Case Study in ICU: When a Tracheostomy Can’t Be Avoided!

Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So today I want to talk about a case study when a tracheostomy is actually unavoidable and is needed. So, let’s look at one of the clients that we worked with recently, and the client was basically asking us, would they give consent to a tracheostomy or not after their loved one has sustained a heart attack.

So let’s look at this closer. A man in his late sixties sustained a heart attack and they couldn’t put in a stent after a heart attack and they couldn’t also perform emergency open-heart surgery because he was simply too unstable in the beginning.

He ended up on a ventilator with a breathing tube because he ended up in pulmonary edema after he sustained the heart attack. He basically had fluids on his lungs.

Next thing that happened within 48 hours after he sustained the heart attack was he ended up with an ischemic stroke. He basically developed a blood clot and that went to his brain and he sustained an ischemic stroke due to lack of oxygen to the brain.

He then was in an induced coma for about 16 days. They have done follow-up CT scans of the brain to confirm the stroke when they were sedating him with propofol and remifentanil. They were trying to wean him off the ventilator and they were trying to wake him up after the induced coma to see whether he can be weaned off the ventilator and whether he can wake up and have neurological cognition to see, can he follow commands? Is he appropriately moving arms, legs and can he follow commands?

Now, after multiple days of trying to get him out of the induced coma and trying to wake him up. It was found that every time he’s waking up, he’s breathing against the ventilator. He’s getting tachycardic, high heart rate, high blood pressure, and he was not cognitively and neurologically intact.

And therefore he was in no position to maintain a safe airway if the breathing tube was to come out. But at the same time, he was still on BiPAP ventilation with high pressures as well as high oxygen demands. And therefore he couldn’t be extubated and the breathing tube was not in a position to be removed.

So, therefore, a tracheostomy is the right next step cause there’s no way that sedation can be reduced or even stopped without a tracheostomy because the tracheostomy is much more comfortable compared to a breathing tube. And once the tracheostomy has been done, sedation can be stopped. It’s much more likely that waking up without the breathing tube in the mouth is so much more comfortable and our client’s family member can actually tolerate that.

That will then as the next step also give an indication whether once sedation is off, what he can do neurologically? Can he wake up? Can he obey commands and other thing that happens with the tracheostomy once the tracheostomy has been done, their loved one can be mobilized, can get in a recliner chair and that will stimulate our client’s family member and hopefully, he can wake up just by natural stimulation.

Now the next steps are still there also, as I mentioned before, the client’s family member probably needs open-heart surgery to get the blockage fixed, but he won’t be able to do that with the breathing tube and without establishing what he’s capable neurologically and also after he’s a little bit stronger, he won’t get stronger in an induced coma.

So that’s my quick tip and summary of the case study today.

Now, if you have a loved one in intensive care and you need help, please check out intensivecarehotline.com. Call us on one of the numbers on the top of our website, or send me an email to [email protected].

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Take care for now.