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 Mother is in the ICU Post Cardiac Arrest. Will She Be Able to Recover and Wake Up?
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 clients Stephanie as part of my 1:1 consulting and advocacy service! Stephanie’s mother
had a cardiac arrest for 3-4 minutes and in the ICU, and is asking if the sedatives are hindering her waking up phase?
My Mother is in the ICU for Cardiac Arrest. Are These Anti-Seizure Medications (Phenobarbital) Keeping Her Asleep Much Longer?
Tonette: Their vent unit is not a long-term care unit. It’s a transitional unit.
Miranda: That’s right.
Patrik: Mm-hmm (affirmative) okay, okay. So what is important to know with the long-term acute care, we see especially in the United States, that a tracheostomy is often illegal to get patients out of ICU to
long-term acute care as quickly as possible? Why? ICU beds are in demand, right? From an insurance perspective an LTAC is way more cost-effective. From my perspective and my experience talking to people in a situation
like yours every single day, an LTAC, most of the time, is a disaster zone. Right?
Patrik: Anybody on a ventilator with a trach should not leave Intensive Care until they’re weaned off a ventilator. Why? Anybody on a ventilator needs the specialist skills from an ICU doctor, ICU nurse, respiratory therapist and so forth.
The minute somebody on a ventilator with a trach goes to LTAC, those
skills are not available. Right?
Don’t get me wrong, there may be some good LTACs out there. They are far and few between from my observations. Right?
Rebecca: The distraction is that Miranda is at the hospital, so just ignore her until she has something to say, okay.
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Patrik: Right, right, okay, so that’s the bigger picture? Right? The other issue is somebody like Carmen whose had a cardiac arrest, you know, then day nine to nine in ICU, let’s just say she had a trach tomorrow and then she goes to LTAC in another hospital, you know, the risk, for her to deteriorate is still there.
So then, where would she go from LTAC? Back to an ICU. I mean, the situation is stressful as it is, she doesn’t need to be going from one hospital to another because that’s just another added
on stress.
Rebecca: Mm-hmm (affirmative)-
Tonette: I agree.
Patrik: You know, the whole LTAC arrangement, as far as I can see, and it’s not unique to Carmen’s situation, it’s across the board, you know. I can’t tell you how many people that I talk to every day they ring us up and they say, “Hey, my mom’s in LTAC, how can we get her out there?”
Tonette: Mm-hmm (affirmative)-
Rebecca: Mm-hmm (affirmative)-
Patrik: Right, and from an ICU perspective, what they’re trying to do, you know, they’re trying to empty their beds because they have people knocking at their doors, literally, you know. ICU beds are in demand. And their artificial timeline is sort of, day ten, day 14, they can’t be-
Rebecca: Right
Patrik: That’s their critical time point.
Rebecca: Yup.
Patrik: Right? So now they’re putting pressure on you. And say, “Well, she needs a tracheostomy because we can’t wean her off the ventilator.” Well my first question is, “Have you tried?”
Rebecca: Right.
Patrik: Right? And if so, how have you tried? What are you doing to achieve this? Right. Then what’s important to understand is, the worst case scenario from an ICU perspective is to look after a patient indefinability with an uncertain outcome. That’s their worst case scenario, and they’re trying to prevent it.
Rebecca: Right.
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Stephanie: Yes. And they have to be accredited, in other words, their ICU has to be able to take care of a person indefinitely. There’s no such thing as they have to get them out of there.
Patrik: Correct. Correct. And what we’ve certainly done in the past with other clients in similar situations, you know, we can help you to make the clinical case to keep her in ICU. Right. We’ve certainly done that successfully and I can point you to some case studies on our website, right.
But before even going there, my question is, “Why can’t she have the breathing tube removed in the first place?” That would be the make or break question to me.
Stephanie: Right.
Patrik: Right? And a lot of ICUs as far as I can say, are complacent, because they know, “Oh well,” you know, “if somebody doesn’t come off the ventilator at day 10, day 14, well we just do a trach and just send them out to LTAC.” And
they wash their hands clean.
Stephanie: Mm-hmm (affirmative)-
Rebecca: That’s true.
Patrik: Right? And they’re complacent because they know they have that option, whereas other ICUs that don’t have that option, they take a very different approach.
Rebecca: Mm-hmm (affirmative)-
Stephanie: Mm-hmm (affirmative)-gotcha.
Patrik: How old is Carmen, if I may ask?
Stephanie: Sixty-four.
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Patrik: Okay, that’s very young. And, you know, what needs to happen from my perspective, she needs to have that breathing tube out, even as a trial. You know, if she gets the breathing tube removed and she fails, fair enough, let’s try. Then let’s look at the trach. Right?
But as long as they haven’t tried that, I just go like, “Hang on a sec, you haven’t even tried.”
Tonette: They haven’t. They have reduced the sedative and Propofol and at that point, she was having some seizures, okay. Or what do you call the jerks, myo-
Patrik: Myoclonic jerks. Mm-hmm (affirmative)-
Tonette: Myoclonic jerks, yes, she was having that. And so we automatically assumed that, you know, she wouldn’t be able to be coming off, so, you know, but they never really tried to, “remove it” but at the same time, they switched from the Propofol to the Phenobarbital. And the Phenobarbital controls,
pretty much controls the seizures.
Patrik: Yes.
Tonette: You see, but I don’t know what cahoots, if you will, the Neurologist, they’re trying to get her, whether they’re trying to get her to say, you know what I mean?
Patrik: Right, right.
Tonette: She’s supposed to be highest, the most, what do you call it, the Intensive Neurologist.
Patrik: Right.
Tonette: That’s aligned with patients in ICU.
Patrik: Right, right. With the Phenobarbital, is she still on that?
Tonette: I believe so.
Patrik: You think so?
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Rebecca: Yes.
Tonette: I think they’ve D/C it, I think they discontinued it. I’m not certain. I think they changed quite a few things, because I’ve been here the whole time. I think they did D/C it.
Miranda: I’m at the hospital, I can ask.
Rebecca: There you go, yes you can. She can ask them right now.
Tonette: Let me answer the question that he was asking about in reference to the Neurologist, okay.
They had a machine, Patrik, in the room, okay, and I questioned about it, “What is all this?” Well, what they were telling me, you know the lines are up and down, to make a long story short, that they are watching 24/7 as far as you know, dealing with the neurology, you know, that’s what they were doing. That’s what they’ve been doing.
Rebecca: That’s the EEG.
Patrik: Yeah, yeah, and what, if somebody’s on Phenobarbital, they need to have the EEG monitor. So it, the minute somebody gets Phenobarbital in ICU, the EEG is
not optional. Right? You need to monitor, because you could overdose somebody, so it’s not-
Rebecca: Very powerful.
Patrik: Okay, so, okay, so, can you say with 100% confidence that she’s still on Phenobarbital as of this minute?
Miranda: I’m about to walk down there and ask the RN.
Tonette: I have a question about the vent.
Patrik: Is that a yes or a no? Is she still on Phenobarbital?
George: Miranda.
Miranda: Can you hear me Mr. Patrik, what I’m saying? Mr. Patrik, what I’m saying is I have to come out of the room so I can hear you all clear, but it only takes me a minute or two to get down and open the door for me and I’ll go-
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Patrik: Alright, look, look, it doesn’t matter, I’ll give you the two scenarios. If she’s on Phenobarbital still, she, it could take a fairly long time for her to come out of the induced coma. Because the phenobarbital is strong stuff.
Rebecca: Right, strong.
Patrik: Even if they stopped it today or tomorrow, it could take another three, four, five, six, seven days for her to wake up from the induced coma because the Phenobarbital is very powerful.
Tonette: Oh, can I ask a question about the vent?
Patrik: Sure.
Tonette: Um, so, her Propofol was 55-65, that’s what they were giving her, and then I thought that all vent machines take a pause every so many minutes in
between the vent sessions? Or does she take a-
Patrik: When she had the Propofol, was she also on Phenobarbital at the time?
Tonette: No, they had her on something different.
Patrik: Okay, okay, so, if somebody is on, okay, there’s two ways to look at that.
If somebody’s on Propofol, and she probably would also have been on Morphine or on Fentanyl for pain relief while she was on Propofol, there’s a very good chance for that.
Stephanie: It was Fentanyl. It was, it was Fentanyl.
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Patrik: Right, right, so if she was on that, there’s a very high chance that the ventilator would have done most of the breathing for her. While-
Tonette: And it did-
Patrik: Right. Right. While she’s on Phenobarbital, there is no way she will breathe spontaneously. The Phenobarbital is so powerful it will knock people out completely.
Tonette: Mm-hmm (affirmative)-
Patrik: Right, so now that we’re talking about this it gets clear to me that the Propofol, the Fentanyl and now the Phenobarbital is clearly stopping her from getting that breathing tube out. Because that could be another week until she wakes up.
Tonette: Okay.
Patrik: Right? So now I can see that removing the breathing tube is not on the cards for the next few days.
Tonette: Gotcha.
Patrik: Right, and that’s why they are so uh-
Miranda: Can I ask you a question?
Patrik: Yeah please.
Stephanie: Yeah, so listen to Miranda-
Miranda: The answer to Phenobarbital? So my mother is still on the Phenobarbital.
Patrik: Right, right.
Miranda: They took her off of the Propo stuff, like two days ago.
Patrik: Right.
Miranda: The Propofol.
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Patrik: The Propofol, yeah.
Miranda: And then-
Patrik: They wouldn’t need-
Miranda: I think they started that two days ago, right?
Patrik: They won’t need any Propofol with the Phenobarbital. So, from that perspective, of course they are now pushing for a tracheostomy because she’s literally knocked out by the Phenobarbital. Right?
So then, the question is, okay, let’s just take the scenario for a moment, it takes her another week to wake up, let’s just say, okay? In the meantime, they want to do a trach because the cut-off for sort of, breathing tube vs. trach is around the 10 to 14 day mark for the-
Rebecca: Yes, maybe 12 to 14 days.
Patrik: Right, right, for safety reasons. However, my question is, what if she woke up in the next five to seven days? And they can take the breathing tube out, yes, they’re going over the recommended time, but if she has the breathing tube removed on day 17 and won’t need a trach, you know, that’s a question that always needs to be asked.
Rebecca: Mm-hmm (affirmative)-
Miranda: What they saying is- What they’re saying from my understanding, what they’re saying is that they keep the ventilator on her, and that is an infection
risk. As far as infection. Oh, and I know which one they keep saying, her vocal cords.
Patrik: And, no doubt about that, no doubt about that. The infection receives there, but the infection receives there with a trach, and the vocal chords are paralysed with a trach as well. That’s not going to change.
Rebecca: Yeah, okay.
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Patrik: The question really is, is there a likelihood for Carmen to have the breathing tube removed in the next week or not? And if not, then maybe a trach is the right way to go. But, with the Phenobarbital, I have another question, you know, and you need to stop me if I’m getting
too clinical here, but as you can already see, the devil’s in the details.
Rebecca: Not at all.
Patrik: You know, you can already see the devil’s in the details. From my perspective, they need to wean, reduce and stop the Phenobarbital and need to start her on some Keppra or Phenytoin to manage the seizures.
Do you know what I mean by, have you heard of Keppra or Phenytoin also known as Dilantin?
Rebecca: Yes, they got Dilantin.
Miranda: She’s on Dilantin, I know that much.
Patrik: Right, right. So then-
Miranda: There’s another one. Dilantin and one more. Do you have the name of it or prescription?
Stephanie: Let me see.
Tonette: No, I don’t.-
Stephanie: I wrote it down Patrik?
Patrik: The other one could be Keppra. Which is similar, well, similar-type drug to Dilantin. Or, it could be Levetiracetam, which is Keppra, but anyway-
Rebecca: I heard that name. I heard that.
Patrik: Right, right.
Rebecca: That’s what I think it is. Yeah.
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Patrik: Okay, okay, well. Okay, then, okay, if that’s the case, right, they should really reduce the Phenobarbital and make sure that the Keppra and the Dilantin are working to stop the jerking and the seizures.
Stephanie: Mm-hmm (affirmative)-they say that’s they’re doing-
Miranda: I’m sorry.
Stephanie: Can I say something?
Miranda: Can you repeat that? I didn’t get it.
Patrik: Do you want me to repeat what I just said, is that what you’re saying?
Miranda: Yes, I couldn’t hear over the noise.
Patrik: Yeah, yeah. So the Phenobarbital, it’s very powerful, and it really completely knocks people out. And it takes people a long time to wake up after the Phenobarbital. You know, it takes them a long time to wake up after the Propofol and the Fentanyl, but it takes them even longer to wake up after the
Phenobarbital, because it’s so powerful, so now that they’re introducing the Keppra and the Dilantin, right, they now should start reducing the Phenobarbital and see whether the Keppra and the Phenytoin can contain the seizures, because Keppra and Dilantin are anti-seizure medications.
Right. So-
Stephanie: She’s taking those.
Patrik: Right, so, from my perspective, it’s way overdue now to start reducing the Phenobarbital.
Rebecca: Absolutely.
Patrik: How long has she been on the-
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Miranda: That’s what we’re asking.
Patrik: How long has she been on the Dilantin and the Keppra for?
Miranda: Two days ago and three more…Something, I’m asking them right now.
Patrik: Right.
Miranda: Oh, I see it.
Patrik: That’s a big … and she’s been having seizures and those myoclonic jerks from the start? From day one, day two?
Rebecca: Yes, she’s been having them. Yes.
Patrik: Mmm. I’m surprised that they didn’t start the Keppra and the Dilantin earlier.
Stephanie: They said the Propofol, Propofol first.
Patrik: Sure.
Stephanie: Um, and have Vimpat, Vimpat on 9 to 13, they put on Vimpat.
Patrik: Vimpat, yeah, yeah, yeah, sure, okay.
And, let me ask you another question, on admission, did they cool her? Was she in cooling therapy?
Stephanie: Yes.
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Miranda: Yes, they did the cooling therapy. Yeah.
Patrik: Okay, that’s good, that’s good. Okay.
Miranda: Yeah they did.
Patrik: Right, okay, now that’s good, they’ve done all the right things, then, okay.
From that perspective, with the Phenobarbital going, and the the timelines for tracheostomies sort of day 10, day 14, I can see why they’re pushing towards that. However, my question still remains, you know, doing a trach now, and then send her off to LTAC as soon as she wakes up, or, not doing a trach, waiting a little bit longer, and potentially getting her off the ventilator while she’s in ICU, and then not to to LTAC. Go on to rehab.
Stephanie: Yeah.
The 1:1 consulting session will continue in next week’s episode.
