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
How Can We Keep Our Dad with Tracheostomy in ICU if They Push Him Out to LTAC?
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 Rosie, as part of my 1:1 consulting and advocacy service! Rosie’s dad is with a tracheostomy and is
on a ventilator in the ICU. Rosie asks how the ICU team can get her dad off a prolonged induced coma.
How Can the ICU Team Get my Dad Off this Prolonged Induced Coma?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Rosie here.”
Part 1
Part 2
Part 3
Patrik: They would be ventilating him with pressure control, they would be controlling the pressure but they can’t control the volume. But by using pressure instead of volume they are risking, they’re minimizing the risk of a hole in his lung.
June: Okay.
Patrik: But also they’re minimizing the volume they can give him. He then might get air. So it’s a fine line they’re walking there, very fine line. The line between how can we ventilate him adequately and how can we not cause any more damage?
Which again comes back to ECMO. If you’re using ECMO you give the lungs a rest. The lungs can just rest and heal. The ECMO whilst it’s not a miracle machine, but the ECMO buys people time because it takes over the function of the lungs 100%. That’s why it should have come in early.
June: We’ll ask but it’s a low probability.
Patrik: You should ask.
June: Yeah. It’s a low probability.
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Patrik: Yeah it’s a low probability I agree. But it’s definitely a question you should ask. I think you should just do it just to let them know that you are doing research.
June: So, if he went on ECMO they would remove the Nimbex, but wouldn’t he still have the urge to breathe?
Patrik: No, because they can give him all the oxygen he needs through the ECMO, he wouldn’t have the urge to breathe. ECMO takes … You could hook up an ECMO machine to any of us and you could stop breathing because the ECMO machine is doing the breathing for you.
June: So-
Linda: How is that different from a ventilator?
June: So, it’s not through the lungs right?
Patrik: No, it’s external.
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June: So right now he’s saturating in the high 90s anyways right? So he gets what he needs right now.
Linda: Through the ventilator.
Patrik: On Nimbex.
June: On Nimbex yeah.
Patrik: That’s the negative. Yes he gets everything he needs but in order to achieve that, he gets Nimbex, he gets versed, and he gets fentanyl. He gets this toxic cocktail of medications.
June: Yeah.
Patrik: In order to achieve that.
Linda: Yeah.
June: So is Nimbex a drug that needs to be weaned off?
Patrik: As quickly as possible.
June: No.
Linda: No.
June: I know the answer, obviously we know that but is it something … Is it like a switch, is it on or off?
Patrik: I see what you mean.
Linda: Can you like decrease the amount that you give slowly, slowly and wean off?
Patrik: Yeah look that is the ideal, you should wean it down like step by step but I have seen you just switch if off and see what happens. If that doesn’t work you go back to whatever, 2 mg and then you wean it down to 1 mg maybe for 12 hours and then you switch it off. I have seen both approaches.
June: Yeah, okay.
Rosie: In your realistic opinion with them adding that other sedative into it or whatever they’re adding to wean that off you think that would work?
Patrik: No not really because it’s antipsychotic drug. Having said that, when patients are in prolonged induced comas, so your dad has been in a prolonged induced coma, with that, when he wakes up there is a very high chance that your dad will have ICU
delirium or ICU psychosis. That’s when you might bring in the haloperidol, right? But in order to wean the Nimbex I have not heard that. Yes the haloperidol might have its time and its place when people come out of an induced coma. But I argue, from my experience I don’t think that the Haldol will help to get her off the Nimbex.
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Rosie: It’s not the Haldol, it’s another medication.
Patrik: Oh the other one yes the other one yes.
Linda: Yeah.
Patrik: Yeah the other one yeah.
June: I’ll get the spelling, proper spelling tomorrow.
Linda: Yeah.
Rosie: Yeah because it might not be the same medication were talking about.
Patrik: Because fentanyl is an opiate, versed is a-
Linda: Salpril
Patrik: Pardon?
Linda: No it’s called Salpril.
Patrik: Salpril.
June: We don’t know what that is.
Linda: We don’t what the spelling.
Patrik: Right so, fentanyl is an opiate, versed is a benzodiazepine. And the Salpril is something entirely different, right? When someone is in an induced coma you use usually versed, fentanyl you might use propofol I don’t know whether you’ve heard of propofol?
June: Yeah.
Linda: Yes.
Patrik: It doesn’t matter. Then as you take patient out of that coma and if they are delirious and if they are having a psychosis, yes that’s when you might introduce the Haldol or the other one that you’ve just mentioned the Salpril. But before that we’re not even there yet. Before that you need to take away the Nimbex. So, I’m curious to find out how that is supposed to work.
Linda: Yeah.
June: Me too.
Rosie: But we might have that name wrong too though because I mean the way that he mentioned it, it was-
Linda: Yeah.
Patrik: Ask them for precedex, P-R-E-C-E-D-E-X
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Linda: What is that for?
Patrik: That’s a light sedative. They’re saying that Precedex, if you use Precedex you don’t need to use fentanyl and you don’t need to use versed. The debate is out there, for some patients it works, for some patients it doesn’t. The other medication you could ask them for is clonidine C-L-O-N-I-D-I-N-E. As them for clonidine.
Linda: Okay. You know I don’t know if we have enough time, I just had another random question about and this is not necessary its COVID related about Ivermectin. What is your kind of take on that for therapeutic and then also this is not
specifically for him, but just for other family members? What do you think about Ivermectin?
Patrik: What is it? I haven’t heard of it.
Linda: No it’s-
June: No, well it’s now part of some of the protocols for early COVID patients.
Patrik: In ICU or in the community?
June: Or even prophylactically.
Patrik: I have not heard of it. I wouldn’t even have an opinion on it and I’ll tell you why, my area of expertise is ICU that’s my area of expertise. Anything that’s sort of-
June: But if you look up there’s something called the I-mask protocol.
Patrik: How do you spell that?
Linda: M-A-S-K.
June: Yeah
Linda: I-MASK.
June: Just I-MASK, like you know the face mask.
Patrik: Oh like I-MASK, okay.
Linda: Protocol.
Patrik: Protocol.
Linda: Yeah. Anyways.
Patrik: Okay it’s coming up, just give me a second. Prophylactic and early outpatient treatment protocols.
Linda: Yeah.
June: They also suggested for ICU patients as well.
Patrik: Right.
June: It’s basically a-
Linda: It’s an antiparasitic.
June: It’s supposed to be better than I would say Remdesivir.
Linda: Remdesivir.
Patrik: Remdesivir yeah.
Linda: Who knows?
Patrik: Who knows? I do believe in two years’ time, in three years’ time there will be standard protocols around the world how to treat COVID in ICU. I think it’s still all experimental, that’s what I believe.
Linda: Yeah.
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Patrik: I have not come across the I-Mask, I’m talking to families that have loved one’s in ICU with COVID every day. I have not come across the I-Mask, it’s the first time actually that I’m hearing about it.
June: Yeah some hospitals are already putting it into action here.
Patrik: Right, have you asked them about that?
Linda: I think for him-
June: He’s too far.
Linda: Too far.
June: He’s far along right?
Patrik: Too far.
June: Yeah.
Patrik: To far down the line.
Linda: This is probably better for when your first onset of symptoms or even therapeutic-
June: When you first enter the hospital that’s probably when you want to.
Patrik: Right. I’m sure it’s constantly evolving until COVID is either eradicated or they find a good strategy to treat COVID in ICU in particular. So, sorry that I can’t really answer your question on that one.
June: That’s all right.
Linda: It’s okay.
Sarah: Is clonidine an alternative for the Precedex to take over versed and fentanyl?
Patrik: Precedex has clonidine in it. So Precedex is partly clonidine and then you’ve got clonidine as a standalone sedative, right. Precedex again the argument is that, is if you use Precedex you don’t need fentanyl, you don’t need versed.
Clonidine is just a light sedative but doesn’t really work on pain that much, whereas Precedex does.
Sarah: Okay so then he would still continue some of these other medications then?
Patrik: Well yes but hopefully not. That might be one strategy to get him off the versed. He needs to come off the Nimbex, but then he needs to come off the versed and the fentanyl because of the addictive nature of those drugs.
June: Yeah.
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Rosie: Cool. Okay. All right Patrik.
Sarah: Thank you.
Rosie: Thanks for your time man appreciate it.
Patrik: It’s a pleasure. I really hope I could do more. I believe I can do more if he can come off the Nimbex. If they can’t get him off the Nimbex it will be a struggle.
Rosie: Okay. All right appreciate it.
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Patrik: No thank you.
Linda: Thank you so much.
June: Thank you Patrik.
Patrik: Thank you. I wish you all the best for now and I really hope that they can get him off the Nimbex as the next step.
June: Me too.
Linda: Yeah. Thank you.
Patrik: All the best.
Linda: Bye.
Patrik: Thank you so much.
June: Thank you Patrik.
Patrik: Bye, bye. Thank you bye.
The 1:1 consulting session will continue in next week’s episode.
Kind regards,
Patrik
