This is another episode of “YOUR QUESTIONS ANSWERED" and in last week’s episode I answered another question from our readers and the question last week was

Thank you for keeping me going! My 64 year old sister has Legionella’s disease and has been in an induced coma for 6 weeks! The doctors wanted to withdraw treatment but we stood firm and now my sister can live! What should we do next?

 You can check out the answer to last week’s question by clicking on the link here.

In this week’s episode of “YOUR QUESTIONS ANSWERED”  I want to answer another question from our readers and the question this week is

My brother is in ICU with cardiac arrest, abdominal sepsis, ventilated and in an induced coma, will he need a tracheostomy?

This question from Prim has been part of an email counselling and consulting session with me.

Prim writes

Hi Patrik,

I need your urgent advice!

I am very worried about my brother who went into hospital with abdominal pain and was diagnosed as diverticulitis.

We have been told that he had a minor heart attack, also septic shock and Peritonitis.

He was transferred to another Hospital where they operated on him and they found he had an abscess in his abdomen.

He was put in an induced coma and on artificial ventilation since last Tuesday.

It has been 6 days now since he was operated on. They are trying to wean him off the ventilator, from what we have been told he has opened his eyes and cried.

He is breathing 60% by himself and 40% by the Ventilator. They are gradually reducing the sedation.

He became very agitated and when they first removed the ventilator he had a cardiac arrest, so they had to put him back on the ventilator.

He also has a fever and chest infection and today they have started him on Antibiotics. My main worry is that they are going to perform a Tracheostomy without giving the Antibiotics a chance to work and also not giving him enough time to be weaned off the Ventilator.

6 days seem too short as he is not breathing by himself.  With the chest infection his lungs are not strong enough to cope with breathing, surely they need to see if the Antibiotics work and he gets strong enough to breathe by himself.

The problem as I see is they have made a decision to do a tracheostomy without giving us all the risks and options.

They have told my sister in law that it will be for 48 Hours and it will heal. I am not sure this is correct?

Should we ask them to delay doing the Tracheostomy by 7 days to see if he is strong enough to breathe by himself? How long does he have to live with a Tracheostomy?

Many thanks look forward to hearing from you.

Prim

Hi Prim,

thank you for your question and thank you for using my email counselling and consulting services.

I'm very sorry to hear what you and your family are going through with your brother!

And congratulations for seeking advice and not just relying on what the Intensive Care team is telling you.

The main thing that stands out to me here Prim is that your brother still has a chest infection and that he had a cardiac arrest after his first attempt to remove him from the ventilator(=extubation).

The cardiac arrest is most likely why the Intensive Care team may want to do a tracheostomy in the first place.

What also stands out to me is that your brother had a minor heart attack in the beginning and the cardiac arrest unfortunately would have caused some more damage on his heart.

But let’s look at the bigger picture as well.

Your brother went into hospital with abdominal pain which turned out to be diverticulitis and peritonitis. Peritonitis is abdominal sepsis and was most likely caused by the diverticulitis(=inflammation of a diverticulum, especially in the colon, causing pain and disturbance of bowel function).

He had to have bowel surgery and the peritonitis was confirmed by the abscess they have found.

This is obviously a major concern and a major cause of the sepsis and the subsequent septic shock.

On top of that your brother has a chest infection which he’s on Antibiotics for. Your brother would also be on Antibiotics for the Peritonitis. Given his various sources of infection, he would be on a few Antibiotics.

Furthermore, even though it’s very likely that he has a septic shock from the chest infection and the Peritonitis, he might also have a cardiogenic shock from the heart attack and the cardiac arrest.

Therefore your brother would have sustained hypotension(=low blood pressure) and he is most likely on inotropes to stabilise him and resuscitate him.

Therefore the issue of performing a tracheostomy or not can’t be looked at in isolation.

Whilst you are absolutely correct to say that your brother should be given more time before performing a tracheostomy, what might work against him is that he has had one failed extubation(=removal of the breathing tube/endotracheal tube) already that caused him to go into cardiac arrest.

When critically ill Patients in Intensive Care are failing extubation(=removal of the ventilator and the breathing tube/endotracheal tube), the risk for them to get a tracheostomy is increased.

Lowering sedation and see how your brother is coping to get out of the induced coma makes sense.

Normally a tracheostomy should be performed after 7-14 days of ventilation with a breathing tube/endotracheal tube.

And a tracheostomy once inserted might stay for many days, weeks or sometimes even months. Therefore it makes perfect sense that you want to make an informed decision before you give consent to a tracheostomy.

Related articles/videos:

• HOW LONG SHOULD A PATIENT BE ON A VENTILATOR BEFORE HAVING A TRACHEOSTOMY?

• Why would a critically ill Patient in an induced coma need a tracheostomy in Intensive Care?

• Why does my loved one need a Tracheostomy in Intensive Care?

Moreover, the heart attack and the cardiac arrest may put further strain on your brother.

Let me explain.

Cardiac arrest and/or a heart attack weaken the heart. Therefore your brother may have an increased risk of getting fluid overloaded on his chest, due to the heart being weakened and potentially de-compensated.

This could potentially get your brother into pulmonary oedema(=fluids on the lungs).

Normally this is treated with Diuretics(medication to increase urine output and offload fluids) as well as inotropes for strengthening the heart and increase blood pressure.

Your brother would have most likely also had an Echocardiogram or TOE for his heart after the heart attack and after the cardiac arrest.

In the Echocardiogram or TOE they would have been able to determine your brother’s ejection fraction(measurement of the heart’s ability to pump blood).

After cardiac arrest and/or heart attack, there is a chance that your brother’s ejection fraction has been lowered and again the risk for going into pulmonary oedema is increased.

With all of this in mind, you now have the bigger picture what needs to be considered from a clinical point of view.

And I agree with you that they should try and extubate your brother again before performing a tracheostomy.

Many critically ill Patients before getting a tracheostomy may well go through a couple of failed extubations in order to be sure that a tracheostomy is the right thing to do.

And you are right that doing a tracheostomy after only 6 days is potentially too early, especially since they haven’t explained the bigger picture to you.

The pros and cons of a tracheostomy are outlined here

Related article/video:

• “WHAT ARE THE RISKS AND BENEFITS OF A TRACHEOSTOMY?”

Overall, the next steps for your brother are

• Clear the infection in his bowels and on his chest with Antibiotics

• Manage the weakness of the heart with inotropes(=medications to increase blood pressure and improve the contractility of the heart)

• Get out of the induced coma

• Try and extubate(=removal of the breathing tube/endotracheal tube), again if your brother is “waking up” after the induced coma within the next few days

• No matter how much you want to speed up your brother’s recovery, he will take as much time as he needs

• It’s very rare that you can speed up “waking up” after an induced coma, your brother will need time

• Again, if your brother isn’t “waking up” quick from the induced coma it increases the likelihood of him needing a tracheostomy

• If your brother’s heart is weak with poor ejection fraction, as well as ongoing chest infection it’ll increase the risk of getting a tracheostomy

• Both infections, the chest infection and the peritonitis are making it more likely to delay “waking up” after the induced coma

• Normally 6 days after surgery and not “waking up” is almost a normal time frame in ICU terms, however the failed extubation as well as the cardiac arrest/heart attack have increased the likelihood for your brother needing a tracheostomy

Further reading

• THE 7 ANSWERS TO THE 7 MOST FREQUENTLY ASKED QUESTIONS IF YOUR LOVED ONE REQUIRES ONGOING MECHANICAL VENTILATION WITH TRACHEOSTOMY IN INTENSIVE CARE!

• THE 7 ANSWERS TO THE 7 MOST FREQUENTLY ASKED QUESTIONS IF YOUR LOVED ONE IS A CRITICALLY ILL PATIENT IN INTENSIVE CARE!

• THE 7 QUESTIONS YOU NEED TO ASK THE MOST SENIOR DOCTOR/ PHYSICIAN/ CONSULTANT IN INTENSIVE CARE IF YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE- you’ll also get one BONUS QUESTION at the end of the EBook/Video or Audio recording!

Your friend

Patrik Hutzel

PS: I only have one slot left for counselling/consulting left for the weekend, as I'm fully booked otherwise. Let me know if you want the one slot left by hitting reply to this email or by calling me on one of the numbers below!