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
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, Lloyd as part of my 1:1 consulting and advocacy service! Lloyd’s mom is on a ventilator in the ICU and he is asking, how long can his mom stay in ICU, and why do the doctors insist on tracheostomy.
How Long Can My Mom Stay in ICU & Why Do the Doctors Insist on Tracheostomy? Help!
You can also check out previous 1:1 consulting and advocacy sessions with me and Lloyd here.
Lloyd: And they said that the fact that she didn’t have any distress from moving from the bed to the chair, they had to lift her up in one of those hammock type things. And so she was fine and with no distress, so that was perfect. Everything was going according to plan.
Patrik: Okay. And at the moment she’s no longer following commands, is that correct?
Lloyd: She’s only responsive with her eyes, like with the left or the right.
Patrik: Right. Have they got an explanation what changed? Why was she able to follow commands before extubation and now she no longer is?
Lloyd: I asked and they haven’t been able to give me an answer. Probably been or nothing.
Patrik: Right. Have they changed some of the medications? Have they done a follow-up CT (Computed Tomography scan) of the brain? Do you know?
Lloyd: Oh my God. Yeah, I mean, they gave her such a high dose of fentanyl a couple of days ago. Because they gave her two types of antibiotics and she had an adverse reaction to the antibiotics. And I guess she was in pain. They gave her a super high dose where the nurses were coming in the night than before and the day after. And they’re like, “Oh, she’s so super doped up. She wasn’t responding at all.” Because the day before they-
Paul: Had her on fentanyl.
Lloyd: They had her on fentanyl, but they had her on the lowest dose and she was fine. She wasn’t in pain. The lowest dose, like 25 or 25, whatever it is. And he she wasn’t in pain. And then the following day they put her in 12.5 or some super high dose. And I don’t know if it’s because the rash from the antibiotics or if she was in pain from the antibiotics. And then the following day they took her off. I think they were weaning her off and then she was without fentanyl for a little bit. And then they get started getting it to her again because they said the Tylenol was passing her liver. But before they were giving him Tylenol round the clock. So, I don’t know if that had an effect, or the antibiotics had an effect.
Patrik: With the antibiotics, where is the infection?
Lloyd: I don’t know if it was preemptive.
Patrik: Yep, might be, might be.
Lloyd: I’m not sure.
Patrik: Might be. Might be. And who’s the person that is more positive in all of this? Is that the neurosurgeon?
Lloyd: The attending.
Patrik: The attending.
Lloyd: Oh, the more positive?
Lloyd: Positive is the neurosurgeon. The one who put in the stent.
Patrik: Yeah, okay.
Lloyd: And the attending is just doom and gloom.
Patrik: Right. And when you say doom and gloom, can you be more specific? What are they saying?
Lloyd: Paul you fill in, because I don’t want to say it loud.
Patrik: Oh, I see. I see. Okay.
Lloyd: Paul are you there? Paul, Belle?
Paul: No, well, she
Lloyd: Oh, go ahead.
Paul: She’s very straightforward. Let’s put it that way. She’s like, “You need to get this done right away and you need to figure it out now,” type thing. And she gave us our options between letting my mom stay on the ventilator for a little bit longer. Or we could do the tracheostomy right away, which would get her straight into rehabilitation and she can get better quicker according to her.
Paul: So, we felt as we were being pushed to make a decision to get the tracheostomy put in right away, because they wanted to schedule it for Monday, Tuesday type thing, just to put the tracheostomy on their schedule. Instead of having my mom stay on the ventilator a little bit longer, let’s see if her lungs can get a little bit better. But she was saying, “I don’t think she can get better staying on the ventilator.”
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Patrik: Okay, have they-
Belle: She also wanted them to have a do not resuscitate. Before they tried the first tube removal she had a big discussion saying that if it doesn’t work, do we want us to try to resuscitate her? She was really talking it up, like, “Should this fails, we want you to sign this thing where they wouldn’t try to do any lifesaving measures.”
Patrik: But you haven’t agreed to a Do Not Resuscitate, have you?
Lloyd: No, no, no.
Patrik: Good, good.
Belle: We forcefully told them said no.
Patrik: Excellent. Excellent. No, that’s good. That’s good. Have they disclosed to you that, let’s just say you would have agreed to a tracheostomy last week, have they mentioned to you that they would have wanted to send your mom out to Long Term Acute Care or a skilled nursing facility? Did they disclose that to you?
Lloyd: Well, they said that for her to get better quicker we need to do the tracheostomy right away and we can just send her to rehabilitation and then she can work in rehabilitation. It was basically saying that they wanted to get her out of Intensive Care Unit quicker.
Patrik: Of course. Of course. Are you aware at the moment that this is what might be happening if you do give consent to a tracheostomy?
Lloyd: Well, are we aware?
Belle: We haven’t had a chance to talk to anybody about it.
Belle: We have that question as well. So, nobody will talk to us.
Patrik: Right. Okay. Here is what’s really important for you to understand, I believe. A tracheostomy has its time and its place, and I’m … For the right patient, right time a tracheostomy can be a wonderful thing. What Intensive Care Units are often not doing is they’re saying, “Well, your loved one needs a tracheostomy.” And then next thing you know, once that’s done they’re trying to send them out to an Long Term Acute Care or to a skilled nursing facility. LTAC stands for long-term acute care facility.
Now, we are very opposed to any such moves because from our experience that those LTACs are designed to empty ICU beds and save costs, but they’re not designed for clinical need. And then whilst, if you look at any LTACs website, they’re advertising it as weaning facilities and rehabilitation facilities. From our experience, it’s nothing but. It’s a better version, a better version of a nursing home. And patients yet go from Intensive Care Unit to an Long Term Acute Care, we think it’s dangerous. But that’s not to say that your mom doesn’t need a tracheostomy, but before we can establish that, I believe, do you know what ventilator settings she’s on at the moment?
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Paul: She’s on, she’s breathing on her own. Right now, I’m looking at it. It says, what am I looking for? O2 concentration 40, PEEP is 5, PS above PEEP is 10. The backup has not lit at all. Apnea times 20, end expiration 30, 10 rise point 15 trigger negative foods. Right now, he’s breathing 20 beats per minute, I guess.
Patrik: Yep. Can you see the volumes?
Paul: Pretty much breathing on his own-
Paul: Say that again?
Patrik: Can you see the volumes?
Paul: The MB? Is that what that is?
Patrik: No, VTE probably
Paul: V-T. Oh, V as in Victor?
Paul: Oh, 474.
Patrik: 474, okay.
Paul: And now it’s 466.
Patrik: Yeah. Yeah, sure. It varies, okay. What’s mom’s weight roughly
Paul: Right now, she’s 180.
Patrik: 180 pounds.
Paul: Pounds, yes.
Patrik: Yes. No, no. That’s fine. I just need to quickly use my Google, because I’m a kilo person. I just need to quickly establish what’s that in kilo. Just give me one second. But anyway, do you know why I’m doing that? Do you know whether they’re doing arterial blood gases?
Lloyd: No, I don’t know.
Lloyd: What does that mean?
Belle: They did it once. They did it once.
Patrik: They did it once-
Belle: They did it once in a while.
Patrik: Okay. Well, okay, it’s about 80 kilo and she’s breathing about 474 mls. Is it fluctuating a lot? The number there with-
Paul: No, now it’s at 457.
Paul: The lowest that I’ve seen I go was 444, but it’s between 444 and that number.
Paul: Right now it’s like, yeah.
Patrik: So, look.
Patrik: Right. Quite frankly, so here are the criteria for extubation from my experience. The criteria for extubation is someone needs to breathe spontaneously. You’re saying pressure support is 10, Positive End Expiratory Pressure is 5, did you say oxygen is 35%?
Paul: No, oxygen, she’s 96.
Patrik: Yeah, sure. That’s his oxygen saturation. What is-
Paul: Oh yeah.
Patrik: What is she getting through the ventilator? Can you see that? There must be Fraction of Inspired Oxygen, must be a number next to.
Paul: The concentration 40%.
Patrik: 40%, okay. Okay, so here is the criteria for extubation. Obviously, you need to be breathing spontaneously, which is what she’s doing. The pressure support should be 10 or less, PEEP five, oxygen concentration, 40% might be a little bit too high. Room air, the air that you and I are breathing is 21%. So, 40% of oxygen is still a little bit on the high, side should be 35 or less. But then that’s where the arterial blood gas kicks in. If they took an arterial blood gas they could tell you oxygen concentration in his blood, as well as carbon dioxide concentration in his blood. Both parameters would be very important to know, because that’ll determine if his ventilation is adequate or not. Now, another criteria for that-
Paul: Is that called the ulterior … What was that called again?
Patrik: Arterial blood gas, also known as an ABG.
Paul: ABG, okay.
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Patrik: And if she’s awake and obeying commands, she should be extubated. The missing link to me are, from what I’m hearing are two things here. One missing link is, well, is she awake and obeying commands? If no, what has changed between today and Wednesday? Has her neurology deteriorated, or is it simply that they re-sedated her and that’s why she’s not awake and obeying commands? The other criteria is, if they were to take out the breathing tube, can she protect her airway, I.e., does she have a cough? Do you know whether she’s got a cough?
Paul: Yeah, I mean, when she has mucus in her lungs she will try to cough out. And the respiratory people yesterday were saying, “Yeah, she has a good cough.”
Patrik: Right. Okay, that’s good. That’s really good. Because she needs to be able to protect her airway if they were taking the tube out. So, those are the criteria. And it sounds to me like the missing link is not awake, not awake enough. And also-
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Paul: Oh, she’s awake. I mean, right now she’s awake. She’s listening to what I’m saying.
Patrik: Right, okay.
Paul: Yeah, she’s awake. She’s awake. They started giving her a stimulant for yesterday and today because, and I asked her why, because she was awake two days ago without a stimulant or whatever. And before, I think before they did the debacle with the antibiotics, but they said, just because when you’re in ICU your circadian rhythm tends to go off. And so they just try to get her some during the day so she’ll stay up there instead. Not sure whether she needed it or not, but.
Belle: She has natural light in that room though. There’s a window there.
Paul: Yeah, there is natural light today.
Paul: And the other day was, yesterday was cloudy, and the day before.
Patrik: Right. And sorry, I didn’t get that. What did you say they were giving her?
Lloyd: They were giving her a stimulant. Oh, I don’t know. They put it in her arm. If I find it, I’ll let you know.
The 1:1 consulting session will continue in next week’s episode
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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Sign up and download your FREE “INSTANT IMPACT” REPORT now by entering your email below! In your FREE “INSTANT IMPACT” REPORT you’ll learn how to speak the “secret” Intensive Care language so that the doctors and the nurses know straight away that you are an insider and that you know and understand what’s really happening in Intensive Care! In your FREE report you’ll also discover
- 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 you 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)
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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