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 my clients and the question in the last episode was
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 continue answering the next questions regarding James’ and Christine’s Dad in ICU who’s had a haemorrhagic stroke.
James’ and Christine’s Dad had a brain decompression where they evacuated a large bleed from his brain after the haemorrhagic stroke. And their Dad also underwent a craniectomy (removal of skull) to decrease the brain pressures after the bleed.
James’ and his sister Christine were getting their Dad in one of the best hospitals in the USA, the Cleveland clinic in Ohio.
He also had ongoing seizures due to the stroke and his anti-seizure medications needed to be optimized so he could “wake up” and progress to Neurology Rehabilitation.
In today’s 1:1 consulting and advocacy sessions with James and his sister Christine, we look at some setbacks their Dad is going through.
He had to be put back on the ventilator due to a Pneumonia and he also ended up with a central line (CVC) and arterial line again.
So in today’s episode of “YOUR QUESTIONS ANSWERED”, I answer a series of questions from James and his sister Christine again that are excerpts from various 1:1 phone/email consulting and advocacy session with me and the topic this week is
Dad’s still ventilated with tracheostomy after 5 weeks in ICU, now he’s confused and agitated, what should we do?
You can also read or watch previous episodes of 1:1 consulting and advocacy with James and his sister Christine here
Thanks Patrik for your last email, that makes perfect sense.
And thank you for your help
You offer an invaluable service it is very much appreciated.
I wanted to give you a quick update. My father was on tracheostomy collar all last night. And today.
They are doing something called inflation where they are putting him back on the ventilator every four hours. Just for 1/2 hour.
I believe they are going to stop doing this to see if he can breathe on his own indefinitely with the tracheostomy collar.
It sounds as though they are trying to get him to step down early next week.
Please let me know your thoughts on all of the above.
In addition my father is still very angry and irate. He is so strong it is hard to restrain at times. He is also trying to push himself out of bed I believe he cannot get very far because he is weak on his right side.
They did take the CVC line out of his neck. And we visited with the infectious disease doctor that is going to put him on a more mild antibiotic.
What is your suggestion for the delirium? I was thinking a short acting tranquilizer my calm him down but I do not believe his seizure doctor wanted to add any medications at this time. However I don’t believe the seizure doctor understands how irate he is.
In addition he is mumbling and talking nonstop. He is very responsive to commands today and respond instantaneously with ease. He can lift his leg and raise his arm but cannot seem to open his mouth or stick out his tongue on command. Why do you suppose that is?
We are getting little words out of him like yes and no and so.
Please give us your thoughts on all of the above but appears as though we are on our way to step down.
We are also looking for guidance on where to go after step down and how long you believe they may keep him in step down?
I don’t believe he can go to rehab until he can do three hours of rehab a day.
Thanks for the update.
I’m pleased to hear about the progress in relation to staying off the ventilator, knowing that he can breathe on the tracheostomy collar almost 24 hours a day.
Inflation with the ventilator every few hours for about 30 minutes will help him as well, as he will get additional inflation for his lungs.
Once your Dad can be off the ventilator continuously he will be ready to go to step-down and they can manage the tracheostomy. I think if he can proof to stay off the ventilator over the weekend he will be truly ready to go to step down and he won’t need ICU anymore.
Do you know how often they suction him via the tracheostomy, do you know if he has lots of secretions and do you know if he has a strong cough? The answers to those questions will determine if he’s a candidate to have the tracheostomy removed at some point as well. He also will need to be able to swallow.
I’m not surprised your Dad is angry and irritated after 5+ weeks in ICU with a stroke. It comes with the territory, but it’s good to know he’s more awake, he’s trying to speak and he’s also trying to get out of bed. Those are all good signs and the next challenge will be to channel those efforts in the right direction if possible at all. That’s where I believe Neuro rehab will have its place.
I don’t think restraining him is the right approach as it will make him more frustrated but I also know from experience that sometimes that’s the only option.
The delirium or ICU psychosis probably needs to managed with medications such as Seroquel (Quetiapine) for anxiety, potentially some Diazepam or Ativan, maybe small doses of Haloperidol. But I am advocating for small doses of tranquilizers or antipsychotic drugs rather than big doses, because you only want him calm and not asleep during the day, however he needs to sleep at night.
But I would also strongly advocate to get him back to “normality” as much as they can, I.e. get him some fresh air, natural daylight, a shower etc… just as we discussed this week.
Patients who have been in ICU for many weeks are often confused, agitated and aggressive because of the side effects of the drugs they had during the induced coma and they have a disturbed day and night rhythm because of the lights on in ICU 24/7, noise, people doing things 24/7 etc…
Therefore getting out of ICU is a good thing!
On top of the confusion that many Patients experience in ICU after long-term stays, your Dad has to deal with the effects of a stroke which will increase his confusion…
On that level he has many challenges to deal with and it’s advantageous going forward if he won’t be ventilated so the focus can be more on Neurology rehabilitation.
If he can go on to Neuro rehabilitation, they will also be reviewing his seizure medications. For now they are probably erring on the side of caution still to keep him seizure free, hence high dose of Keppra.
It’s good to hear he’s trying to mumble words and moving his limbs, sticking out tongue etc… I think that’s encouraging given where he was at a few weeks back. A Neurology recovery after such a significant event like a stroke including many weeks in ICU is difficult to predict because the brain is the only organ ion the body that can’t be controlled. Every other organ like the heart, liver, lungs kidneys can be at least temporarily controlled but not the brain.
Therefore from everything you are describing he’s making progress and his efforts need to be channeled in the right directions with a neuro rehab team.
As far as step down goes, I don’t know how long they’ll keep him there, potentially a few more days, also depending on whether they can remove the tracheostomy or not. Some hospital wards don’t have the skills/expertise to look after tracheostomies, you probably need to find out…
Hope that helps for now, please let me know if you want to get on the phone or if you have any other questions.
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I agree and good advice.
What should we expect from a neuro rehab? I am a bit concerned that they will not be able to manage him as well.
He still needs to get suctioned every hour or so. His cough is strong and I do believe he can swallow but they have not done the barium swallow test yet with the dye!!
He could get pneumonia or seizure at rehab and then what!?
Yes your concerns are valid with Neuro rehab having difficulties managing him.
Moving forward however, from what you are describing your Dad has come a long way even within a week.
Last weekend he was just on the verge of weaning off the ventilator and now it looks like he’s managing the transition to breathing by himself fine within less than a week. That’s encouraging.
He also got progressively more and more awake and stronger and that’s on a large dose of Keppra and so far he’s been seizure free!
Neuro rehab should be focusing on strengthening his movements, as well as strengthening his right side which is weak from what I understand. Mobilisation and walking as well. Furthermore, they should also be focusing on speech recovery and talking abilities.
He’s probably not quite there yet to go on to rehab, but I believe he’s clearly taking steps in the right direction. Let him go to step down and let’s give him more time there. AT this stage you can only take one day at the time but given he’s come a long way even within the last week from what you are describing, he’s making progress.
It would be advantageous if they can remove the tracheostomy as well but he’s not there yet.
There will be less ICU input going forward and hopefully more input from Neurology and they should be the experts in driving his recovery forward.
Any questions please let me know.
When will he be clinically considered to be “weaned” off of the ventilator by definition of the hospital and for insurance purposes?
I.e. Can he go to rehab on the tracheostomy collar ? Or does he need to completely off the tracheostomy collar and hose??
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He’ll probably be considered breathing by himself after about 3-4 days without the ventilator.
He should be able to go to rehab with the tracheostomy and the collar. Many neurology Patients have a tracheostomy, therefore the chances that a neurology rehabilitation can manage a tracheostomy and the collar are pretty high, although you better start asking them now to find out for sure.
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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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