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

So, at the moment, we’re working with a client who has their 59-year-old mom in ICU after ARDS (Acute Respiratory Distress Syndrome). Now, even though it’s 2022, it’s actually not COVID -ARDS it’s just an ARDS that seem to come out of nowhere. Anyway, she’s been in ICU for two weeks. She was in an induced coma. She’s on a ventilator with a breathing tube or endotracheal tube. She was on and off proned over the last two weeks to treat the ARDS. She was on steroids and antibiotics. The chest X-ray  was a complete white out. She was on multiple inotropes to deal with the infection, to deal with the sepsis. But thankfully, she’s come out of it. And the lungs are slowly recovering, even though she has some fibrosis and that’s probably the main obstacle to get her off the ventilator, but nevertheless, she’s fought the infection. But as it often happens with ARDS, some patients are unfortunately left with scar tissues in the lung, also known as fibrosis.

Now, sedation has been switched off about four days ago, and the patient is not waking up, and it’s very slow. She’s now slowly starting to open eyes. Slowly starting to move her legs and her arms. For context, when someone is in an induced coma, especially for ARDS, and especially when it comes to proning, they often need double the amount of sedation because proning is just even more uncomfortable than just having a breathing tube in the mouth. Keep in mind that a patient, when proning is turned on their tummy, head down on their tummy, it’s incredibly uncomfortable. But it’s necessary to treat the ARDS, to free up some lung space more or less.

When patients are being proned, they’re often also paralyzed. Again, because high sedatives and high doses of opiates are not enough to keep a patient comfortable when they’re being proned. So again, high doses of sedation, propofol, midazolam, in this situation, fentanyl and alfentanil as well, and paralyzing agents. So, no surprise that this lady isn’t waking up in a hurry because when patients are having heavy sedation plus paralyzing agents, it takes even longer to wake up.

So now, we’ve been in a family meeting this week with the ICU team. The ICU initially was very doom and gloom saying that she has very little chance to survive, that she won’t wake up. And saying that it’s “in her best interest” to withdraw treatment and let her die. And the family and me obviously objected. Three days after not waking up after an induced coma  is not a long time. And thankfully, in the meantime after the meeting, before recording this video, she had a CT (Computed Tomography) scan of the brain, which was basically showing that the brain is intact. So, it’s probably just a waiting game. It’s just a case of doing physical therapy. And yes, her quality of life may not be as good as before the ARDS, that may well be the case with the fibrosis. She may need to be on a ventilator for the rest of her life. We don’t know at this stage, but patients need to be given a choice. And who is to say, what’s the quality of life for this lady going forward? It’s very difficult to look into the future.

Now, on a ventilation level, she’s now breathing in CPAP (Continuous Positive Airway Pressure) or pressure support, but she has high pressure support levels. She’s up to 16 with very low tidal volumes, around 300 and this lady should be breathing at least 500 to 600 mls per breath. And that’s probably part of the fibrosis. Again, scar tissue in the lungs, the volumes can’t get in. If you’re putting too much pressure into the lungs, there’s a risk of pneumothorax or barotrauma. So, the weaning off the ventilator will probably be a challenge, but hopefully, she can improve over time. Hopefully, she can have time off the ventilator. Hopefully, she can spend time with the family.

Another issue is that, the family can only visit for an hour a day and English is not the lady’s first language. So, she would be in an ICU, terrified waking up, and having people around her where she doesn’t understand the language. So, the only time she has a language that she understands is when her family is around and that’s only an hour a day, and that will delay waking up as well. Imagine how scary it is for someone to wake up in ICU, even if they do understand the language.

So, you’ve got multiple barriers here for this lady to wake up in a time that’s probably convenient for the ICU, but it’s not about convenience for the ICU. It’s about what patients and families want and what they need to go from A to B. And quality of life is something that can be assessed later, not three days after the induced coma. It’s a process that needs to be dealt with and needs to be assessed on a day-by-day basis. Not by making predictions that may or may not be accurate.

So, that is my quick tip for today and also some insights. What happens when patients are coming out of an induced coma if they’ve been proned? If they’ve been in paralyzing agents? The devil is in the detail when it comes to treatment in ICU. And if you don’t understand the details, you’d be fighting an uphill battle.

The biggest challenge for families in intensive care is simply 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 and that’s what we’re dealing with here.

So, I hope that helps.

That’s my quick tip for today.

Now, if you have a loved one in intensive care, go to intensivecarehotline.com. Call us on one of the numbers on the top of our website, or simply send us an email to [email protected].

Also, have a look at our membership for families in intensive care at intensivecaresupport.org.

If you need a medical record review for your loved one, while they’re in intensive care or after intensive care, if you suspect medical negligence, please contact us as well and we can help you with that.

Like the video, share it with your friends and families, subscribe to my YouTube channel for regular updates for families in intensive care, and click the notification bell, and comment below what you want to see next.

Now, also, before I forget about for this particular lady, there’s also services now like Intensive Care at Home that can take this lady home if she can’t be weaned off the ventilator. You can find more information at intensivecareathome.com.

Thanks for watching.

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