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 with Sepsis. How Can My Mom Be in the ICU Ventilated and on Vasopressors for Three (3) Weeks Without an Arterial Line?
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 with sepsis for more than three (3) weeks. Julie is asking whether it’s possible to do the tracheostomy and feeding tube insertion through abdomen all
at the same time.
My Mom is in the ICU with Sepsis. Why Do The ICU Team Want To Do Tracheostomy and Gastrostomy on Her at the Same Time? Help!
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
PART 14
PART 15
PART 16
PART 17
Marvin: Hello?
Patrik: Hi, Marvin. It’s Patrik here. Now, if you want me to add some numerous conference calls, if you want me to I can try and dial her in if you want me to.
Marvin: Yeah, go ahead and do that because I think I’m having a problem on my end.
Patrik: Yes, it sounds like. Okay, just give me one sec, please. Just give me one sec.
Marvin: Okay.
Patrik: Just give me one sec.
Julie: Hello?
Patrik: Hi, Julie. It’s Patrik here from Intensive Care Hotline. I’ll just bring Marvin into the call, just give me one sec, please.
Julie: Okay, it’s perfect.
Patrik: Okay, can you all hear me now?
Julie: I hear you.
Marvin: Yes, I can hear you.
Patrik: Oh, wonderful, okay, so that worked. Okay.
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Marvin: It’s perfect.
Patrik: So you are waiting for the doctor to come in now, is that right?
Julie: Marvin?
Marvin: All right. Yeah, I’m here.
Patrik: Are you waiting for the doctor to come?
Julie: Is the doctor coming in?
Marvin: I’m going to go into the meeting room. Sorry. Hold on one second, let me take the gown off, and then we’ll go in there. All right, still there?
Julie: Yeah.
Marvin: Okay. We’re in a meeting with Dr. Smith.
Julie: Okay.
Patrik: Okay.
Dr. Smith: Hi.
Julie: Hi. Yes.
Dr. Smith: Yes. Okay.
Julie: Yes.
Dr. Smith: So, yeah, last time we spoke, of course she had that tough day when we removed the tube and then had to put it back in about six hours later. Since that time, her condition has worsened some. You know, when we put in the tube back, we ended up having to suction a lot of stuff out of her lungs.
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Julie: Okay.
Dr. Smith: You know, it’s very possible that she might have redeveloped a little bit of pneumonia there. It’s very possible she might have aspirated some stuff into her lungs, and you know, she was having fevers and those sorts of things. It’s very possible
that she wasn’t, what we call protecting her airway very well, because, you know, the secretions from her mouth was going into her lungs. So anyway, you know, her blood pressure, and she’s had some persistent fevers. Things kind of unstable after a little bit, but her fever curve is trending a little bit better. Her blood pressure’s a little bit better. But you know, it’s just, so anyways, we’ve been kind of dealing with that. She’s already on antibiotics that covers most things.
But I guess the reason why I thought it was important to speak was I’ve been discussing getting, just like we said, moving forward with caring for her is becoming an issue. You know, the tube in her windpipe is, apart from those six hours, it’s been in for now for three (3) weeks. Well,
it’s been over three weeks, excuse me.
So, you know, we’re talking about how to best care for her going forward. You know, procedures are going to be risky in that, you know, because of her size, you know, there’s, for example, the feeding tube will have to be an open procedure.
We’ll have to open her up, and have to give her some anesthesia.
Julie: Can we for now, since the most important thing would be the tracheostomy, is there a way to just do the feeding through the nose until she’s a little stronger, just so it’s not as invasive, like currently, so not
two surgeries?
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Dr. Smith: Its intent is just to get it all done at once under one… Because she’s going need, likely anesthesia for one thing, and then might as well do both. At least that’s been our thought process. But let me tell you-
Julie: So you, okay.
Dr. Smith: The tracheostomy is also going to be risky in that she doesn’t have much neck to work with. There’s going to be issues with her skin there. There’s also, you know, going to be issues where, that the skin may, you can have problems where, you know, the airway’s going to be short, that she could have skin issues, where there’s a lot of redness. Whenever you have a lot of loose tissue around the tube, you know, it
can cause infection, and things like that. But I mean, the proceduralists here are willing to do it.
I think what everybody is, and it’s a very valid point. What everybody’s bringing up, and we’ve also discussed the care also with the other pulmonologist, Dr. John Simmons saw her yesterday, and Dr. James Wallace over the weekend. Is that, and I think it’s something that is very important for you guys to know. It’s clear that we need to do something to continue to care for her. These tubes have been in so long that we just need to move on to a better way to care
for her. But the bottom line is that the chances we’re going to be able to get her off the ventilator, and get her back eating, is very, very low. I guess that’s something that we really haven’t touched bases about, you know, what things will look like once we get these tubes in her? The tracheostomy. You know, and the feeding
tube, if you feel that way.
But, you know, I think that the chances are of her coming off the ventilator are very low, and I know that the plan from the start has been to get her back to where she was. Of course if she becomes a ventilator dependent person, you know, she’s not going to be able to eat. She’s not going to be able to talk. She’s going to pretty much be, you know, she was already pretty vegetative, but she’s going to be overwhelmingly vegetative because of those
things.
Julie: So she’s not going to be able to talk?
Dr. Smith: Not if we take it off ventilator.
Patrik: Can I just ask here, Dr. Smith, it’s Patrik here. We’ve spoken a couple of weeks back. You’re talking about her potentially being ventilator dependent for the rest of her life, and you know, I understand that’s the possibility. I also think it’s the worst case scenario. But a question that comes up when talking to Marvin and to Julie, really, is it sounds to me like she hasn’t had an arterial line for the last three weeks. How can you say she’s going to be ventilator dependent if you only do an arterial blood gas every now and then, and you’re going to stet
her?
Look, I think you’re not following best practice here because I’ve worked in intensive care for 20 years. I mean, not putting an arterial line in for somebody who’s ventilated and on vasopressors on and off, that’s not best practice . So you’re talking about numbers that you only get
every now and then. I understand you had a failed extubation, but let’s also look at what’s best practice in intensive care. If you’re not following best practice , you know, you’re making up a potential scenario that’s not really underlined by parameters that need to be checked regularly if somebody’s on a ventilator.
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Dr. Smith: Yeah. Well, you know, the blood gas. It’s hard to measure what it’s at here. An arterial line, if she were to be on a severe condition then arterial line is needed to monitor blood pressure, and we can check arterial gases. But she didn’t fail because she is fighting. Not because we were following a carbon dioxide or oxygen. But-
Patrik: If you extubated her, she failed, and she doesn’t have an arterial line, then I question your practice. I question your practice if she hasn’t had an arterial line, and she’s failed extubation. I mean, one thing you do before extubation is an arterial blood gas, and you probably do a couple of them. So I’m questioning your approach at this point in time, Dr. Smith. I mean, it’s dangerous not having an arterial line for somebody on
multiple vasopressors and on ventilation. I mean, you, look. I’m not a doctor, but I’ve worked in intensive care as a nurse for 20 years. I’m really questioning your approach, and I think you haven’t been open and transparent with the family.
Dr. Smith: Well, she’s got an arterial blood gases. I’m not sure where you’re coming up with this idea.
Patrik: Well, I’ve seen the monitor. There is no arterial line.
Dr. Smith: Yeah, I don’t-
Patrik: The family’s telling me that she’s getting stabbed for an arterial blood gas, which is very painful. So I’m sure that the family’s giving me the right information that she doesn’t have an arterial line, and she hasn’t had one from day one. I’ve seen the monitors, and I haven’t seen any signs of an arterial line being present.
That’s very concerning, doctor. That’s very concerning, Dr. Smith, from a clinical perspective. That is extremely concerning.
Dr. Smith: You’re kind of missing the trees from the forest here.
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Patrik: I don’t think so. I don’t think so. I’ve never seen somebody being ventilated for three weeks, and on vasopressors without an arterial line. In 20 years I’ve never seen that. You are withholding best practice treatment, potentially, from this patient.
Dr. Smith: Yeah. I mean, arterial line is a monitoring device, it’s not a therapy.
Patrik: Correct. But you need an arterial line with somebody who’s ventilated and on vasopressor. I mean, you look at the literature, you look at the literature. As I said, I’ve never worked in an ICU where this has not happened. This is the very first time I’ve come across that. Very first time in 20 years. I’ve not seen that before.
So explain to the family why she hasn’t had an arterial line. Please explain that to the family.
Dr. Smith: Because we haven’t required it.
Patrik: Maybe you don’t have the staff there. Maybe you don’t have the staff there to put an arterial line. That’s what it looks like to me. They had to call you in the other day for intubation. Maybe you don’t have to the staff and the skills on the ground to provide the patient with the care they
need. That’s what it looks like to me.
Dr. Smith: I know the blood pressure on a second to minute by minute basis. The arterial line will also allow to draw gas. That, there’s no need for us to do that.
Patrik: t’s cruel. It’s cruel stabbing a patient for an arterial blood test, because that’s what happened. It’s cruel. It’s patient.
Dr. Smith: The arterial line’s one of the pertinent things, and you know, such as when she was involved in the respiratory failure. We don’t do routine arterial blood gases every day.
Patrik: That’s not best practice. I mean, you look. Do you want me to send you some literature? Sorry. I just don’t think she’s in the right environment. It doesn’t look to me like she’s in the right environment. I’ll leave it there for now.
Dr. Smith: Okay. That is your opinion. But in any case, like I said, there’s a high chance that she’s going to be ventilator dependent. So that’s why it’s important for you guys to understand that, that that’s something that will have to be dealt with, once we put those tracheostomy and the feeding tubes in. If you feel like she’s not in the right environment, perhaps a transfer to another facility would be appropriate.
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Julie: I think that that would be appropriate in many forms, just because of the drive it takes for us to be there for her as well. It’s pretty far away. I do feel like some university hospital is a really, really big hospital, and they also have a lot of her history there from a complete workup they did when she had a baseline. I don’t know, I feel like maybe, and another thing I have to question is, I don’t understand
how, you know, if we were at the five peeps, and the 40 on the ventilator just a few days ago, off of the blood pressure medication, going smoothly. I just have to question why now there’s no chance of coming off of a tracheostomy because now we’re talking no sedation. We’re talking the ability to exercise, and to seek therapy to help with swallowing and things like that. So I just don’t understand what has happened here.
Dr. Smith: Yeah. Well, I think what’s concerning is how quickly she failed when we removed the tube, and just how weak she is. I think it’s a real concern that, like I said, that you guys have to understand that there is a real chance that she may never come off the ventilator. That’s, you know, of course, there’s, in this situation, there’s no 0%, there’s no 100%. But I’d say the likelihood of her ever coming off the
ventilator is poor. You know-
Julie: Okay. That’s even being, huh?
Dr. Smith: Generally when people come off the ventilator is a time when, you know, people have rehab. You know, physical therapy, speech therapy, to try to get stronger. Because of her underlying neurologic problems. Because she was bed bound, because
she was not a healthy person to start with, you know, physical therapy for her to start getting stronger is going to be very difficult.
Julie: Okay. But, oh, sorry, I can’t really hear.
Marvin: It’s okay. I’m just saying that the only way she’s going to get stronger or get better is if she’s off sedation. She will really be off sedation with the tracheostomy.
Dr. Smith: Correct.
Marvin: So that’s her only chance to get better.
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Dr. Smith: That’s her only chance, and that’s what I just wanted to make sure with you guys, that, yeah, tracheostomy and a feeding tube are the only way for her to get better, period. But it has to be understood that, you know, the hope is that she gets back to where she was, and I would say that you guys have to understand that her chance of getting there is very, very small. The chance of her becoming ventilator
dependent, feeding tube dependent person for the rest of her life is pretty significant. That’s kind of what I wanted to explain to you before having to undergo these procedures. Now, if you guys just want to transfer her over the way she is, that’s also possible. You can do that. All things are on the table here. But I will be completely honest and up front with you with that. It’s a very, it’s an awful position to be in. She’s been through so much.
Julie: She has. She has, but I have such a hard time knowing where she was prior to coming in there. That’s my only struggle. I don’t understand. I guess I just, I can’t be told enough that somehow three weeks later, being in the ICU, that she’s just not going to be back to where she was. I don’t quite grasp that.
Dr. Smith: Yeah.
Julie: I don’t, because I feel like she originally came there with pneumonia, and it’s just progressively just gotten worse and worse.
Dr. Smith: Sure. Sure. Yeah. Well, we’ve talked about how, you know, you have kind of a certain time frame to get better. Otherwise you get weaker and weaker, and that’s kind of what’s happening now. You know, she’s-
Julie: So, there’s a point where you can get so weak that you can not recover from that weakness?
Dr. Smith: No, I’m not saying that it’s impossible, what I’m saying is it’s unlikely.
Julie: Okay. What makes it unlikely? The further health problems, or the patient not being willing to do what it takes?
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Dr. Smith: No, what makes it unlikely is that she gets weaker and weaker and she develops more and more complications. Yesterday, also what ended up happening, and I’m not sure if the nurses told you, she also developed a clot in her PICC line, so we did start blood thinners for that. So you know, and of course she needs an IV to continue to receive the fluids. So that’s kind of, so that happened yesterday. But it’s expected, like I said, you know, the longer you’re down with these catheters in your body, the more complications will arise. That’s what I’m trying to say. But we
can continue to plan to pull the tracheostomy and the feeding tube, but you know, I think all the doctors that have seen her have their own opinion. The chances are very poor for Roselyn to recover. But it is the only chance that she has to recover. I can’t argue with that. It’s also, you know, it’s the only way to continue to care for her, because those tubes can’t be in there indefinitely.
Julie: Okay.
Dr. Smith: Yeah, so she is on blood thinners now. We’ll have to stop the blood thinners to do the procedure, obviously, and it does add another little layer of risk, and that she can bleed.
Julie: How long does it take for those to get out of her system?
Dr. Smith: Oh, no, we just hold it for… I’m not saying it’s a complication, but you know, it’s another layer of risk, in that, you know, she can get the procedure. In any case, I’m not saying that that’s going to stop us from doing what we need to do, but it’s kind of a case in point that, you know, things get more complicated the longer anyone’s in the hospital longer. But it sounds to me, I’m getting the feeling that you
guys want to continue to get the tracheostomy and the feeding tube, and so we’re going to work on doing that, unless of course you guys want to have her transferred, then we’ll work on that with the case manager.
The 1:1 consulting session will continue in next week’s episode.
