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 Brother Is Brain-Dead In The ICU But The ICU Team Refuses To Give Their Hospital Policy For Brain Death. What Should I Do?
You can check out last week’s question by clicking on the link here.
In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Kathy, as part of my 1:1 consulting and advocacy service! Kathy’s father is in cardiac ICU
after undergoing three open-heart surgeries and Kathy is asking about the right questions to ask the ICU team to know about their dad’s quality of life.
My Dad is in Cardiac ICU After Three Open-Heart Surgeries. What are the Right Questions to Ask the ICU Team to Know About My Dad’s Quality of Life?
Kathy writes in–
My father has been in the cardiac ICU for nearly four weeks after his third open-heart surgery, CABG, tamponade aortic dissection in three months. He requires re-ventilation with a tracheotomy and now is on dialysis.
The doctors keep assessing that there are very reasonable expectations that he can make a near-full recovery, but that it will be a long road. We keep asking and that is what they keep telling us, but his organs seem to not be getting much better. He is really struggling with his breathing. And his kidneys are shut down and he’s on dialysis.
As I mentioned, we’re not sure the right questions to be asking. We don’t know what this means for his quality of life. And he has a medical directive and we don’t want to do anything that contravenes his wishes. But it is so hard to know how to decide to say yes or no to something they are recommending. My father has in his advanced care directive that he wants to have everything done.
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Well, thank you, Kathy, for writing in and for sharing your father’s situation. So three open-heart surgeries in three months. CABG, tamponade, aortic dissection that is a lot I have looked after 100 patients with post-cardiac surgery aortic dissections, and some of them have developed the tamponade and it usually requires for them to have their chest reopened and go back to surgery.
It’s definitely difficult enough recovering after CABG (Coronary Artery Bypass Graft), let alone if tamponade is a complicating factor because that usually prolongs the stay in intensive care. And it sounds like he’s had to have another aortic dissection after all of this,
which again, in and of itself would be massive surgery that is often going hand in hand with complications. An aortic dissection is a high-risk surgery, and again, it usually requires a long stay in intensive care. So, therefore, I’m not surprised that your father is battling all of the issues that you have highlighted in your email.
So let’s break this down a bit further step by step. So number one, you know, you mentioned that your dad has an advanced care directive where he says, he wants to have everything done and you certainly should be honoring that. Now, I’m surprised that the intensive care team says that he can make a near-full recovery.
Now I am not questioning that he can’t. But my experience is that intensive care teams generally speaking are overtly negative. They often pay a doom and gloom picture for families in intensive care. And if you don’t know how to challenge that, if you don’t know how to ask the right questions, it’s very difficult for you to get the outcomes that you want. Because if anything is going to happen in intensive care teams with their negativity and their doom and
gloom, often want to shorten treatment and want to simply withdraw life support, so they can free up an intensive care bed and focus on the next patient that might have a higher chance of recovery.
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But let’s break this down even further and go through it step by step, so I can help you. Number one, asking the right questions that are so important that when you have a loved one in intensive care because as a matter of fact, the biggest challenge for families in intensive care is they don’t know what they don’t know. They don’t know what questions they need to ask. And worst of all, they don’t know how to manage intensive care teams.
Yes, you’ve heard me saying this correctly, how to manage intensive care teams. There are most families in intensive care who feel completely powerless. And they think that you know, they have to look up and even worse, suck up to the doctors and the nurses in intensive care and they are at their mercy, and nothing could be further from the truth, especially if you know how to manage them. If you know what questions you need to ask and if you get professional
consulting advocacy from us here at the intensive care hotline, because we understand intensive care inside out. And we can help you very quickly to make informed decisions get peace of mind control, power, and influence in those situations.
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So, but let’s look at the clinical situation of your dad. And let’s break this down even further step by step, Kathy.
So, your father would have been in a prolonged induced coma multiple times. Normally what happens after cardiac surgery, if everything goes as planned, you know, patients get out of cardiac surgery, they wake up within often 24 hours and if cardiac surgery went well, they’re not bleeding, they’re hemodynamically stable, wake up, get extubated get taken off the breathing tube and often go back to the cardiac ward on day one.
Now, in your dad’s situation, there’s a very high chance he didn’t even get to the stage of extubation because he had a tamponade. Now, for those of you who haven’t heard of a tamponade before, basically what it means, it’s an accumulation of blood around the heart after surgery, probably from a leak. And it often shows an increased heart rate, a drop in blood pressure, an increase in central venous pressure. And it could go as bad as developing ventricular tachycardia, ventricular fibrillation or cardiac arrest.
So it often requires going back to surgery, having the chest reopened, drain the tamponade and look for where it’s bleeding and stop the leak. So that’s one complicating factor. It’s a very high chance your dad would have needed multiple blood transfusions such as blood products, such as red blood
cells, but also FFP ‘s fresh frozen plasma, potentially platelets or potentially cryoprecipitate even.
So, that’s certainly one complicating factor it would have required to wake up.
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And it would have prolonged and complicated further, the chances of your dad coming off the ventilator quickly. Now, during this period where your dad had been in an induced coma and he needed multiple surgeries, is a good chance that he was so hypotensive, meaning his blood pressure dropped,
where he needed inotropes and vasopressors which are considered life support to sustain a physiological blood pressure that sustainable with
life or compatible with life.
During that period, there’s a good chance the kidneys wouldn’t have received enough blood perfusion, they would have shut down, and therefore your dad went into kidney failure. And now he’s at the point where he needs dialysis. Furthermore, your dad with prolonged ventilation with the
need for more surgery that might have ended up with an infection, right, could potentially ventilator-associated pneumonia, potentially an infection from the surgery could have been a wound infection could have been a bloodstream infection, but the chances are there that this was another complicating
factor that again, setback your dad in his recovery, and again, couldn’t come off the ventilator and that’s why he needed a tracheostomy.
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As a rule of thumb, somebody needs a tracheostomy after 10 to 14 days on the ventilator. And then tracheostomy needs to be done. And then patients can come out of the induced coma, which is a good thing. Now a tracheostomy is a procedure. And it could be, you know, a device that could be there for
your dad for a long time to come, which is what you’re trying to avoid, but at the same time, it gives your dad time to recover in his own time, and it minimizes the need for sedation and opiates.
Now another further complicating factor, if your dad, for example, needed the aortic dissection, he would have had a central line, an arterial
line, he would have had potentially a Swan Ganz catheter to check cardiac output, cardiac index and SVR systemic vascular resistance again, to check closely on the function of his heart. He would have had echocardiograms potentially transesophageal echocardiogram to again check his ejection fraction to make sure his heart contracts adequately.
So, with that being said, you know, your dad might have been close to what’s called multi-organ failure, or he might have been in multi-organ failure. You know he’s had surgery on his heart, his lungs were failing, he needs mechanical ventilation and his kidneys were failing. So, in that light, somebody with multiple organ failure certainly can spend a lot of time in ICU and recovery times can be prolonged.
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And the other thing, obviously, and now we’re coming to the questions you should be asking, you know, and sort of starting from the top, you know, his neurological condition. What’s your dad’s neurological condition? Like, you know, can he obey commands? Is he in pain? You know, can he follow simple instructions? Those are all very important questions for you to ascertain. And find out, you know, if your dad, for example, is confused, can’t follow simple
commands, you know, that is a sign, you know that he may need more time in intensive care.
And they may have to wean him off sedation if he’s still on that he might go through some withdrawal because of the prolonged time in the induced coma. Right. So, moving further down, and also when somebody is coming out of an induced coma and they’re not waking up properly. Also, you know, for example, can you rule out that your dad had a stroke?
Again, the complicating factors with three high-risk surgeries and the risk of a stroke are often there. So again, you got to ask that question. Next moving, one system down, you know, sort of neurological, that’s moving one system down. Let’s look at the cardiac condition or the heart condition. Right? So you are saying your dad had three surgeries. So how stable is he? Is he hemodynamically stable? Is he still on inotropes or vasopressors to sustain a
potentially low blood pressure? Right? That’s a very important question.
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Is his cardiac output sufficient? Does he still have a Swan Ganz catheter and what was the last echocardiogram? What was your dad’s ejection fraction? Those are all important questions to be answered, especially in light of the fact that your dad eventually needs to get mobilized. And if he gets mobilized, you know, you want to make sure that his heart is strong enough to tolerate the mobilization aspect.
Next, you want to look at your dad’s heart rhythm. For example, with those high-risk surgeries, there’s a good chance your dad might have temporarily or potentially permanently gone into an irregular heart rhythm, such as AF or atrial fibrillation, you certainly want to ask that question. If your dad has gone into AF or atrial fibrillation, which is an irregular heart rhythm, he might need things like medications like the Digoxin, Amiodarone, he might need
potassium, he might need magnesium so he might need his electrolytes replaced and corrected. Because sometimes when somebody does go into AF, number one, it could be a result of the surgery.
And number two, it could be a result of electrolyte imbalance. And especially now with him on dialysis. Electrolytes might get out of balance if they’re not being replaced appropriately. Next, you then look at the respiratory function hands his ventilation side of things. You know, you mentioned he has a tracheostomy, now the question is, what ventilation mode is he in? Is he breathing spontaneously already? Is he breathing with support being delivered only by
the machine? Is he getting a set rate of breaths delivered by the machine per minute? Can he take his own breaths on top of that? You know, those are the type of questions you need to ask if somebody has a tracheostomy, they should be weaned off the ventilator as quickly as possible if they can tolerate it because again, you don’t want to ventilate somebody for longer than necessary.
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So you may want to find out, you know what ventilation mode he’s in. If, for example, he can breathe spontaneously, you know, during the day, that’s great, you know, and then maybe the next step is, you know, overnight, put him on in a controlled mode so he can only have assist and then maybe the next day, he can breathe spontaneously again, and then take off the ventilator for a few hours, see if you can tolerate that.
And then step by step, weaning off the ventilator, once he’s off the ventilator hopefully can get off the tracheostomy as well and can have that removed as well. But it sounds to me like he’s a few steps away from that still. Other things you should be looking at from a respiratory point of view. You know, what does his chest
X-ray show? You know, how often does he need suctioning from the tracheostomy? Those are all indicators for you, and how far away from your dad might be to get off the ventilator. But again, the most important thing probably is to find out what ventilation mode your dad is in.
Next, also, if your dad still has an arterial line, you can check arterial blood gases and again, the arterial blood gases will give you an indication if your dad can be successfully weaned off the ventilator. The arterial blood gas results need to be seen in the light of what
ventilation mode your dad is in, for example, if he’s breathing spontaneously, and arterial blood gases are not that great, and they’re not within physiological levels, he’s probably not ready to breathe by himself yet.
And again, those are all indicators for you to look for. And again, you can already see, intensive care is such a highly specialized area. You know, I’m talking, I’m using a lot of medical terms here, and I’m not using them to brag to you. But you know, you need to understand what’s happening. And you need to understand how things are broken down in intensive care. And you need to understand that, you know, it’s not as simple as when can my dad come off the
ventilator? It’s not as simple as that.
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There are multiple things that you need to look at before you can before I or somebody else can give you an answer to that. You need to look at all of the issues that are at hand when somebody is coming off the ventilator. So then next, let’s look at blood results. Right. So for example, your dad should have daily lab results and you need to look at things like white cell count to rule out an infection, you need to look at hemoglobin levels. Hemoglobin is the red blood or is the red blood cells.
And again after having had three surgeries is a good chance your dad’s hemoglobin levels would be low or lowish and also often tamponade, there’s a good chance he would have had blood results as I mentioned earlier or two after the aortic dissection because again, the risk of bleeding after an aortic dissection or during the surgery is pretty high.
Also need to look at the blood results for magnesium and potassium levels in particular as I mentioned earlier, look at coagulation levels such as INR and also PT/APTT. So you know, you want to keep a very close eye on the coagulation levels to see how thin
the blood is. It’s a fine line between your dad not bleeding but also not developed deep vein thrombosis.
Next, with your dad in kidney failure, you need to look at the urea and creatinine levels to make
sure that dialysis is actually working. So urea and creatinine levels need to be watched daily. So again to see whether urea and creatinine are recovering and also is your dad making urine so you know if your dad starts to make urine and urea and creatinine level or going back to normal, there’s good chance dialysis can be stopped.
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But again, those are the questions you need to ask. Next feeding, for example, you know, is your dad having a nasal gastric tube most likely will have a nasal gastric tube, but there’s also a chance he might have a PEG tube in his tummy, right? So, again, find out what’s the plan with nutrition for your Dad, is he getting adequate nutrition? That is really important for you to find out as well, you know, is the opening bowels regularly? We talked about urine and kidneys already. And again, if he hopefully starts making urine he
probably needs a catheter still in the indwelling catheter. And then hopefully the dialysis can come off.
Next, you know, with your dad being on the ventilator and he’s being weaned off the ventilator, you need to find out, is he strong enough to be mobilized now that he’s got a tracheostomy? There should be no reason for your dad to not get out of bed. Right as long as he’s hemodynamically stable and not on inotropes anymore.
The dialysis could be an obstacle to getting out of bed depending on where the dialysis catheter is. If the dialysis catheter is in the groin. Then that could be an obstacle for getting out of bed because you know as soon as you sit someone up, the dialysis catheter in the groin would kink and would stop basically dialysis. So if your dad’s dialysis catheters in the shoulder in his subclavian vein, or in the jugular vein, then the chances are your dad can get
mobilized are increased.
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So I hope that really helps Kathy to answer your question and help you to talk to the intensive care team. And, you know, really continue to ask the right questions. You know, and get the right questions and move your dad’s care and treatment forward so we can leave intensive care soon and recover fully. And also, if you want us to talk to the doctors directly, we can organize that and thanks for being a member.
Kind Regards
