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 Julie as part of my 1:1 consulting and advocacy service! Julie’s mother is critically ill in the ICU with sepsis, and she is asking what are the parameters to safely remove her mom’s breathing tube.
My Mom is Critically Ill in ICU and is Ventilated. Is it Safe for my Mom to Remove Her Breathing Tube If She is Confused?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Julie here.”
Julie: How to be aggressive about the ventilator? Because you know my feelings on this, was the intubation came because she was so highly sedated on the Precedex, that was she was not on aspirating her own CO2, and went into induced coma.
Julie: So the only reason intubation was done, was because of that. Otherwise, it was very manageable with her own body saying, hey, this is what you need to do. And a little bit of her behavioural trying to rip stuff off. But at that time she was still very strong, in what she knew she wanted for herself. And I just feel like we’re kind of recovering from that CO2, the acidity in the blood. But prior to that things were running just fine. As long as she’s not so sedated, she can’t remove her own CO2. So that’s why I just kind of wonder like, how aggressive can we be? They get that intubation out of there and kind of get her without any setbacks.
Patrik: Yeah. Look, the next thing that needs to happen is, sedation needs to come off sooner than later. Then there needs to be a neurological assessment. Let’s just say they take the sedation off, she’s waking up, she’s sort of following simple instructions like you know, squeezing fingers. And they can wean the support off the ventilator. There is no reason that they can’t extubate her as long as she’s following instructions and as long as she has a good strong cough, right?
Patrik: But that still remains to be seen. There is a sort of risk that she is confused once the sedative are off. And when there is confusion or delirium setting in, that could be sort of put a stop to taking out the breathing tube. But again, we will see that in the next few days, in how she responds to having sedation taken off. We can only speculate at the moment. A lot of it is in her hand. And we just have to go with the flow at the moment.
Julie: Okay, okay. All right, well thank you so much. I’m going to send you those pictures.
Julie: And we’ll just keep in contact with you.
Patrik: Absolutely. Absolutely. But it is very, very encouraging. Very encouraging.
Julie: Yeah, it is. If we needed to turn a corner, that was the corner we needed to the turn, at the moment.
Patrik: Yes, yes. It’s often two steps forward, one step back. So if she can’t come off the ventilator in the next couple of days, do not give up hope. I mean she’s taken a big milestone for now, and hopefully she can take the next step.
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Julie: Okay. And what is the next step, in communication with you, just kind of, the daily updates or what do you…
Patrik: Yeah, daily updates. Keep referring back to the questions. Having said that, yeah, keep referring back to those questions that I sent you. The other thing, on a ventilation point of view, you might have seen in the email that I sent to you, I was referring to arterial blood gases?
Julie: Yeah, I think we tried her… yeah, okay.
Julie: Because that was in that same email, right?
Patrik: Say again?
Julie: That was in the same email about the questions and stuff-
Patrik: Yes, yes-
Julie: because there’s a little bit that I needed to look over and read a little bit more, because I focused a lot on the questions at that time.
Patrik: Yes, yes, yes. So your mom would have an arterial line, I would think. And that’s why, can you also send me a picture of the monitor please?
Marvin (Husband): Yes. We will send you a picture of the ventilator later. And the monitor.
Patrik: The monitor, that would be good. So your mom would have an arterial line. And because of that, they can take bloods, and they can measure effectiveness of ventilation.
Marvin (Husband): I don’t think she got an arterial line.
Patrik: Right. Are you sure?
Marvin (Husband): I’m pretty sure because I’ve watched them do an arterial blood gas test on her, and they had to bring in a machine, like a little handheld machine, and they took a sample and put into the machine.
Patrik: And they stopped doing that?
Marvin (Husband): We asked yesterday, and they said they have not done an arterial blood gas. That was one of the questions we asked.
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Patrik: And they haven’t done an arterial blood gases because she simply doesn’t have an arterial line. You think that’s the reasoning behind it?
Marvin (Husband): I think so. Because I remember you asked me to send you a picture of the monitor.
Marvin (Husband): To see if her blood pressure is being measured off an arterial line or not.
Julie: Do you think that’s something we need to have?
Patrik: Well, I feel that way. Because we’re talking about ventilation weaning, and one way to assess where she’s at on a ventilation point of view is simply by checking arterial blood gases. That would be a little bit of a surprise, if she didn’t have that. Look, I guess send me a picture of the ventilator, the monitor. Also asked the nurse about the arterial line and the arterial blood gases and see what they say.
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Marvin (Husband): When you say she has an arterial line, do you mean an arterial line that’s continuously hooked up to the monitor?
Patrik: Very much so-
Marvin (Husband): Or do you mean…
Patrik: Look, if she has an arterial line it would be hooked up to the monitor, I have not seen arterial lines being inserted and then not hooked up to the monitor. Because simply if you don’t, they’re almost… you want them for both. You want them for continuous blood pressure monitoring, and you want them for taking blood. If you’re not monitoring an arterial line, it’s dangerous. Because if it came out, it could cause some severe bleeding.
Marvin (Husband): Well, she has a PICC line in her right arm.
Marvin (Husband): But I know her blood pressure is measured by an inflatable cuff on her left wrist.
Patrik: Okay, if that’s the case, it is unlikely arterial line.
Marvin (Husband): Sorry, say that again.
Patrik: If that’s the case, it is unlikely that she has an arterial line. But again, you got to ask and see what they say.
Julie: Okay. And then is that something that you recommend or the measures they’re taking now are adequate?
Patrik: Well, I feel from my experience, I feel like eventually the weaning can only be happening with an arterial line.
Patrik: Is she having daily chest x-rays, do you know?
Marvin (Husband): Yes.
Patrik: She is, okay.
Marvin (Husband): Yes, she has a chest x-ray every day to verify placement of the ventilator tube, and also the feeding tube that is inserted into her stomach.
Patrik: Yeah. Talking about feeding tube, they haven’t started feeds again, have they?
Marvin (Husband): No.
Julie: They have not.
Patrik: No, no, I would be surprised. Yeah, okay. I mean checking oxygen saturation on the monitor is one way to gauge effectiveness of ventilation, checking daily chest x-rays is another way of checking effectiveness of ventilation. But the arterial line is another, or the arterial blood gases, you can get so much more from that. Because there’s a large number of parameters that you can assess there. It’s very detailed.
Julie: Okay. Okay. And then also, talking on the food too, because we’ll bring that up and then just see what their thoughts are and let you know what they say about that. And then on food, when do you see, like when should we be alarmed about the food?
Patrik: I would think that if she started to open bowels, and if she continues, you know, if her swelling goes down and if abdomen is soft, I would think that maybe by tomorrow they could start very, very gently. And what do I mean by that? You know, like they might start with 10 ml an hour tomorrow, very slowly. How many days has your mom not been fed for?
Marvin (Husband): I think it’s only like two or three days now.
Marvin (Husband): I think it was Thursday afternoon when the GI problem kind of really popped up…
Julie: And the swollen bowels.
Marvin (Husband): And that was when they… when I got here Thursday afternoon, she was still getting a feeding.
Marvin (Husband): And then they took her to CT scan, to get another CT scan of her belly. And at that point was when they stopped the feedings and started prepping for a colonoscopy.
Patrik: Okay, okay.
Marvin (Husband): And she hasn’t had food since.
Julie: And she was given a half gallon of GoLytely. Right, a half-gallon?
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Marvin (Husband): Yes, correct.
Julie: And that was two days over.
Marvin (Husband): That was on Thursday night.
Julie: Thursday night at 5:00, she was given GoLytely, and then they didn’t see a bowel movement until today.
Patrik: Sure, sure. How is your mum, like, is she very skinny? Does she have some reserves?
Julie: She has reserves. She’s got, they’ve packed on 100 pounds at the nursing home. So now she is obese.
Patrik: Okay, I see, I see.
Marvin (Husband): Yeah she was 126 kilograms when she arrived here.
Marvin (Husband): And right now her weight, she’s at 109 kilograms.
Patrik: Okay so she does have some reserves, that’s good. Nevertheless, should she be fed whenever the bowel issues have been resolved? If for whatever reason, they think they can’t feed her in the next three or four days, she would need to be started on TPN. Have you heard of TPN?
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Patrik: TPN is basically intravenous nutrition. But that’s can… I’m not too worried about the next 24 or 48 hours, not having any feeds, but if for whatever reason it’s going to be a long-term issue, she would need some TPN, which is intravenous.
Julie: Okay. Okay.
Julie: And then PPN you call it?
Patrik: TPN, T for Tom, P for Peter, and N for Nelly. And-
Patrik: TPN stands for Total Parenteral Nutrition.
Patrik: You can find some…
Julie: And that would be in a couple days from today, or a couple days from when she stopped eating, like are you thinking that tomorrow? Or are you thinking they try to feed her slowly tomorrow, and then…
Patrik: Yes, yes. Look if they can’t give any feed through the nasal gastric tube in the next 24 to 48 hours, they need to consider alternatives. And TPN would be the alternative.
Patrik: So yeah, but she can probably go for another 24, 48 hours without any feeds at all. And if they do restart the feeds, it would have to be slowly. 10, 20 ml an hour, to begin with. And then slowly increase it up.
Julie: Okay. Okay. All right. All right, thank you so much Patrik for all your time today.
Patrik: You’re very welcome. Send me a picture of the monitor and the ventilator, and then I can advise from there.
Marvin (Husband): Thank you.
Patrik: Thank you so much.
Julie: And we’re going to ask all the questions and we’ll also ask about the arterial blood gases and we will let you know about that.
Patrik: Please, please, please.
Julie: Okay, thank you so much.
Patrik: You’re very welcome. All the best for now.
Julie: Have a good day.
Patrik: You too, bye, bye.
Julie: Bye bye.
The 1:1 consulting session will continue in next week’s episode.
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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
- How to eliminate fear, frustration, stress, struggle and vulnerability even if your loved one is dying
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- 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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