My name is 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, control, power, and influence, making sure your loved one always gets best care and treatment in intensive care, even if you’re not a doctor or a nurse in intensive care.

Now, in today’s video, I want to answer a question from Janine. It’s one of our clients. She’s got a very important question about her mother’s ventilation status and whether she’s coming off mechanical ventilation in ICU.

So, let’s read out Janine’s question. It says:

“Hi Patrik,

My mom is still on the ventilator in ICU. They were giving my mom the high blood pressure and cholesterol pills that I was unaware of. That could have been a reason why she was so disoriented. I’m glad that they allowed me to stay the night before. I’ve attached some photos from the last couple of days from the ventilator and her monitor. Is my mom close to coming off the ventilator? She’s still on meropenem and vancomycin. They took a culture sample because her white cell count went up a little and was trying to see why. Other than that, I’m staying there tonight, Friday. They allowed 3 days a week for me. Thank you for your guidance.

From Janine.”

Understanding Your Mother’s Current Situation

Janine, thank you for reaching out and for sharing these detailed photos as well from the ICU monitoring equipment. Let me break down what I’m seeing and what it means for your mother’s recovery and trajectory.

Let’s Look at the Vital Sign Monitor First

Looking at the Masimo Radical-7 monitor, I can see SpO2 (oxygen saturation) is 100%. That’s excellent oxygen saturation, showing her lungs are adequately oxygenating her blood. Heart rate is 92 beats per minute. It is within a normal range, but it’s also slightly elevated, and it’s no surprise because anyone in ICU on a ventilator with a breathing tube, that’s very uncomfortable and that in and of itself would get the heart rate up.

Now she’s got a perfusion index of 0.33. This is on the lower side, which can indicate reduced peripheral perfusion, possibly related to blood pressure medications or her overall circulation status. But I’ll come to that a little bit later, especially when it comes to getting access to medical records and so forth.

Now, Let’s Look at the Ventilator Settings

The Puritan Bennett 980 ventilator shows she’s on SIMV (volume controlled, which stands for Synchronized Intermittent Mandatory Ventilation volume control with these essential parameters: respiratory rate 24 breaths per minute, tidal volume 332 mls, minute ventilation 8.47 L per minute, peak pressure 22 centimeters of water, PEEP (Positive End-Expiratory Pressure) 5 centimeters of water, and FiO2 (Fraction of Inspired Oxygen) 35%.

Now Let’s Come to Your Main Question: Is Your Mother Close to Coming Off the Ventilator?

Based on what I’m seeing, there are some encouraging signs, but she’s not quite ready yet, and here’s why.

The Positive Indicators Are:

She’s got low oxygen requirements. Only 35% FiO2 is excellent. Room air is 21%. She’s got a low PEEP. 5 centimeters of water is minimal PEEP support. She’s got good oxygenation. 100% SpO2 indicates her lungs are exchanging gas as well.

So Let’s Look at the Areas of Concern

She’s got a high respiratory rate. 24 breaths per minute is elevated, suggesting increased work of breathing or metabolic demand. She’s still in an SIMV mode. This isn’t a weaning mode yet. They haven’t transitioned her to pressure support or CPAP (Continuous Positive Airway Pressure) trials yet. She’s got ongoing infection concerns. The elevated white cell count and continued need for meropenem and vancomycin, which is a broad-spectrum antibiotic, or both are broad-spectrum antibiotics, suggests that they’re still managing an active or suspected infection.

And next, medication issues. The disorientation from blood pressure and cholesterol medication is concerning and needs careful management. Also, she’s on a respiratory rate of 6. That means she’s getting 6 breaths per minute from the ventilator, and she’s triggering about 18 breaths by herself, but the volume seemed to be too low.

And the only way you can find out whether that’s appropriate or not is really through arterial blood gases. You haven’t mentioned any of that. And that’s why it’s so important that you get access to the medical records as quickly as possible. I’ll come to that in more detail, but the bottom line here is this: the biggest challenge for families in intensive care is that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask, they don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. And that’s exactly what you are up against here.

So, Let’s Look at the Medication Concern You Raised

It’s critically important, Janine. You mentioned discovering they were giving your mother high blood pressure and cholesterol pills you were unaware of, which may have caused disorientation. This highlights several crucial points.

Number one, polypharmacy in ICU. Combining multiple medications can lead to adverse effects, especially in critically ill patients.

Next, blood pressure medications can cause hypotension (low blood pressure), confusion, and reduced perfusion.

Next, communication gaps. This shows why having access to all medical records is essential.

Why You Need Complete Medical Record Access

At intensivecarehotline.com, we consistently emphasize that family must have access to: full medication lists with dosages and timing, all pathology and lab results and trends over time, daily progress notes from doctors, nurses, physicians, physios, RTs (Respiratory Therapists), and the list goes on, nursing flow sheets showing vital signs and interventions, radiology reports, chest x-rays, CT scans, MRI scans, and so forth, culture and sensitivity results from infections. You must leave no stone unturned.

Without this complete picture, we cannot provide you with the most accurate guidance for your mother’s situation, which includes the arterial blood gases that I mentioned a minute ago.

What Questions Should You Be Asking During Your Next Meeting with the ICU Team?

Here are some critical questions to ask.

Number one, what is the source of infection that’s keeping her on meropenem and vancomycin? What were the culture results and are the antibiotics appropriately targeted? Why did the white cell count increase? Is this a new infection or a worsening of an existing one?

Next, what is the weaning plan? When will they trial pressure support ventilation or spontaneous breathing trials? Are the tidal volumes adequate for her weight? Literature suggests that 6 to 8 mL per kilo would be adequate in volumes or some literature suggests 7 to 10 mL per kilo. So it really depends what your mom’s weight is.

Next, what medications is she currently receiving and what are the indications for each? Are the blood pressure and cholesterol medications necessary during her ICU stay, or can they be withheld?

What is causing the elevated respiratory rate? Pain, anxiety, metabolic acidosis, infection, breathing muscle weakness or weakness in general?

Next, what are the objective criteria they’re looking for before attempting extubation?

So, also, another important thing that I’ve noticed is, if she’s hypotensive, if she’s hypertensive (high blood pressure), have they potentially given her inotropes or vasopressors? Again, it is so important that you have access to all medical records. I can’t believe how many families in intensive care are flying blind by just believing everything the ICU team is telling you without you verifying. You must verify. It’s life or death. You cannot afford to get this wrong. It’s a life or death situation. I can’t believe how many families, as a matter of fact, 99.9% of families are completely blasé about just believing everything they’re told. How can you believe everything you’re told if it’s life or death? You must verify.

Another Critical Point

In your email, Janine, you mentioned that they’re limiting your visitation time. Are you going to put up with that, or what? Will you just roll over and say, “Yep, I’ll just accept that you’re limiting my visitation time to my mom?” Are you putting up with that?

I mean, if an ICU is limiting visitation time, the first thing that you need to ask yourself is, do they have anything to hide? What is it you can’t see? So you don’t have access to medical records, they’re limiting your visitation time. Will you just roll over and accept that? I wouldn’t.

Families in intensive care need to wake up. Don’t let rules be imposed on you. Don’t play by other people’s rules. What is it they have to hide? What is it that you can’t see?

So How We Help at intensivecarehotline.com

This is exactly where a consulting call with myself or one of my team members at intensivecarehotline.com together with you and the ICU team becomes invaluable and will help very fast.

We can help review all medical records comprehensively. We join family meetings virtually or by phone or sometimes in person depending on the location, to ask the right clinical questions. We advocate for appropriate weaning strategies. We clarify complex medical information the ICU team provides. We question treatment decisions constructively when needed. We help coordinate care and ensure nothing is being missed.

Myself and my team members, we have decades of ICU nursing and consulting and advocacy experience, and we know exactly what questions to ask and what red flags to look for.

Now Let’s Also Look at the Infection Component

The fact that your mother is still on meropenem and vancomycin tells me that treating or covering for a significant infection. This could be ventilator-associated pneumonia, also known as VAP, blood stream infection, also known as sepsis, urinary tract infection, also known as UTI, surgical site infection if she had surgery, multi-drug resistant organism.

The rising white cell count suggests either a new infection developing, the current infection not responding adequately to antibiotics, a non-infectious inflammatory process.

They took a culture sample, which is the right step. The results, usually 48 to 72 hours, will guide whether the antibiotic regimen needs adjustment.

Now Let’s Look at Ventilation Weaning

Because that typically follows the following path:

1. Resolve the underlying cause, infection in your mom’s case.

2. Stabilize hemodynamics, blood pressure, heart rate, etc.

3. Optimize mental status, reduce and eliminate sedation and opiates, and manage any delirium if there is any. Because one of the reasons your mom has probably gone back to sleep is she’s still on sedation and opiates, and that doesn’t go hand in hand with weaning someone off the ventilator. It needs to be stopped.

4. Reduce ventilation support gradually. Go from SIMV to pressure support and to spontaneous breathing trials.

5. Pass objective criteria: adequate oxygenation, ventilation, cough strength, airway protection and alertness.

6. Successful extubation. Your mother is still in the early to middle stages of this process.

7. Arterial blood gases. I can’t make this argument strong enough that you need arterial blood gases to make sure that ventilation is adequate and appropriate and adjust ventilation according to an arterial blood gas.

Next, What About Long-Term Ventilation Needs?

So Janine, if your mom continues to require prolonged ventilation, or if a tracheostomy becomes necessary, I want you to know about Intensive Care at Home, and you can find more information at intensivecareathome.com.

This is our specialized home care and nursing service that provides long-term mechanical ventilation with tracheostomy at home, 24/7 skilled nursing care in the home setting, full ICU level monitoring and support outside of the hospital, tracheostomy care and management, also non-invasive ventilation such as BiPAP (Bilevel Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure), and a way to keep your mother out of ICU predictably and permanently while she continues recovery with 24/7 ICU nurses.

Many families in intensive care don’t realize that long-term ventilation with tracheostomy doesn’t have to mean indefinite hospitalization. With the right support system, patients can recover in the comfort and safety of their own homes with better outcomes, reduced hospital-acquired infections, improved quality of life, familiar environment, family presence, lower overall costs compared to long-term acute care hospitals or nursing homes, etc., personalized care plans tailored to individual needs.

If the ICU team mentions tracheostomy or prolonged weaning, this is definitely something to explore.

Now, Next, Your Overnight Stay

It’s wonderful that they’re allowing you to stay overnight 3 days a week. Your presence is therapeutic for your mother and allows you to monitor her status in real time, observe the care she’s receiving, communicate with different shifts of nurses and doctors, advocate immediately if concerns arise, provide comfort and reassurance that only family can give. But they shouldn’t be limiting it to 3 days a week.

As I said, there should be an open door policy, and if there’s no open door policy in an ICU, it should worry you. It should worry any of you that has a loved one in intensive care. If there’s no open door policy, you must ask yourself what do they have to hide and what is it that you can’t see.

In the meantime, Janine, continue documenting what you observe, take photos of monitors and keeping detailed notes, of course.

So, Final Thoughts and My Summary of My Professional Assessment

Based on the limited information from these images and what you’ve told me, your mom is showing some positive signs but is not yet close to extubation because she still requires significant ventilation support, respiratory rate 24, full ventilator breaths. The infection hasn’t fully resolved yet because she’s on continuous broad-spectrum antibiotics and she’s got a rising white cell count. She’s not yet on a weaning mode of ventilation. Medication-related mental status issues need urgent resolution.

Expect a timeline: if the infection resolves and she demonstrates improved respiratory mechanics, we might see weaning attempts in 7 to 14 days, but this is highly variable and depends on her response to treatment.

Next Steps for You

1. Request complete medical record access immediately. You’re entitled to it. It’s a right, not a privilege.
2. Schedule a consulting call with myself so we can review everything comprehensively.
3. Ask about the culture results from the recent sample they took.
4. Request a formal family meeting with the ICU team to discuss the weaning plan and have myself there as an advocate.

Number 5, document all medications she is receiving and verify each one necessary in the medical records. Continue your overnight or day stays to maintain close observation.

So, book a one-on-one consulting call with me and we’ll review your mom’s entire case and you will see the dynamics change very quickly in your favor. And get your checklists on our website for families in intensive care, and you can have access to extensive library of ICU educational resources on our website at intensivecarehotline.com. 

I have worked in critical care nursing for 25 years in 3 different countries where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy, because of our insights, and you can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast section where we have done client interviews. Because our advice is absolutely life-changing.

The biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask, they don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. That’s why we help you to improve your life instantly, making sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets the best care and treatment always. That’s why you can join a growing number of members and clients that we have helped over the years, saving their loved ones’ lives.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. And I talk to you and your families directly. I handhold you through this once-in-a-lifetime situation that you simply cannot afford to get wrong. And when I talk to families directly, I also talk to doctors and nurses directly, asking all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real-time. We also do medical record reviews after intensive care, in case you have unanswered questions, if you need closure or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care, and you can become a member if you go to intensivecarehotline.com. If you click on the membership link, or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team 24 hours a day in the membership area and via email, and we answer all questions intensive care-related. In the membership, you also have exclusive access to 21 e-books and 21 videos that I’ve personally written and recorded. And all of that will help you to improve your life instantly, make informed decisions, have peace of mind, control, power and influence, making sure your loved one gets best care and treatment, always. And all of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

And if you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share the video with your friends and families, and comment below what you want to see next, what questions and insights you have from this video.

I also do a weekly YouTube live where I answer your questions live on a show and you will get notification from the YouTube Live if you are a subscriber to my YouTube channel or if you are a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care.