My husband hasn’t been waking up for the last two weeks after open heart surgery and he remains in an induced coma in Intensive Care! Is this normal?

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 last week was

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

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 one of our readers and the question this week is

My husband hasn’t been waking up for the last two weeks after open heart surgery and he remains in an induced coma in Intensive Care! Is this normal?

The following question from Erin is an excerpt from a phone/Skype 1:1 counselling and consulting session with me.

Erin writes

Hi Patrik,

My husband has been in a medically induced coma after Open Heart Surgery(three Bypass grafts) for now 14 days.

During this time period he had only responded minimally to commands on a few occasions.

Me and my family have been wondering if this is normal and how long it could take?

My husband is 64 years of age and generally speaking in good health. He had to have cardiac surgery because he had Angina in the last six months and he was getting short of breath all the time and he could barely get up the stairs in our house because he was getting exhausted quickly.

He had a stent put into his heart about a year ago, but his Angina has gotten worse again even with the stent.

Initially, in the first 24 hours after he had the heart surgery, he developed severe bleeding and he had to go back to the operating theatre for the bleeding.

During his stay in Intensive Care in the next 24 hours, he required multiple blood transfusions and he therefore didn’t wake up because they kept him in the coma until he stopped bleeding.

After about three days after surgery, they were trying to wake him up, but he wouldn’t and he was fighting the ventilator, so they had to put him back into an induced coma.

It’s now been two weeks and he still hasn’t responded appropriately. Every time they’ve been trying to wake him up, he would fight against the ventilator, not breathe up properly and then they have to put him back into the induced coma.

They have done a CT scan of his brain and the CT scan was fine and it didn’t show anything wrong with my husband’s brain.

Another issue he’s dealing with is having high blood sugars and he’s now requiring an Insulin infusion.

The doctors have been telling me and my family that he will “wake up” that he needs more time.

Is this normal that it takes so long and what can we do to help my husband?

Many thanks,

Erin

Hi Erin,

thank you for sending through your question and thank you for using my 1:1 phone/Skype counselling and consulting service.

It must be very difficult and frightening to watch your husband not “wake up” after two weeks after an induced coma for open heart surgery. I can see why you are seeking out for help and try and find out how I can help you in this difficult situation.

Now “waking up” after two weeks after open heart surgery in Intensive Care must feel like an eternity for you and I will put things in perspective for you.

First of all, not “waking up” after an induced coma after open heart surgery or bypass grafts is happening very rarely but it certainly does happen and I have seen it in ICU a few times.

Most of the time if it does happen, it almost follows this sequence that you have described in your first email to me.

Some Patients after they had open heart surgery (usually for Bypass grafts or valve repairs or valve replacements) they start bleeding and they need multiple blood transfusions.

Open heart surgery is high risk surgery and the risk for bleeding and going back to the operating theatre after open heart surgery is real.

Many Patients who come back to ICU after open heart surgery have been on blood thinning medication(=anticoagulation such as Aspirin, Clopidogrel/Plavix or Warfarin) before they have open heart surgery. Depending on when it’s save for the Patient to cease the anticoagulant medication before surgery, it still comes with a higher risk of bleeding after the surgery.

I’m sure your husband would have been on Clopidogrel/Plavix before the surgery because of his stent and whilst they would have stopped the Plavix/Clopidogrel before the surgery, it would have still increased the risk of bleeding manyfold.

Therefore the bleed after the surgery, the return to the operating theatre and the delay in “waking up” don’t come as much of a surprise to me.

From my perspective and from my experience there are three major forces at play that contribute to your husband not “waking up” after the induced coma

Major surgery with an induced coma

Return to the operating theatre for bleeding, therefore a delay in “waking up”

Massive blood transfusions to stop the bleeding- massive blood transfusions have a tendency to slow “waking up” down after an induced coma

The combination of those forces, are often what delays critically ill Patients from “waking up” after an induced coma.

Related article/video:

What is an induced coma and why is my critically ill loved one in an induced coma?

The good news is that they have already done a CT scan of your husband’s brain and they have already ruled out any brain damage. Therefore your husband is “just” taking his time to “wake up”. I will explain what that means in a moment.

Lets quickly also look at what most likely contributed as well to your husband’s delay in “waking up”.

When your husband wasn’t “waking up” properly while he was fighting the ventilator they most likely would have changed some of the sedatives and there is a high chance that he was changed from Propofol(Diprivan) to Midazolam(Versed). Propofol(Diprivan) is a short acting sedative and Midazolam(Versed) is a long acting sedative.

Normally if it’s expected that an induced coma is short lived, Propofol(Diprivan) is the drug of choice and for an ongoing induced coma, Midazolam(Versed) is the drug of choice.

Especially if your husband was fighting the ventilator and he couldn’t be “woken up”, there is a very high chance that they changed sedation from Propofol(Diprivan) to Midazolam(Versed).

This often helps with better sedation and also a smoother “waking up”, but it can also often dampen your husband’s response because Midazolam(Versed) is a longer acting sedative because of it’s prolonged half life compared to Propofol(Diprivan).

On top of that, your husband would have had Morphine or Fentanyl for pain relief. After all, open heart surgery is very painful and requires a fair amount of opioid drugs such as Morphine or Fentanyl.

In normal circumstances after open heart surgery where Patients don’t bleed, come off the ventilator within 12-24 hours after surgery, Morphine or Fentanyl is ceased and Patients go on to “lighter” opioids such as Endone(Oxycodone), Codeine Phosphate, Tramadol or Targin.

Because your husband was staying in the induced coma, he would have continued on either Morphine or Fentanyl and again the combination of Midazolam(Versed) and the Morphine or Fentanyl can be so potent that a delay in “waking up” is almost inevitable.

Related article/video:

HOW LONG CAN YOU KEEP A CRITICALLY ILL PATIENT IN INTENSIVE CARE IN AN INDUCED COMA?

Therefore, even though two weeks is not a particularly long time in Intensive Care terms for an induced coma, if you see your husband unresponsive for such a period of time it will feel like an eternity to you…

Now, given that your husband had such big surgery, he will also take his own time to recover. Most critically ill Patients in Intensive Care will take their own time to recover no matter how much the Intensive Care team and families want to speed up the process.

As a next step what could happen is that the Doctors might give your husband some either Naloxone(=Antidot for Morphine or Fentanyl) or Flumazenil(=antidote for Midazolam) to help him coming out of the induced coma and “wake up”.

If the Intensive Care team is still waiting for your husband to “wake up” without giving antidotes for Morphine/Fentanyl or Midazolam(Versed), then you may have to remind them of what you want them to do.

As a rule of thumb and general advice, sometimes it’s best to wait and see, however the longer your husband isn’t “waking up” after the induced coma, the higher the risk that he might need a tracheostomy and that’s something you, as well as the Intensive Care team would want to avoid.

Therefore reminding the Intensive Care team of what can be done is probably a worthwhile exercise. It shows them that you’re not afraid to demand things and it shows them that you’ve done your research.

Furthermore, what you and your family can do is certainly to keep asking all the right questions to the doctors and the nurses and by me advising you, they will very quickly see that you know what you are talking about.

Related article/video:

How Long Does It Take To Wake Up After An Induced Coma?

You have also mentioned that your husband is now on an Insulin infusion for high blood sugars despite not being a diagnosed diabetic.

This is nothing uncommon for a critically ill Patient in Intensive Care. Many Patients in ICU end up with high blood sugars despite not being diabetic and therefore have an Insulin infusion at least temporarily.

The reason being is that a high blood sugar tends to be a stress response from the body during critical illness.

High blood sugars and temporarily being on Insulin is rather common in Intensive Care for non-diabetic Patients and blood sugars usually go back to normal after the stay in Intensive Care.

Moreover, I would also advise you to talk to him when you are with him, just like if he was awake. There is a very good chance that he might hear you.

Touching him, holding his hand and just talking to him will help also.

I wouldn’t advice spending day and night in Intensive Care, because your husband will need you more when he’s more awake and on his way to recovery.

Sometimes it just takes time and I have seen those situations before, however if it’s ongoing the risk is getting higher for your husband needing a tracheostomy and again it’s something you want to avoid.

What’s really important Erin is that you take this advice and run with it. I have counselled families in the past who don’t use the advice that I’m giving them and then they don’t get the results.

Just implement what I’m teaching you and you’ll get the results!

Wishing you and your family all the best!

Your friend

Patrik

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