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 Critically ill in the ICU and Extubated. Should I Take the Risk of Pushing my Mom for Another 24 hours of BiPAP to Avoid Reintubation?
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 client Julie as part of my 1:1 consulting and advocacy service! Julie’s mother is critically ill in
the ICU, reintubated and she is asking if the ICU team can’t do a tracheostomy on her due to blood thinners she is taking now.
My Mom is Critically Ill in the ICU and Reintubated. Is It True That the ICU Team Cannot Do a Tracheostomy on Her Because She is on Blood Thinners?
You can check out previous 1:1 consulting and advocacy episodes with Julie 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
Patrik: How are you?
Julie: Good. How are you?
Patrik: Very good, thank you.
Julie: Okay. So I think we’re going to keep the seven days. But, if we needed to add the seven plus the four to roll into the two weeks, we could do that?
Patrik: So basically, what you … And I think now I understand what you meant. So initially I said if you booked an hour to begin with, I would have rolled that into the four day or the seven day option, right? You didn’t, at the time, use the hour option. You went with the four day option straight away. And I looked at the email that I sent you originally. I can’t offer to roll the four day option into the seven day option. What I can offer
is if you wanted, so you’ve used four days and if you wanted to go up to seven days basically, choose another three days.
Julie: Okay. We will use the two weeks and we just keep those seven days and we keep the four days, and we later on wanted to do two weeks, could we roll what we paid and then get the extra few days, or whatever it is?
Patrik: Yes, yes, if you haven’t used them, of course.
Julie: Okay.
Patrik: Right?
Julie: Great. And so, I did just want to talk about the new status with you a little bit tonight, too. You know we re-intubated her?
Patrik: So, that did happen, did it?
Julie: It did, because she got worse and worse.
Patrik: Right. Were you there?
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Julie: Yes. And I sent you pictures of… Did I send you pictures of the machine? Sorry, this has been a lot. I feel like it’s just a big blur. I thought I sent you some pictures. You know what? I think I took pictures of the machine last night and… Oh yeah, what is that, the gas, the arterial blood gas? I sent you a picture of that. Did you see that?
Patrik: No, I never received anything. Did you send that via a text or via email?
Julie: Via text. I’ll send it again to make sure.
Patrik: No, I have not received anything.
Julie: Okay. So it was all the blood gases they had taken and the levels and then it was a screen shot of the BiPAP machine and a screen shot of the machine that she was on. So I’ll resend those. But basically, she did get re-intubated. I know they took another blood gas again after they
re-intubated her. So, I’ll have to get the results on that later.
Julie: But now the problem is… So today they wanted to get a specialist in, an ENT specialist, to see if they could get her tracheostomy. Because remember, she’s a difficult tracheostomy case because of her short neck and her anatomy. Her hand has been swollen for about three days, and we’ve been
telling them, “You know, her hand’s swollen. Is the blood pressure cuff too tight?” And they would come in and loosen it and then the next day her hand was just the size of a balloon.
Patrik: Oh my goodness.
Julie: And we showed it to them, and they said, “Oh, it was sitting funny under the blankets.” Then, finally today, they got alarmed as well because she’s so swollen.
Patrik: Oh my goodness.
Julie: They went ahead and took an x-ray of her arm, and her arm has a blood clot in it. Now, they’re telling us that the medication that they’re giving her, they’re giving her some sort of shot to her tummy. They’ve been giving her a little amount. Well, now
they’ve doubled that shot to her tummy to help clear up the blood clot and now she’s no longer a surgery candidate because the surgeon said that she could bleed to death.
Patrik: Yeah, yeah. Do you know off the top of your head, what she’s getting for the anticoagulation? So, anticoagulation basically means, the shot that she’s getting to basically keep the blood thin. Do you know what medication she’s on?
Julie: Yes, let me see.
Patrik: Is it Heparin?
Julie: We do know, yeah. So, what blood coagulator is she getting, is that what you asked?
Patrik: Yes, yes.
Julie: Let me see if I can get an answer. So they said that it causes her blood to be too thin and then she’d bleed during the surgery. I also got the worst case scenario talk again today, where they’re telling me how weak she is. I said that she was just so strong. She’s just recently was so strong.
Patrik: Yeah. Have they given you a reason why she had to be re-intubated? Have they told you that she’s got pneumonia? Have they told you she’s not strong enough? What was the reason?
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Julie: They really dance around that. They said, “Well, we’ve been trying to tell you that she is really, really weak.” And I said, “Well then explain to me how five days in a row she stayed completely off of sedation and was able to say yes and no, what television channel. She would walk you
through the television channel. She’d squeeze your hand. She was smiling and also she did four or five hours a day where the breathe-trials went great.”
Patrik: Yes, exactly. What was they’re response to that?
Julie: They said, “Well we keep telling you that your mom on the big picture, you’re not understanding the big picture. Your mom is very, very ill and weak and your mom is not a normal person to begin with. When she came in here she was bedridden and overweight and on oxygen at the nursing home. So, she came in here weak to begin with.” And they said, “So she just couldn’t fight her disease,” is what they’re
saying.
Patrik: Right, okay. Would you agree with that your mom has a short neck. Would you agree with that, or…
Julie: To me it looks like she has a double chin. She’s always laying in the bed so her chin is tucked down as well. I feel like that if she was laid back and her neck was lifted, that there’s probably some neck.
Patrik: Right, right. I’m just trying to find out the accuracy of what they’re saying. I’ll tell you something. When somebody has a blood clot and they go on blood thinners, yes, there is a higher risk for surgery. No doubt about that. However, so if you have an emergency situation and you have somebody on blood thinners and they need surgery for something; it’s a life or death situation, they stop the blood thinners and they will perform
surgery. Right? I’ve seen that. So, they are giving you the worst case scenario, right? Maybe she’s not a candidate in the next couple of days until they get the blood clot under control, right? I agree with that, that they’ve got to be conservative at the moment. I agree with that. But in the long run, it’s not going to prevent her from going for surgery, if they could do a tracheostomy.
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Julie: Okay. So we should be pushing for that. Because, I mean, well now … And there’s other things. So there’s also this. All of a sudden my mom was off all blood pressure medication. She was on 40% on the ventilator, she was on five PEEP, she was on no sedation medications. Her bowel was moving. They were starting to feed her Total Parenteral Nutrition and her vital nutrients. Everything was going good. Her trials were going great.
Julie: Well then all of a sudden they take her off the intubation, they extubate her. And now she’s sensitive. So that night ultimately what caused her to go into
failure was them turning her and even though they turned her back, she never recovered. Well, now today she starting to recover. The numbers were better today; everything was starting to look good and they came in and turned her and instantly her blood pressure dropped down, so they had to come back in with all of the blood pressure meds. They maxed out on one and got the other one going, the one with the V.
Patrik: The norepinephrine.
Julie: Yeah, so they had both. They’d maxed out on one so had to fall back on another.
Patrik: Right, right.
Julie: That’s after they turned her.
Patrik: Right. I tell you what I think is happening there. You know, there’s a couple of things that could be happening there. You remember yesterday, I explained to you that potentially one side of the lungs is poor, right? That could be one of the reasons, right?
Julie: Yes.
Patrik: But it could be another reason. Your mom has been bed-bound now for how long, for three weeks? Or, has been in RT for three weeks?
Julie: Yes.
Patrik: It could be as simple as, your mom is hemodynamically not stable and even a slight turn is too much for her. That could be one of the reasons as well. But I would argue, it’s an issue with the lungs. It’s not an issue around hemodynamics. If she drops her oxygen levels when you turn her, there’s a very good chance. You know, there might be a secretion shifting around in her lungs when they turn her, that basically gets her to
deoxygenate.
Julie: Because they turned her around?
Patrik: Because they would have turned her two days ago while she was extubated. They would have turned her two days ago while she was extubated and she didn’t desaturate. Is that accurate?
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Julie: So, while she was… Yeah. Yesterday, last night they tried to turn her while she was extubated and she failed. I told Dr. Smith because I got to talk to him last night, because he came to re-intubate her. I said, “What is going on with her lungs? You guys took an x-ray prior to extubating her; what did you see on the chest x-ray?” He said, “The x-ray was fine.”
Patrik: Right, right. That’s interesting. So they have no explanation why her oxygen levels dropped when they turned her? They have no explanation for you for that, do they?
Julie: They said because she’s so weak that she can’t even handle being turned.
Patrik: Look…
Julie: So, let me ask you this. Last night, before we reintubated, I know it’s too late now but sometimes my mind just likes to have the clarity, why did we not try to bring her respirations from 32 down to 10 and her heart rate at 153? Why didn’t we try to bring that down with sedation medications? Do people not do that?
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Patrik: No, no. You wouldn’t. No, no, they wouldn’t do that and I’ll tell you why. One of the side effects of sedation or potentially pain medication such as Fentanyl or morphine, the main side effect of those medications is a respiratory depression leading to a respiratory arrest.
Julie: Oh, okay.
Patrik: Right? It’s all good in theory. In theory, you think, “Yeah, why wouldn’t you give something sedative in a situation like that?” It’s good in theory, but it doesn’t work in practise. It would create the opposite effect. It would create the opposite effect.
Julie: Okay. Because I kind of was like, “Why didn’t we even…” And I asked him last night, I said, “Why are you not giving her a little bit of Precedex to just kind of see?” And he said, “No, because she could stop breathing.”
Patrik: Yes exactly. That’s exactly right.
Julie: Okay, okay. So, the blood thinning, the blood coagulation medication she’s receiving is Lovenox.
Patrik: Lovenox. Okay, I just need to… That’s the brand name. Just give me one sec. Just need to type that in.
Julie: Okay.
Patrik: Lovenox. Oh, Enoxaparin, okay. Yeah. How much is she getting? 40 mg, 80 mg, 120, do you know?
Julie: Let me ask that. She’s getting into her stomach and I know it was a very small amount because in the beginning they were worried she might have blood clots on the lung and she said the amount that they were giving to prevent blood clots was a very, very little amount. Well, now they upped it to help with the actual blood clot that she has.
Patrik: Yeah. The standard dose of Lovenox is 40 mg. That’s the standard dose. I would imagine she is now at least on 80 mg. I would imagine. If you can find out, that would be good.
Julie: Okay. I might have to call a nurse and ask because I don’t know that we’ve got an update on that because that’s fairly new news. That was after our visit today and then I called and got a nurse on the phone and she was the one that told me the new really bad news. So I was like, “Oh my gosh.” And then she also is saying that just overall my mom is weak and I thought the whole reason to get the tracheostomy going was so that we could get her in a wheelchair and get her moving and get her off sedation.
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Patrik: Yeah, absolutely. That should be the goal. That should be the goal. Look, at this point in time, as I mentioned to you yesterday, I do believe a tracheostomy is the right thing to do, however, you need to be very aware of the risks and the benefits of a tracheostomy. Because at the end of the day, it sounds like it would be yourself who gives consent to that.
Julie: To getting it?
Patrik: Yes, you would have to put the signature on the piece of paper that gives consent for a tracheostomy. You are the medical power of attorney, is that right?
Julie: Yes.
Patrik: Right, right. So you would have to give consent. You need to be aware of the risks and the benefits. I do believe that there are more benefits than risks at this point in time. In the ideal world, your mom could come off the ventilator without needing a tracheostomy, given that she
failed extubation once now. I think chances are fairly slim that she will succeed with another extubation. But that’s also why I would like to know what ventilation is she on at the moment; what are the gases; what are the arterial blood gases saying. And, at the moment … This is the other question. She is sedated now?
Julie: She is sedated now. They did take her off a few of the things. So, I believe all she has on her is the pain medication, gosh.
Patrik: Fentanyl?
Julie: My fiancee’s keeping track of all this.
Patrik: Right.
Julie: Yes, the Fentanyl. She’s on the Fentanyl and she’s on the blood pressure medication, but the lady did say she’s being able to slowly wean off the blood med… Is this pretty typical after a failed extubation?
Patrik: It’s very typical what’s happening here. You re-sedate a patient after failed extubation, you re-intubate them. And they’re more or less crashing, quote unquote, crashing, and they need to be restarted on the vasopressors like the norepinephrine or the Vasopressin. Sorry. What
is she on besides the Fentanyl? Did you say she’s back on Precedex?
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Julie: I don’t think … I need to find out. I knew earlier prior to-
Patrik: Is she back on the Propofol?
Julie: She was, but that’s the one she’s off of. So she’s off of Propofol today and she’s down to
65% but she’s up to eight peeps.
Patrik: Right. That’s a lot. 65% is a lot. Given that she was on-
Julie: Yeah. And then she’s on all the blood pressure medication and then they said every time they go and roll her to try to prevent her from getting sores on her back, it’s a nightmare all over again. Since you said that’s typical, then is it typical to do this for a
couple of days and then re-stabilise again?
Patrik: Yes, it could be. But I think there’s a missing link, Julie, in all of this. If she’s back on 65% of oxygen, and a peep of eight there is a very high chance that your mother has another infection and that they haven’t even looked at that. Does she have a temperature?
Julie: Yeah, her fever goes up.
Patrik: Right, right.
Julie: Yes, her fever started going up last night to 101.
Patrik: Right, so I think there’s a very high chance that your mother has another chest infection/pneumonia. If she had, whatever, an abdominal infection or whatever, she wouldn’t be on 65% of oxygen.
Julie: So, they did say that when they re-intubated her last night, they said that they sat her up after the re intubation and they heard all kinds of stuff in her chest. So, they went down with a tube and they said they sucked out all kinds of secretions. What does that mean?
Patrik: Okay. Have they done a bronchoscopy?
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Julie: I don’t think so.
Patrik: Okay. I’ll tell you what it means. On the one hand the doctor is telling you that the chest x-ray looks normal. That’s what I understand, right?
Julie: They took the x-ray before they extubated. Go ahead and watch, Marianne. I’ll be in there in a minute. They said that right before the extubation they did the blood gas, blood withdrawal, and they did an x-ray. And he said according to the x-ray, the x-ray looked fine.
The 1:1 consulting session will continue in next week’s episode.
