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
Should I Give My 100% Trust to the ICU Team Who’s Managing my Critically ill Mom in the ICU?
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 Juan, as part of my 1:1 consulting and advocacy service! Juan’s mom is with a tracheostomy, balloon pump and is on ECMO.
Juan asks what to expect if her mom will finally come off ECMO.
What Should We Expect if Our Critically Ill Mom in ICU Will Finally Come Off ECMO?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Juan here.”
Part 1
Part 2
Part 3
Part 4
Part 5
Part 6
Part 7
Part 8
Part 9
Patrik: Hi, Juan. How are you?
Juan: How are you?
Patrik: I’m very well. Thank you.
Juan: Great. So yeah, today’s been all good.
Juan: So as well, because earlier her BP was fluctuating a little bit from the early part of the night, and they’d introduced a tiny dose of Azor, but then they took it off. And this morning, she’s been stable, she’s been good. They clamped the arterial cannula line earlier to
test it out, and she responded well to that. And so they’ve scheduled for the removal today.
Patrik: That’s great.
Juan: Yeah. Yeah. I think there’s only Fentanyl she’s been on today at four.
Patrik: Is she waking up? Have you seen her?
Juan: Yes, we saw her. Her eyes are open. She was moving quite a lot. She’s trying to talk a lot. She’s been moving her tongue a lot, moving her mouth. She was responding to the nurse as she was cleaning her mouth and telling her to open and take out her tongue. So it seemed like she was responsive to her as well. She was responding to our voices. Yeah. I think she showed them and us, I think, that she’s ready for this to happen today. So I think
that’s just the focus for now.
RECOMMENDED:
Patrik: That’s fantastic. When you say she’s moving around, is she moving her legs? Is she bending her knees?
Juan: No. It’s her head. It’s her head, mostly. Her head, he moves it from left to right. And she’s moving her mouth a lot, like opening it, trying to talk, trying to sort of make sounds. She’s licking her lips a lot or attempting to.
Patrik: That’s great. That’s really positive. Now, it sounds to me like she’s ready for that. And with the Milrinone and the Noradrenaline they introduced, do you think that’s a result of you pushing for it or do you think they would have done that anyway?
Juan: No. I think as from what the actual specialist said, he said, “Yeah, we use Milrinone. I’ll be using Milrinone mostly throughout.” So it sounds like something that they do anyways. I just think that that protocol or the way they go about it here is a bit different. And that it seems like they would begin it the day of, or yeah, very soon before they begin the ECMO removal, and probably carry it on for a few days to support the removal of it, I think. It seems like that.
Patrik: Right. Okay. Yeah, it’s very different compared to what I have seen. I’m still worried about the balloon pump.
Juan: I think they plan to remove that tomorrow.
Patrik: Okay.
Juan: It sounds like it.
Patrik: Look, if they think they can do it, that’s great. My concern is around the cardiac output. When I see what the cardiac output is like, it’s around five. That is obviously the last pictures you’ve sent me of the cardiac output on five on ECMO, on the balloon pump. My question is what
happens with the cardiac output without ECMO, without the balloon pump. That is my question, which is why I keep coming back to have they introduced the Milrinone quick enough.
Juan: Hmm. I think that’s a fair question. We can ask them definitely, how do you feel like the removal of the ECMO and then the balloon pump will affect cardiac output? What should we anticipate? We will bring that up and we can talk to them about it. When we did talk about it yesterday, again, it just seems like that’s quite standard protocol here. It seems like that’s the way they’ve done it with lots of patients. So I don’t think this is
something completely new here, but it definitely seems like it’s something very different from how they do it wherever you are or maybe in other countries as well.
Recommended articles:
Patrik: Yes. Yes. Yes. And that’s fair. I mean, as long as they get the same outcomes, I guess, all you worry about is the outcome, really.
Juan: Yeah. Yeah. It almost seems like… They’ve said multiple times, and different doctors who otherwise disagree or have different perspectives on other things have all said this is the way they do it here, and that they keep doing it here. So I guess, yeah.
Patrik: That’s all right. That’s all right. As long…
Juan: Oh, there’s one more thing. They were talking yesterday about wanting to measure volume analysis or do volume analysis, and they were talking about either using a PiCCO (Pulse index Continuous Cardiac Output) device or FloTrac for that. So, I think they’re going with FloTrac.
Patrik: I would feel much more comfortable with a PiCCO than with a PA catheter. And I’ll tell you why.
Juan: Sure.
Patrik: I’ll tell you why. You get the same measurements and it’s less infection risk.
Patrik: So basically, how the PiCCO works, from memory, you need access at the central line and you need access at the arterial line, and then you inject whatever you inject to get your cardiac output measurements.
Juan: That’s right. That’s right.
Patrik: Right. Right. So it’s less invasive and less infection rate compared to a PA catheter.
Juan: Right. So, that’s good to know. We’ll just call them now and talk about that. Because they did tell us that yesterday, when we spoke about a PiCCO device. They told us that it’s not invasive, or they didn’t say that about the FloTrac.
Patrik: Yes, it’s less invasive because you are using what you’ve got already, without inserting something else. So basically, what it means is… So at the moment, she’s got the PA catheter, which is you’ve got to insert that, whereas with the PiCCO, your mom has a central line and your mom has
an arterial line, and you can use the PiCCO with those two devices, so you don’t need an extra device. Yes, you are attaching something new, but you are attaching to an already established line.
Juan: Is there a reason why they would say FloTrac over PiCCO?
Patrik: Hang on, just give me a second. Did you say FloTrac?
Juan: Yes.
Patrik: FloTrac…
Juan: F-L-O-T-R-A-C.
Patrik: … over PiCCO. Just give me a second.
Juan: Okay
Patrik: Oh, that’s even better. Okay, now I know what they mean. The FloTrac, they’re talking about, an external monitor. That’s even better. That’s even not invasive at all. So you said they are going to use the FloTrac and not the PiCCO?
Juan: Yes.
Patrik: Oh, I see. That’s even better. That’s even better. It’s a specialized sensor that attaches to the arterial line. And basically, the pressure readings from the arterial line, you can calculate the cardiac output, right? So, that’s even better. You don’t even need the central line for that.
Juan: Oh, excellent. Okay. So, that’s what they’re going to be using.
Patrik: Yeah, that’s even better.
Suggested links:
Juan: And there’s been a tiny improvement in the SGOT SGPT.
Patrik: Improvement in what? In?
Juan: SGOT SGPT.
Patrik: Sure. Yeah. That’s good. That’s good. Now it looks like everything is heading in the right direction.
Juan: Great. Okay. That’s good to hear. I think once we cross that bridge, then we’ll just know the next steps. You know exactly where they’re headed.
Patrik: So they will remove ECMO today.
Juan: Yeah.
Patrik: Okay. Hopefully, it’ll get through the night. They wouldn’t do it if they didn’t feel confident. And they could always increase the Milrinone and the Noradrenaline, if they felt like that’s needed, and then reassess tomorrow. You don’t really want to cannulate ECMO overnight, unless you really have to.
Juan: Right. Okay. What should we expect after this procedure, Patrik, for the rest of the day?
Patrik: Well, if they feel confident that ECMO removal is the right thing to do, cardiac output shouldn’t change. My concern is, is cardiac output going to change? My concern is, is organ perfusion going to change? Is her blood pressure going down?
Juan: Okay.
Patrik: Right? I mean, according to them, nothing is going to change, because the balloon pump and the Milrinone will keep her cardiac output at a certain level. I guess you’ll have the answer to that fairly quickly.
Juan: Okay. Okay. All right.
Patrik: How many days now, ECMO? 15 days?
Kevin: Yeah, ECMO around… Yeah, the VA ECMO is 20 days.
Patrik: 20 days. Right. Okay. Well, the longest that I’ve seen is around three weeks, so it’s yeah, hopefully, they can make that shift without too many issues.
Kevin: Well, they clamped it this morning.
Patrik: So when you sent me the pictures earlier, was that on a clamped line?
Juan: No, we’ve not sent you pictures from today, actually. We’re going to go see her before the procedure, so we take some pictures and send them to you before as well.
Patrik: Right. Because with the clamp line, if her cardiac output is still at five, well, that’s a good sign.
Juan: So Kevin, when they clamped it this morning, did they reopened it again? Yeah? Okay. So we’ll check, and we’ll just get some photos anyway.
RECOMMENDED:
Patrik: Because that’s what it is. You clamp the line, you’re basically taking ECMO off.
Juan: Yeah. Yeah.
Patrik: Does that impact the cardiac output? If it doesn’t, well, she’s definitely ready.
Juan: Yeah. Yeah. I think that’s what they tried in the morning, and they obviously felt confident. And I think all the doctors said yeah, she’s looking good, she’s looking ready. So I think they are comfortable. So now it’s up to… Yeah, we’ll see.
Patrik: Yeah.
Juan: Okay.
Patrik: Wonderful. Okay. Well done.
Juan: Thank you, Patrik.
Patrik: Thank you so much.
Juan: Well done. Thank you for all your help.
Patrik: Oh, pleasure. Pleasure.
Juan: Okay. We’ll keep you posted.
Patrik: Thank you so much. Thank you. Bye-bye.
Juan: Bye.
Patrik: Bye.
The 1:1 consulting session will continue in next week’s episode.
