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 one of our readers
You can check out last week’s episode by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer another the next question from our client Robert, which are excerpts from email counselling and consulting sessions with me and the question this week is
My 68 year old mother is in ICU with gastric perforation and she’s not “waking up” after the surgery! Will she need a tracheostomy? (PART 14)
You can find previous questions from this series of questions answered here
Robert continues with his mother’s situation below
thank you for your email.
Good to know that pain management trumps waking up. That seems to be how they’re thinking about it as well.
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They did mention that the dialysis will mask temperature and so we need to “adjust” based on that. One of the Doctors also said the white blood cell count is a better marker/signal for infection than temperature. Today, her temperature has been between 98 – 99.5F(36.7C-37.5C).
I’ll ask about albumin, haemoglobin level and possibility of liver functioning issues.
They’re testing her platelets every 6 hours or so, so will know where those stand in a few hours.
I also talked to the ICU nurse a bit.
They’re testing blood every 6 hours (which gives us haemoglobin, white blood cell count and platelets).
The haemoglobin level on last test was 7.3. (Seems a different scale). She said that if it drops below 7.0 then they usually do a blood transfusion.
it’s reassuring to hear that they are checking blood levels every 6 hours.
Yes, sometimes Haemoglobin level scales can vary by one decimal point, but even a Haemoglobin level of 7.0-7.3 grams/decilitre(which equals 70-73) is still suggesting a major bleed or a chronic bleed, especially if she had blood transfused already.
60-69 for Platelets is concerning too. Normal levels are 150-450.
Also, I agree that as long as your mother is on the Dialysis machine her temperature readings will be inaccurate to a degree because the blood will be cooling down whilst running through the dialysis machine.
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And yes, White Cell Count is a much better parameter to assess if an infection is present, on the decline or on the rise.
Keep asking questions to get to the bottom of things.
Especially if your mother keeps bleeding and haemoglobin levels are dropping, they need to find out what’s happening.
I’m looking forward to your next update.
There have been no concerns about liver function issues or failure.
Albumen level is about 3 and has been reasonably stable.
Also, the dark blood we were seeing coming out of her nose tube is no longer there. Now just greenish stuff which nurse says is bile and is normal.
Not out of the woods yet, of course. But, makes me feel a bit better that the dark blood is no longer coming out in her nasal tube.
By the way, she is still getting nutrients via I.V. because they don’t want to irritate the gut by putting a feed tube in.
Next FBC(=Full blood count) will be sent down in about 3-4 hours.
I really was worried about liver failure and low Albumin and it’s good that it’s off the table for now!
It still leaves the question why she’s having low Platelets?
I still don’t understand where all the abdominal fluids have come from especially in light of the fact that they had to drain it.
It’s a good sign that the bleeding seems to have stopped for now.
It looks like she may have had a gastric/stomach bleed if you have observed that old blood has been coming out of the Nasogastric tube.
A number of things in ICU can lead to a gastric/stomach bleed and Patients are often prone to it. Let me explain.
When Patients are admitted to Intensive Care for critical illness, their bodies are under huge stress. One way the body responds to stress is by producing acid in the stomach. This could cause an ulcer, eventually leading to a bleed.
One way to identify the location of a gastric/stomach bleed is to do a Gastroscopy(video camera down the oesophagus into the stomach).
Because the evidence is there that if critically ill Patients in Intensive Care don’t get either fed early through the nasogastric tube(=NG tube) and also get Proton pump inhibitors such as Pantoprazole and/or Ranitidine to prevent acid production in the stomach, Patients are much more likely to end up with a gastric bleed.
Especially with your mother being under so much stress in recent months with being in Intensive Care in basically three different countries, her body would have been under enormous stress.
You see, prolonging the intravenous feeds (TPN= Total parenteral nutrition) vs enteral feeds via nasogastric tube that would go directly into her stomach concern me a little, since it would now be around one week since she had surgery and was put on IV nutrition(=TPN).
As I mentioned in one of my earlier emails, normally there is a tendency to feed early and often via nasogastric tube into the stomach because it reduces the risk of gastric/stomach bleeding as it maintains a normal and healthy gut flora and it also maintains a normal PH in the stomach to reduce acid production that can often lead to gastric perforation.
Given that your mother had such a perforation and is now potentially bleeding somewhere in the abdomen, I believe they should lean towards nasogastric feeds, as well as medically trying to reduce the risk for bleeding by giving proton pump inhibitors such as Pantoprazole or Ranitidine.
Furthermore, even if they think that your mother is not quite ready for enteral/nasogastric feeds as yet, they could for example start with 20 cc/hr nasogastric feeds and see how she can tolerate it and then gradually reduce the IV nutrition(=TPN).
One week of IV nutrition after surgery appears to be a long time and from my experience as well as from a lot research that is out there should be more of a bias towards enteral/nasogastric feeding especially with abdominal bleeding.
Maybe there is something else going on that we’re not aware of why they are continuing with the IV nutrition for now. I hope that at least your mother is on a Pantoprazole infusion or on regular Ranitidine to inhibit acid production in her stomach and therefore minimize the risk for any further bleeding.
- PEACE OF MIND, CONTROL, POWER AND INFLUENCE EVEN IN THE MOST CHALLENGING OF CIRCUMSTANCES THAT YOU, YOUR FAMILY AND YOUR CRITICALLY ILL LOVED ONE COULD POSSIBLY FACE IN INTENSIVE CARE
The situation overall remains critical from the information that you are sharing, but given that she’s off blood pressure meds(inotropes/vasopressors), off the Flagyl with White cell count(WCC) coming down and given that she’s now on Dialysis to manage the fluid balance, as well as her trying to “wake up” even though she’s still getting pain meds is encouraging.
Still lots of challenges to work through, especially with the bleeding and potential abdominal fluid accumulation.
I really hope that you and your family are OK? I keep talking about all the clinical stuff, which I believe is important, at the same time given that there seems to be no end in sight for now, I really hope that you and your family are OK, keeping your sanity.
I know it’s been a long ride, including the hospital stay in Brazil, plus the flight back to the United states with now all the battles she’s continuing to fight.
The good news is she’s fighting and so are you and your family. I also can’t see any hint that they are not trying to do their best, although they may still be negative?
Stay strong, wishing you and your family all the very best!
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
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- How to ask the doctors and the nurses the right questions
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
- How to eliminate fear, frustration, stress, struggle and vulnerability even if your loved one is dying
- 5 mind blowing tips& strategies helping you to get on the right path to making informed decisions, get PEACE OF MIND, control, power and influence in your situation
- You’ll get real world examples that you can easily adapt to your and your critically ill loved one’s situation
- How to stop being intimidated by the Intensive Care team and how you will be seen as equals
- You’ll get crucial ‘behind the scenes’ insight so that you know and understand what is really happening in Intensive Care
- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
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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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