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 6 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 7)
Robert continues with his mother’s situation below
the tracheostomy went well today. The doctor decided not to do the PEG at this time. She was having a hard time finding a clear line in which to do it. They will revisit doing the PEG in a few days.
Right now, all vitals are stable. She was showing more eye movement last night than we have seen for a while. Not all the way open, and not making eye contact or focusing — but at least it’s unprompted.
They’ve done an ultrasound to check for gallbladder issues (I understand that’s common) and have also done an EEG.
So, for now, we’re back to our 3Ps: patience, persistence and positivity. 🙂
thanks for the update, I’m glad the tracheostomy went well.
It’ll be way more comfortable now for your mother to tolerate the ventilator because she will need less sedation.
I don’t see the need for a PEG at this stage, a Nasogastric tube can feed her just as well and there is no need for another surgical procedure.
I do believe that PEG’s are only necessary for Patients who will not be able to eat again for a very long time to come.
We don’t know what’s going to happen with your mother, but it’s still too early to say which way she’s going. There is no need for a PEG at this stage.
It’s still been a roller coaster few days.
My mom had to be taken in for surgery a couple of days ago. The CT Scan revealed some air in her abdomen and it was more than they had seen there before. The doctor that conducted her first operation was also available for this one.
What they found is that part of her smaller intestine had been damaged — almost dead with some blood clots. They ended up removing 85cm of it — leaving about 100cm after restitching.
The operation went well. The doctor indicated that her intestine issue may have been contributing to her mental status and was hopeful that now that we had resolved that, there was a chance we would start seeing improvement.
That evening, a few hours after surgery when we went to see her, she had her eyes open (for several minutes). This was a much better response than we had seen in the prior week. My brother asked her a question (can you see us / recognize us) and she blinked in response to that. Could have been a coincidence, but didn’t seem that way. There were 3 members of the family there to witness it (including me). Could not get subsequent responses, but her eyes did remain open.
Now, the bad news is that yesterday, she took a turn for the worse (she’s still fighting infection in several areas). The antibiotics she is on are about the most powerful they have available. The most recent one they added evidently takes a high level of “approval”. The ICU nurse said that in her 26 years of practicing, she had never seen anyone actually given that antibiotics. (Will have to find out the name, but I think it’s Primaxin).
In any case, yesterday, they started seeing some issues with her kidney functioning. They use some number to measure the degree of non-functioning. It was 1.2 when things were going pretty well, but had risen to 1.8 (higher being worse). Doctor said in the 6-7 range is when they get really worried and 9-10 is when they consider dialysis. Thankfully, we’re not there yet, but not a good sign.
Her breathing also deteriorated and she is now 100% breathing through the ventilator. (We’re thankful that the tracheostomy is already done, so getting her back on the ventilator was not an issue).
Blood Pressure meds have been staying relatively low at around 3 (highest yesterday was 8).
No fever at all, but white blood cell count 15,000.
Urine production lower and a little cloudy — they have sent it in for analysis.
Basically, it sounds like she’s fighting multiple infections, but they’ve given her all the antibiotics they can — and also an anti-fungal.
My brother is at the hospital now, and will be listening in on rounds (as we have been doing) and talking to the doctors. I’ll get an update within an hour or so.
Meanwhile, if you have any feedback or thoughts, would love to hear them.
thank you for your update.
I’m very sorry to hear that things are not going so well.
Here are my thoughts on the situation from what you’ve shared.
- Whenever abdominal surgery is performed- which was the case when they stitched the perforated stomach- there is a risk that other parts of the abdomen do get harmed, I.e. small intestine blood clot with dead bowel tissue. I assume she must have had some sort of mesenteric infarct. Which makes me ask two questions 1) have they anticoagulated her sufficiently- anticoagulation meaning blood thinning medication such as Heparin or Clexane (Enoxaparin), which is imperative in most critically ill Patients and 2) Have they started to feed her early- I presume they must have, because you mentioned early on in our communication that she had the feeds/nutrition going via the nasogastric tube
- Also, do you know if they’ve done a stoma or closed the abdomen?
- It’s good that she hasn’t got a PEG, they might have ended up removing the PEG during the surgery anyway
- 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!
- I also assume that contributing to all of the abdominal issues would be not having opened bowels for several days, making it more likely to end up with blood clots, as well as putting pressure on to the lungs, making breathing more difficult. Not opening bowels for several days as well as having had previous abdominal surgery also often contributes to accumulating air in the abdomen
- There is a very good chance that the intestine issue contributed to your mother’s mental status and it most likely didn’t help your mother “waking up”
- It’s encouraging to hear that your mother had her eyes open for several minutes, making eye contact and responding to simple questions
- The sources of infection appear to be in her gut and the lungs, especially with being on 100% of oxygen. The antibiotic Primaxin is usually being given for Pseudomonas infection in the lungs. You may want to ask the doctors if she’s got Pseudomonas in the lungs? (Pseudomonas infection in the lungs is not all that uncommon in ICU but certainly nasty). Another Antibiotic commonly used for Pseudomonas is Tazocin/Piperacillin
- White cell count 15,000 is confirming that she’s fighting infections. It’s also a sign that the immune system is working
- It’s perfect indeed that she’s got the tracheostomy now, there is no way to do a tracheostomy on 100% oxygen as it would be too risky. It would be good to know why she is on 100% of oxygen now. Besides pressure from the abdomen restricting her lung capacity and the Pseudomonas infection what else is going on in the lungs? I hope she’s not going into lung failure/ARDS? It would be good if you can ask them for results of the chest X-ray? Also, are they considering a CT of the chest?
- Also, with oxygen levels 100% for now, what’s their plan? Are they adding on something else to the therapy? I.e. nitric oxide comes to mind
- I’m not surprised that kidneys are slowly starting to deteriorate. It’s often a catch 22 in Intensive Care Patients with severe infections and all the Antibiotics and Antifungal medications. Some side effects of Antibiotics are to impair kidney function. On top of that your mother would have most likely had periods of low-ish blood pressure throughout her ICU stay, resulting in not giving her kidneys enough perfusion, adding on to the kidneys slowly deteriorating and going into acute renal failure (ARF)
- The kidneys are usually the first organ that’s failing in critical illness after the lungs, when Patients are ventilated. The kidneys are also the organ most likely to bounce back even after Haemodialysis therapy
- In terms of kidney blood markers and kidney blood results, they are referring to Urea and normal Urea levels are 2.5 to 7.1 mmol/L, therefore it makes sense to look at Dialysis >9 mmol/L. If it’s currently 1.8 I see no reason for concern (yet) and I would also be interested in her Creatinine blood level (=another kidney marker)
- It’s very likely that they will try and increase urine output with medications (Frusemide/Lasix) first. Especially with breathing on 100% oxygen, it’s going to be important to keep the lungs “dry”, making sure there is no excess fluids in the lungs. Generally speaking, in critically ill Patients it’s very important to maintain a fluid balance that’s of benefit for a critically ill Patient. Most of the times it’s a negative fluid balance especially in light of mechanical ventilation and wanting to keep lungs “dry” to reduce oxygen requirements
- If diuretics like Frusemide/Lasix don’t work and kidney markers keep going up, a logical next step would be Haemodialysis
Overall, I’m certainly worried about the new developments and going back for surgery during critical illness is not a good sign, but it is what it is and again sticking with your three P’s, patience, positivity and persistence is still a wise approach from my perspective.
To give you some perspective: We have been working with a client since the end of November last year, a 61 year old gentleman who came to ICU after perforated bowels and severe abdominal sepsis. Ventilated, high doses of inotropes/vasopressors, tracheostomy, up to 80% of Oxygen… When we first started working with the family, they initially hired us because the ICU team wanted to “withdraw treatment” against the will of the family. Cutting a very long story short, after nearly two months and many conversations with family, the doctors and the nurses and after encountering much resistance from the Intensive Care team, the gentleman has left ICU alive last week and is now going on to rehabilitation…
- THE 5 THINGS YOU NEED TO KNOW IF THE MEDICAL TEAM IN INTENSIVE CARE WANTS TO “LIMIT TREATMENT”, WANTS TO “WITHDRAW TREATMENT”, “WITHDRAW LIFE SUPPORT” OR WANTS TO ISSUE A “DNR” (DO NOT RESUSCITATE) OR “NFR” (NOT FOR RESUSCITATION) ORDER FOR YOUR CRITICALLY ILL LOVED ONE!
Now, we never promise to save lives, but we believe we are in a position where we can help people one way or another, irrespective of the outcome. Even when we are counselling families in end of life situations, we can help them go through the process…
Also, if you can please clarify, what do you mean by “BP meds have been staying relatively low at around 3 (highest yesterday was 8).” I’m unclear what you mean by this?
Wishing you and your family all the best!
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- How to ask the doctors and the nurses the right questions
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- 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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