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 Ron, as part of my 1:1 consulting and advocacy service! Ron’s son is critically ill in ICU and Ron is asking if his son is not waking up because of induced coma or brain injury?
My Son is Critically ill in ICU. Is He Not Waking Up Because of Induced Coma or Brain Injury? HELP!
“You can also check out previous 1:1 consulting and advocacy sessions with me and Ron here.”
Patrik: Right? So the challenge that your son is facing at the moment is he might be now in a cycle where he’s not coming out of the induced coma yet for a number of reasons. By the same token, he has brain damage. So what is actually not waking up from the …induced coma and what is his brain damage? What’s really contributing to this? Is it the brain damage or is it just not waking up from the coma?
Ron: Right, right, right.
Patrik: Right. And that is pretty difficult to determine at the moment.
Ron: Right.
Patrik: Very few patients, by the time they are leaving intensive care with a brain injury, would be at the point where people can make a proper cognitive assessment.
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Ron: Yeah.
Patrik: Right. So what does that mean? It means like, again, you take the example of where somebody takes a long time to come out of an induced coma, but they are not having brain damage, right? I’ll give you the sort of scenario; when they leave intensive care, they might still be confused. It’s a side effect of the induced coma. They might be totally confused by the time they’re leaving intensive care. They may not have a clue where they are, what’s happened, all of that. That comes back with time. And then you’ve got Daniel who, you know at this point in time they think there is significant brain damage. So yes, he might survive intensive care and by the time he leaves intensive care alive, they still wouldn’t be able to do a proper cognitive assessment because he’s simply not there yet.
Ron: Right.
Patrik: Right. So, and just, and nobody else, since we spoke yesterday, nobody else has mentioned at this point in time, anything about the withdrawal of treatment? Nobody has been, you know…?
Ron: Right.
Patrik: Right. Okay. Okay. And that is important to me to test the temperature, so to speak. You know, I have not heard him mention any of that and you know, why is this important? Because all of a sudden they might say, Oh, again, coming back to the quality of life issue, they might say look, Daniel might not have any quality of life, let’s stop treatment. Right. And that means you know, as long as that’s not happening, I’m very positive that they give… That they do everything that they can.
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Patrik: Right. That brings me… unless, you have any other urgent questions, that bring me to the norepinephrine then. Or do you have any other questions in terms of what he mentioned? What the neurologist has just mentioned?
Ron: No, no.
Patrik: Right, right. So that then brings me to the norepinephrine. You remember yesterday he was on the epinephrine. Is he still on that?
Ron: No he’s off of that.
Patrik: Okay. All right. It’s just a change and the epinephrine and the norepinephrine are very similar drugs. They’re not the same, but they’re very similar. They’re basically what’s called vasopressors or inotropes. They are drugs… Without the norepinephrine or the epinephrine yesterday, he would have a blood pressure that’s too low.
Ron: Right, yeah, that’s what it is.
Patrik: Right, right. Potentially a blood pressure that’s too low and would be… and life would not be sustainable. And it’s a fairly low dose, what he’s on, so potentially he could sustain life without it. However, then his blood pressure would potentially be so low that neither his kidneys, nor his brain would be perfused with blood and oxygen. Right. So it all comes down to organ perfusion, right? The epinephrine and the norepinephrine are basically there to maintain a physiological blood pressure and to maintain organ perfusion. Here is another thing, because it seems a fairly low dose. Is he still on the dialysis?
Ron: He is. He’s on a dialysis.
Patrik: Right? Right. So what happens is…
Ron: When he’s off?
Patrik: Yeah, if he came off the dialysis, there’s a very good chance that…
Ron: His vasopressors a little higher when he’s off the dialysis.
Patrik: Yes, absolutely. Absolutely. So some of it may simply be a low blood pressure caused by the dialysis. Why is that? Probably about 300 to 500 ml of his blood are basically constantly in the dialysis machine. Right. And by doing that, the blood pressure goes down automatically.
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Ron: Right. So when they had him off the dialysis machine. They had him off and on. His blood pressures didn’t drop. Like they didn’t need the epinephrine.
Patrik: Yes. You know?
Ron: Yeah, so he’s off it for a few days.
Patrik: That’s good. That’s a good sign because that’s a sign that his heart can most likely cope. Okay. Because if he needed the epinephrine or the norepinephrine while he’s off the dialysis, it would be a sign that the heart is potentially weak, right? That could be a sign. Infection could be a sign or…
Ron: Hold on a second.
Ron: I’m sorry about that. Sorry about that.
Patrik: Not at all.
Ron: Right.
Patrik: Or a number. What did I say? Heart weak. Yes. Infection or potentially dry. That means if they took away too much.
Ron: Too much fluid. It’d dry him out. Right.
Patrik: Yeah, that’s right. That’s right. That’s right. That could be a sign as well. Or it could be because he’s been on blood transfusions almost daily, it could be that his haemoglobin would be too low. You would be aware of the hemoglobin?
Ron: Yes. Yeah. It was up today from seven, I think. 7.5 or 7.1 to 8.4.
Patrik: Okay. Okay. Then…
Ron: Patrik, can I call you back in about 10 minutes or so?
Patrik: Certainly can, certainly can.
Ron: Okay. Awesome. Okay. I’ll call you back then.
Patrik: Thank you.
Ron: Bye.
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Ron: Hello?
Patrik: Hi Ron, it’s Patrik.
Ron: Hi there.
Patrik: Hi, so …
Ron: Let’s answer the questions that you sent. He has stuff for fresh areas. He is making spontaneous urine. He’s making urine but it’s not as much being put out with his dialysis machine but he is making urine. It’s coming out.
Patrik: Good.
Ron: I spoke to his renal doctor today and she said with his current kidney, his creatinine is at 0.67. His bicarbonate is at two, three, 23 or 24. One of those and so because he’s on the dialysis they got to see how far it will rise or come down. Rise after he gets off this dialysis machine. The dialysis machine is removing fluids, but they put in what they take out plus whatever extra they’ve targeted except it’s the removal for him and it’s also cleaning his filter and cleaning his blood as well, I think.
Patrik: It would.
Ron: He just started pooping for the first time about three days ago.
Patrik: Say that last part again?
Ron: I said he just started moving his bowels about three days ago.
Patrik: Okay, good.
Ron: Since then he’s moving it steadily throughout the day.
Patrik: Yep. Okay, that’s good. Is he getting any nasal gastric feeds?
Ron: He was given feeds in his tube called Vital, but it was running at a low rate, like 5 cc.
Patrik: Okay.
Ron: I stopped it because his dominant area was tense and a little slightly distended so they didn’t know if it was the food that he wasn’t tolerating or what so I stopped that and … One moment.
Patrik: Sure.
Ron: Cough it up. Cough it up. Good job. Cough it up. Good job. Good job. One moment Patrik.
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Patrik: That’s okay.
Ron: Hello?
Patrik: Yes. Can you hear me?
Ron: Hello?
Patrik: Yes. Can you hear me?
Ron: Yes, I hear it now. Sorry about that. Yeah, the Erythromycin that they’re giving him, it’s for his eye drops for a section that they … It was a little yellowish so the ophthalmologist, she came by and she looked in the back of his eyes and stuff. She said it wasn’t that bad. It didn’t look like a bad infection but she wanted to give him a little something to clear it up. That’s why he gave him that. Prescribed that to him, his eye drops to put in his eye and he also takes Azithromycin.
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Patrik: Azithromycin not Erythromycin.
Ron: No, Azithromycin.
Patrik: Okay.
Ron: Azithromycin. Yep.
Patrik: Yep. Okay. Not Erythromycin at all?
Ron: With an E yeah.
Patrik: Yes.
Ron: He gets that. That’s the eye drops that he is taking.
Patrik: Oh, I see. I see. Okay.
Ron: Yeah. That’s the eye drops that you gave him. He gets that twice a day.
Patrik: Okay. Have you seen a ward round?
Ron: I’m sorry, say that again?
Patrik: Yeah. Have you seen a ward round? Basically, have the doctors done their round this morning?
Ron: Oh, have they rounded? Yes. They round this morning.
Patrik: You were there? You were present?
Ron: No, I wasn’t present this morning but they always come in afterward and speak to me.
Patrik: Okay, and you’ve got answers to all of those questions?
Ron: Do I have access to them? Yes.
Patrik: Right, so they’ve answered. They’ve answered all of those questions that I wrote down.
Ron: Most. Most of them. The oxygen thing … They put oxygen down as 50%.
Patrik: Yes. That is very positive. I was really shocked.
Ron: The tracheostomy hasn’t been discussed yet. To my knowledge he doesn’t have pneumonia or chest infection, but I’m going to double check when he comes in.
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Patrik: Sure. I think you may … It’s a good sign that they reduced oxygen from 90% to 50%. That’s a good sign with the …
Ron: Oh, the blood thinner.
Patrik: Yes.
Ron: He’s on … We did a tiny bit to flow through his arterial line so that his line won’t give, but he doesn’t get a big dosage.
Patrik: Okay.
Ron: Yeah, that’s the only thing he gets.
Patrik: Right, and he has been on the blood transfusion he’s been getting platelets as well, didn’t he?
Ron: Yeah. He gets platelets a few times throughout the day to keep his blood counts up.
Patrik: Okay, so that means his blood is probably thin as it is even when they top him up with platelets, his number of platelets would probably still be reasonably low.
Ron: Yeah. Right, it could be probably from the bleeding he was having but yeah, they usually give him a few times a day.
Patrik: I’m glad. As I said, I’m glad they reduced the oxygen almost by 50%. Reduce it from 90 to 50 which is also a sign that ARDS is not really … I would say they almost ruled that out by now.
Ron: Right. I’m definitely going to speak to the attendant that’s on this morning to get a better understanding as to how they gauge whether he has that or not but that according to the attendant last night to her, it didn’t appear that he had any ARDS.
Patrik: Okay, that’s good. That is good.
Ron: She said by the looks of the X-ray and everything, it didn’t look like he has it but I’m going to check with the attendant that’s on this morning. Their opinions and stuff vary.
Patrik: They would vary but knowing that he’s down to 50% is a relief in and of itself.
Ron: I have seen him start to open his eyes a little more in the day.
Patrik: Is he still on the Precedex and the fentanyl?
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Ron: Yeah. He’s still on the Precedex and the fentanyl. He’s on two of the fentanyl and 0.5 of the Precedex.
Patrik: Yeah, so that means the rate hasn’t been changed, have they?
Ron: No, as of yesterday they went up from one to two on the fentanyl, and on the Precedex he’s at 0.5 so that’s been the same.
Patrik: Okay, good. Did you say you feel like he’s a little bit more alert?
Ron: Today I think he popped his eyes open a little more today than the previous days.
Patrik: When he is opening eyes … Do you feel like he’s making eye contact?
Ron: I want to say that he does and when Dr. Pringle, the neurologist that you spoke with, I want to say that when I saw him looking with the flashlight in his eyes it looked like his eyes were a little bit more reactive and he was blinking much more.
Patrik: Okay. As part of his treatment since March, would you be aware of white cell counts? Have you heard of the white cell count?
Ron: Yeah, his white count is up from … He’s actually on Filgrastim twice a day to boost his counts because he’s also been on immunosuppressants like the Bactrim, which they got … Today was the last day of the Bactrim so he’s no longer on Bactrim.
Ron: It was on Bactrim because he had an infection in the blood. That’s no longer the case so today is the last day.
Patrik: Okay.
Ron: Yeah, right so they tried to keep it above because the Ganciclovir suppresses his counts. His immune system and also the Bactrim. The goal when he got down to ICU to was to … We got him off of the Ganciclovir and switched him over to Letermovir as a prophylactic for CMV, what’s he’s never had.
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Patrik: Okay.
Ron: Because, it’s non-suppressant.
Patrik: Yep.
Ron: But, they had to put him back on because you know the Letermovir, usually there’s no other way to give it except orally and it can’t be crush and broken so they can’t put it through his nasogastric tube so they had to put him back on the Ganciclovir to suppress his counts, and the Bactrim which also suppresses his bone marrow, so the Bactrim is gone as of today. So, we’ll see where they go from there.
Patrik: Yep. Has he ever been neutropenic? Have you heard that term before? Have you heard of neutropenia?
Ron: Neutropenic. I want to say he’s been prior to having his transplant. He was getting a mutagen while he was at home as well, but prior to this whole getting sick incidents? The whole disorder? No, he’s never been neutropenic.
Patrik: Okay, that’s good and his white cell count do you remember any figures in terms of if he’s got an infection, how high went his white cell count? Do you have any? Do you recall them?
Ron: How high his white cell count is?
Patrik: Yes.
Ron: It depends on … it varies because like I said, he’s on the immunosuppressant and an immunosuppressant meds, but when they do get the chance to get them up there, they go as high as probably some of the highest I’ve seen on him. This time around it was like 14 or so.
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Patrik: Okay, so not too high. That’s okay.
Ron: No, and they didn’t want it. They wanted to keep him at a high dose of mutagen like that because of the Bactrim that he was getting and they know that it would suppress his bone marrow so it comes down to his balances.
Patrik: Okay, and at the moment they still haven’t localized any infections? They’re still …
Ron: They’re given him the … What is that? They’re giving him … One moment.
Patrik: Thanks.
Ron: What’s the name again? Yes.
Nurse Anne: Azithromycin, Bactrim, Meropenem, and iron.
Ron: Okay, and what was the intensive?
Nurse Anne: It was the Vancomycin-Resistant Enterococci (VRE)?
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Ron: The VRE was in his?
Nurse Anne: The sputum.
Ron: The sputum, okay and that’s why we started the Sudafed.
Nurse Anne: Yes.
Ron: Okay, and why are we using the Cera? What was the other one before you said?
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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- How to ask the doctors and the nurses the right questions
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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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