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 was
10 Common Problems Coming Off the Ventilator in ICU and How to Solve Them! Live stream!
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients, Iyah, as part of my 1:1 consulting and advocacy service! Iyah’s dad is in the ICU, ventilated with tracheostomy and is unable to wean off the ventilator. She is asking if her dad can stay in the ICU and avoid LTAC.
How Can Dad Stay in the ICU with Tracheostomy & Avoid Going to LTAC (Long-Term Acute Care)?
You can also check out previous 1:1 consulting and advocacy sessions with me and Iyah here.
Patrik: Yeah. And FiO2 (Fraction of Inspired Oxygen)?
Remy: FiO2 right now is running at 50, PEEP (Positive End Expiratory Pressure) of 10.
Patrik: Yep.
Remy: Rate is set at 16, but he is over breathing. Last hour he was up at 24. He’s been up in the mid-20s all day.
Patrik: Right. And target volumes (Tidal Volumes) are adequate for what you’re looking for?
Remy: Yeah. He’s set to 380 right now, and it hasn’t been too much lower than that, 350 to 380 is right around where we’re seeing.
Patrik: Right. And you’re happy with the ABGs (Arterial Blood Gas)?
Remy: Let me look up yesterdays.
Remy: Of course. So, ABG (Arterial Blood Gas) from yesterday, of course, is low on his CO2 (Carbon Dioxide), because of that over breathing. But he’s still a 7.41, so looking decent there. His PO2 (Partial pressure of Oxygen) is 85 at those settings.
Patrik: All right, that’s-
Remy: So it’s okay, but not great.
Patrik: Yeah, that’s right. That’s right. And what does the chest x-ray show?
Remy: We were just looking that there is no pneumonia in his chest X-ray, heart and mediastinum are unchanged. A little bit of small left pleural effusion, and then mild bilateral pulmonary opacities, but they’ve been stable.
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Patrik: Right. Yeah. Okay. And does he have a lot of secretions on his chest?
Remy: Does he have an increase in what? I’m sorry.
Patrik: A lot of sputum. Do you suction very often?
Remy: Oh, oh. You know, he hasn’t had a respiratory muscle tone. He definitely has a small to moderate amount.
Patrik: Yeah. But you’re not worried about it, especially with him being in kidney failure, I would imagine you’re aiming for a negative fluid balance now that he’s on dialysis?
Remy: We’re trying to. That is definitely the goal. Total for his visit, he is still up 5.1.
Patrik: Right. Right.
Remy: But we’re trying to get that back down to at least net neutral.
Patrik: Of course. Of course. And you mentioned earlier that he’s on Precedex and Versed. Is he also getting any opiates, or…
Remy: Getting any what? I’m sorry.
Patrik: Opiates, like fentanyl or morphine.
Remy: Oh, yeah, opiates. Opiates, of course. You know, he has gotten a couple of pushes recently of some fentanyl. Let me see exactly when the last time that was given. So yeah, he got some at 07:00 this morning, 100 micrograms. And it looks like that’s about it since the 23rd.
Patrik: Right. Right.
Remy: And he does have a drip ordered for fentanyl, but it has not been going since the 17th.
Patrik: Okay. Okay.
Remy: Yeah.
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Patrik: And no spontaneous breathing trials as yet?
Remy: Let me see when his last one, but we’re still doing the… We generally try to do one every single day.
Patrik: Right.
Remy: But it’s not here that he has to do one, nor did I hear that it went overly well. Looks like SVT (Supraventricular Tachycardia) criteria was unfortunately not met to perform. I will hop onto the pulmonary note real quick for you.
Patrik: Thank you.
Remy: Of course. Yeah, so it’s just because the settings are too high.
Patrik: Yeah, no, fair enough.
Remy: So, it’s for the SVT.
Patrik: Fair enough. And then, I would imagine he has a nasogastric tube, and you’re feeding him through the nasogastric tube?
Remy: That is correct.
Patrik: And there’s no issues there, he’s absorbing feed, he’s opening bowels?
Remy: Yeah. Yeah, we have a rectal tube in, it’s putting out well. He hasn’t had any emesis.
Patrik: Right. And with his diabetes, is the diabetes controlled, or how are you managing that?
Remy: We’re giving Lantus, and we also do sliding scale.
Patrik: Uh-huh. Yep.
Remy: So, I just give him Lantus. I haven’t pulled a glucose yet for today, on this shift, but it is still elevated. His most recent was 242.
Patrik: Yep.
Remy: But we’re trying to control it, of course.
Patrik: Of course. Yeah, okay. And liver function is okay? There’s no issues with the liver?
Remy: Yeah, all of his liver enzymes are looking good.
Patrik: Okay. That’s great. That’s great. What are the next steps from your perspective, or from your team’s perspective? What are you aiming for as a next step?
Remy: Well, that really does kind of come down to decision-making of the family, of course. But where we are sitting now would be length of time that he has been intubated, and with the lack of decrease in FiO2 (Fraction of inspired oxygen) necessity and all of that, he’ll end up needing to get a tracheostomy, and likely a PEG (Percutaneous Endoscopic Gastrostomy Tube).
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Patrik: Yep.
Remy: And that, I’m sure you know, it can go either way, where it’s a positive change, neutral, or it doesn’t slow the process sort of thing at all.
Patrik: Yeah. No, I understand that. And just remind me, it’s been about 16 or 17 days since he’s been intubated, is that correct?
Remy: Yes. He was admitted on the 9th, so yeah, 16. We’re after that two-week mark, when we really want to start looking at a trach.
Patrik: Yeah, no, of course. Of course. Yeah, okay. Iyah, I don’t have any other questions at the moment. We can take this offside and discuss it. I mean, Iyah, did you have any other questions at the moment?
Iyah: No, I don’t have any other questions.
Patrik: All right.
Remy: No more questions, is that what that was? Sorry.
Iyah: Correct, no other questions.
Remy: Okay, perfect. Okay. Sorry, the phone is questionable.
Patrik: Yeah.
Iyah: Yeah.
Patrik: Yeah, it’s a bit choppy. Look, that’s been very, very helpful. I can’t thank you enough for all your help.
Remy: Yeah, of course. And if anything else does come up this evening, please feel free to give me a callback. Like I said, I have a triple, and one of my other patients is pretty intensive, so I may not be able to hop on right away, but I can at least get back to you this evening and stuff.
Patrik: Thank you so much. Have a good shift.
Remy: You are very welcome. Yeah. Have a good night.
Iyah: Thank you so much, Remy.
Remy: Bye.
Patrik: Thank you, bye. Bye. Okay. That went really well, Iyah, I think.
Iyah: Yes.
Patrik: Very nice nurse.
Iyah: Yes.
Patrik: Okay. All right. So let’s put this in perspective. And I did want to… At the moment it’s really all about information gathering, rather than making recommendations to them, because I don’t think that would’ve been the right time. I mean, it’s in the middle of the night for her.
Iyah: Yeah.
Patrik: It was really all about information gathering at the moment. So as far as I can see, so one of the reasons they’re giving Versed, Precedex, and fentanyl, is simply that when they’re trying to reduce it, he’s breathing against the ventilator, which is basically a recipe for not being able to wean off the ventilator. So whatever they’ve tried to this point sounds to me like they’re not achieving the goal to get her off the ventilator, and that can often happen when someone is in a prolonged induced coma. And I would say anything above seven days I would argue is a prolonged induced coma.
Iyah: Okay.
Patrik: So, nothing new from my experience, that when you try and wake someone up, they’re not waking up properly, and they’re breathing against the ventilator. That’s one issue. But the other issue is obviously the metabolic alkalosis, which your sister picked up correctly. He’s got a metabolic alkalosis, which makes his brain foggy. That doesn’t help with waking up, right?
Iyah: Yeah. Yes.
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Patrik: What happens next as far as I can see… Here is the benefit of a tracheostomy. The benefit of a tracheostomy is that you can pretty much stop sedation. And why can you stop sedation? Because a tracheostomy’s… A breathing tube in the mouth is very uncomfortable. You might have heard me ask in the beginning of the conversation; I was talking about tube intolerance.
Iyah: Yeah.
Patrik: What that basically means is he’s intolerant to the breathing tube, and that’s one of the main reasons people end up in an induced coma. So therefore, once they are doing the tracheostomy instead of the breathing tube, they can pretty much stop sedation, because a tracheostomy, contrary to popular belief, it’s not painful. A tracheostomy eliminates the need for an induced coma.
Iyah: Yes. And that’s a benefit. Yes.
Patrik: That is one of the main benefits, right?
Iyah: Yeah.
Patrik: Right. So just on that level alone, I would argue a tracheostomy is the right next step. Now, there are numerous other issues that he’s dealing with, including, she was sort of referring to query sepsis. But it’s not there yet. His vital signs are pretty stable. He got positive blood cultures, but we just got to wait and see what happens next. There’s no need to jump to conclusions or panic, because at the moment he’s not septic.
Iyah: Yeah.
Patrik: She also didn’t sound as negative as they might’ve painted the picture to you. I mean, from her end, it seemed to me, well, it would be quite natural to do a tracheostomy as a next step, rather than worrying about end of life.
Iyah: Yeah.
Patrik: She certainly didn’t paint that negative picture. So as far as I can see, with having a good understanding of what he’s dealing with, I would argue on a clinical level the next possible step is a tracheostomy. Now, here is what is important to know. And again, I don’t know how much research you’ve done, Iyah. Are you aware that some ICUs, once patients have a tracheostomy, are you aware that they want to send outpatients to LTAC (Long Term Acute Care) very quickly, have you heard of-
Iyah: Yes, right.
Patrik: Right, you’re aware of that.
Iyah: Yeah.
Patrik: Is this something they mentioned to you?
Iyah: I did ask the nurse about that, and they said once he is no longer needing a ventilator, with the tracheostomy, that they would send him to a nursing home, or a long-term care.
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Patrik: Right. And have they given you any timelines around that?
Iyah: No. It was just a question I had. It’s a hypothetical.
Patrik: Okay. Okay. Okay, it’s good that you’re aware that this is what might happen. Now, from my perspective, and again, depending on how much research you’ve done, I am very anti-LTAC/nursing home. And there are ways-
Iyah: Right.
Patrik: Right. There are ways to keep him in the ICU. I think here is what I would advise you to do next. Sleep over it. I do believe that a tracheostomy is almost inevitable. Sleep on it, think about a tracheostomy, and then we can strategize that once you’re clear, you and your family are clear that you want a tracheostomy, then we can strategize how you can keep him there without him going into LTAC. And there are ways of doing that. A lot of the work that we are doing is keeping patients in the right places through the advocacy. But that’s something, I think you should sleep over it, discuss with your family. The other thing that I want to advise you on is, you might’ve heard him saying he needs a trach and a PEG. Have you heard of a PEG (Percutaneous Endoscopic Gastrostomy Tube)? Do you know what a PEG is?
Iyah: Yeah, it’s on the videos. Yes. It goes through the stomach rather than the nasal-
Patrik: That’s right. That’s right. So, once a patient has a PEG and a trach, and they’re stable, they can go to LTAC. Now, one of the strategies that we are implying to families is, don’t consent to a PEG straight away. They can do the tracheostomy…
Iyah: Yeah, right it’s from the videos, yeah.
The 1:1 consulting session will continue in next week’s episode.
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Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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