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 weeks question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer the next questions from one my clients Andrea who has her 34 year old sister in Intensive Care with non-Hodgkins Lymphoma and a stroke.
Today’s questions and excerpt from the 1:1 consulting and advocacy session is
Is it best to have a breathing tube /endotracheal tube after stroke and seizures?
You can also check-out previous consulting and advocacy sessions with Andrea here
Patrik: One thing that- I tell you what I’ve seen in ICU over the years especially with cancer patients right? I can’t recall ever a cancer patient having a stroke, I can’t recall that, but I can tell you what I can recall and sort of it’s almost like a golden rule in ICU that anybody with a weak immune system after chemotherapy, radiotherapy, should not go on a ventilator.
And by that I mean they should be going on the ventilator if they have to, but with a low or almost non-existent immune system it can be very difficult to get those patients off the ventilator. That’s what I’m saying.
More specifically, I mean Patients with cancer end up having radiotherapy or Chemotherapy and then their immune system is so weakened that they often end up with sepsis as part of a Pneumonia for example.
On top of that like you have already described, your sister has low Platelets, low Haemoglobin, low white cell count (WCC) and she is potentially neutropenic.
Keep in mind getting on a ventilator is risky at the best of times, let alone when you have all those other risk factors such as cancer and no immune system. Imagine you have a sepsis, Pneumonia, you have no immune system to fight the Pneumonia and the sepsis and you are on a ventilator?
Chances for survival are rapidly diminishing in situations like that which is why avoiding going on a ventilator is a good strategy to have in order to increase the chances of survival!
I have rarely seen Patients on a ventilator with no immune system survive, it’s very rare.
Patrik: That is a concern and I can tell you I have seen people coming off the ventilator successfully but if it’s more difficult in any patient group it’s probably with cancer patients with no immune system going into ICU on a ventilator. It can be very difficult getting them off that ventilator
Andrea: I’m sorry is that the machine that goes down into their lungs?
Patrik: Yes. Yes. Mm-hmm (affirmative).
Andrea: And why would they put a ventilator in because they had a stroke she was having seizures why would they?
Patrik: Okay, okay. So she had seizures did she?
Andrea: Well they said it was a stroke or a seizure. I can’t remember the-
Patrik: They weren’t sure?
Andrea: Yeah, no.
Patrik: Okay no, no it’s good that you mention that. So what happens, so what’s probably happened as well. If she had seizures or if they had suspected she had seizures she would be getting medications like Keppra, or Phenytoin which is a prophylactic seizure management medication and that would dampen her neurology even further.
Patrik: So what I’m saying is we’ve talked about Propofol and Midazolam
Patrik: -a while back. So if she had a stroke or if they had suspicions she had a stroke she is now probably on Keppra or on Phenytoin.
And that would delay waking up even more.
Patrik: Right? So I will send you all of those drug names in a moment.
Andrea: Mm-hmm (affirmative)?
Patrik: You know you can ask them, and why is it difficult to get somebody off a ventilator with you know, sort of low immune system. It’s just that they’re general condition is very poor and I’m sure that’s the case in your sister’s situation, would that be fair to say?
Andrea: Yeah. Yeah, yeah.
Patrik: And that can make it challenging to get off of the ventilator, but she needs to wake up as a next step. You know that’s the next step.
Andrea: That’s what we’re waiting for.
Patrik: That’s right, that’s right. And then you can sort of once she’s waking up then you can worry about, can we get her off the ventilator or not.
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Why did they put a ventilator on in the first place with a stroke? I could probably tell you. Number one she may have stopped breathing for a period of time and number two that one of the biggest risks for stroke and for seizures is aspiration, have you heard of that?
Patrik: Basically what it is, stroke, or seizures, a lot of people vomit because of it. Right? During that episode stomach content is going down their lungs and that’s called an aspiration Pneumonia.
Patrik: Right? And if that happens. The next thing is a Pneumonia is happening. Alright? And you can only protect somebody from aspirating if you put a breathing tube/endotracheal tube in and the breathing tube is blocked with an air balloon and that stops, that stops anything going down the lungs.
Patrik: So, that would have been one of the reasons they would have put your sister on a ventilator.
Patrik: Right. And what might have happened during the stroke or the seizure as well, her oxygen levels might have come down and I would hope that during the seizure or the stroke they would have done some neurological observations. And her oxygen level was probably down.
Andrea: Mm-hmm (affirmative).
Patrik: So those are the most likely reasons they put her on a ventilator.
Andrea: Mm-kay (affirmative).
Patrik: So what I’ll do with the next step is I will send you more information, more questions you should be asking.
Patrik: In terms of other things we can do down the line if you want that, of course. if you want me to talk to doctors and to nurses that sort of stuff we can do all of that we can also participate in family meetings over the phone.
Andrea: I understand.
Patrik: But you know, we’ve touched base. Get a feel of what we can do. You know we’re talking to people every day we’re participating in family meetings every day we can come in as an advocate for your sister if you feel that’s what’s needed but I’m glad to hear that you don’t feel under pressure from the ICU team. I’m feeling-
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Andrea: No, not yet. I wouldn’t let them make us feel that way anyway.
Patrik: Good, good, good.
Andrea: She’s my little sister.
Andrea: Not theirs, the question I would ask them is what would you do if your family was on that bed?
Patrik: That’s exactly right. That’s exactly right. And I’m glad to hear that you don’t experience a pressure and as you said, don’t let them.
Andrea: No I won’t let them. That’s one thing I strongly believe in. I was thinking of actually getting a second opinion for a neurologist as well.
Patrik: Mm-hmm (affirmative). Yeah, but speak to the neurologist at St. George first.
Patrik: You know, get a feel for what they think, you know. And then yeah, absolutely get a second opinion for sure!
Andrea: Yeah. I’ve taken enough of your time, can you just send me a list of your availabilities if you don’t mind?
Patrik: Absolutely, I’ll put that in an email!
Andrea: Okay. Great thank you so much for your time.
Patrik: Your welcome, your most welcome.
Andrea: If you could just E-mail me a list of all those questions I would greatly appreciate it.
Patrik: Absolutely I will do that. It might take me couple of hours but you’ll definitely get it today.
Andrea: That’s okay. That’s fantastic.
And just, what’s that thing that she should be putting on her legs? That machine?
Patrik: Calf Compressor. Calf, Yeah. Thanks.
Andrea: Thank you so much.
Patrik: Your most welcome, all the best.
Andrea: Okay, cheers. Thanks.
Patrik: Take care. By-bye.
Here is the email summary that I sent to Andrea after the consulting and advocacy session.
Just a quick email summary what we’ve discussed today.
- Was her airway blocked because her tongue fell back and obstructed her trachea and therefore she couldn’t breathe?
- Was she at risk of aspirating stomach content into her lungs because she vomited? Aspiration means getting stomach content into the lungs which can cause Pneumonia. Patients at high risk of aspiration may need intubation to protect their lungs
- Were they giving Midazolam or Diazepam (Valium) to manage the seizures? Midazolam and Diazepam usually work very well to manage seizures and Patients usually stop seizing very quickly after those drugs are giving. Both drugs have sedative effects and therefore your sister may have stopped breathing, hence whey they needed to intubate
In any case, if they thought your sister had a seizure they should have done a follow up CT of her brain within 24 hours after the seizure/ stroke.
Alternatively, your sister may have had a compromised airway after the stroke if she didn’t have a seizure. This means she may have had shallow breathing after the stroke or she may have again been at risk of aspiration.
They must have some documentation in regards to this stroke/seizure episode on the ward and why they intubated her.
Every such an episode which would either be classified as a medical emergency or even a code blue would have some documentation of the event. You may want to ask for this documentation amongst other medical records as per the “freedom of information” act. If you ask for it, ask with deadline and let them know that you want the documents by a specific time (I.e. tomorrow 12pm).
Also, as we discussed, for any Patient with non-Hodgkin’s Lymphoma, the following blood test results are important especially with a potential infection
- White cell count (WCC)> A high white blood cell count usually indicates: An increased production of white blood cells to fight an infection. Normal levels are 4.5-11 Low white cell count indicates that the immune system is down and can’t fight an infection
- Neutrophils are a type of white blood cell that fights against infection> https://en.wikipedia.org/wiki/Neutropenia
- Also, if your sister’s Haemoglobin is <70 she probably needs a blood transfusion or two
Furthermore, find out if she has an NFR= Not for resuscitation order. As we discussed, they may have taken away the NFR but you probably need to verify as I wouldn’t trust them with this specific information.
Because it could potentially also be “life or death” information I would definitely verify if I was you.
If you do want more information about the whole topic, you can read this article here
- 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!
Also, find out if your sister requires any medication for low blood pressure. If her blood pressure is <90 mmHg she will need intravenous drugs such as Noradrenaline or Adrenaline, they are classified as inotropes.
I can be available for a family meeting tomorrow pretty much anytime, let me know what time you’ll meet. It might be worthwhile if we talk beforehand. If you have any questions in the meantime, please give me a call.
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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
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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 in another update!
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