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

Today, I have an email from Oksana who says, 

“Hi Patrik,

I came across your videos on YouTube, and I was wondering if you could help me by answering a question. 

My dad suffered a massive heart attack exactly a week ago from today. He was put under sedation medication since that day. He had an Impella device put into his heart to open up a blocked artery. All went well, the heart is good. 

He was also put on a ventilator. Yesterday, they started to wean him off sedation medication to get him extubated. He was not fully awake and alert. They pulled the ventilator out but ended putting it back in because my dad was delirious. He was very agitated, sleeping medications back on and he’s out of it again. Today, they told me they want to keep him sedated for a few more days to slowly wean him off.

Does that sound right? I’m asking for a different approach this time. Around half the nurses are clueless, and the other half are telling me different things. As far as the ventilator goes, it’s on spontaneous mode and dad is breathing on his own. To me, it sounds like he is ready to be woken up, but the ICU is taking their sweet time. 

What do you recommend we as a family demand? Is being on sedation medication for 7 days too long? Is being on the ventilator for 7 days too long? 

Thank you and I hope to hear from you soon.”

Thank you, Oksana for writing in. Let’s just break this down one by one. 

So, if he had an Impella device put in, which is basically like an LVA (left ventricular assist) or an RVA (right ventricular assist) who’s taking over the function of the heart for a period of time. That’s a concern. The heart might be fine for now, but the question is, what support is he needing in the meantime? The heart needs a lot of support if he’s on the Impella. Also, the Impella is not necessary to open up a blocked artery, it’s simply to take over the pump function of the heart. 

Now, if he had a blocked artery, I hope they’ve done an angiogram or an angioplasty to unblock the parts of the heart that needed to be unblocked. I’m not surprised he needed to be put on a ventilator. I’m not surprised he was on sedation to get him off the ventilator or to get him comfortable on the ventilator, and then they were waking him up and now they’re trying to get him off that ventilator. So, no surprises there, that is actually a sign of progress.

But if he failed extubation, there’s a number of questions to ask. Was he still sedated? Is he over sedated? Is the heart potentially not coping? You’re saying the heart is fine, but it’s only been a few days. Is the heart not fine yet? Because if the heart’s not fine, the first organ that’s often impacted is the lungs. So, therefore, now he’s back in spontaneous mode. Let’s wake him up and let’s see whether they can extubate him. It would be very important to extubate him and not have him move towards the tracheostomy. 

Here is why. Your dad has an Impella, let’s just say he can’t be weaned off the ventilator. With an Impella, your dad most likely would be on a heparin infusion, and because he most likely would be on a heparin infusion, he is at risk of bleeding. Heparin is a blood thinner, and if someone is on a blood thinner, it’s very difficult to do a tracheostomy because it’s a surgical procedure. You can’t really stop the heparin when someone is on an Impella. The risk of a blood clot forming and causing damage is very, very high. Therefore, getting your dad off the ventilator would be a major step and would almost be imperative.

So, what should you as a family demand? Well, here are a number of questions that you need to consider. Is the Impella going to be temporary? Is it really to unblock an artery? I doubt it. I tell you what I think happened. He had a blocked artery, the heart suffered severe heart muscle damage, and that’s why he ended up on the Impella. But did they manage to unblock the artery? Does he need cardiac surgery? Did they manage to put in an angioplasty after an angiogram?

Also, what is the plan with the Impella? Can it come out after a period of time? Or is it a bridge to a heart transplant which an Impella can often be used for? It can be a bridge to a heart transplant. So then, what you as a family should demand, you should demand some answers. 

But again, the biggest challenge for families in intensive care is that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights and they don’t know how to manage doctors and nurses in intensive care, which is exactly what you are dealing with.

So, if he’s in a spontaneous mode already, get rid of the sedation completely. They should make a second attempt at extubating him, absolutely. But this time around, also maybe ask to put him on BIPAP (bilevel positive airway pressure) or on CPAP (continuous positive airway pressure), so he can cope.

Seven days on a ventilator, it’s not a case of is it too long or is it not. It depends on a case-by-case basis. I’ll give you an example. Let’s just say, God forbid, someone is in a major accident, they have multiple fractures, they need surgery for multiple days and they’re very unstable. Being on the ventilator for 7 days is not very long. 

In your dad’s case, if the heart is fine and the Impella is doing the job, then it might be too long. Then, he should get off the ventilator as quickly as possible, no question there. When someone is weaning off the ventilator, it’s almost like you have a unique window of opportunity that you need to capture on to make it a success when taking the breathing tube out. Obviously, the first time around, they didn’t get it right and some of it will also depend on if your dad is going to be delirious, agitated, combative, all of that. You got to see how that goes. But is 7 days too long? It depends. The problem is if it goes on for more than 10 to 14 days, then the risk is that he needs a tracheostomy. So, the sooner the breathing tube can come out, the better. No question.

So, I hope that helps you and your dad’s situation.

I have worked in critical care nursing for nearly 25 years in three different countries where I worked as a nurse manager for over 5 years. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. We’ve been saving many lives. We’ve served hundreds of clients and members here. We’ve helped hundreds of members and clients here at intensivecarehotline.com, saving many lives. You can verify that on our testimonial section at intensivecarehotline.com. You can also verify on our intensivecarehotline.com podcast section.

Also, we have a membership for families in intensive care and you can become a member if you go to intensivecarehotline.com if you click on the membership link or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership you also have exclusive access to 21 eBooks and 21 videos that I’ve personally written and recorded, making sure you make informed decisions, you have peace of mind, control, power, and influence so that your loved one gets best care and treatment always.

I also do one-on-one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever meeting works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply can’t afford to get wrong. I also talk to doctors and nurses directly. When I talk to doctors and nurses directly on your behalf, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. Remember, the biggest challenge for families in intensive care is that they don’t know what they don’t know.

I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence. 

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.

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