Intubation necessary?

[ScottieDNurse2b]

I'm currently a nursing student who hopes to work one day in the ICU. The following happened to my fiance and I was wondering what you thought.

My fiance delivered a healthy baby boy. After the delivery she started getting headaches. Since she had a botched epidural that turned into a spinal, everyone assumed she was getting the dreaded spinal headaches. After a blood patch 4 days later, she got some relief. A couple of days later, the headaches started coming back. On 7 days postpartum, right before I was going to take her to the ER again, she had a seizure. She was taken to the ER (to a hospital we don't go to) by ambulance. She was confused and had to be restrained in four-points. She had a CT/MRI/MRA performed where it was decided she had postpartum eclampsia and PRES due to high BP 180/110 and proteinuria. After the CT/MRA she was resting and sleeping comfortably unrestrained. They said she was going to be fine, started her on Mag Sulfate, and were going to send her to a regular (I'm assuming OB) room. She wasn't having any respiratory issues.

Here comes the ER doctor. He said the first MRI/MRA didn't come out as clear as he wanted (she was moving) and he wanted to intubate her to make sure it wasn't an amniotic fluid embolism (because he thought at 24 she was too young to have eclampsia) and they were also going to do an LP to rule out meningitis. I said this was fine as long as she was extubated after the procedures. He told me this was fine since she wasn't having respiratory issues she didn't need it afterwards.

After the MRI/MRA/LP, she is now being transferred to the ICU 8 hours later still intubated with bilateral wrist restraints (this was a Saturday night). When I saw her she was on Propofol but she was following commands (squeezing hands, shaking yes or no). Her vent was set at 100% oxygen and her oxygen pressure was over 500, which had to be reset to 30%. At first I was told they were talking about taking it out, but then the residents came in and basically said that they didn't want to extubate her because "she needed to rest, and to protect the airway in case she had another seizure. She'll be the first one extubated in the morning, and she won't have to ween off too long." It really had to do with the attending doctor didn't want them to remove it in the morning until he came in. Basically, she didn't get too much rest at all, she was maxed on Propofol and had to be given additional morphine to sedate her further. Her BP dropped to 100/50, even though the OB said he didn't want her systolic below 140. The ICU nurse, who was great and helped me out a great deal, was telling me that he tried to talk them into taking it out but they wouldn't budge. He was really supportive, and I think he helped me out a lot because I was obviously stressed.

So, after a long night of trying to comfort her, the ICU attending doctor walks in Sunday morning and says, "So, I heard we had to intubate her because she was having trouble breathing." Livid at hearing that, I explained to him that she was intubated to do testing and she wasn't having respiratory issues at all. Needless to say, she had to ween off the vent for 2 hours and have another ABG done that she wasn't a fan of, and it was determined she could come off and she did. She was cooperative, confused about what had happened (doesn't remember being restrained or on the vent, thank God!), but pretty much back to normal. Looking back on it now, she has no memory of Sunday or Monday (perhaps the Propofol?) although she was on Dilaudid as well to help her headache. She required oxygen for the next 3 days because her saturation kept dropping, but she ended up leaving the ICU on Tuesday night and left the hospital Thursday night on labetalol and Procardia (the infectious disease doctor gave her a prescription for an antibiotic in case it was meningitis, even though it had been ruled out, but she didn't get it on advice of the regular attending doctor) to keep her BP down.

My question is, was the intubation necessary? What might have been reasons for keeping her intubated overnight that are not respiratory distress related? I'm confused as what to think about this, and was wondering if any insight on what happened can open my eyes. Overall, I'm happy she's okay and can enjoy our baby boy now. I was extremely pleased with the rest of the care given (think I.D. doc went a lil overboard with Rochephin, Vanco and Acyclovir for a "not likely meningitis" breastfeeding mom, but it didn't seem to harm) and the nursing staff as well.

Thanks in advance. Needless to say this wasn't the first time birthing experience we were expecting!

[akulahawkRN, ADN, RN, EMT-P]

Unfortunately we don't offer medical advice here. Even if we could, we'd want to know the rest of the story before we'd be able to even guess as to whether this was necessary. It may have been, it might not have been...

[enuf_already]

Way too many variables to be able to determine what happened. I think this would qualify as a case where unless you were there, you wouldn't be able to guess what happened or why.

I hope she is doing well and fully recovered. That had to be very scary for you.

[ScottieDNurse2b]

Thanks for the replies. I'm thinking about writing a letter to the hospital to make sense of it all. It seemed unnecessary to me, and to her regular OB (at a different hospital). I was just checking for other reasons for intubation besides respiratory distress. I know they will intubate in case of status elipticus, but that wasn't the situation here. She never had a seizure at the hospital.

It was extremely scary, and she is doing great now. Her BP is still elevated, but the medication seems to be working enough. I just feel bad if I made the wrong decision to have her intubated if it delayed her recovery, or even worse, she got injured from it (thankfully she didn't). It definitely has made us rethink about having more children!

[Gooselady, BSN, RN]

DEFINITELY contact the Patient Advocate, and have a conversation with the nurse manager or a clinical someone who can explain what went on. Not necessarily because they did anything wrong, but your heart won't rest until you get to ask these questions.

How absolutely horrifying, what you two went through. Good grief, post partum ecclampsia?? I can't imagine what went through your head

The thing is when mothers go down right after a birth it is usually something really awful, like a pulmonary embolism, or amniotic fluid embolism -- both of which have high mortality. If this ICU did go overboard, they did it to keep your fiance from dying, whether or not her condition actually WAS so serious. Add in their that some docs are quick and some slow to remove life support, and being a little slow in case she had another seizure was done in good faith.

What you two went through was quite a trauma. It will help a lot to get some answers! I hope you follow through, and if you do, let us know what they said? Our Director of Nursing (350 bed hospital) frequently spoke to family members for exactly these reasons, she considered it part of her job.

[akulahawkRN, ADN, RN, EMT-P]

Gooselady has some excellent advice for pursuing this from a different angle. I do agree... the only way you're going to get some peace out of this is to be able to ask those questions and find out the rationale for what they did. It won't change what they did, but at least you'll know why and if it makes sense to you and that will probably help you make decisions about what to do afterward.

[Esme12, ASN, BSN, RN]

First Congratulations on your son! I am so sorry you had such a scary beginning.

Welcome to AN! The largest online nursing community! As per the Terms of Service we cannot give medical advice but we can give you general normality that go on inside the ICU.

It is impossible to know the why's of what they did. It is easy for her regular OB to play Monday morning quarterback. Many times in the emergency department patients are intubated for the sole purpose of sedating to keep a patient still to obtain the necessary exams when they are confused or combative. It is not uncommon to be agitated/confused after a seizure and in the presence of unknown etiology...to cover all angles, meaning, Lumbar puncture, antibiotics/heavy and strong...to cover all possible bases.

Many times in medicine we never find out the exact cause but the patients remain very ill or present critical and the final diagnosis remains an enigma. Intubation to protect an airway is usual and customary especially in the emergency department. It is best that if there would be any doubt of the airway protect it immediately. The emergency department doesn't play and wait until the least minute when it is a code situation....they simply can't wait. Time is of the essence.

Leaving her intubated may have been an over cautionary length of time, however, once again always side on the side of caution. IN the presence of her acute presentation I can understand the staff's nervousness.

Depending on the time of day...meaning night...certain things are just not done (again on the side of caution) like extubation until there is more experience and actual bodies present in case something goes wrong.

Propofol....wonderful drug! I recently had to have emergency surgery for ischemic bowel, small bowel obstruction, sepsis. They left me intubated (or so I was told) for a couple of days....to "let me rest" and unstable vitals.

I remember NOTHING! Apparently I was a piece of work on the vent. Propofol, Ativan, Fentanyl, and Dilaudid and I still would fight the vent, get my hands untied, moved constantly with only very brief moments that I was actually resting. My B/P was low as was my urine output and my heart rate was 140. They decided to stop fighting me and extubate me. I am told I promptly told them what I thought about being left intubated and how to fix my B/P, volume, sepsis, urine issues. Rolled over and went to sleep. I was told that my surgeon said...."Well she told us....do what she says". (I am a long term critical care nurse of 35 years and completely embarrassed at my alleged behavior )

The next thing I remember was 4 days after admission at 7 at night when my children came to see me. I am so happy my husband didn't let them see me with all that crap however they did see me newly extubated still talking turkey from the meds.

I think this has been very scary for your fiance and you...I think talking to the patient advocate will help you piece together the pieces. Ask to speak/have a meeting with the attending or medical director of the ICU to get the best perspective on this traumatic event. Maybe even seek some counseling to help you process this trauma.

In the end...you have a healthy son and fiance.....Merry Christmas :candle:

[SubSippi]

Way off topic, but I just have to say, Esme, I can't wait to know as much as you do!! Your posts never cease to impress me

OP, it did sound very strange to me at first. But, as a new-ish critical care nurse, after reading Esme's response, I can understand why they might have felt the need initially. It is, however, unfortunate that there seemed to be such a lack of communication between the MDs.

I'm so glad your son and wife are safe and healthy! That sounds like an absolute nightmare!

[ScottieDNurse2b]

Thanks all for the replies. She doesn't remember being on the vent and doesn't seem to be too phased by any of this as much as I am (she can't believe she was acting like she was, though!). I think it is best to contact someone to see their response is. I was just confused because she wasn't intubated in the ER for 5 hours and they didn't seem to think she was critical (her vitals were stable). The ICU team originally wanted to do the MRI/MRA in the morning (not leave her intubated) but the ER doctor was pushing for the intubation/MRI/MRA/LP.

Overall, though, I am happy she is fine and I should stop worrying about this all. I seem to be taking it way worse than she is!

[amoLucia]

Way off topic, but I just have to say, Esme, I can't wait to know as much as you do!! Your posts never cease to impress me

THIS!

Esme is the grande dame of this website as I like to think. She has probably forgotten more than I ever knew in the first place.

Sometimes it's a very humbling experience to read her posts.

[TraumaNurse95]

I've been an ICU/ER/Trauma nurse for almost 20 years now. My educated guess on why she was intubated was that she had eclampsia. Her symtpoms do not sound like an Amniotic Fluid Embolus as she very likely would have been going into respiratory and cardiac arrest almost immediately and the reason for an amniotic fluid embolus is directly related to the presence of amniotic fluid DURING pregnancy, therefore it requires a placenta to be present. There are likely several reasons why her eclampsia put her at being an airway risk: 1) eclampsia can quickly lead to cerebral edema (as well as HELLP syndrome and DIC). 2) its almost impossible to intubate a patient actively having a seizure and so their plan was likely proactive plan in protecting her airway, 3) Intubating her may have helped prevent her HTN from worsening and/or more eclampsia complications by sedating and intubating her

[ScottieDNurse2b]

Hi TrauamNurse,

Thanks for the reply. I can understand that...I guess my confusion arouse from the fact that the ICU team wanted to do the MRI/MRA the next day without intubating her but the ER doctor said he was worried about the AFE so he wanted to do the intubation and the MRI/MRA right away. I guess in retrospect I should have denied the MRI/MRA until the morning and she probably would have never been intubated and probably could have recovered quicker. All sources and case studies have said that intubation should be a last resort for postpartum eclampsia unless they go into SE, but perhaps they weren't familiar with the situation (they kept saying they were unsure of her case). Luckily she never experienced the HELLP or DIC!