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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip and questions answered for families in intensive care.

So Reggie writes me an email and she says that her 76-year-old mom had a stroke and a seizure. She was found at home and she had trouble breathing on her own, so they called an ambulance and then they suggested putting her on a ventilator but in order to do that, they obviously had to induce her mom into a coma and now the ICU has run several tests and  they can’t figure out why she won’t wake up.

She was also diagnosed with dementia last year, and Reggie’s very nervous about her mom’s brain activity, although everything looked fine up to now. Any insight I could give would be great. Thank you in advance.

So Reggie, getting your mother on a ventilator always requires an induced coma. There is no such thing as ventilation with a breathing tube in intensive care without inducing somebody in a coma because it’s very painful, very uncomfortable and the body also needs to rest and it’s the same on the other hand, an induced coma also always requires mechanical ventilation and a breathing tube.

Also dementia, potential seizures and a stroke will delay waking up after an induced coma. It would be good to know if your mom is still on any sedatives such as midazolam or versed or on propofol or diprivan. And future prognosis will also be determined by a cat scan or an MRI scan of the brain. Have they already done that? Do you know?

So then Reggie writes back, she says, my mom is on no other sedatives and according to them, the CT scan look good. She has a breathing tube which they want to transfer to her neck. They’re saying that it would make them more comfortable and they also want to place a feeding tube in the stomach cause it’s been day nine and the nutrition may leak into her lungs if they don’t move the feeding tube.

I guess my frustration is that they tell me they have no idea why she won’t wake up and the hospital that she’s in is a two-star hospital. I am contemplating getting her transferred to a better hospital, but at this point in time, I’m not sure whether the outcome would be any better. Again, any insights would be much appreciated. From Reggie.

It’s interesting that you say that your mom is on no other sedatives after day nine and that sounds reasonable that after day nine on ventilation and a breathing tube and a stroke and seizures, that you don’t want your mom on any sedatives and you’re saying that the CT scans look good.

So the reality Reggie is when patients wake up from an induced coma, it can take time. Sometimes it can take weeks. It can take sometimes days. It can take months. The reality is nobody has a crystal ball. And as I said, the stroke and seizure is definitely a delay in waking up and even if she’s not on anymore sedatives.

The other thing that’s probably happening if she’s having seizures, she’s probably on medication such as Keppra or phenytoin to control the seizures and they also have a sedative effect, which means again, even though she might be off the midazolam and the propofol, the Keppra and phenytoin might make her still sleepy.

The other thing that’s important to look at Reggie is to find out what your mother’s Glasgow coma scale is or GCS. That’ll be another indicator how quickly your mom could wake up, what neurological function is there by assessing the Glasgow coma scale.

Now, then you were saying she has a breathing tube, which they want to transfer to her neck. Basically what you’re referring to is transferring the breathing tube to a tracheostomy. The tracheostomy sits here in the neck and yes, that will make her more comfortable.

However, before doing that, your mom or the intensive care team needs to make sure that they do everything beyond the shadow of a doubt to get your mom off the breathing tube and the ventilator in the first place. Only after they have done everything beyond the shadow of a doubt to take out the breathing tube in your mom’s mouth, then they can consider a tracheostomy, only then, and I can’t stress that enough.

Your biggest challenge is that you don’t know what you don’t know, and a lot of ICUs are getting more and more complacent by not trying hard enough to get to remove the breathing tube and just do a tracheostomy, which changes the recovery path for your mom considerably.

Imagine, removing the breathing tube, your mom can move on to a hospital ward, whereas a tracheostomy, she has an artificial airway. She probably stays on the ventilator. She might have to be weaned over many weeks, sometimes months. She might end up, if you’re in the United States in a long term acute care facility, which is a disaster, right?

So you will need to make sure these, before you even considering a tracheostomy, that the ICU is doing everything. Everything beyond the shadow of a doubt to get out that breathing tube and get your mom off the ventilator.

You are saying also placing a feeding tube into her stomach because it’s been nine days and the nutrition may leak into the lungs. Well, if nutrition leaks into her lungs, you’re referring to the nasogastric tube and you are referring that the nasogastric tube may leak into the lungs.

Yes, the risk is there, but then again, if the nasogastric tube is in the right place and that can be tested just simply with some auscultation with a stethoscope and a syringe, there is absolutely no need for that to happen, right? It just needs a couple of tests every shift to make sure it’s safe. Again, I would not rush into a feeding tube put into his stomach just as much as I wouldn’t rush into a tracheostomy being done.

Yes, I can hear your frustration that they tell you that they have no idea why she won’t wake up, but you need to give this time.

I know ICU’s don’t have time that’s why they keep pushing for the things that they are pushing, but they’re pushing because they don’t want to lose money. They want to free up their beds. It’s not about clinical need, clinical needs as your mom is not waking up and she needs to be given time to wake up in her own time without necessarily rushing to do a tracheostomy and a feeding tube or PEG tube in her stomach.

So transferring her to another hospital might be an option. Absolutely, but you got to make sure this is a good hospital where she’s going to, and we can help you with that. We have a large database of where good hospitals are. The best next step really is to contact me on any of the numbers on the top of the website or just send me an email to [email protected].

So, that s my tip for today. I hope that helps Reggie. This is Patrik Hutzel from intensivecarehotline.com and I’ll see you again in a few days.