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 in the ICU for Pneumonia and is asking if the abdominal fluid adds to respiratory failure.
My Mom is in the ICU for Pneumonia. Which Should Be the Priority, Abdomen, Kidneys or Lungs?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Julie here.”
Patrik: Right. So, from that perspective, let’s just run through the worst-case scenario and run through the best-case scenario, as far as I can see with the information that I have. The worst-case scenario would be that they continue treating, but she’s going into septic shock. She would shut down. What do I mean by shut down? That the nurse, Mel, has already told me that she’s very cool in her legs and in her arm. That it’s a sign of septic shock. And, if they keep going up with the Vasopressors, the Norepinephrine and the Phenylephrine, and I don’t want to get you disheartened but you need to understand the mechanisms of the Phenylephrine and the Norepinephrine. It’s important for you to understand.
When somebody has a cardiac arrest outside of hospital, or in hospital, basically their heart stops. One way to reactivate the heart is with those medications, Norepinephrine and the Epinephrine, and your mom is on those drugs. Now, her heart is fine, however the septic shock causes her to become hypotensive, which means she’s currently having a very low blood pressure, and in all that, to manage that low blood pressure, they need to give her those drugs. And they are considered life support.
Patrik: And if they keep going up with those drugs, which is what happened just in the last hour from what I understand, it’s a sign your mom is very critical. And that drug, as well as the ventilator now, is what’s keeping her alive. It’s important.
Julie: The Adrenaline?
Patrik: The Adrenaline as well as the ventilator are keeping her alive now.
Patrik: So, what that means is the ventilator, as well as the Adrenaline and the Norepinephrine, are keeping her alive, and that gives her time to, number one, fight the infection, and number two, let the surgeons decide are the bowels perforated, are they not perforated. What do we need to do, in terms of potentially managing the bowels?
So, what your mom needs at the moment is she needs time. Whether she has that time, we will find out. But at the moment, I would say she is pretty much sort of entering a state where she’s in limbo, and where she can find the infection, which would be great, or she potentially can’t. I would imagine the next 24, 48, 72 hours will show us what’s going to happen next. How she can cope with the treatment that she’s getting.
Julie: Now … Oh, no.
Sam: Is there a point where they cannot give her anymore Norepinephrine or the other one? Is there … They just can’t give her anymore?
Patrik: Yeah. There is. It becomes …
Sam: What’s that number?
Patrik: Probably, maybe, 100. If you have the …
Sam: Is she on …
Patrik: She’s pretty high already. She’s on 80 now, however if they’ve maximised the Norepinephrine and the Epinephrine, they can also give a drug called Vasopressin and he has already mentioned that. The nurse has already mentioned that. He said, “Look, if all fails, we give the Vasopressin.” Which is another sign, to me, that they are prepared to go all the way. Which is important.
Julie: So, let me ask you something. Can you fight an infection that is going to continue to bleed into your abdomen? You can fight that?
Patrik: Very difficult. If the bowels are perforated, I would say it’s very unlikely that she actually can survive that.
Julie: So, from what you’ve heard right now, you think that it’s very likely that they are perforated.
Patrik: I’d say that … I’m not a surgeon, and I haven’t seen the CT scan. I believe that you, or we need to talk to a gastric surgeon as quickly as possible to find out what’s their opinion. Do they-
Julie: Okay. But in your opinion, because of the septic shock and the extremities, and all that stuff, you’re saying that is a sign of a perforated bowel?
Patrik: It’s a sign of a septic shock.
Julie: What can cause that septic other than a perforated bowel?
Patrik: The pneumonia could potentially cause a septic shock as well. However, it’s more likely that the … whatever is happening with the bowels is causing that. Now, you also mentioned that some of the tissue of the bowels might have died. That’s what you’ve been told. Is that right?
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Patrik: Right. So, even that could get infected fairly quickly, and that could cause septic shock, too.
Julie: So, with these antibiotics are the only cure for her?
Patrik: Well, the only cure that I can see at the moment would be surgery, but I believe she’s way too unstable for that. And the other cure is simply that if the bowels are not perforated, with the antibiotics that they’re giving, that she can fight that. But at the moment, nobody knows what they’re dealing with. They’re only guessing at the moment.
Julie: Okay. And so, you don’t feel like she’s suffering to any amount because of all the sedation and stuff.
Patrik: No. I don’t feel …
Julie: And you think because as long as there’s life, there’s hope.
Patrik: Very much so. If she wasn’t comfortable, if she was in pain, I would say why would you continue that suffering. But, if your mother is comfortable, why would you not continue treating her and, yes, I’d say at the moment, survival chances are fairly low. At the same time, why would you not continue if she’s not suffering and give her the opportunity to let her body fight whatever she’s fighting?
Julie: Because they said that the most comfortable way is to detach her, and to let her go a peacefully off the ventilator and stuff, because it’s a peaceful way.
Patrik: Look, I tend to agree with that. The other question on a more cultural, or spiritual level even, is … And I don’t know what you believe in, if you’re a Christian or if you’re an atheist, or … But I’ll tell you that from a sort of, I believe, objective point of view, let’s just say you take your mother off ventilation, and you make her quote unquote comfortable, and you let her go. Some people might argue that’s euthanasia.
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Patrik: Do you know what euthanasia means?
Julie: Yeah, that you’re taking her life, basically.
Patrik: You’re basically hastening this.
Julie: So, Patrik, what is your opinion on if her heart gives out? Should they sign a DNR, or should they ask them to resuscitate at all costs? Because that’s what it’s at right now. Resuscitate at all costs.
Patrik: Yeah. I do have an opinion on that. I do. I would not sign a DNR, and I’ll tell you why. The worst-case scenario for an ICU, and I’m talking about the worst-case scenario from an intensive care perspective, is to look after a patient indefinitely with an uncertain outcome. That’s their worst-case scenario. By having a DNR in place, that’s one step to manage their worst-case scenario. By having a DNR in place, it limits treatment options.
ICU beds are in high demand. Very high demand. So, one of the reasons that ICUs are negative and say, “Look, we got to stop treatment,” is simply bed management. In 20 years of ICU, I know what DNRs are used for in ICU. And they’re not used for the reasons that they should be used. They’re used for reasons to manage beds, and I heavily object to that, because it’s not about the patient, it’s about their bed management.
Julie: Okay. Thank you for that.
Patrik: A DNR is often used to take the first steps to withdraw treatment.
Brady: Okay. Thank you so much.
Patrik: And if your mom, god forbid, if your mom is not going to survive that, let’s give her every opportunity to survive, and let’s not even go with a DNR, because that means they have to do whatever is in their power …
Julie: Patrik, hold on. Mel just came in.
Mel: Obstruction of the bowel.
Julie: What does that mean?
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Mel: It basically means one of her bowels is not giving circulation anymore.
Julie: So, that’s a surgical intervention?
Mel: Yes, bowel resection.
Sam: How quickly does a surgical intervention need to happen?
Mel: As soon as possible.
Mel: As soon as she is fit for surgery, with less inotropes that is.
Julie: But you said maybe because it got a little better, it seems like the perforation would be putting bowel movement into the abdomen.
Mel: Before that was the case, but now is a different scenario.
Julie: Would it get in through the twist somehow?
Mel: Yes, it could further become twisted and no perfusion.
Sam: If we have a twisted bowel, won’t at some point that bowel come up the other way versus going down, what is in front of the twist? Won’t we know it that way?
Julie: It will be twisted down.
Mel: At this point, we’re not sure of the bowel imaging unless on surgery table.
Art: You guys did two gallons of the Go Lightly.
Mel: That’s what I was told.
Sam: Go lightly administration, right?
Mel: Yes, Go Lightly.
Julie: And that’s supposed to be helping it go down, but it’s not.
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Mel: Normally, we give Lactulose.
Mel: Any laxatives for that matter.
Julie: So, if it’s a twisted thing, and possibly can correct itself, how are we getting the air into the abdomen? That we don’t know.
Mel: It will be further b twisted and I’m not even sure the GI knows at this point.
Julie: Okay. But they did take the CT Scan the last time.
Mel: Yes, they did but they are not sure if its perforated bowel or ischemia.
Julie: Pat, do you have any questions for Mel while he’s here?
Patrik: I don’t. But I could not hear what he said. I could not.
Mel: That is all for the GI I guess.
Sam: Yeah, I wanted to talk to him about that.
Mel: Okay. Pat, I just looked at the … I just had a chance to look at the GI doctor’s note, and what she’s saying is she doesn’t think it’s a perforated bowel. They think it’s ischemic. So, they said … What’s that?
Patrik: They said it’s not a perforated bowel.
Mel: The GI doctor does not think that it’s a perforated bowel. She believes it’s ischemic.
Patrik: Oh it’s … Okay.
Mel: And she also said at this point they are not comfortable doing surgery. They said if she starts to deteriorate, things look like they’re going downhill, they would reconsider. But at this point, they are not comfortable doing the surgery.
Patrik: Sure. Okay. Wonderful. Thank you so much for that.
Mel: Sure thing.
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Julie: Is there a way to start moving the bed again?
Mel: What do you mean?
Julie: She was on a rotating bed and then they took it off.
Sam: So, Patrik, we’re asking about a rotating bed. They had her, when she first came in, on a rotating bed. Would that help?
Patrik: I can’t see the need for a rotating bed at the moment. The reason for that is the rotating bed they usually use for somebody with respiratory failure. I can’t see what the benefits of a rotating bed at the moment.
Sam: You wouldn’t. Okay.
Patrik: I can’t see the benefit of it.
Sam: So, why do they put people on a rotating bed? What is the first purpose?
Patrik: So, mainly, if somebody has respiratory failure, mainly like lung failure, you would put them in a rotating bed because you could rotate them from side to side, and therefore free up blocked parts of the lungs. So, I can’t see that’s what’s needed for your mom at the moment.
Patrik: It’s good news that they think it’s not perforated.
Julie: They think it’s a septic bowel … ischemic?
Sam: Ischemic bowel.
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Patrik: Yeah. Ischemic bowel. Yeah.
Mel: Ischemic bowel.
Julie: All right. Thank you.
Sam: So, it just depends on how better the doctor thinks her bowel … Pat, you’ll have to explain what you were saying about the bed. It was more for her lungs than it was anything else.
Patrik: I can’t see the benefit of a rotating bed at the moment. I can’t. Unless there is … I just can’t. Usually, a rotating bed comes into play when somebody is in severe lung failure.
Julie: Is in what? Severe length failure.
Art: But is she not severe lung failure, with all the life support she’s receiving through the ventilator?
Patrik: Not really.
Julie: If they put her on a ventilator and rotating bed, that will be lung failure. But they recently stopped when they … what was it?
Sam: The CT scan.
Art: CT scan.
Julie: The CT scan.
Russ: What about help on the twisted bowel scenario? That’s what we were …
Julie: Would that help with the twisted bowel?
Patrik: Not really. I can’t … As I said, at the moment, I can’t see how a rotating bed would help in her situation. I can’t. I would … if anything …
Russ: At least get it untwisted.
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Julie: It’s more of a rocking bed. It just kind of tilts side to side.
Patrik: Yeah. I understand. It’s not going to harm, don’t get me wrong. It’s not going to harm. But I just can’t see the benefit of it at this point in time.
Sam: What helps … whatever bowel.
Russ: Ischemic bowel.
Julie: Ischemic bowel. What helps it correct itself? Anything? Just time?
Patrik: Time. Time and antibiotics.
Sam: Time and what?
Patrik: And antibiotics.
Julie: Okay, but, that’s just weird that she still has the air in the abdomen.
Patrik: Yeah. If somebody’s not opening bowels for a period of time, there is often air in the abdomen.
Julie: Oh. If somebody doesn’t open the bowels for a period of time, air can go into the abdomen.
Patrik: Very much so.
Julie: Okay. So, are the chances of a perforated, or a what is it?
Julie: Ischemic bowel, is that pretty good readings of it untwisting itself?
Patrik: No. Not at all. It just means it’s better compared to a perforated bowel. It’s the better version of a perforated bowel, but there is also … the risk is still there for perforation. The risk is definitely there.
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Julie: The reason what … What’d you say?
Patrik: The risk of the bowels perforating is there.
Sam: It’s still there-
Julie: Oh. So, ischemic could lead to perforated bowel.
Patrik: Could lead to it, for sure. For sure.
Julie: How do we prevent that?
Patrik: By time. At the moment, your mom needs to rest. There is … A lot of it is outside of anybody’s hands. Your mom will need time. The next few days will show where it’s going.
Julie: Okay so, tomorrow then we just try to get the doctor on the phone?
Patrik: Absolutely. And especially the doctor, as well as the gastric surgeon.
Patrik: But the good news, as I said, at the moment, I have no indication that they’re not trying everything. I have no indication that they’re not doing everything within their power.
Sam: Do you have any gut feeling that anything that they’ve done in the past has caused this deterioration?
Patrik: If they have not managed for her to open bowels, that is a big concern. That is a big concern. If they haven’t … Day three of not opening bowels, they should have been aggressive to get those bowels opened.
Julie: So, Pat, tomorrow when you talk to the doctor, will you be hard on that, please, for us?
Patrik: I can absolutely. Absolutely. Ask them why they haven’t been more aggressive in trying to open the bowels.
Julie: And maybe even see when they started the laxative and more stuff about that, because I don’t think … We’re kind of left in the … about that.
Patrik: Well, all you’ve got to do is you’ve got to ask for the medical record, for the drug chart, and then you can get an answer there.
Julie: Okay. Maybe we’ll ask that on the way out tonight. Like, when did the laxative start, when did the first enema start? Okay.
Patrik: Yeah. You could ask that and see what they say.
Russ: Okay. All right, well, thank you so much.
Julie: Yeah. Thank you so much, and we’ll call … We’ll talk to you tomorrow.
Patrik: Okay. Any time. Give me a call. Or send me a text if you need something, if you have a question quickly, send me a text or send me an email and I’ll get back to you as quickly as I can.
Julie: Okay. Thank you so much.
Patrik: Thank you. Thank you so much. 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
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- 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
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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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