness.
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This is where you come in. I know that you won’t sugar coat anything and will be blunt, honest and positive. That’s all she wants. She wants to mentally prepare for what reality will probably be at and after LTAC and what outcome is most likely for her husband and our family. We know that ICU, LTAC and if need be Skilled Nursing all have their agendas (hidden and open). We need to know that they are and will be doing the right steps and not prolonging their care
for him to further their financial agenda. We (she) need to know when to push the facilities because they are unnecessarily stalling and when not to because it really does need time.
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I’m not sure we need the 5 session package you have listed on your website because we have already made it through the ICU phase. But I was wondering if you would do a one-hour call with her where she could fill you in on her husband’s history in ICU, where he is now and where he will be going. She is a strong, feisty woman who will demand and get people to do what she wants and at the same time make those people love her (for the most part). She is a force to be
reckoned with. But, from time to time she has moments of uncertainty, doubts and negativity. Once again, in this situation, I think you would be a valuable asset to help her get through the uncertainty, doubts and negativity and give her a clear picture of what to do and most of all what to expect.
If you would please respond and let me know what we can do for a one-hour phone/Skype session with maybe a month of email support also.
Thank you again for your wonderful website and support.
Regards,
Jim
Thank you Jim and Kaye,
Just to quickly summarize, I do believe your husband is in a much better position than I initially thought he’d be, given he’s been off the ventilator for about 7 days. That’s a good start and it’s good to know that he’s been getting out of bed regularly.
I do believe this to be an insurance issue and if you can keep asking for the admission criteria for LTAC vs. skilled nursing you should get all the answers you need.
Also, as I mentioned please have a listen to this interview here
If you need more help, I’d be very happy to counsel, consult and help you advocating for your husband/ brother
Kind Regards
Patrik
Hello Patrik,
It was very interesting and helpful conversation today which gave me an ammunition for my next meeting with case manager….?, which is tomorrow and we need a lot of luck…..
So a little summary of my husband’s situation for tonight:
His blood pressure is 98/48
Heart rate is 87 (takes digoxin),
And he’s respiratory is 32 at most of today it varies from 22 to 32 (respiratory team comes 4 times a day and giving him ipratropium bromide & albuterol sulfate),
Per doctors (Heart surgeon) order he will receive 2 units of blood tonight, my husband is lethargic due to sleeplessness, he takes cats nap, every 20 minutes. We tried the oscillating positive respiratory pressure device with my husband, but he is so tired, he did maybe 4 times…..?
I hope this will improve his situation. PLEASE let me know your thoughts, I am so afraid to go backwards.
Thank you very much,
Kaye
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Hi Kaye,
It’s good to hear that he will get 2 units of red blood cells.
That will most likely help with his low-ish blood pressure as well as with his sleepiness.
Furthermore, 2 units of blood might also help with his breathing rate. The lower the red blood cells, the less oxygen can bind to the blood, therefore the blood transfusions might help with breathing as well.
Also, how much Digoxin is he taking do you know?
Kind Regards
Patrik
Hi Patrik,
He takes midodrin 10mg. for low pressure
And digoxin 250mcg in a morning.
Thank you for a speedy reply
Dear Kaye,
I don’t think that doing breathing trials is too early.
The picture you sent me showed that the machine is doing some of the breathing for your husband and he’s breathing on top of that.
The sooner they can get him to breathe on his own again the better, therefore I don’t think the breathing trials will be too early.
However, I would also want to know what the chest x-ray shows and if they have found a reason for your husband why his breathing rate has been going up and then his CO2 went through the roof?
Have they given you an answer for that?
What is important to know is that on the one hand, a breathing trial is good to see where your husband is at, however on the other hand, he might just need to rest for a few days to get his strength back.
They will pretty quickly see if he can breathe by himself or not.
This is also where the day and night rhythm comes in that we discussed yesterday.
You may remember me saying that a good night’s sleep is important and it will be even more important going forward.
Most patients in Intensive Care who are weaned off a ventilator will be off the ventilator during the day and on the ventilator during the night when they are asleep.
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Being off the ventilator during the day is making them tired and then they can rest and sleep during the night whilst being back on the ventilator.
Your husband might need a few days like this and it’s really important he can go back to a normal day and night rhythm as after a couple of months in ICU his day and night rhythm will be disturbed and upside down.
In order to find out why the CO2 has been going so high, here are the things you need to look for
- Any pain killers like Morphine, Fentanyl, Endone etc… your husband may have been receiving in recent days? Those medications reduce spontaneous breathing and can increase CO2
- Has your husband been delirious in recent days? (I don’t remember you saying so)
- Again, mobilization, physical therapy and getting him out of bed will help to stimulate him and hopefully help him breath and reduce CO2
- I also hope they have ruled out pulmonary oedema. Pulmonary oedema occurs when fluids are entering the lungs. This could cause a high CO2 also. Especially with A-fib and potentially failing kidneys because of low blood pressure, a pulmonary oedema is something that may have happened. Please ask for this.
Depending on the reason they find why your husband had to go back on the ventilator, they may not be able to mobilize him for the next few days, but it should happen again as quickly as possible.
You mention the blood tests they are doing. In ICU blood tests are usually done daily. Here is what to look for
- HB= Haemoglobin= red blood cells, you mentioned he was getting 2 units of red blood cells on Sunday, find out what his Haemoglobin levels are like now, if Haemoglobin is still low after 2 units of red blood cells, there may be some underlying bleeding. Normal Haemoglobin levels are 13.8 to 17.2 grams per decilitre for men
- WCC= White cell count= An elevated WCC is a sign of an infection. Normal WCC levels are 3.6-11.0 Anything >11 is indicating an infection
- Arterial blood gases. Your husband must have an arterial catheter where they can check oxygen and CO2 levels in his blood. Ask for the following results
PO2= Oxygen levels >75 mmHg
PCO2= Carbon dioxide levels (CO2) 35-45 mmHg
Lactate levels <1 is normal and >1 could indicate an infection/sepsis
- Also, ask them if his kidneys are OK. In the blood results Urea and Creatinine are the kidney markers and if they are elevated and could mean your husband’s kidneys are failing which is always a possibility with low blood pressure and after many weeks in ICU. Besides the markers in the blood, also ask them if he has been producing urine, which at the end of the day is the main indicator for the kidneys working or not
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I don’t want to paint a negative picture but speak from experience what might have happened and work out the next steps.
Also, as discussed yesterday please ensure you are looking after yourself. I have seen many families in Intensive Care crash and burn when they spend day and night in Intensive Care and high have grave concerns for your well-being if you are spending day and night in Intensive Care to be with your husband!
Having been a shift worker for many years in ICU and having done many years of night shifts, I know how unhealthy it is staying awake at night. Just some food for thought.
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Let me know the next steps and let me know when you want to talk again.
Kind Regards
Patrik
The 1:1 consulting session will continue in next week’s episode.
