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 Son is Critically ill in ICU. Is He Not Waking Up Because of Induced Coma or Brain Injury? HELP!
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 Ron, as part of my 1:1 consulting and
advocacy service! Ron’s son is critically ill in the ICU with a brain injury and has a breathing tube in place. Ron is asking why is it important for the ICU team to reduce the sedation during the ventilator weaning?
My Son is in ICU with a Breathing Tube in Place. Why Does the ICU Team Need to Reduce the Sedation During Ventilator Weaning?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Ron here.”
Part 1
Part 2
Part 3
Part 4
Part 5
Nurse Anne: Azithromycin, Bactrim, Meropenem, and iron.
Ron: Okay, and what was the intensive?
Nurse Anne: It was the Vancomycin-Resistant Enterococci (VRE)?
Ron: The VRE was in his?
Nurse Anne: The sputum.
Ron: The sputum, okay and that’s why we started the Sudafed.
Nurse Anne: Yes.
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Ron: Okay, and why are we using the Cera? What was the other one before you said?
Nurse Anne: Meropenem?
Ron: Meropenem.
Nurse Anne: That’s an antibiotic.
Ron: Okay, because of the fevers he was having or?
Nurse Anne: Yeah.
Ron: Okay, got you. Just for coverage. Okay. Thank you.
Patrik: Thank you. Okay.
Ron: Hello?
Patrik: Yes, I can hear you.
Ron: Did you get that?
Patrik: Yeah.
Ron: Okay.
Patrik: You mentioned earlier he spiked a temperature in the last few days, but not today.
Ron: No, he hasn’t been afebrile in-
Nurse Anne: In few days.
Ron: He hasn’t been febrile in a few days.
Nurse Anne: Oh yeah, no.
Ron: He hasn’t been febrile in a few days.
Patrik: Okay, so with the Vancomycin-Resistant Enterococci (VRE) have they started to isolate him? What I mean by that is do you need to wear a gown now when you go into the room?
Ron: Yeah.
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Patrik: Right, and that was only-
Ron: Yeah, anytime they have that. Yeah, they make us. They have everyone.
Patrik: Right. Okay, And the VREs knew that’s like in the last 24 hours, isn’t it?
Ron: No, he’s had a VRE before he came down here.
Patrik: I see.
Ron: Before he came to ICU he already had the VRE like in his urine. I think in his urine but they believe it’s colonized so that’s what our Infectious Disease Specialist believes.
Patrik: Okay, what else did you have in terms of the questions that I sent through? I think we’ve answered most of them.
Ron: Yeah. I have a few on here that I have to read what more is available. Got to see what we can gather.
Patrik: Yep, so the sedation. The fentanyl and the Precedex, there is still no plan to reduce it further?
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Ron: From what I’ve heard from, I want to say Dr.Pringle told me this. The neurologist. I think that attendant has no intention on doing that. At least to date.
Has had no intention on as far as … But, my intentions are somewhat different.
Patrik: Sure. The reason I think this is important and the reason I bring it up is simply number one, now that he’s down to 50% of oxygen I still feel like they need to see whether they can wean him off the ventilator and one of the ways to move him towards that is by
reducing the sedation. Also then, if they can’t wean him off the ventilator then there is no question that the tracheostomy will become a topic to talk about but it’s not there yet. I do believe that the next question is to find out do they reduce sedation or not, and see whether he can slowly move towards having the ventilator removed and if
he can’t then I believe the tracheostomy will become a point of discussion. Inevitably.
Ron: I think right now he doesn’t feel like he’s able to get off the ventilator as compensation.
Patrik: Yeah, and he wouldn’t as long as he’s on sedation.
Ron: Yeah, and I think that he’s saying that once they turn off of the Propofol and then they reduce the sedation meds, like the fentanyl I told you and the Precedex, they reduced it down. They felt that he was still breathing too fast for them to feel that he’s able to come off the
ventilator.
Patrik: Yeah and that’s fine. It’s something that they need to slowly progress with and if they can’t progress with it, fair enough then the tracheostomy will become a point of discussion. I’m jumping probably one step ahead with the tracheostomy. If that was the option going forward. If his blood is too thin because he’s got low platelets, there’s a risk there because if they were doing the procedure, if platelets were too low, there’s a risk of significant bleeding but there’s also a chance that they would top him up with platelets before the procedure. That’s thinking about this going forward, but it’s not there yet. I really hope that they will give him every chance to get him off the ventilator. Then I’m trying to think. His blood gases, have they
improved? Do you know?
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Ron: His blood pressure?
Patrik: No. His blood gases. The arterial blood gas. Do you remember?
Ron: The last time overnight when she told me, it did improve from what it was.
Patrik: Great.
Ron: I want to say it’s up from there now but let me check if it has. I think she recently sent that one off.
Patrik: Thank you.
Ron: Okay. I’ll let you go.
Patrik: Thank you.
Ron: I guess that’s all. Yeah.
Patrik: Okay. I’ll tell you my concern, yesterday his CO2 was 82 or something like that. That was way too high, so all the other numbers were okay but the CO2 was way too high. The potassium was around 3 which was way too low. Potassium needs to be at least
above 4, right?
Ron: Yeah, they’ve been giving him potassium through the dialysis. Through the dialysis machine. This morning it was like, I want to say 3.1?
Patrik: That’s too low and I’ll tell you why this is so important. Especially after cardiac arrest, maintaining potassium above 4 or 4.5 is very important. Some patients, they stay in a cardiac arrest because potassium is too high or too low but they know about that and it
sounds to me like they’re doing the gases regularly so that’s all good. Then yeah the CO2, I would be very interested in the CO2. In the carbon dioxide. What is his breathing rate at the moment? Can you see that?
Ron: His respiratory rate or?
Patrik: Yeah, respiratory rate. Yes.
Ron: His respiratory rate 46.
Patrik: 46. That’s still too high so that means his CO2 might still be through the roof.
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Ron: How could they adjust that?
Patrik: Quickly looking at the ventilator that you sent me here, so they could adjust that, can you see the PEEP is 7?
Ron: The PEEP yeah. The PEEP is 7.
Patrik: Yeah, the PEEP is 7. There would be one way to potentially increase that. We don’t have any verifiable numbers. His CO2 might come down so we don’t know. His CO2 might have come down already. However, another way to potentially improve the CO2, at the moment he’s on a ventilation mode. You can see the VC. Can you see that?
Ron: Yeah, the VC.
Patrik: It stands for volume control and they could potentially change that to pressure control. That would potentially bring CO2 down depending on the cause of the CO2 rise. I feel like that’s another question we need to put on our list of questions to ask. However, if you see a blood gas. Maybe if you can ask her what’s his CO2.
Ron: When was the last blood gas he had taken?
Nurse Anne: The last one was 2 AM.
Ron: At 2:00 AM.
Nurse Anne: Yeah.
Patrik: 2:00 AM?
Nurse Anne: Oh no, she did one at 4:00 AM. I’m sorry.
Ron: What’s the deal with the next one?
Nurse Anne: pH is 7.34. Do you want me to read it or you got it?
Ron: One sec.
Nurse Anne: Okay.
Ron: pH is 7.34.
Nurse Anne: 7.34, yep. CO2.
Ron: CO2 was 53. PO2 was 54.
Nurse Anne: Yup.
Ron: Bicarbonates is 28.6.
Nurse Anne: Then the lactate is 1.
Ron: The lactate is 1. Thank you.
Patrik: Okay, thank you. What was CO2 again? Did you say 30?
Ron: 53. CO2 was 53 right?
Patrik: 63.
Ron: 53.
Patrik: Okay, that’s still a bit too high, but it’s not like 82 yesterday so a lot better.
CO2 ideally should be below 45. Yeah, 35 to 45 so it’s not quite there but it’s a massive improvement from yesterday. That’s good for something. His ventilation settings might not be too bad then. That’s good so most of it seems to work then because you again, if those numbers were all off, I would say there’s a low chance of him getting off the ventilator but again, given that those numbers are improving my next question is okay, can they wake him up and make a full neurological assessment and try and wean him off the ventilator? That would be the next natural step. Okay, you mentioned he’s got no pressure areas, which is good. Is he on a soft mattress or on an air mattress?
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Ron: He’s on … It’s kind of like an air mattress because they’re able to inflate it and deflate it.
Patrik: Okay, that’s good. Yeah, no, that’s good.
Ron: Yeah, he’s on one of these beds where they’re able to turn him and stuff like that.
Patrik: Great. Okay, now that we’ve gotten more answers I really do believe you need to wait for the round or you need to wait for another update and see what are the next steps. What’s the plan.
Ron: Yeah I plan on that. I’m waiting for him because they were still rounding on the other patients so I was waiting for the attendant to get a moment so I could speak with him.
Patrik: Yes. I think that’s going to be important. To speak to him and find out what are the plans moving forward, including waking him up. I do believe the focus needs to be to find out are they planning to reduce sedation? Are they planning to wean him off the ventilator. If not are they planning to do a tracheostomy? Those are from my perspective, the important questions.
Ron: Okay, and him being on the ventilator, is a cause for infection and pneumonia right?
Patrik: Very much so. It’s a huge infection risk and pneumonia risk in particular.
There is this term called VAP which stands for ventilator associated pneumonia, and again you could probably ask. With the question that I gave you yesterday you should almost rinse and repeat every day. See whether there are any changes.
The reason I wrote them down in that order in particular is so when you get hand over from the previous shift, it’s almost like starting off with hit from head to toe, which is pretty much how I structured those questions. It’s from head to toe starting neurological, which is the brain. Going down to the heart. Going down to the lungs.
Going down to the gut. Going down to the kidneys. It’s almost like a head to toe so hand over. I do strongly feel like you should almost rinse and repeat those questions daily and yes, they would change as time goes on, hopefully because he hopefully will wake up but it’s a good guide post for you to keep an eye on the clinical issues.
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Ron: Okay.
Patrik: The other thing now that we have a better understanding of antibiotics and VRE and but that from my perspective should not stop them from trying to wake him up, but you want to find out whether in their mind it potentially stops them from trying to wake him up.
Ron: The antibiotics?
Patrik: Yes. Antibiotics and query infections. Yes, the VRE has been confirmed, but nothing else has been confirmed in their mind, do they think that something positive will come back from other sources?
Ron: Got you. Okay.
Patrik: It shouldn’t but again, it’s all about finding out what is happening in their mind, so the most important thing to me really is that irrespective of the gravity of the situation, nobody’s talking about not trying everything. That to me is the overarching theme and that is very important because a lot of clients we’re dealing with in a situation like that or in a similar situation would be like, oh yeah we’ve got to stop treatment,
blah blah, blah. That hasn’t been the case and I’m pleased about that. Is that how you feel too?
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Ron: Yeah, they haven’t. No way, shape or form.
Patrik: Yes and that’s good, so get a feel for what their plan is. I think you almost need to ask that daily. Also, did you get a rest because again, I do believe you looking after yourself is just as important as you’re staying with your son, but at the same time you will need some sleep and I have seen too many people burn out in those situations.
Ron: Yeah. I try to get some. Trying to get some.
Patrik: But, you’re basically living in the hospital.
Ron: Absolutely.
Patrik: Right, and you’ve got some hospital accommodation type of thing.
Ron: Say that again?
Patrik: I said the hospital is providing you with some accommodation.
Ron: Yeah. I actually stay in his room with him.
Patrik: Right. Okay.
Ron: Yeah I stay in his room with him. Families are allowed to stay in their own.
Patrik: Sure, okay. I see. Okay. Look, as I said, because when we’re working with giants, we’re well aware of how emotionally draining these situations are and I want to point out that your wellbeing is as important as Daniel’s wellbeing. I think it’s often being almost dismissed because the situation is so difficult and you’re trying everything you can of course, but you are the most important person in all of this because without you or
without you being at your best it would impact on your son as well.
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Patrik: I can’t stress the importance of sleep. I’m not telling you what to do by any means.
Ron: I understand. I totally understand and I do my best.
Patrik: Yes, but I have seen people burn out and it’s not what you want or what your son needs. Sometimes it might be worth staying somewhere else for a night.
Again, I’m not trying to tell you what to do, but if you are in the room, it’s noisy.
Alarms are going off. This, that, and the other. Sometimes getting a good night of uninterrupted sleep might be worth but that’s as a side note.
Ron: Yeah and I totally understand.
Patrik: I do believe Ron, the next step is to talk to the attendant. Find out what their plans are, and then I’d say we’ll reassess, depending on the plans. Where, what the next steps are.
Ron: Okay. Sounds good.
Patrik: Are there any other questions that you have at the moment?
Ron: No, not at the moment. Thank you so much Patrik.
Patrik: Okay. Get back to me when you have some answers.
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Ron: Okay. Take care.
Patrik: Okay. All the best for now. Take care.
Ron: Thank you.
Patrik: You’re welcome.
Ron: Bye.
Patrik: Bye bye.
The 1:1 consulting session will continue in next week’s episode.
Kind Regards
