weaning

[bjaeram]

I work in the ER an generally put people on vents instead of weaning them. My SIL is on a vent due to sepsis from a staph infection. She has been on 2 1/2 weeks. Her blood cultures are now negative but she has been having issues with her lungs now. They have tried to reduce sedation and "wake her up" three times. Each time her BP, P, and R increase. She has been awake enough to reach and shake her head yes/no, but not really alert. They keep resedating/paralizing due to her vitals. They seem to think she has another infection causing these changes but can't find one. WBC normal usually, was low at one point. CT head to toe negative. Cultures of of blood and every line negative. They just keep increasing antibiotics. My question is couldn't these vital sign changes just be her anxiety? She has no idea where she is or what is going on, she has a tube down her throat and can't talk....I would be anxious as hell waking up like that. I am getting frustrated that each time she starts to really come around the resedate her and we begin again at square one.

One other question is about traching her. They are talking about doing this soon. I guess I'm wondering if this is necessary. I'm hopefully she will be off the vent soon. I know being intubated for too long causes isssues but what is too long? Is it really more comfortable for a pt to be trached then orally intubated? Just curious on opinions about this practice.

I do have to say I've come to appreciate ICU nurses more since spending so much time in one. You guys do a lot of things we don't in the ER. We can handle code or critical situation with no problem but these long term issues and decisions I've realized I know nothing about. Monitoring the little changes and the ups and downs aren't a big deal in the ER as we only have people a few hours. We put in tons of tubes and meds but as far as monitoring them long term or weaning off these things I just don't have a clue.

[getoverit, BSN, RN, EMT-P]

I'm so sorry to hear about your sister-in-law. I understand how frustrating and confusing this whole ordeal must be.

About the tracheostomy...it's generally not done for comfort as much as for preventing necrosis/malacia around where the ETT cuff sits. there's no way of telling exactly how long is too long, but 2 1/2 weeks is certainly long enough to start thinking about a trach if the weaning isn't going well. Hospital I used to work will trach ya after 3-4 days, I think that's jumping the gun a little bit but I'm "just an RN".

I'm sure you understand it's tough to comment on your sister-in-law's case without being directly involved in it. During weaning trials it is common for a patient's hr/rr/bp to rise d/t anxiety and that can be easily controlled with meds (e.g beta blocker, anxiolytics etc). When we do weaning trials, the continuous sedation is off and the patient is placed on CPAP. We gauge them by their clinical picture, namely their work of breathing and we obtain ABGs after a sufficient time on CPAP. Sometimes they are ready more quickly than others, but our real basis for weaning is more related to their blood gases and respiratory effort than any level of agitation.

As for the infection?? Where do they suspect the source is? Is she febrile?

Again, I'm so sorry to hear about her situation and I hope that things get better real soon. don't know if any of this information helps or not. Take care, I"ll be thinking good thoughts for you and your family.

[Hoozdo, ADN]

I understand your worries and I am sorry your family is going through this.

I find a couple of things odd about her scenario.

1) Why are they paralyzing her? She is just on a vent, not an oscillator right? Normally pt's are not paralyzed except while being intubated, on an oscillator, or going through hypothermia protocol (to keep from shivering.)

2) Normally, a "sedation vacation" is called for at least Q24 hours, more often Q12 hours.. You wake the pt up to see if they are responsive. This time is also used to orient the pt and explain what is going on to them. This also helps with the anxiety because they have some kind of focus of why they are laying in a bed with a tube down their throat. Then you turn the sedation back on at the minimal levels to keep them sedated.

3) Concur with above poster about trach times and reasons. The really big concern is that you don't want the vocal cords damaged.

4) The agitation she expresses when trying to wean could be related to pain in addition to anxiety.

Normally, a pt is given a sedation drug (such as Propofol or Precedex) in addition to something for pain (Fentanyl drip). If anxiety is a big issue, a Versed drip can be added.

* This is not medical advice*

[bjaeram]

Thanks for you thoughts! I spent the day yesterday with her and have a bit more information.

She is having continued problems with metabolic acidosis. She had a rough morning with her bp dropping to 50/, her sat dropping ect. She was extremally acidotic and after bicarb she recovered quickly. The doctors aren't understanding why acidosis continues. They have scanned, scoped, and cultured everything and are not finding a cause, or infection anywhere. She is not febrile for now but does seem to get that way when they take her off dialysis. Her white count flucuates. They are getting very concerned.

The other issue is her lungs. They seem to have sustained lots of damage from the initial sepsis. Scarring and stiffness. They don't seem to be improving. She has been on a vent for three weeks. They put her on an ossilator two days ago and a special bed that vibrates her lungs. She is on steroids as well. The doctors don't know of any other ways to treat her and are starting to get concerned that her lung damage may not be recoverable. She seems to be in a holding state where they wait and treat the fires but she is not progressing. If anything she is taking small backward steps.

As far as the paralysis they have had that on most of the time which I found odd as well. I do understand now with the ossilator but she was on a regular vent for a long time. They do give her sedation holidays but they don't go well. She arouses quickly and moves everything but it's been over two weeks since they let her get awake enough to communicate or really even be aware. Her vitals all increase, her breathing worsens, and they resedate and paralize. They have her on Precedex, versed, dilaudid, and vec. Her vitals do change rapidly. Her bp and hr increase when anyone does anything to her. She is VERY jaundiced the last couple of days. We know she has liver and kidney damage from the initial infection but these things seem to be worsening instead of improving. The doctors aren't too concerned about these things but are focused on the lungs and the acidosis they can't find a cause for.

I know you can't give advice and I know it's hard when you don't have the whole picture but I would love any thoughts or comments. Do you see people recover after such significant lung damage that has had no improvement in three weeks?

[bjaeram]

What do you think about ecmo for her? No one has mentioned it but I'm wondering if it would be helpful at all...

[dmc_rrt]

Sorry about your Sister in Law, She sounds very sick. I don't know all the parts to this story, but here is my two bits:My guess is that the acidosis is probably caused by increased urea(ARF) and/or increased lactate from the liver failure. After two weeks she is ready for a trach. Sounds like your SIL has ARDS, which can take a long time to recover from. I would say that your SIL is probably far from being weaned from the vent. Paralysis and increased sedation will be required to improve ventilation and oxygenation.

ECMO could be worth a try. I have seen people pull through ARDS after many weeks of being on the vent, but there are many factors to take into account.

[bjaeram]

Thanks! You might be right about the liver failure. She is very jaundiced the last couple of days. Is there anything you can do for that other then wait for the oxygenation to get better?

I also think you are right about ARDS. I have not heard them say that specificly but that has but that is what I've been searching under when I'm doing my own research. Do people that have been on vents for months recover fully from it or do they have major issues forever?

Last week they were talking about a trach but yesterday the doctor said she was too unstable and they were not going to do it for now.

Back to the ecmo, is it useful for lung healing or is it mostly used as a bridge to transplant?

Sorry so many questions and I appreciate all responses. I thought I knew a lot but I've learned the ICU is a completely different world and there is so much I don't know.

[Hoozdo, ADN]

My own mother has had ARDS twice and lived through it both times. It was not severe

enough to be on an oscillator though.

What I see that is very concerning with your sister-in-law is multi-organ failure.

The lungs, kidneys, and now liver. I am sure you have done some reading on this

and know the mortality rates.

I don't know enough about ECMO in the ICU environment to comment. What does

her medical team think about the idea? Personally, I have never seem ECMO used,

but I googled it and it has been done before with ARDS cases.

Once again, I am so sorry that your family is going through this. Please keep us

updated. I am thinking of you.