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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 am here with a live stream today, where I want to answer your questions if you have a loved one in intensive care. And this is one of the most commonly asked questions for families in intensive care and it’s a question that we get all the time. And today’s live stream is about, what should I expect my mom coming out of sedation in ICU and waking up after a tracheostomy in ICU.
What Should I Expect My Mom Coming Out of Sedation in ICU and Waking Up After a Tracheostomy in ICU?
Welcome to another Intensive Care at Home livestream. My name is Patrik Hutzel from Intensive Care Hotline and Intensive Care at Home. I want to thank you for coming on to this livestream.
Today’s topic is, “What should I expect my mom coming out of sedation in ICU and waking up after a tracheostomy in ICU?” A question we get very, very regularly from our readers and clients. They have loved ones in intensive care that are in induced coma, can’t come off the ventilator with a breathing tube and tracheostomy, and therefore, they want to know what’s next. “What happens if my mom, my dad, my brother, my sister, my spouse comes out of the induced coma after tracheostomy? What does that look like? Is it the best option? What are timeframes and so forth?” And we are going to look at all of that today.
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Before I go into today’s topic, you might be wondering what makes me qualified to talk about this topic today. I am a critical care nurse by background. I have worked in critical care and intensive care for over 20 years in three different countries. I have worked as a nurse unit manager for over five years in intensive care, and I have consulted and advocated for families in intensive care all over the world since 2013 as part of my Intensive Care Hotline consulting and advocacy service. I am also the owner and founder of Intensive Care at Home, where we provide home care services for long-term ventilated and tracheostomy clients as a genuine alternative to a long-term stay in intensive care. So, that’s a little bit about me.
I do these live streams regularly, usually once a week around the same time. I also upload regular YouTube videos, mainly tips for families in intensive care that you can find on my YouTube channel under Patrik Hutzel. That’s Patrik just with a K at the end.
And if you like today’s video, give it a thumbs up, subscribe to my YouTube channel and share this video with your friends and families that can benefit from this information today.
If you have questions, please type them into the chat pad, try and keep them to today’s topic. If you have questions that are not to today’s topic, I will definitely get to them towards the end of this presentation and I will definitely answer them. I will also give you the opportunity after this presentation to call in live to the show if you like, and I can answer your questions while you’re on the call.
So, let’s dive into today’s topic, “What should I expect my mom coming out of sedation in ICU and waking up after a tracheostomy in ICU?” So, one of the most frequently asked questions we’re getting is how long does it take to wake up after an induced coma? If people don’t wake up after an induced coma, they often end up with a tracheostomy. And then the question is, “What do I expect once my mom, my dad, my wife, my husband, my sister, my brother, my son, my daughter has a tracheostomy? What does it look like? What are timeframes? Why does it take so long to wake up? Can they be weaned off the ventilator?” And they have endless questions and rightly so, it’s a highly specialized area, intensive care. It’s an area where it’s sometimes very difficult to predict what the next day brings, sometimes what the next hour brings. So, they’re all very relevant questions.
And as you would also know if you had a loved one in intensive care, it’s not a sprint, it’s a marathon. Most patients in intensive care stay there for quite some time and you want to know what does it looks like? What can I expect if a situation happens?
Now, before we break down what happens after an induced coma and tracheostomy, I want to quickly focus on what should happen before your loved one comes out of an induced coma and has a tracheostomy. What should happen before then is you should rule out that the intensive care team has done everything beyond the shadow of a doubt to get your loved one off the ventilator and the breathing tube in the first place. That is the most important question you should be asking yourself before you even think about a tracheostomy. Has everything been done to avoid a tracheostomy in the first place? That is probably the most important question that you need to answer or that you need to get an answer from the intensive care team.
And they will probably tell you, “Oh yeah, no question. We have done everything beyond the shadow of a doubt.” But without a second opinion, you can’t really verify that. And that’s where we can help you. We can ask questions with you. We can ask the question for you. We can get on calls with doctors, nurses, respiratory therapists. We can participate in family meetings. We can set you up with questions to interpret the information for you, and make sure that intensive care teams are actually doing the right things and that they’re not just telling you what you want to hear, but they’re actually not following through.
So, that is probably the most important question that you need to ask yourself. Has everything been done to avoid a tracheostomy in the first place and get your loved one off the breathing tube or the endotracheal tube? And I have done videos and live streams about this particular topic, “What needs to happen to avoid a tracheostomy in the first place?”
So, then you need to look at what sedatives and opiates is your loved one on and how long have they been in the induced coma? So, a lot of it depends on, for example, if your mom has an early tracheostomy, which means your mom might have come into intensive care and they’re already starting to talk about a tracheostomy after two days, or if your mom has been in ICU for 14 days, there’s a different approach and a different outcome.
Let’s just take the short-term approach. Sometimes you have patients coming into intensive care and they really need an early tracheostomy because they might have so many fractures. Maybe they’ve had an MVA (Motor Vehicle Accident), or they have so many fractures, or they have a severe traumatic brain injury where the intensive care team can confidently predict, “Okay, we need to do many, many surgeries here. It’ll take weeks for someone to be woken up, let’s do an early tracheostomy.” And that may not be a bad thing, and then it’ll probably take a while for someone to wake up, especially if there’s multiple surgeries in the pipeline.
So, early tracheostomy also doesn’t necessarily automatically mean you can wake a patient up straight away. There are situations where you can do that, but an early tracheostomy is often being done if you know, “Yeah, this patient needs multiple surgeries, has maybe rib fractures, femur fractures, traumatic brain injury, and so forth.” So, that’s when you can predict a fairly long period of time in the induced coma and no quick weans.
Whereas if someone is, let’s just say in a two-week coma, they can’t come off the ventilator and the breathing tube and they then hit for a tracheostomy, the goal should be to stop sedation straight away pretty quickly. If that is the case, if you can stop sedation pretty quickly and then you should also expect that your loved one can hopefully wake up pretty quickly. But then it also depends on what sedatives has your loved one been on. Have they been on propofol? Have they been on midazolam or Versed? Have they been on Precedex? Have they been on a combination of all of it? So, it really depends on what sedatives you are dealing with.
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It also depends what opioids are being given. So, as you would know, when someone is in an induced coma, they’re also on opioids such as morphine or fentanyl and the combination of morphine, fentanyl and propofol, or morphine or fentanyl and midazolam or Versed can lead to a prolonged waking up time. It can take days, weeks, sometimes even months depending on the circumstances.
So therefore, it’s hard to predict sometimes how long it takes for patients to wake up. Some of it is dependent on age. Let’s just say as a rule of thumb, a younger patient is more likely to come out of an induced coma quicker than an older person. A 25-year-old patient is much more likely to come out of an induced quicker compared to an 85-year-old patient. So, that’s just the reality.
Then, some of it will also depend again on your loved one’s condition, do they have impaired liver function or kidney function? Because then it simply takes longer for sedatives and opioids to be metabolized and get out of the system. So therefore, you might have your mom being on low doses of sedatives, low doses of opiates, and yet your mom is still in a coma, and you stop sedation. And with normal kidney or liver function, medications would be metabolized pretty quickly. And then with impaired kidney or liver function, it takes longer. The opiates and sedatives are still lingering around in the system because they’re not being metabolized very fast. So therefore, it can take longer to wake up.
So again, other issues are if there’s a head or brain injury. Is there a traumatic brain injury? Is there anoxic brain injury? Are there seizures that all inhibit waking up or prolong waking up after an induced coma?
Hi, Modema, nice to see you again.
So, they are all issues that need to be considered. Then, a lot of it also depends on what ventilator settings your mom or your dad or your spouse is on. So, for example, let’s just say you do a tracheostomy, you stop sedation, and your mom or your dad or whoever it is was breathing on CPAP (continuous positive airway pressure) or a pressure support ventilation already before they even had a tracheostomy. If you stop sedation, and you should be able to stop sedation once they had a tracheostomy, then the goal is to get them onto a tracheostomy mask or a tracheostomy mask as quickly as possible, or tracheostomy hood, or a tracheostomy collar. There are different terms.
But basically, what you do is you disconnect them from the ventilator, and you let them breathe just with an oxygen mask over the tracheostomy just with some humidified air or humidified oxygen. That would be the ideal scenario, and that is actually the best-case scenario. Do a tracheostomy for early weaning. That is the best-case scenario, but that is not always being possible, depending again on the nature of your loved one’s critical illness, there are different courses for different horses and it’s very difficult to predict what a weaning process or waking up process looks like. As you can already see, there are many, many variables in such a situation.
Also, let’s just say you’re doing a tracheostomy, and again, there are still maybe in the next three days, there is surgery scheduled. Would it then make sense to wake up a patient straight away or should you leave them in an induced coma because they’re going for surgery, and they will come back in an induced coma anyway? Those are all considerations that need to be taken into account when you are looking at predicting what it looks like once your loved one had a tracheostomy.
Next, once your loved one had a tracheostomy, you should be looking at, again, stopping all sedations, stopping all opiates. You should be looking at mobilization, early mobilization, very critical in the recovery process. Deconditioning in ICU is real. The longer you wait with mobilization, the higher chances are you get deconditioned and then recovery takes even longer. So, from that perspective, if you can predict with certainty that someone needs a tracheostomy and can’t be weaned off the ventilator quickly, you need to start mobilization as quickly as possible. That’s very, very important.
So, then for example, if you can’t move on to taking someone off the ventilator pretty quickly after they had a tracheostomy, let’s just say you need to continue ventilation in a controlled mode such as SIMV (synchronized intermittent mandatory ventilation), where critically ill patients still need mandatory breaths from the machine, you can also predict that there will probably be a prolonged process to wean them off the ventilator. So, it’s really critical to look at the interception where someone has a tracheostomy, what ventilator settings are they on before the tracheostomy? Is it likely for them to get them onto a quick wean pretty quickly, or is it unlikely for them to get weaned quickly? Do they still need mandatory breaths from the machine, for example?
And if they do need that, are they able to breathe with the machine? Are they synchronous with the machine? Are they fighting against the machine? Which is something that I’ve seen over and over again as well. If they’re fighting against the machine, either you need to look at changing some of those settings or unfortunately, sometimes you need to re-sedate him, which often is counterproductive to doing a tracheostomy because one of the goals of a tracheostomy is to minimize, reduce, stop sedation so someone can wake up and you can talk them and you can help them with weaning off the ventilator.
Also, the goal of a tracheostomy is to start mobilization. Now, it doesn’t mean that you can’t mobilize a patient with a breathing tube, but it’s much safer mobilizing someone with a tracheostomy so you can start mobilizing them as quickly as possible. Sometimes I find it hard to believe when I talk to people over the phone or when I talk to clients, when I explain to them that you can actually mobilize patients in ICU, they often can’t believe it. I can hear the disbelief when they say, “Oh, they say my loved one can’t be mobilized.” And I say, “That’s nonsense.”
Some ICUs that I’ve worked in, we mobilize patients with a breathing tube. There are special chairs, you can move people over to special chairs, into a tilt chair. It’s all possible, with a slide sheet. And I can tell you that recovery generally speaking is so much quicker when you start mobilizing people. So, don’t let ICUs tell you they can’t mobilize your loved one. If they do, I tell you, they are lazy and complacent. I have no other words for it.
There are contraindications to mobilization, again, such as fractures, such as high inotrope use. But even if patients are on dialysis, for example, you can mobilize them as long as they have the vascular catheter in their shoulders or in their neck. You can’t mobilize them if they are in the groin because some of those catheters are in the groin because if you sit up a patient, the groin is kinked and then the vas catheter gets kinked and then dialysis clots. So, there are exceptions to this rule, and there are contraindications in intensive care for mobilization, but there are many indications for mobilization as well.
So then let’s assume your loved one gets a tracheostomy, off all sedation, off all opiates, and they’re still not waking up, but they have a tracheostomy. Let’s just run through that. Again, it comes back to mobilization. The sooner you can mobilize a patient, the higher chances their brain gets stimulated. Imagine you’re lying in bed for days, weeks on end. Imagine you would be doing that as a healthy person. Well, I don’t think you’d be healthy for much longer, because again, you would decondition as well.
So, imagine you’re sick, you’re critically ill, you’re lying in bed for days or weeks on end and you’re not getting mobilized. There are all sorts of complications waiting for a patient, whether it’s thrombosis, embolus, muscle wastage, swelling. You will see that a lot of patients in ICUs look swollen because simply they’re not being moved and therefore the tissues are swelling because blood is not circulating around. So, mobilization is absolutely critical whenever you can.
And you can do mobilization even if someone is fully ventilated still, the ventilator does not stop people from being mobilized. But if you don’t mobilize, you will have a much harder time getting off the ventilator. So, think about this. In order to be weaned off the ventilator, your breathing muscles need to strengthen. Again, if you’re lying in bed, you’re ventilated, you’re in an induced coma, your breathing muscles waste within no time.
So, in order to strengthen your breathing muscles to get off that ventilator, you need to sit up, need to do breathing exercises, need to strengthen your upper body, and then get gradually weaned off the ventilator. There are patients that can get weaned off the ventilator very quickly after they have had a tracheostomy. I’ve seen patients, especially younger ones, that can be weaned off the ventilator within a day or two, and then they’re just stuck with the tracheostomy. And if they’re young, fit, and healthy, they cough out the tracheostomy in a few days. That is the ideal scenario.
But if you are watching this, I would think your loved one is not in an ideal scenario, and you are wondering what is next for them. And again, you probably need to get ready for a gradual weaning process, a gradual waking up process. Maybe a loved one can have time off the ventilator for two hours a day to begin with on a tracheostomy shield, tracheostomy hood, tracheostomy collar for two hours, back on the ventilator, have a rest, back of the ventilator again for another two hours, and hopefully increase the time that your loved one can spend off the ventilator. That is the ideal scenario.
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What is also important to know when you wean someone off a ventilator, you need to see how effective it is, and how can you check that? Well, you can look at vital signs. For example, if your loved one is off the ventilator, breathing spontaneously with a little bit of humidified air, humidified oxygen, you need to look at what does their breathing looks like. Do they get tachypneic? Do they get a high breathing rate? If all of a sudden, they breathe 40 breaths per minute and their breaths are shallow and their oxygen levels are dropping down, one could confidently say they’re not quite ready and therefore they need to be put back on the ventilator.
You can also check that with an arterial blood gas. You can check arterial blood gases. You can see the values in their PO2 (partial pressure of oxygen), oxygen levels in the blood, carbon dioxide levels in the blood, pH. They’re all good indicators in terms of how a critically ill patient progresses towards weaning off the ventilator.
Another factor you can look at is coughing. Does your loved one have a good strong cough? Can they protect their airway once they’re off the ventilator? No one can get off the ventilator and the tracheostomy if they can’t protect their own airway. So, if they can’t cough, if they can’t swallow, it’s going to be very difficult to (A), wean them of the ventilator and (B), remove the tracheostomy. Coughing is essential and a strong cough, in particular, is essential so you can manage your own secretions. Swallowing is important. There are patients that after a stroke, after neurological conditions, head, and brain injuries, can’t swallow because of their neurological condition. And that puts them at risk of aspiration, which means they can’t have the tracheostomy removed. The tracheostomy protects them from aspiration. So, those are all factors that need to be looked at.
Next, when someone wakes up with a tracheostomy or they’re not waking up, let’s just say they had the tracheostomy, they’re not waking up even though sedatives and opiates have been off, but they’re still looking like they’re in an induced coma, even though now it’s a natural coma. What needs to happen is to ask for a CT brain or an MRI of the brain to rule out a neurological event. What do I mean by a neurological event? Seizures, rule out, a stroke because that could prevent your loved one from waking up. It may actually not be sedatives or opiates. It may actually be a neurological event that prevents them from waking up. Now also, you need to look at if your loved one prior to the tracheostomy, did they have any seizures? Do they have antiepileptic drugs on board such as Keppra or phenytoin? Are they getting other benzodiazepines that potentially prevent them from waking up? So, there are a number of issues you need to think of when waking up doesn’t happen in a timeframe that’s convenient for you or convenient for the intensive care team.
Next, you also need to look at how many secretions are there on the chest. So, for example, if your loved one can have time off the ventilator, do they need a lot of suction? If they need a lot of suction, that is another sign that the tracheostomy can’t come out pretty quickly. Needs more management, needs more nebulization, breathing exercises, physical therapy, chest percussions and so forth. So that’s another sign you need to look for.
Next, you need to be patient. And I’m sure you’ve heard me saying that before. Recovery in intensive care is a marathon, not a sprint. It’s often two steps forward, one step back. So, when a loved one comes out of the induced coma, has a tracheostomy, maybe one day they can have six hours off the ventilator, they can be mobilized, and the next day they’re so tired that they can’t have time off the ventilator, they need a whole day off to recuperate their strength. And then the next day maybe they can do eight hours off the ventilator. So, it’s often two steps forward, one step back. You need to be very patient. A critical illness really knocks people around.
And again, I’m sure you’ve heard me say that before if you’ve watched my blogs for any period of time, 90% of intensive care patients approximately survive. So, there’s no need for you to panic. Most patients in intensive care survive. And I’m not talking here about what does quality of life looks like after their recovery because we don’t know what that looks like. But if they survive, chances are they will get back to some level of quality of life that might be acceptable for your loved one, might be acceptable for you. It’s hard to predict. But by not trying, you are denying your loved one and yourself the chance to get back to some level of quality of life.
So that’s it in a nutshell, what to expect when your loved one is waking up after an induced coma and has a tracheostomy.
Another thing that is important to note is when patients come out of the induced coma, have a tracheostomy, bear in mind they can’t talk. So, all of a sudden, they’re slowly waking up. They would be, for lack of a better term, they would be gobsmacked by waking up in ICU. They have no recollection of what’s happened, they can’t talk. It would be very scary for them. Don’t be surprised if they appear to be confused, if they appear to be agitated, if they appear to be sometimes even aggressive because their communication is limited.
And sometimes you can try getting people to write, but they’re often too weak to write. And it’s very difficult. And whilst patients with a tracheostomy, once they’re off the ventilator can try a speaking valve, it’s probably too early in the first few days. It takes some training; it takes some effort. It can’t just happen straight away to talk with the speaking valve. So, there are certainly some obstacles that your loved one has to go through when it comes to weaning off the ventilator with the tracheostomy, waking up after induced coma.
Worst case scenario is the longer they have been in an induced coma, there could also be issues around ICU psychosis, ICU delirium, where they could be depressed, they could be staring at the wall, which is not nice to watch. But again, it takes time for them to make sense of the situation and come around.
Another issue that can happen after induced coma and tracheostomy is that patients go through withdrawal. They go through withdrawal from benzodiazepines depending on how many benzodiazepines they had. They go through withdrawal from morphine or fentanyl because they’re highly addictive substances in nature.
So, it’s not advisable to just stop midazolam, stop morphine, stop fentanyl. It’s advisable to reduce it gradually, especially if they have been on high doses, because otherwise, if you stop it too quickly, you might go through withdrawal. And then you need to manage a withdrawal. And again, I talked about ICU psychosis, ICU delirium, and if someone is going through a withdrawal, that could be getting worse with going through withdrawal.
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So, that’s it in a nutshell. I want to now open the floor for questions. If you have any questions about today’s topic or if you have any other questions relating to intensive care, please feel free to ask them. You can type them into the chat pad, or if you want to, you can also call live on the show if you like. You can call on 415-915-0090 for our U.S. viewers. That’s again, 415-915-0090. If you’re in the U.K., you can call on 0118-324-3018. That is again, 0118-324-3018. Or if you’re in Australia, you can call on 041-094-2230. That is again, 041-094-2230, or type your questions into the chat pad.
Now, whilst I’m waiting for your questions to come through, also want to take the opportunity to thank you for watching the video. Thank you for participating in the live streams.
I offer one-to-one consulting advocacy as well over the phone, via email, you can book a 15-minute free consultation with me if you click on the “Schedule my appointment” button on our website or below this video.
We also have a membership for families in intensive care. You can look that up under intensivecaresupport.org.
We review medical records for your loved ones. If you want to, if you have a loved one in intensive care and you need a medical record review, please contact us as well. We also put a link below this video where you can order a medical record review.
I would love for you to share this video with your friends and families, give it a thumbs up, subscribe to my YouTube channel for updates for families in intensive care, and click the notification bell.
I do these live streams once a week, usually around 8:30 PM Eastern Standard Time in the U.S., which is 5:30 PM. Pacific Time in the U.S., it’s usually on a Sunday morning, 10:30 AM Sydney, Melbourne time in Australia. So, that’s when I usually do these live streams and I will do another one next week.
If there are no questions, then I would like to wrap this up today. I’ll give it another minute in case you do have any other questions about today’s topic or to any topic that’s related to intensive care. If you have a loved one there, I’ll be glad to see your questions. And if there are no questions, then I want to wrap this up and I’ll see you again next Saturday, 8:30 PM Eastern Standard Time, 10:30 AM on a Sunday, Sydney Melbourne time here in Australia.
It’s a pleasure, Modema. Thank you for your comment. It’s a pleasure.
I wish you and your families all the very best and I will talk to you next week. Look out for my videos that I will publish during the week.
Take care for now.
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