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 in ICU with Lung Collapse and on ECMO. Why has the Tracheostomy Procedure Been Delayed?
You can check out last week’s question by clicking on the link here.
This is another episode of “YOUR QUESTIONS ANSWERED”. And in today’s episode, I want to answer a question from one of our readers, Laureen.
So Laureen is asking, my 64 years old mom is in ICU after open-heart surgery. She’s been extubated, but she developed Pneumonia. What should they’ve done to get her out of ICU sooner?
My Mom is in ICU After Open-Heart Surgery. What Should They’ve Done to Get Her Out of the ICU Sooner?
So Laureen writes in
Hi Patrik,
My mom is 64 years of age and she went into open-heart surgery last Friday. She had an Aortic valve replacement. Everything went well with the surgery. Her heart is fine, but while she was recovering, the endotracheal tube was removed the first night after the surgery around 11:30 PM
soon after that she had to use a BiPAP machine for two or three days, but it wasn’t working because she developed pneumonia. Now they are saying her kidneys are functioning poorly
because they have been trying dialysis for the last few days. They also say her blood pressure keeps dropping back whilst on the ventilator.
Yesterday she also went into atrial fibrillation or Afib. She’s also still very sore in her chest, especially with the BiPAP on. Initially, we were told that she would be leaving ICU within a couple of days after the atrial valve replacement and now it’s been over five days. How much longer would you stay in ICU? Do you have any suggestions? What should they be doing in order to get her out of ICU sooner? Any questions we should be asking?
Much appreciated.
From Laureen.
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So Laureen,
Thank you very much for writing in and I’m going to look at this, in very much detail now. So Laureen, thanks again for being a client, and thank you for writing in. So the first thing that’s important here, Laureen is, it’s not uncommon that they want to within less than 24 hours after an Aortic valve replacement at the ventilation tube or the breathing tube is coming out, that should always be the gold standard because you don’t want to keep somebody on a
ventilator for longer than necessary. If surgery goes well, if there’s no bleeding, if somebody’s vital signs are stable. After an Aortic valve replacement, you know, sedation is being weaned off, pain should be controlled with morphine or sometimes with an epidural, but most of the time its morphine or fentanyl. Then the breathing tube should be coming out. Once sedation is off, propofol is off, then the ventilator should be weaned and then the breathing tube should come out. Again, if your mother is hemodynamically stable and
if your mother has no signs of bleeding.
Now there’s a bit of a challenge there. You said that the breathing tube came out at 11:30 PM. There’s a little bit of an argument in ICU when you should extubate the time of the day because, you know, if something was to go wrong and you don’t really want to extubate or take the breathing tube out in the middle
of the night, which is what’s happened here and it sounds like, it might’ve been a little bit premature.
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Imagine you’re tired overnight already. Now you had surgery and you’re sort of coming out of a coma and now you’re on a ventilator and then you need to start breathing in the middle of the night when you’re already drowsy. So there’s a bit of an issue there. Maybe they should have waited until the morning until there’s more staff around also in case if you have to re-intubate overnight, there are fewer people around, it’s just safer to extubate or remove the
breathing tube during the day. That’s not to say it can’t be done overnight, but most ICUs actually do have policies and procedures to avoid extubation overnight or in the middle of the night. Anyway that leads me back to why your mom probably went on BiPAP. So she had a pneumonia or she has pneumonia. So here’s what happens during cardiac surgery.
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Laureen, when patients have cardiac surgery, they go on a bypass machine, also known as the ECMO machine. Now, what’s happening, during bypass ECMO, the lungs are collapsed and when the lungs are collapsed, right? The risk for pneumonia to develop is so much higher because alveoli
collapsed and gas exchange taking in oxygen and breathing out carbon dioxide is just so much more difficult after the lungs have been collapsed for a few hours, which could have also been another reason why to keep the breathing tube in for a few more hours because there is something, some ventilator function that’s called PEEP that keeps the lungs open at the end of expiration. And that really helps to open up the collapsed parts of the lungs and potentially could have avoided your mom and
developing pneumonia, but it’s too late now. She is on BiPAP and you need to deal with and she needs to deal with that.
So also, you’re mentioning that your mother had sustained low blood pressure and that could be part of the surgery because, during cardiac surgery or open-heart surgery, a lot of blood is often lost during surgery there’s a lot of bleeding, which means blood pressure usually goes down. And then if the blood pressure goes down, the kidneys aren’t perfused enough or not well enough. And that’s when patients go into kidney failure after open heart surgery. And this is what’s happened in your mother’s situation.
So you mentioned that she is also very sore, which is not uncommon. Again, after cardiac surgery, the chest is basically being cracked open, right? And that is very painful. Now, while your mother was in the coma on a ventilator with a breathing tube, she would have had probably some morphine or fentanyl and that would have kept her more or less pain-free.
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But now that she’s off the ventilator, they need to minimize the morphine and the fentanyl because she needs to be awake. But also the BiPAP can be very uncomfortable. And again, that’s probably why she’s in pain. Also, after open-heart surgery, patients have chest drains in their chest simply
because of excess drainage.
So again, after open-heart surgery, there is bleeding fluid accumulation around the heart and that needs to be drained because otherwise, patients could end up with a tamponade. And a blood accumulation or fluid accumulation around the heart that could lead to cardiac arrest. That’s why
the chest drains are there. Again, they should be coming out after a couple of days at the most if drainage has stopped. But if they’re still in, it’s very uncomfortable, very sore and it needs to be managed.
So with the pain management, in particular, you have mentioned also earlier, low blood pressure, your mom might be on vasopressors or inotropes such as noradrenaline or norepinephrine or epinephrine to maintain sustainable blood pressure. Furthermore, you also mentioned that your mother has gone into AF or atrial fibrillation, also known as AFIB. So what happens again, often after open-heart surgery, patients do go into AF or AFib.
You got to understand that during cardiac surgery the heart is often in the hands of a cardiac surgeon and they’re modeling around with the heart. And because I’ve seen such a surgery when I was working in ICU as a nurse, I’m not surprised that patients go into AF after open-heart surgery because they’re literally having their heart, in their hands and you know, they’re fiddling around with it while they’re doing surgeries.
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So I’m not surprised that patients end up in AF, post-open-heart surgery. So atrial fibrillation is also often caused by electrolyte imbalances such as low potassium or low magnesium. Again, that is often a result of bleeding and sometimes also a result of diuretics such as Furosemide or Lasix being given. And that’s when patients lose electrolytes such as potassium or magnesium.
So, therefore, it’s very important that after open-heart surgery, electrolytes such as potassium and magnesium are being checked regularly. And one way to manage AF or atrial fibrillation is to replace potassium and magnesium. And if that’s not enough medication management is necessary such as with Amiodarone or digoxin depending on how, whether it’s fast AF, where they’d slow AF, you wouldn’t give the digoxin if it’s a slow AF. And another option for treatment
of AF is cardioversion, where an electric shock will be put through the heart and the heart is basically getting reset so it goes back to a normal rhythm.
So those are all treatment options for AF or atrial fibrillation. On top of that, your mother is on dialysis and again with dialysis, potassium levels drop and therefore the risk for AF is even more increased combination of again, open heart surgery and dialysis and leading drops, electrolyte levels down
and therefore the risk for atrial fibrillation is significantly increased.
Next with pneumonia, your mother will need to be on antibiotics most likely. I hope they have found the bacteria and for now, I hope they have sent a sputum sample so they can isolate the bacteria for pneumonia so they can treat it with antibiotics.
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Furthermore after open heart surgery it would be very good if patients can get mobilized. What do I mean by that? The sooner a patient can get out of bed after open-heart surgery, the better it is for the lungs, the less likely it is. Patients develop a pneumonia. Why do they develop a pneumonia after open heart surgery? Again, the lungs are deflated during open-heart surgery have to be re-inflated. The risk for pneumonia to develop is very high. That’s number
one. Number two, after open heart surgery, patients have pain. It’s very difficult for them to breathe properly and if they can’t breathe properly because of the pain, again, the risk for pneumonia is increased because they can’t fully inflate their lungs and that again increases the risk for pneumonia. Next, also after open-heart surgery, your mother should have had an echo, an echocardiogram of the heart to see whether the actual valve replacement has been successful.
She should have had an ECG, which I know she’s had because somebody must’ve found in the ECG that she’s got atrial fibrillation. Also, what’s important, why it’s your mother is still on BIPAP to do regular arterial blood gases. I hope your mother still has an arterial line so they can check arterial blood gases and check the effectiveness of the BiPAP so they can see that oxygenation
is normal and also that CO2 levels or carbon dioxide levels are normal on the BIPAP.
Also, your mother should have daily blood checks, right? So especially hemoglobin levels are important to look at after open-heart surgery. Again, with all the bleeding that’s going on after surgery, your mother’s hemoglobin might be low and therefore, she might need a blood
transfusion. If hemoglobin drops below seven or six, she might need a blood transfusion. Also, other important numbers to look for are coagulation results such as INR, APTT.
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And again, check platelets for example as well. So to make sure there is no bleeding and also check the white cell count. With your mother’s pneumonia, her white cell count might be increased. White cell count will indicate whether your mother has an infection or not. Obviously, all other
vital signs need to be looked at, such as, you know, blood pressure, heart rate, temperature. You know, if your mother has pneumonia and she might have a temperature, other things that need to be looked at.
As I mentioned before, electrolyte results such as magnesium, potassium need to be checked regularly, you know, and that’s all part of the routine checks. Now those are the type of questions you should be looking for, talking about mobilization as well. One of the challenges that I can see why a mother may not be able to get mobilized at the moment is because she is on dialysis.
It really depends on where her vascular catheter sits. So if a vascular catheter sits in her shoulder or in her neck, she should be able to get mobilized should she should be able to get out of bed. If your mother’s vascular catheter for the dialysis sits in the groin, it’ll be very difficult for your mother to get mobilized and sit in a chair because as soon as she sits in a chair, the vascular catheter in the groin gets kinked and she can’t have dialysis.
So those are the issues to look out for Laureen and you know, I’ve given you ideas about what questions to ask, but as always, you know, you’ve been a member of our membership platform and that’s really great, but the best way for you to get all the right answers and also for us to help you advocate to get your mother out of ICU is for you and me to speak to the doctors and we can set that up.
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That is the shortcut to give you faster results and help you faster to get your mother out of intensive care and get her the right care and treatment. The biggest challenge as I always say for families in intensive care is that you simply don’t know what you don’t know. If you don’t know what to look for if you don’t know what questions you need to ask. And if you don’t know how to manage doctors and nurses, you’re fighting an uphill battle.
Again, imagine you would have come into ICU and you would have known not to extubate in the middle of the night. Maybe your mother would have had a few more hours of ventilation with a breathing tube and then she would have been ready for extubation. She would have had more PEEP overnight, higher pressures, and maybe pneumonia could have been avoided.
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We don’t know. But again, if you don’t know what to look for, if you don’t know what questions to ask, it’s very difficult to avoid complications. And this is exactly what’s happened to your mom in this situation. So thanks again Laureen for being a client.
Kind Regards
