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

Today, I have a question from Gabby who says,

“Hi Patrik,

I need to ask you a question. My mother is in ICU. She’s 67 years of age. She got intubated about a month ago and ten days later, they put in a tracheostomy. Now, she’s back in the ICU due to low hemoglobin and low platelets. The blood pressure has been dropping, the nurses put in three medications, and the blood pressure started getting better 96/53, but her O2 (oxygen) started dropping 60% to 65% SPO2 (oxygen saturation). The ventilator setting is assist-controlled PRVC (Pressure Regulated Volume Control). The FIO2 (Fraction of Inspired Oxygen) is at 100%, respiratory rate at 16, no PEEP (Positive End-Expiratory Pressure), tidal volume is 475, inspiratory time is 0.75.

I have attached a picture, but her saturation reading is very low. Are there any settings that could be adjusted? I’m concerned, the problem is the lung expansion. Any information would be greatly appreciated.

From, Gabby.”                

Well, thank you so much, Gabby for sending this information. Also, for the picture of the ventilator. I really appreciate it.

So, what you should be looking for here is, first off, if she has low hemoglobin and low platelets, they should replace that, and that in and of itself might get the blood pressure up to the point where it’s sufficient and compatible with life, compatible with kidney infusion, organ perfusion, and so forth.

If they started medications, they probably would have started norepinephrine or Levophed, epinephrine, vasopressin, and maybe also an inotrope such as dobutamine. I’m not sure, but that’s probably what they would have done. Also, I would hope they would have given us some blood transfusions to get the blood pressure up.

Now, coming to the ventilator settings. Very, very rarely have I seen a patient being ventilated without a PEEP. So, here is when not to give a PEEP: Not to give a PEEP is sometimes for traumatic brain injuries, sometimes for hypovolemia, sometimes for cardiac failure, sometimes for emphysema, asthma, COPD (Chronic Obstructive Pulmonary Disease), that’s when I’ve seen PEEP not to be given, but it is very rare that PEEP isn’t given.

Now, when I look at the picture from the ventilator, I am very concerned that there is no PEEP, and like I said, I’ve not seen it. Well, if hypoxemia is the issue here, then I would argue let’s start with a little bit of PEEP and see what happens. That would be my strong recommendation here. Now, you haven’t given me all the information, so there might well be a very legitimate reason why they’re not giving a PEEP. So, I don’t want to talk out of context here because I don’t have all the information.

But from my experience having worked in intensive care for over 20 years, nearly 25 years now in intensive care in three different countries where I also worked as a nurse unit manager for over 5 years. I have been consulting and advocating for families in intensive care here at intensivecarehotline.com for over 10 years.

You can look up our testimonials on our testimonial section or you can look up some podcast videos where we interview clients. I can safely and without any exaggeration, say we have saved lives over the years with the consulting advocacy that we are doing.

Coming back to your question, what is the underlying issue here? Obviously, the underlying issue is hypoxemia, but what is it? Is it a pneumonia? Is it ARDS (Acute Respiratory Distress Syndrome)? Is it something else? What is the underlying issue, and why are they not giving a PEEP? Very, very unusual. So, either they don’t have the experience, which I doubt. You haven’t mentioned where you are, or which hospital you’re at. Is it a small country hospital? It doesn’t have a lot of experience. I don’t know, just something for you to consider. Are you in an area where there’s simply not enough skilled and experienced staff? Question for you to ask.

Now, if lung expansion is an issue, again, PEEP is one of the ways to expand the lungs. Now, let’s just say they use a PEEP 5, 7.5, maybe even 10, and it’s still not working, again, is there any other underlying issues? Does she need a little bit of nitric oxide? Does she need nebulizers? Worst-case scenario, does she need ECMO (Extracorporeal Membrane Oxygenation)? That would be the worst-case scenario. Does she need ECMO to let the lungs rest and heal and let the ECMO take over the function of the lungs for a period of time to let the lungs rest, heal, and recover. That would be my recommendation here.

I would argue if they had 100 patients in this ICU where your mom is at, there would not be one other patient without a PEEP, not one because I haven’t seen it. Looked after thousands of critically ill patients in intensive care over the years, I can’t remember one without a PEEP. Maybe from my very early days in ICU when some traumatic brain injuries didn’t have a PEEP to take the pressure off the brain. It’s the only time I can remember not having a PEEP. So, let’s look into that, and ask those questions.

If you have a loved one in intensive care and you need help, we have created a membership for families of critically ill patients in intensive care at intensivecarehotline.com. You can click on the membership link, or you can go to intensivecaresupport.org directly.  In the membership, we answer your questions for any anything related to your loved one in intensive care via email and in a membership area. You also have access to 20 eBooks and more than 20 videos specifically designed for families in intensive care where all your questions are answered there. They are only available if you are becoming a member, and we’ll answer your questions in the membership. Again, you get access by going to intensivecarehotline.com by clicking on the membership link, or by going to intensivecaresupport.org directly.

I also offer one-on-one consulting advocacy over the phone, Skype, Zoom, WhatsApp, whichever medium works best you. I talk to you and your families directly. I talk to doctors and nurses directly. I ask all the questions of the doctors and nurses directly that you haven’t even considered asking but must be asked when you have a loved one in intensive care so that you can make informed decisions, and have peace of mind, control, power, and influence.

We also offer medical record reviews in real time so that you can get a second opinion in real time, once again, so that you can make informed decisions, have peace of mind, control, power, and influence. We also offer medical record reviews after intensive care, if you have unanswered questions, if you need closure, or if you are simply suspecting medical negligence.

I also represent you in family meetings with intensive care teams so that you have clinical representation there from an advocate with intensive care experience.

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

Thank you so much for watching.

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Thanks for watching.

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

Take care for now.