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How does the choice to automatically sedate every patient on a ventilator impact patients for the following weeks, months, and years? Let’s dive deeper into how our favorite sedatives change the course of critical illness.

Episode Transcription

Kali Dayton 0:00
This episode is really important, but maybe a lot. So I hope to make this somewhat cohesive, we’re going to be exploring a powerful case study that is full of important principles. So before we talk with my friend Leah about her father’s ICU journey, let’s clear the air on a few foundational topics. We know that prolonged deep sedation and inability have a lot of detrimental repercussions.

For this episode, let’s talk about how our cultural sedation practices increased their risks of ICU acquired weakness and diaphragm dysfunction, and how that leads to failed excavations. Re intubations prolonged time on the ventilator readmission to the ICU, ventilator associated pneumonia, and other hospital acquired infections. When we see in studies, that a significant risk factor for failed extubation and re intubation is ICU acquired weakness and diaphragm dysfunction.

We need to be looking at how that comes to be. disuse of muscles is certainly a factor. We have seen in studies that even bedrest which is different than immobility, and healthy young adults for a week without critical illness, still lost 1.4 kilograms of lean muscle and had a 5% increase in insulin resistance. Now in the ICU setting, one week of immobility can lead to a 12 to 40% loss of skeletal muscle. We all know what that looks like when a patient’s physical capacity, rapidly declines on the ventilator. disuse, atrophy is tough. recovery happens slowly at about a 6% per week rate.

It takes longer to recover from disuse, atrophy, then from muscle trauma. So, I see acquired weakness can be caused by unavoidable conditions, such as septic shock, but can also be caused by or exacerbated by factors that are often avoidable, such as malnutrition, sedation use base suppressor, use hyperglycemia, and prolonged time on the ventilator. Remember that last episode, we talked about proper falls role in insulin resistance and hyperglycemia. neuromuscular disruption, and even vasopressor use all huge risk factors for ICU acquired weakness.

One study suggested that ICU acquired weakness is so profound and COVID-19 patients that perhaps propofol is not appropriate to use due to its impact on the muscles and diaphragm. In one study on rats, one group was given propofol with mechanical ventilation, and the other group was given propofol while spontaneously breathing. Now, in my mind, I have understood that the disuse of the diaphragm due to the work of the ventilator was a main cause of diaphragm dysfunction in this kind of scenario that lacks all the other factors of critical illness right.

Yet surprisingly, both concluded with about the same level of diaphragm dysfunction, which makes a suspicious case for profiles independent adverse effect on the diaphragm, right, blew my mind as well. And of note on a similar study done evaluating the dazzle lambs impact on the diaphragm, it was shown to have a possibly even worse impact on the diaphragm. So this reaffirms my experiences in the awakened walking ICU and which time on the ventilator is drastically reduced and failed. excavations are almost non-existent. Propofol is an extreme exception in their practice, and midazolam, or versed, is not even in their vocabulary.

Most patients are moved shortly after intubation and throughout their entire time on the ventilator. So diaphragm dysfunction is greatly prevented. We do not talk about diaphragms enough in our teams when we are in mobilizing patients or trying to do breathing trials. Diaphragm dysfunction is present in about 80% of patients with ICU acquired weakness. Diaphragm dysfunction is most common And when there is extremity weakness. So if you’re a patient that can’t give you a strong high five or throw their legs out of the bed, you may want to cross your fingers if you’re going to do a breathing trial, or dare to excavate them.

When we automatically start deep sedation on every patient on a ventilator, we are likely given agents that disrupt the diaphragm cause hyperglycemia disrupt the connection from the brain to the muscles require supportive vasopressors that will all contribute to muscular atrophy and even neuropathy on top of absolute disuse, and critical illness. This should help make sense when we see that sedation and immobility increase the chances of prolonged time on the ventilator. When we fry the diaphragm, then there is no chance of independently breathing.

Once the acute process in the lungs is resolved, the longer a patient is on the ventilator. And the less they move, the less likely they are to be able to mobilize their secretions there a greater risk of subglottic aspirations and the development of ventilator associated pneumonia. This is why the awakened walk in ICU went years without a ventilator associated pneumonia and the rare cases they had, or with exceptional patients that were immobilized. They’ve had high acuity COVID icu since the very beginning, and have not had any ventilator associated pneumonia.

So the weaker they are and the longer they are in the hospital, the more likely they are to end up back in the ICU for so many things, such as falls aspiration or other hospital acquired infections. I invite you to do your own research on this. I always includes my patients for information shared on the blog. It’s basically my literature review, and you are welcome to it. So now that we’re all on the same page about how all of this is connected, let’s dive into a sobering story told by an ICU survivors daughter, Leah, to preface I was clearly not present for this hospitalization.

So there will be some assumptions or speculations. Yet, we will see how the decision to automatically sedate patients, sign them up for months of complications and perhaps a lifetime of consequential suffering. Leah, thank you so much for coming on to the podcast, and sharing your journey or your dad’s journey. I guess it’s your whole family’s journey through the ICU. And can you tell us a little bit about how this all started with your dad?

Leah 7:40
Sure. So my dad had back surgery. So he had a C six and C seven vertebrae. Hopefully I’m saying this correctly, we’re kind of compressed together. And he went to like a neurosurgeon and said that if he didn’t have the surgery, he basically be paralyzed within some amount of time, which he had some hard time walking and everything. ill health like kind of during, you know, historically with anti anxiety, bipolar disorder, and he had knee replacement like two years ago, too, so he hasn’t been the healthiest person but still not not the most, you know, unhealthiest person at 70. He’s 70. Now,

Kali Dayton 8:21
what was he doing at home? What’s his functional status before this?

Leah 8:24
Basically, he’s retired, he used to work in kind of a hockey industry. And he, you know, was able to, like, be at a computer and stuff walk a little bit with a walker or with crutches sometimes, but he did try to walk without that. He tried to like exercise on the bike. And he always like, you know, is really great with his grandkids reading to them. So really, you know, you know, functioning to the best of his ability that his physical ability would let him

Kali Dayton 8:53
….and the hope was with this surgery that his mobility would improve, right?

Leah 8:57
Yes. Yep. That he’d be able to walk more and participate more.

Kali Dayton 9:01
You left the hospital after his surgery and returned to the ER.

Leah 9:04
Yep, he returned to the ER he had a ton of pain. He was discharged on a Friday, the next day Saturday at midnight, he had a ton of ton of pain that he just couldn’t the he had hydrocodone don’t and some other pain meds and they just weren’t cutting it. So my mom took them to the ER at the hospital. He had the surgery when they gave him morphine and he coded so it’s heart lung stopped. So they brought him back then immediately was intubated.

Kali Dayton 9:34
And immediately upon intubation. They had him on continuous sedation Correct?

Leah 9:40
Correct. Yep. On continuous sedation.

Kali Dayton 9:44
Whether or not he was waking up responding to anyone before that consolidation was started.

Leah 9:50
No wasn’t told anything kind of what his his mental status was or functionality was, but I didn’t cry. Yet. They did. I am All right, his his brain was completely, you know, not injured at all. So he was still, you know, everything looked good and from that aspect, and yet they kept him sedated. Yes, they kept him to stated sounds like

Kali Dayton 10:12
he was over sedated from the morphine stopped breathing. So his heart stopped. And they were able to resuscitate him had him intubated during that resuscitation. I, personally am not sure why he was on no sedation. I prefer to note my patients neuro status is doing following an arrest. The MRI showed no brain damage. Right. So my suspicion is that he was probably okay. And yet he remained intubated because he was sedated and sedated because he was intubated is what it

Leah 10:45
sounds like. Yeah, that definitely like, was key that what I saw,

So he was intubated. He arrested on May 16 and was intubated then, and two days later, they tried to extubated him. Yes. And then what happened?

He was extubated and then he was doing okay. He was on a high flow nasal cannula. And he does have a history of sleep apnea too. But he is claustrophobic. So he hates having a mask on. So my brother was there and he was extremely combative, trying to kick my brother wanted to leave the hospital really combative with the nurses. So they ended up having to intubate him again and sedate him in order to keep him calm.

Kali Dayton 11:29
So he was, it sounds like he’s had signs of delirium. Recently by he has bipolar disorder. Yes. So how about higher risk of having delirium and being very traumatized and coping very poorly with delirium? I would suspect that’s why he was combative. Yes. And so he until the 16th. He rested, he and his ex debated. He was combative. And so he was re intubated and re sedated. On the 20th. Then what happened?

Leah 12:03
So they ended up excavating him again. And then he basically he lasted a little bit longer being extubaed on high flow nasal cannula, but I remember going in there to visit him and he just was cranky. And and he told me to go away, which is not, you know, not really his personality either had to have restraints on. And then during that night after I’d seen him in the evening, that night, he had to be re intubated because he was being too too combatative, getting agitated.

Kali Dayton 12:37
And he was on high flow nasal cannula to express concerns about his oxygenation.

Leah 12:44
Kind of Yeah, there was some currents about his oxygenation just because he was on a high flow. But But that didn’t seem like I mean, his stats were still like a little rocky when he was on the high flow nasal cannula, but it wasn’t. I mean, it wasn’t something that I think it was like 80%. But his heart rate kept. I don’t know going up and down just because he was agitated to his heart rate would would go up.

Kali Dayton 13:08
So who’s receiving 80%? From the nasal cannula, correct? Yep. Okay. And so they were concerned because they’re so agitated and difficult to manage and maybe had a little bit of a tenuous, oxygenation, right. And not really clear. You said that later, he got Lasix, and they pulled a lot of fluid off. I’m not sure why he had too much fluid on him. My thought is we can also diaries, people when they’re on high flow. Again, I wasn’t there. So it’s hard for me to make these conclusions.

I’m just concerned about he was agitated probably because he was delirious, he told you to go away. He didn’t wasn’t himself. He was probably delirious, re intubated, re sedated, because he was delirious. That’s, that’s concerning. But again, I wasn’t there. So we have to give some leniency because we don’t know exactly what else circumstances were but so from the 14th to the 20th. He was basically sedated, intubated, extuated twice re intubated on the 20th by the 25th. So we’re now into a nine days on the ventilator, with some brief breaks for high flow. He’s never moved, right. He’s never worked physical therapy. never sat up, has been deeply sedated. Not mobilizing the secretions getting weaker and weaker. And lo and behold, he develops a ventilator associated pneumonia. Yes, yeah. Well, what kind of infection was that?

Leah 14:37
It was in his left lower lobe and it was pretty bad. They were getting a ton of secretions and whatnot from from the ventilator and having to suction a lot.

Kali Dayton 14:46
Do you know what kind of bug it was?

Leah 14:49
No idea. Okay. I want to say it was like on this trip MRSA. It wasn’t MRSA. It was. It was another hospital like acquire Word infection. I don’t know if there was a word My brother used for it, and I cannot remember what it was. But maybe it was a type of MRSA thinking back to it.

Kali Dayton 15:11
So he has a ventilator associated pneumonia. He’s treated for it. He’s been diagnosed there hope he’s doing better because he’s on 40% people five, right. And then they excavate him again, correct?

Leah 15:26
Yep. Well, so that that last time, so he was doing good. He was slowly getting off the sedation a little bit, because he was doing better. And he ended up coughing up his EA T to which, you know, I don’t think he didn’t pull it out. They were worried that he was going to try to pull it out because he had been like that, you know, that’s why he had the restraints, basically, basically, this entire time to he had restraints on. And he kept it up. And since he was on the cusp of being able to be excavated, they kept him excavated. So he was on the high flow nasal cannula at that point, but really, he was okay at the beginning. But when I saw him that next day, he was struggling.

Kali Dayton 16:08
And I’ve never seen anyone cough up the endotracheal tube. Yeah, I seen it like slightly dislodged, but never seen it coughed up. I’ve seen maybe the tubing become slightly disconnected from the 82. But I’ve never seen someone cough it up. So I know that’s a big concern. If you think that people have to be sedated, so they don’t cough up their tubes. I would suspect that maybe it wasn’t adequately secure. Yeah, yeah.

As I’ve seen lots of people coughing with the ET tube. It happens when you have a raging pneumonia, you have lots of secretions, and you’re awake on the ventilator? We think coughing is pretty good. We can look good to clear out secretions. So ultimately, it’s extremely rare to cough up your ET tube, and it’s unfortunate that it did. But nonetheless, he was on a PEEP of five and 40%. So he should have been excavated by that point, right? Yes. So third try without the endotracheal tube. And you said he was struggling? What does that look like?

Leah 17:04
He was just like very agitated, sleeping kind of. He had to be no when I saw him when he was intubated. He he was pretty okay. There was a moment a few hours where he didn’t have to have restraints on when he was no see more, in his mind seemed more relaxed. But then when I saw him when he was on the high flow nasal cannula, he had to have the little puffs on his wrist because he kept trying to rub off the nasal cannula.

And had to be restrained again, and just like super agitated, the nurse kept asking him questions like who is the president who, you know, can fish swim in the sea? Like very simple questions just to see how he was. And he just couldn’t really stay awake, like, you know, kept shaking his head like he didn’t know. So that was peculiar, too. And I think they did some blood gases on him, too. And his his co2 was high. So we wasn’t like, that’s been I mean, throughout this journey, like, you know, he hasn’t we realized, you know, this last week that he’s not the best about getting, you know, the co2 off.

Kali Dayton 18:11
And this is a really good case study of that, because he went from May 16, being intubated to now June 7, being totally immobilized mostly on the ventilator and sedated and we have to look at what that does to the diaphragm. When we don’t use the diaphragm to breathe or to sit up or to walk, the diaphragm atrophies and can become paralyzed.

So I would suspect that your dad’s diaphragm was and probably still is dysfunctional. Yeah. So though his lungs were fine, fine enough to have low oxygen setting low peep setting, his diaphragm still couldn’t drop and expand the lungs enough to have adequate ventilation. And so he was likely taking more shallow breaths. He was delirious, he’s probably a little over sedated still.

Or he was becoming more lethargic because his co2 was rising because he was not able to breathe that off because of dysfunctional diaphragm. And so all this plays into this big picture of these statistics that we have showing that patients that are deeply sedated and immobilized for extended periods of time, like your dad are at higher risk of re intubated. Even once the lungs are better. If the diaphragm can’t work, you can’t breathe. You said once I, when he was excavated, he was saying I can’t breathe. Yeah,

Leah 19:32
yep. Yep, he was. Yeah, he told my mom that and I remember like, it was that third time he was excavated and like he wanted my mom to like, tap on his chest or like pushdowns on his chest in order to like breathe better. Like he just like he felt like you know, something caught like in his chest tightening.

Kali Dayton 19:52
And the only thing I mean, I’ve never experienced that, but I would liken it to having someone laying on your upper abdomen or on your chest, and you get panicked, and you start getting agitated. And you say, because you can’t drop your diaphragm you can’t breathe and these little shallow breaths, no one is comfortable with that.

Yeah, so it makes sense that he’d be agitated, panicked, and say, I can’t breathe and wanting someone to support his respiratory muscles. That’s interesting to you when your mom pushed on his lungs, because he knew he needed to expel and inhale. Deeper, like that is a natural survival instinct that he still had even in this delirium. And yet, did anyone mentioned the diaphragm to you?

Leah 20:33
No one mentioned the diaphragm at all. And like, I pushed them to like maybe do more PT or like I asked him about the diaphragm and stuff, because I know too from running and I remember marathons, like how the diaphragm and everything works to for your breasts and stuff, and to keep your heart rate steady. And no one knew like no one even mentioned it. No one could really answer my questions when asked about that.

Kali Dayton 21:01
So they had to intubate him because he wasn’t ventilating adequately. And so he was re intubated. Shortly after, right back on the seventh,

Leah 21:13
yep, yep, re-intubated. He, my sister was there at the time. And he was just trying to get up out of bed, saying he wanted to go homes telling people to help him. And it was kind of a mess. And then, you know, my sister called my mom, my mom said just you know, if he had to be really intubated to to get calm,

Kali Dayton 21:34
So he was re-sedated upon intubation. So now we’re going from May 16, down to June 16, have been almost on continuous sedation the whole time. So that’s almost a month of being intubated and sedated and immobilized. Yes. Yep. He’s been excavated, three times, reanimated three times. And you reached out to me, I think 10 days after he had been intubated.

Leah 22:02
Right. Yes.

Kali Dayton 22:04
And that’s, I think, when you start to advocating for physical therapy, to work with them, and to keep moving, and my goal was for him to avoid a tracheostomy. Because this is all related to weakness.

Leah 22:18
Yep.

Kali Dayton 22:18
And what was the response when you would request physical therapy and at the team get him moving to avoid a tracheostomy?

Leah 22:27
Basically, that they didn’t have enough resources to get him up and moving, and they just didn’t have the time to get them going. Because I was asking, “Can we just get them up and you know, dangling his feet at the end of the bed, or, or maybe just sitting in a chair?” and they just said they didn’t have resources, and there wasn’t enough like physical therapists or occupational therapists, to, you know, come that often for that entire, you know, for patients. There’s only like, in PT would only come like every other day, too. So like, I couldn’t even get them there every day.

Kali Dayton 23:02
It was normal, that you would request someone on a ventilator work with physical therapy. Were they confused by that at all?

Leah 23:08
They seemed confused about it. They were just like, no, like, that’s not how it works or didn’t didn’t like make sense to them was asking about it.

Kali Dayton 23:17
every hospital, every unit has their own culture. And so it sounds like this might be a team that doesn’t usually work with patients until they’re excavated.

Leah 23:26
Yep, yep. Yeah, exactly. They you know, excavator with the trach. And, you know, then they go to L tech, and

Kali Dayton 23:34
I’m talking about don’t have time, right. Yeah. How much time was consumed? How much work was it to have? Your dad deeply sedated and intubated for maybe almost a month longer than he should have been? I mean, he. Most patients that they’re overstated, and they arrest, we catch them right away. Maybe they’re intubated for that moment.

But we let them wake up. I mean, the point was that they were overstated. So why would we keep sedating them and keep taking away the respiratory drive that caused them to arrest in the first place? So theoretically, if he had been allowed to wake up right after his arrest, and he didn’t have brain damage, and then we don’t give them delirium that would have spared potentially another three, four weeks of being intubated and sedated.

Or even at some point, if someone had just said, let’s keep his muscles strong, that would have spared so much time and effort work. So when we say we don’t have time to mobilize patients, I feel like how do we how can we afford not to? Yeah, yeah, everything has been deeply impacted by those first choices upon your dad’s admittance to the ER into the ICU. Everything impacted where he ended up. So, of course, he gets a tracheostomy on June 15. Finally turn off with precedents on June 16, and move them to the stepdown And it sounds like he had just had a terrible time they placed the PEG tube it got dislodged.

He had an alias which your chances of having an alias when you’re deeply sedated and mobilized probably on a fentanyl drip numero uno card narcotics, your chances of having an alias greatly increased. And I keep hearing about these COVID patients and all these patients having aliases. We probably cause it if not greatly contribute to it. And so your poor dad has been vomiting and having a PEG tube dislodged and then he gets shipped off to LTACH.

Leah 25:32
Yep, yep. They he kind of had like some transition where he was in the step down, had to go back to the NICU because of the PEG tube getting dislodged. So had to go into emergency surgery at like 3am for that, then, you know, got, you know, medically stable the NICU and then went back to the step down.

And then once he was after, like 24 hours of being stable, even maybe it was even less than that maybe 12 hours, they said, you know, you’re a frail tech and my mom, my mom was awesome. She was an advocate for him like he’s not ready, like keep them just another day. And they basically told us, we didn’t have a choice like he had to go to El tak.

Kali Dayton 26:07
They were no one was no impact patient, they’re just tired of the chronic care that all the recovery stuff that they’re not interested in, in ICU, you should have antibiotics for the pig to dislodgement. And so could have potentially had an infection, another hospital acquired infection. So that’s to hospital acquired infections, which are extremely hospital, expensive for hospitals, again, weeks longer because of all of these complications.

When I right now I’m working through a lot of the financial pictures of things. And when we say we don’t have enough money to hire more physical therapists, or money to adequately staff or educate the teams, we are costing the hospital so much money and the patient’s so much money by allowing this whole scenario to unfold where we causes all complications. And we’re just patching up and trying to fix everything that we’ve caused. And then it goes to attack. And most of us from the ICU, we don’t really know what attacks are like. So what is your dad’s journey in the LTACH been since then?

Leah 27:07
So he he went there. And first he couldn’t get a private room, he had to be in another room with someone which I understand that does happen. But knowing my dad with his, you know, anxiety, depression, that sort of thing that he just be extremely uncomfortable there. So he was there for probably 12 hours, and my mom pushed for him to get a private room. So the next day, he was able to get into a private room. And then the staff there had been pretty good, but I mean, it’s a high nurse to patient ratio. Each nurse has five patients, most of these patients are in ventilator, so I can’t like imagine having to take care of that, that many patients that are pretty, pretty ill.

Kali Dayton 27:44
Deconditioned, completely helpless and dependent on nursing care.

Leah 27:49
Yep, yep. Yeah, yeah, exactly. And it. I mean, it’s been good that they, you know, physical therapists, occupational therapists, they come more often. So that’s good. But he’s still like episodes of vomiting just from the PEG tube. And just like, you know, they first thought he had about obstruction, obstruction from the vomiting, but turned out that, you know, they did a CT scan his stomach, everything was completely fine. So then they ruled it out that maybe he just wasn’t tolerating the what they were giving him through the PEG tube.

And I’m like, this is this is crazy. So then I’m wondering what ingredients are in, you know, what he was getting through his peg tube? Because he he’s a pretty sensitive and he has a wheat allergy. I always thought he had celiac disease, just because I’m gluten intolerant. And I thought maybe like, you know, having his wheat allergy, he might have that too. So I’m wondering if there’s gluten in, you know, are we in that, you know, what they were giving him so, tube feeds

Kali Dayton 28:49
…are rough. I mean, they’re, they’re not what we’re bodies are used to. So it’s a whole nother shock to the body, they have to have to feed for now weeks, where he may have been able to just walk away and start eating shortly after his cardiac arrest, or his respiratory arrest rather. And they have been trying to put them on a trach mask, right, trying to get him stronger so that he can breathe on his own. And what keeps happening?

Leah 29:16
He keeps his co2 keeps rising. And then he gets kind of agitated and, you know, kind of combative and stuff. He was like telling my brother that he you know, wasn’t proud of him even though you know, that’s not my dad, my dad’s you know, you know, he loves his kids. And so it was it was weird about it just the way he was acting.

So then finally, you might have told him like he needs to be, you know, back on the ventilator because he’s not His co2 is too high. So got puppet back on the ventilator for the night and stuff. So they’ve been kind of doing a more weaning process for him with the trach mask, but thank goodness earlier this week, he passed a swallow test, so he’s able to actually consume foods yesterday and today. Oh, yeah.

Kali Dayton 30:00
So today being July 7 to July 6, so he has gone since May 16. He has not been able to eat food himself. He has not been able to walk. He’s not been able to really communicate. He had a hard time with a speaking valve. He I mean, he hasn’t been allowed to breathe on his own since May 16. And here we are June 6, and he is still now talk and not close to being able to go home.

Leah 30:25
Yeah, yeah.

Kali Dayton 30:29
Is he able to be off the ventilator during the day then?

Leah 30:32
Yes, he’s able to be off the ventilator during the day and then they do put it back on the ventilator at night. So for the past like two three nights,

Kali Dayton 30:41
Good, but as such a process and that’s a process that we do not see in the ICU, we just trick pig and send them off to LTACH. And now he’s on antibiotics for MRSA pneumonia.

Leah 30:52
Yep, well, yep, he has a little bit of pneumonia and then he has Mersa by his spoon peut slip. Hopefully I’m taking this right sputum. So he got Mersa, you know, from the hospital and stuff and that I think, too, they were thinking contributed to his kind of being, you know, agitation and stuff. So a little bit of sepsis. Maybe

Kali Dayton 31:13
me. Yeah. And so we’ve had two probably three hospital acquired infections. Yep. Yep. And I would be bold enough to link Garrett back to the decision to deeply sedate him right after he’s intubated phone has COVID Instead of letting him wake up after intubation and seeing what is neuro status was, the choice was made out of habit to deeply sedate him because he’s on a ventilator, which led him to have delirium and to fail extubation.

The days following that, put that into be reintegrated with made him weaker, and the fail has felt sequential excavations. So when we talk about deep sedation causing patients to be re intubated, readmitted to the ICU, your dad was readmitted in ICU, higher risk of hospital acquired infections. He’s had probably tracheostomy, delirium, he’ll probably have post ICU PTSD from this, he probably had, we asked us ICU dementia. And after a month of being sedated, it affects the brain. He has been to LTACH, and he’s having weeks now have struggles and Eltech. His journey was not one because he was discharged from the ICU. What is this done to your family?

Leah 32:31
It’s just been so hard, like, you know, trying to go visit him. Of course, there’s still like COVID restriction, so only one at a time are able to be in the room. Now in LTACH, two at a time are allowed. So I mean, that’s been hard trying to juggle, like, you know, we all work and have kids and trying to go and see him to make sure that he’s okay. And just we’ve had we had like some close calls thinking if he wasn’t gonna make it. And I mean, that that’s really rough.

We’re very close knit family. So I think there was one time when he was in the NICU within like, probably the first I think it was a week and a half, his oxygen levels dropped. And they just had to turn up the oxygen on the ventilator. But the doctor called my mom and asking if, you know, if he’s a DNR, and my mom thought, okay, something’s majorly wrong. So my mom called us all, you know, that he wasn’t doing well. So all of us, you know, drop work, find someone to watch the kids and go to the hospital. So it turned out that he, you know, was okay, they do seem to turn up back surgeon a little bit.

Kali Dayton 33:31
Maybe that when he was developing pneumonia, from being on the ventilator, because immobilized on the ventilator.

Leah 33:37
And that’s exactly the timing right afterwards when he got the Yeah, pneumonia and stuff and got put in the antibiotics. And he started with healthy lungs. Yeah.

Kali Dayton 33:48
Just because of bad decision to sedate. And what would you have the ICU community understand about? Any and all of this whole process, from your dad’s perspective, to your perspective?

Leah 33:59
I would just have them like, you know, humanize each, you know, patient and seeing them for what they can be capable of, and maybe know, thinking the best and, you know, expecting the worst, I guess, to have them having be more mobile at the beginning and an understanding or maybe even have like Sitecom to help them understand like, what’s going on?

Because no one you know, I’m sure no one explained to my dad like, Okay, this is what happened, you coded. You’re in the ICU and giving him a lowdown of you know, where he was at. So just kind of humanizing each patient and instead of having these step by step processes for for what to do if something happens.

Kali Dayton 34:43
Yeah, and I deeply respect you for advocating for pushing for being insistent to on things that the team wasn’t familiar comfortable with. That takes a lot of courage from families to try to help teams change and do the best thing for patients. And I am sorry that you weren’t listened to.

Leah 35:03
Yeah, yeah, definitely. You know, I tried to talk and understand, you know, medical terminology and stuff so that, hopefully they take me take me seriously and understand things, but definitely, you know, wasn’t, it was an okay experience, I mean, not the best experience. But I mean, the interaction between them was okay with the doctors, but it wasn’t like I was really heard.

Kali Dayton 35:29
Yeah, and I am sure you had a good team that was doing the best to the knowledge that they have. But I hope that this scenario that your dad has endured, does not happen to other people. I really suspect a lot of this could have been prevented by changing our sedation, mobility practices. And I don’t say that everyone as far as families or survivors, but you hunted me down.

Leah 35:53
I found you I was lost. Like, it was such a difficult time with my family, I had no knowledge of ICU and what was going on? So I tried to, you know, find a podcast that you know, I could listen to why work so I could try to understand things better. So I found your, your podcast, walking home from the ICU and started listening and realized some of the things that you were talking about, we were experiencing, as you know, family, and you know, my dad’s a patient. So I reached out to you on Instagram, just to get your insights, I felt lost. And I felt like the doctors weren’t explaining things. So I’m like, I need someone to help, you know, me understand, like, what’s going on here?

Kali Dayton 36:31
Yeah, and these discussions have helped me appreciate how vulnerable patients and even families are in these situations you are at the mercy of the culture of the ICU that you’re at, and whether or not they are open to more information, or the latest research or trying something different, really depends on their own ability and perspective. So that’s, that’s really difficult.

Thank you for sharing this with us. I know this is a hard time for your family even currently, again, I would repeat to ICU community just because someone’s been transferred out of the ICU does not mean that they’re out of the woods and patients like your dad are still at risk of being readmitted to the ICU. And we have to see that the moment I’m gonna wheels enter our doors and ICU. What we want to happen in the following weeks, and that is determined by the choices we make upon admission and upon intubation.

Leah 37:24
Yep, yeah, exactly. And keeping them keeping them walking up just as you know, like you’re saying, just keep them going to, to understand, you know, kind of what’s going on.

Kali Dayton 37:37
The whole body matters. Yep,

Leah 37:39
yep. Yeah.

Kali Dayton 37:40
Thank you so much. Keep us posted. We want to know how your dad’s doing in a couple of weeks in a couple of months. We want to keep learning from him and let us know how we can support you however we can.

Leah 37:51
Yeah, thank you so much for having me on and being able to tell a story, you know, become very passionate seeing things going. I definitely want to get you know his story out. So hopefully no one else has to go through what he went through.

Kali Dayton 38:03
Well, I’ll keep you in my my quiver. We need your voice and I appreciate you offering it. Thank you.

Leah 38:09
Thank you.

Kali Dayton 38:11
So in conclusion, it is likely that if this ICU team had chosen to avoid sedation and perform a true neuro exam, Leah’s father may have been able to be promptly excavated. Perhaps he would have needed another day for diuresis after the code.

Yet it seems appropriate to suspect that had he been able to wake up promptly, with at least a true sedation vacation, he would have been spared weeks of mechanical ventilation, ICU delirium with probable ICU post ICU, dementia and PTSD. Three re innovations, two possibly three hospital acquired infections, and ICU readmission, severe ICU acquired weakness, tracheostomy, and weeks in the hospital and months and rehabilitation.

He went to the ER for back pain. He was admitted to the hospital on May 15. He finally made it home on August 11. I am reminded of a bone marrow transplant patients I cared for as a nurse he arrested three times within two hours for unknown reasons, but was successfully resuscitated after the second time, he was intubated and woke up perfectly clear and understood what was going on. After the third arrest.

He wrote to me that he wanted to be excavated. I told him our concerns about his abrupt arrests for unknown reasons. And he said that he was sore, tired and understood that he could die and requested that if it occurred again, he did not want to be brought back. He was really just in pain from compressions and was hating the bed and wanted to go on a walk. So according to His will, we excellent Did him and I walked him just 15 minutes after doing compressions on him.

Admittedly, it was weird for the team to see the man we were just coding, strolling through the halls. But it was his choice. His code status, advanced directives, pain management, and even mobility were in his hands. Because we did not automatically sedate him as a knee jerk response to having an endotracheal tube. We wanted to know what his neuro status was doing after a code and we got that and more for him.

So before you fall back to autopilot to retain the order or give that milk of amnesia. Please pause and sincerely question the necessity of it. Have you assessed their neuro status? Did you ask the patient or the family about their preferences? Were you transparent with him about the risks involved with deep sedation and immobility? Have you tried to treat the root cause of any anxiety or agitation?

Or is your team subconsciously wanting to mask it? Is their silence worth their suffering? Imagine what where they will be tomorrow, in a few days, in a few weeks, and if you months, you in that moment, have the power to greatly influence their destiny. Choose wisely.

Transcribed by https://otter.ai

 

References

Immobility →Ventilator Associated Pneumonia:

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DeliriumPratik Pandharipande, Ayumi Shintani, Josh Peterson, Brenda Truman Pun, Grant R. Wilkinson, Robert S. Dittus, Gordon R. Bernard, E Wesley Ely; Lorazepam Is an Independent Risk Factor for Transitioning to Delirium in Intensive Care Unit Patients. Anesthesiology 2006; 104:21–26 doi: https://doi.org/10.1097/00000542-200601000-00005

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Lönnqvist, P. A., Bell, M., Karlsson, T., Wiklund, L., Höglund, A. S., & Larsson, L. (2020). Does prolonged propofol sedation of mechanically ventilated COVID-19 patients contribute to critical illness myopathy?. British journal of anaesthesia, 125(3), e334–e336. https://doi.org/10.1016/j.bja.2020.05.056

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ICU Acquired Weakness/Prolonged Time on Ventilator and Hospital:

Vanhorebeek, I., Latronico, N. & Van den Berghe, G. ICU-acquired weakness. Intensive Care Med 46, 637–653 (2020). https://doi.org/10.1007/s00134-020-05944-4

Shehabi, Y., Bellomo, R., Reade, M. C., Bailey, M., Bass, F., Howe, B., McArthur, C., Seppelt, I. M., Webb, S., Weisbrodt, L., Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators, & ANZICS Clinical Trials Group (2012). Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. American journal of respiratory and critical care medicine, 186(8), 724–731. https://doi.org/10.1164/rccm.201203-0522OC

Strøm, T., Martinussen, T., & Toft, P. (2010). A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet (London, England), 375(9713), 475–480. https://doi.org/10.1016/S0140-6736(09)62072-9

Discharge Disposition:

Brook, A. D., Ahrens, T. S., Schaiff, R., Prentice, D., Sherman, G., Shannon, W., & Kollef, M. H. (1999). Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Critical care medicine, 27(12), 2609–2615.5.

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Diaphragm Dysfunction / Risk of re-intubation:

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ICU Acquired Weakness and Failed Extubation

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