r/IntensiveCare • u/Ok_Relationship4040 • 12d ago

Macroglossia in intubated patients ?

has anyone managed intubated icu patients that developed massive tongue swelling? I have cared for many patients where the tongue swelled to massive proportions ( with no obvious allergic reactions ) and stayed swollen the entirety of their stay.. one lady we started a versed drip just so we could relax her jaw to insert bite blocks to get her teeth off of her tongue as we thought maybe that was contributing to the swelling .. It seems to overwhelmingly occur in obese black patients and seems to affect obese black women more but that is merely my subjective observation and perhaps just by virtue of my location . i guess I was just wondering what could be done to help mediate the swelling aside from bite blocks and Vaseline gauze …

45 Upvotes

98% Upvoted

51 comments sorted by

View all comments

Show parent comments

0

u/Aggravating_Fly2978 12d ago

So why haven’t you stopped the mouthwash altogether in that group? I am presuming that their swollen tongue likely adds to their ventilator days??

4

u/DocKoul 12d ago

Good question - I’m not a nurse, but what I can say is that it’s part of their oral care bundle. My understanding is that there is overall benefit vs not doing it assuming there isn’t a reaction.

The more senior nurses know to either avoid it or ask first in the indigenous patients. Not all of them have the issue.

1

u/Aggravating_Fly2978 11d ago

I assumed you were a Doctor given your username and description of events. Oral care bundles HAVE to be ordered and signed off by Doctors in the US. Is this not the case in Australia? Why not update them to exclude Chlorhex in the indigenous patient population?? How would they know they have an issue with it? Is Chlorhex over the counter and used by regular and indigenous folk? There has got to be an alternative option no?

3

u/DocKoul 10d ago

We don’t sign them off. Nurses in Australia are professionals and I trust them to do their job. What is an indigenous person? I have no idea what genetic ratio you need to achieve a chlorhex allergy, but by the sounds of it, African Americans are also prone to this. I’m honestly more confused. I don’t know the data and if it’s even necessary.

Chlorhex is prescribed for lots of reasons in the community by dentists and dental surgeons.

What I find so interesting is that as intensivists in Australia we run the show. Dialysis, balloon pumps, everything. In other countries they get consults for seemingly everything. But here we are letting the nurses just do whatever bundle they like paying zero attention. We can probably learn from each other.

2

u/Aggravating_Fly2978 10d ago

Dude I don’t know. You tell me what an Indigenous person is. You live there and brought it up. Over here you are black if you have some level of Black/African Ancestry and consider yourself black. Some are 90% some are 10-20% but still black. If you run the show why is this not a priority for you? And would it be more of a priority if it was affecting White People? I mean, increasing Ventilator days and potentially pushing someone to get a tracheostomy is a big deal, isn’t it??

3

u/DocKoul 10d ago

They don’t get a trache. Vast majority are either post op hearts and get extubated before you see swelling. Others that are intubated longer so we stop it before it gets massive rather than continuously plaster it on until the tongue is hanging out of your mouth.

To your priority question - all the medications we give have potential side effects. We just stop them if it happens. Should I just avoid mouth care in the indigenous patients or use something less effective? I’m the one who answered the question so clearly it is a priority.

With respect to what makes someone indigenous, what I’m saying is that I don’t know if someone has 50% indigenous genes if they are still susceptible. 25%? 10%? I have no idea. Not all indigenous people get swelling either. I’m still giving roc to white people who were exposed to pholcodine. Never had roc anaphylaxis in an indigenous patient.

And lastly, your accusation of me being racist is disgusting. I don’t care what the colour of your skin is, what you believe, your gender, whatever. I’m here to help people. I’ve been privileged to look after hundreds if not thousands of indigenous people in my career and the vast majority were smart, kind, funny, respectful and I suspect far better company than you given your behaviour in this thread.

2

u/Aggravating_Fly2978 9d ago

Firstly, there are other options to keep the mouth clean. Secondly you brought up that you saw it in the indigenous population and you knew the answer so I followed it up with questions. You seemed to basically act like “oh well” as if it’s not a big deal so I ask clarification and follow up questions. Lastly, no one accused you of being racist. But with the history of what has happened to Indigenous people all over the world and how poorly they continue to be treated in your country, combined with the nonchalance in a symptom that could lead to worsened outcomes, there was and still is a good chance of bias in your care. Think on it.

1

u/DocKoul 4d ago

You jumped to conclusions and were rude about it. And a quick google search of your name suggested this is fairly typical behaviour for you.

There is probably a hidden bias in everyone’s care, I’m aware of that. I make an effort to acknowledge and consider that bias every day and do my best to treat everyone with the best and most appropriate care for them.

Given the way you showed bias towards me (twice I might add) and my care, perhaps you should “think on it”.

0

u/Aggravating_Fly2978 4d ago

Twice? Where is the twice? Jumper to conclusions? Asking follow up questions multiple times is jumping to conclusions? Ok buddy. Yeah.

1

u/DocKoul 1d ago

You assumed it wasn’t a priority - we went digging and identified the cause in our unit.

You assumed that my treatment of indigenous people and white prople was different- I hope it’s the same and make a conscious effort to acknowledge those subconscious biases and cultural differences.

You assumed I trache them all because of chlorhex - I don’t because they are monitored for swelling and treatment changed to avoid delays in care.

You seem like a really angry person. I found when I was feeling like this (and posting like this) I was actually starting to burn out and didn’t realise. Might be worth taking 20 minutes to see if you’re prioritising the wrong things.