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 Mom is in the ICU for Pneumonia. Will I Resort to Surgery For Mom Or Is It Too Late?
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 Julie as part of my 1:1 consulting and advocacy
service! Julie’s mother is critically ill in the ICU and she is asking if how long can her mom be safely on the intubation.
My Mom is Critically Ill in the ICU. How Long Can She Safely Be Intubated Before Risking Everything?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Julie here.”
PART 1
PART 2
PART 3
PART 4
PART 5
PART 6
Julie: Okay.
Patrik: But she also confirmed what the nurse said yesterday, that there is no evidence for a bowel perforation. Okay, there’s no evidence for that. It is what she thinks, and what she refers to as ischemic gut. Have you heard of that? Ischemic gut?
Julie: That’s where the bowel twisted?
Patrik: Yeah. Yeah. So basically, what it means is, ischemia means no blood flow or no oxygen to the bowel tissues. Okay, if there’s no oxygen and no blood supply to an area of the bowels, it becomes ischemic, basically the tissue is dying. Okay? When the-
Julie: How do we get blood supply?
Patrik: Well, the one way to get blood supply would be to take out that part of the bowels, to do a surgery. Right? To operate on her. That would be one way, or another way is to get her bowels going. But the risk to get the bowels going is also if they did another enema or potentially a colonoscopy, have you heard of a colonoscopy?
Julie: Yes.
Patrik: Right. If they did that, again, the risk is there that the bowels could be perforated. So it’s very tricky to manage that, you know? One way to manage it is certainly with antibiotics, to see if the infection is going down, and then swelling would go down. I mean, as you’ve seen, or tummy is very swollen and very tender. Right?
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Julie: Yes.
Patrik: With that, there’s pressure on the bowels. Now, if the infection goes down, the swelling will go down, and then there’s a higher chance that the bowels will be perfused again.
Julie: Okay.
Patrik: This all takes time.
Julie: Okay.
Patrik: You know, all takes time, and there’s-
Julie: In the meantime, we are running out of time on the ventilator, correct? How long can she safely be on the intubation before we are risking everything?
Patrik: Yeah, right. How many days has it been now since she’s been on the ventilator? Since Tuesday?
Julie: What are we at for intubation? 12?
Patrik: 12 days, is it?
Julie: I believe it’s 12. 11.
Patrik: 11 days.
Julie: Today’s day 11.
Patrik: Yeah, okay. To answer that question, after about 10 to 14 days, you should consider removing the breathing tube and do a tracheostomy. Have you heard of a tracheostomy?
Julie: Yes.
Patrik: Right, right. Has that been suggested to you at all?
Julie: They said she wouldn’t make it through the surgery for the tracheostomy.
Patrik: Look, with those high doses of epinephrine and norepinephrine, inotropes/vasopressors, again, the risk for any procedure is fairly high, as long as the dose is also high, right? I agree with that. I would argue she would not survive bowel surgery, but I would argue she
would survive a tracheostomy. But again-
Julie: The tracheostomy, that allows her to wake up? Is that why that starts to be beneficial after 14 days?
Patrik: It would allow her to potentially wake up, however I do believe that with the sepsis at the moment she would still require to be sedated lightly at least. Because if she woke up and she, for example, wake up and move around, I argue that it would not beneficial at this point
in time. As long as your mom is in an induced-
Julie: But would it be beneficial in 14 days to kind of get muscles not to atrophy, to kind of, maybe even restrain her arms to kind of start waking her up? Or it’s safe at the 14 day mark, if things go good, to get the trach going, to get her so that her oesophagus and stuff is not breaking down from the intubation?
Patrik: Look, I would be very supportive of a tracheostomy beca use a tracheostomy, generally speaking, buys patients a lot of time. You’re absolutely right that any day on sedation and in an induced coma is atrophying muscles. There is no doubt about that.
By the same token, your mom is so critical at the moment that you need to weigh up how can you get through her the next day. At the moment, what it is is one day at the time. Now, you need-
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Julie: Okay.
Patrik: We just talk about options long term, but the reality is at the moment, your mom is very critical, so there is probably not too much, doesn’t make too much sense to look too far ahead because at the end of the day, the goal at the moment is one day at the time. Make sure she’s improving, and then see what the situation is tomorrow, and then looking at the next day-
Julie: And address that on day 14, like-
Patrik: Right, right. At the moment, there are a lot of things happening that are certainly not beneficial for your mom. However, she is alive, and that’s the main thing at the moment. You’re correct. Every day on a ventilator in a coma has side effects such as muscle atrophy, such as putting pressure on the oesophagus from the breathing tube. You’re correct there. You know? At the same time, your mom is dealing with much bigger issues at the
moment. Your mom is holding on to life. You know?
Julie: Then, so, okay. So we’re just basically buying time for the infection to hopefully get better, and the swelling to get down, and the possibility of a bowel movement because of that. That is all very possible?
Patrik: Look, that is possible with time. You know, to a degree, as I said, I have no indication whatsoever that they’re not trying and that they’re not doing everything. I have no indication for that. Right?
Julie: Okay.
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Patrik: I’m grateful that they’re getting a specialist involved, like the infectious disease doctor. I’m very grateful for that. At the same time, have you, what she wasn’t quite clear about was if they have consulted the gastric surgeon or not. She wasn’t quite clear on that.
Julie: I know, because we talked to her yesterday, the surgeon. We talked to the GI specialist doctor.
Patrik: In person or over the phone?
Julie: In person, and she said that she was happy to see the CT scans yesterday, that she showed very slight improvement, but improvement nonetheless, and she said, but that’s one part of the picture, not the big picture, and she just kind of said we’re going to keep watching it and see what goes on, and then the infection kicked in and the sepsis, so now we’re dealing with the infection’s control. But I think the GI specialist is still kind of
looking at her as well.
Patrik: Yeah, yeah, okay.
Julie: But they’re addressing the most important part right now, which is the infection.
Patrik: Absolutely, and I’m really glad that they have both specialists involved. Infectious disease and the GI surgeon. There are many situations where the ICU specialists think they know it all, and they don’t. I’m glad they’re getting the specialists involved. Again, that is another good sign, that they’re not trying to micromanage. It’s often the smaller ICUs that don’t get the specialists involved. You know, the bigger ICUs have all the
specialists, whereas the smaller ICUs often don’t, and again, to me, that’s a good sign, that even though they’re a small ICU, they’re delegating appropriately.
Julie: Okay, and so do you think at this time to just, day to day, like you said? Or are you thinking-
Patrik: Day by day. Day by day. Look, I’m very much pro tracheostomy in a situation like that. However, what you don’t want to risk at the moment is, for example, let’s just say they would do a tracheostomy tomorrow. Okay, let’s just say for argument’s sake they would do that. One of the risks doing a tracheostomy would be bleeding. Okay? Because it’s a surgical procedure. Okay. Let’s just say that might happen. With such high doses of epinephrine
and norepinephrine, you do not want to risk a bleed because that could get those epinephrine doses back to where they were yesterday, and you don’t want them. Yesterday, I believe, was very, very critical. She was almost on maximum doses. Right? You really have to weigh up the risks and the benefits. Yes, the benefits longterm of a tracheostomy are better. But in the short term, would you risk a bleed, and therefore set your mom back while she’s slowly improving? You would not want to do that.
Julie: No.
Patrik: Right.
Julie: No, yeah, you’re right.
Patrik: You know, if the only issue would be to wean off the ventilator, if that was the only issue, and she couldn’t wean off day 12, day 14, I’d say, yep. You need to do a tracheostomy because then she can wake up, and then she can wean off the ventilator in her own time. But that’s not the most pressing issue at the moment.
Julie: Okay.
Patrik: The most pressing-
Julie: Then-
Patrik: The most pressing issue is-
Julie: What is it?
Patrik: Getting the infection under control.
Julie: Right, okay. Then do you feel confident with that happening, even though this is a smaller hospital, since you said everything is being done? Or do you feel that it’s very pertinent that she get to a larger facility, since they are bringing in the specialists, and they are-
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Patrik: Given that they have brought in the specialists at the moment, I’d say they have all bases covered. The other thing is how far would that other hospital be? Is that hours away, is it down the road? How far are you talking-
Julie: Down the road.
Patrik: Okay, so it’s not like-
Julie: Down the road.
Patrik: Less than 30 minutes?
Julie: Oh, yeah.
Patrik: Right. Okay, okay. You see, your mom could go to another hospital. You know, very sick patients get flown interstate and sometimes even around the world, right? However, again, when somebody is critically ill, you would want to minimise the stress that’s being put on a patient. Right, and the transfer would be stress. Even though it’s only down the road, but your mom would feel that. Right?
Julie: Okay.
Patrik: Then you got to think about potential delays, so what do I mean by that? You go to another hospital, but then the doctors there need to get to and your mom. They need to get the handover, they need to look at the history, they need to look at, okay, what has happened to this point, what has worked, what hasn’t worked. So there could be a delay of 24 to 48 hours until they’ve mapped out their course of action. Those 24 to 48 hours, I do
believe could be critical. At this point in time, again, I have no indication that they’re not trying, that they’re not getting the specialists involved. I have absolutely no indication-
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Julie: That’s so good to hear. I feel so good with you saying that, it makes me feel like, okay, good. Because otherwise I think that would be important, but since you feel that way it makes me be like okay! All right. I don’t know. Great.
Patrik: It comes back to what they told you on Friday about making her comfortable and letting her die, withdrawing life support and all of that. You see, that’s what they said. Right? But their actions speak much louder, and their actions are they’re doing everything they can. Right? They’re giving your mother every opportunity to get through this. Right? That’s why it’s so important in intensive care to match words against action, and to read
between the line. As I mentioned to you, I think I mentioned it yesterday, they’re trying to cover their worst case scenario, which means their worst case scenario is to look after a patient indefinitely with an uncertain outcome, because it’s blocking a bed, and ICU beds are in high demand.
Patrik: So let’s just say, but on the other hand, they know that they can’t do that without your consent. Right, so they’ve listened, and they’re doing whatever they can. At the same time, by saying that, if your mom, God forbid, is not improving, they can tell you easily, well, we told you from the start. It’s all about, they’re just putting a frame around the situation that covers them.
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Julie: Okay, that makes sense.
Patrik: Right? They’re keeping your hopes low, but at the same time, they’re putting all the resources in place to give your mom the best chance to get through this. That’s why-
Julie: That’s wonderful, yeah.
Patrik: Right. That’s why I’m saying, actions speak much louder than words.
Julie: Right.
Patrik: Right? I know that ICUs are always negative by default. They’re negative by default just to cover themselves.
Julie: Okay, that makes a lot of sense.
Patrik: To keep their options open. You know, they’re keeping their options open by being negative, and they think, well, if she improves, great. If she doesn’t improve, they can say, well, we told you so from the start.
Julie: Right, that makes total sense. I totally, I know that, because now that you say that, I’m like, that’s exactly what’s happening because of the ups and downs.
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Patrik: Yep.
Julie: The other question I had to ask you is, what’s that P word, babe? The Precedex? Remember how when she came in, she had a normal, her heart rate has never been an issue, she’s always had a very good reading on her blood pressure and on her heart. Always. That’s never been an issue. She came in here with a very strong blood pressure, and then they put on the Precedex, and it dropped it significantly, where we were told that they would
absolutely not give her that again. That was the Friday night, the 18th or something. Yeah, it was the 18th, and it was to help her behave because she was trying to rip off the BiPAP and the oxygen. So they said, “We will not give that again because of how dangerously low it dipped her blood pressure.” Well, three days later, they put her back on
it.
Julie: My argument is, is this something we should be getting rid of, because I think it gives her heart rate a fighting chance, and why is there all these different opinions on, well, as long as the numbers are reading right, we’ll keep her on that, even though we know that it drops her blood pressure down significantly.
Patrik: Mm-hmm (affirmative). I’ll give you my thoughts on that. When I spoke to the nurse yesterday, I was very surprised because I asked him what medications is she on? Yesterday, she was on Precedex. She was on fentanyl and propofol. Now, you know enough about Precedex by now. Do you know anything about propofol and
fentanyl?
The 1:1 consulting session will continue in next week’s episode.
Kind Regards
Patrik
