Your Wake-Up Call in the Intensive Care Unit

Hospital Guide, Part 6: The ICU team removes breathing aids, dials back drugs, and watches you closely


Still unconscious and laden with tubes and wires, you'll be moved onto a hospital bed and wheeled to the surgical intensive care unit, or SICU, for close monitoring during the critical post-surgical hours. Surgery assaults the body, hammering the immune system and tilting the balance of fluids and electrolytes, and this particular procedure demands cracking the rib cage and doing needlepoint on the heart's own arteries. The SICU team will track your blood pressure, heart rhythm, respiratory rate, and urine output, and check for bleeding from your incisions to make certain you won't need a return visit to the OR.

The timing of the return to consciousness is usually up to the critical-care nurses, although your surgeon will visit shortly after you arrive. For all of the digital readouts and LCD screens, assessing patients still involves touch. As Glenn Barnhart, chief of cardiac services at Sentara Heart Hospital in Norfolk, Va., gently grasped one of Margaret Denison's feet in each hand, he nodded at a device by her bed. "There's a lot of potential for inaccuracy between her body and that monitor," he said. A few hours earlier, vascular surgeon Noel Parent had cleared a buildup of plaque from the carotid artery on the left of Denison's neck. Then Barnhart had cut out her calcium-encrusted aortic valve and sutured a pig's valve in its place. For heart patients, he explained, the strength of the "pedal pulse"—the beat in the feet, if you will—and the warmth of each foot are the best read on the newly repaired heart's vigor.

You will be weaned from the ventilator over an hour or two, the flow of drugs gradually dialed back as you regain consciousness. The breathing tube will remain in place, which is uncomfortable and can trigger anxiety or frustration because you can't talk. Once the respiratory monitor shows that your lungs are not relying on the ventilator, a nurse will do a quick test for the amount of oxygen in blood drawn from the arterial line in your wrist. If it is sufficient, the nurse will remove the tube, with a respiratory therapist standing by if needed.

Bark, please. Early the morning after surgery, Sentara patient Thomas Adams was extubated—his breathing tube was removed. "I barked a couple of times," he says of the strange sounds he made when a nurse cajoled him to cough. The breathing tube irritates the vocal cords, making the first cough or effort to speak something of a struggle. But coughing is vital—it helps prevent pneumonia by flushing fluid from the lungs, which are back at work for the first time in quite a while.

Your team wants almost as badly as you do to get that tube out of your throat. Intubation for longer than 48 hours raises the risk of ventilator-associated pneumonia, says Michael Klompas, an infectious diseases physician at Brigham and Women's Hospital in Boston. A literature review he headed, published in the Journal of the American Medical Association, showed that patients who develop VAP have twice the risk of dying as those who don't.

Preventing VAP is surprisingly simple: Extubate as soon as possible, raise the head of the bed at least to 30 degrees, and practice diligent handwashing. The surgeon and nurses will also watch very closely for other threats, such as infection at the site of incision.

After extubation, you will be rapidly pushed toward self-sufficiency, even jollied out of bed. "They got him up in a chair right in the ICU!" marvels Adams's wife, Joanne, laughing. Just hours earlier, the evening after his surgery, the family had visited Adams, still unconscious, in the ICU. He could have looked worse. "There were tubes running everywhere," says Joanne. "He was pale, but not as ghastly gray-looking as they'd said he'd be."

Continue reading: Hospital Guide, Part 7: On the Floor >>

This story was originally reported on 7/15/07.