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 in this series of questions from our client Robert and the question last week was PART 3 of
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 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 4)
Robert describes his mother’s situation as follows with those series of questions.
- The doctor hasn’t seen the improvement she would have liked in my mom’s mental status
- They are recommending that we delay the tracheostomy 2 or 3 more days to give my mom a chance at mental status improvement before we put her through another procedure. (She had a set-back two days ago whereby they suspected another infection or some issue with her bowel which manifested as deterioration in blood pressure and an increase in fever). But, that has since improved in the last 24 hours so all vitals are currently stable.
- For the first time, we heard the doctors plant the seed of doubt that if my mom doesn’t show some sign of improvement in her mental status in next 2-3 days, the family may want to consider whether we want to proceed with the tracheostomy at all — basically sounding like they were putting the option of withholding treatment on the table. This came as a shock to all of us, because this was the first time we’ve heard them even hint at that. Though she has not woken up, the last MRI and all scans have shown no evidence of any brain injury, so we were surprised that they would putting withdrawal of treatment as an option out there.
- Yesterday evening, briefly, the ICU nurse witnessed (my brother was present) what she classified as a “purposeful movement”. The nurse was in the process of suctioning out fluids from my mom’s mouth and at that time my mom moved her hand towards her mouth (in order to try and stop the suctioning). She’s exhibited that kind of reaction a couple of weeks ago when in the ICU in Brazil. We saw this as a positive sign, and communicated it to the surgeon today, but we’re not sure how much to read into it.
Right now, our plan is to wait 2-3 days, spend as much time in the room with my mom as possible and attempt to talk to her frequently. The hope is that if there are no other complications with her, she will show some signs of mental status improvement.
Regardless if there is improvement or not, we will ask to proceed with the tracheostomy. Then, we will be in “watch and wait” mode , dealing with issues as they come and otherwise just give her time to heal and to hopefully wake up.
Any thoughts or feedback on the current status and on the plan for the next several days is appreciated.
With all the information that you have given me in this email, I can tell you that I don’t see any correlation between “improving your mother’s mental status” first and then performing the tracheostomy.
If your mother is not ready to be weaned off the ventilator a tracheostomy is usually improving the chances to come off the ventilator without the need for sedatives such as Midazolam (Versed) or Propofol (Diprivan).
Therefore, the statement that her mental status is fragile and therefore causing a delay with a tracheostomy to me is questionable.
A critically ill’s Patient mental status with a breathing tube and after prolonged induced coma is never great and often also difficult to assess, hence the need to either extubate or do a tracheostomy.
A real or a suspected infection is definitely a reason to delay the tracheostomy for sure.
Usually a critically ill Patient’s situation is improving once they have a tracheostomy, because of no need for sedation and also because the discomfort of the breathing tube in the mouth is gone. A tracheostomy usually doesn’t cause any pain.
Especially with your statement that your mother’s vital signs are stable, now would be the time to perform the tracheostomy.
I’m already wondering if they are delaying the tracheostomy to help positioning a “withdrawal of treatment”. Once a tracheostomy is done, it’s going to be more difficult to withdraw treatment, therefore I think doing the tracheostomy sooner than later would help your mother’s situation.
Your mother doing “purposeful movements” is very good, therefore the sooner a tracheostomy the better, so she can be taken off sedation and do more of it.
ICU teams tend to always be negative, just simply because they can and also to not put up your hopes in case your Mom isn’t improving. If they told you from day one “we’re going to fix it” and then they don’t they could be in trouble. Hope that makes sense.
I see my role very much at giving people perspective and read between the lines, explain what it all means so that you can be in a position to make informed decisions, have peace of mind, control, power and influence.
I will have a listen to the recording now and get back to you with more thoughts!
From what you are telling me, I think your mother is doing OK given her clinical picture and critical circumstances.
Here is Robert’s response
I don’t think the doctors are suggesting to hold off the tracheostomy until after we see an improvement in her mental status. The primary motivation for the 2-3 day delay is to avoid having to give her sedation for the procedure, and generally to avoid any trauma/change so she has a couple of days to heal and possibly “wake up”.
Because of the of infections and other complications post-surgery, she hasn’t really had a steady period of 2-3 days where her body wasn’t dealing with fighting something off, so the theory is that since all core things are stable right now, perhaps give her a chance to wake up. Yesterday evening, when we say the purposeful movement for the first time it was about 24 hours after she had improved from her last set-back.
A couple of other notes:
- The sedative is used Propofol (Diprivan)
- Even before this set of issues started, she’s been on Keppra (after she had a stroke about 15 months ago). They are taking her off Keppra today because it has caused her a lot of drowsiness in the past — which I’m guessing is common.
- Her breathing has been very good for last couple of days. Only minimal support required from the ventilator.
- The attending surgeon has said that she would do her best to do the operation herself (instead of the resident) since it gives the family comfort. Though they believe they have a highly qualified team many of whom can perform the procedure.
Thank you for clarifying these points.
Good to know that she was on Propofol (Diprivan) and not on Midazolam (Versed).
Propofol is a short acting sedative and therefore increases chances of “waking up” quicker. Keppra certainly dampens Neurological functionality as it’s anti-seizure medication and hence taking it off to increase your mother’s chances to “wake up” makes sense.
Now that I have also had a listen to the recording it does make sense to wait another 2-3 days to see what she’s doing and if she can continue doing purposeful movements maybe she can escape the tracheostomy.
I liked that the surgeon mentioned “physical therapy” and mobilisation and I believe that needs to be next either after extubation or after tracheostomy.
If your Mom gets extubated there also shouldn’t be a need for a PEG feeding tube either.
It’s very encouraging to hear that your mother’s breathing is on minimal support and that certainly increases her chances to get extubated but it’s also increasing chances to get off the ventilator if she does end up with a tracheostomy.
The other good news is that your mother is off blood pressure medications(Inotropes/Vasopressors) that’s a sign that the infection seems to get better.
The surgeon in the recording seemed to be nice and understanding, I would still like to get a better understanding of what the ICU team thinks besides them talking about “withdrawing treatment” as a possibility.
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The ICU team from my perspective would have a much better idea in terms of where your mother is at in terms of “waking up” and getting her off the ventilator or doing a tracheostomy.
The surgeon sounds to me like she wants to give you control of the situation which I like.
Also, with no inotropes/vasopressors supporting the blood pressure, the only form of major life support your mother is on is the ventilation, therefore making all the more less likely to “withdraw treatment” because there is not much to withdraw. I hope that makes sense.
Therefore, the next steps should really be either your Mother wakes up and gets extubated or she will need a tracheostomy and can wake up and be weaned off the ventilator.
Also, time is often the ultimate healer in ICU and I know how frustrating it must be for you to watch this situation unfold, but time, patience and staying positive are often your biggest assets in a situation like this.
No matter how much you, your family or even the ICU team wants to speed up the process of “waking up”, your mother will do it in her own time. Her body has been through much stress in the last four weeks, especially also with flying from Brazil to the USA in the midst of a critical illness. I wouldn’t underestimate this at all.
I still think that with all the information that I have, your mother is doing OK given the current circumstances and either “waking up” and extubation or a tracheostomy will be next.
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- How to ask the doctors and the nurses the right questions
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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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