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Quick Tip for Families in Intensive Care: One-Way Extubation After Hemorrhagic Stroke in ICU? Why It Might Be Too Soon to Give Up!
“One-way extubation after hemorrhagic stroke in ICU, why it might be too soon to give up?”
My name is Patrik Hutzel from intensivecarehotline.com, and this is another quick tip for families in intensive care.
Today, I want to talk about a 51-year-old man who has been in ICU for 14 days after suffering a hemorrhagic stroke. He had high intracranial pressures (ICP), also known as ICPs, a midline shift, and an external ventricular drain (EVD) placed to manage the pressure. He was heavily sedated and paralyzed with fentanyl, midazolam, propofol, and cisatracurium. He was also on hypertonic saline to help reduce brain swelling.
Two weeks later, sedation and opiates have been stopped for 48 hours since the Glasgow Coma Scale, also known as GCS), is between 3 and 6. He’s currently ventilated on CPAP (Continuous Positive Airway Pressure) with the following ventilator settings, FiO2 (Fraction of inspired Oxygen) 30%, PEEP (Positive End-Expiratory Pressure) of 5, pressure support of 10, tidal volumes is around 500mL, minute volumes around 13L per minute, respiratory rate around 23 breaths per minute, that means he’s passing spontaneous breathing trials.
The ICU team wants to go down the path of what they call a “one-way extubation, meaning they plan to remove the breathing tube and not reintubate him no matter what happens. This is essentially an end-of-life measure without ICU teams naming it so.
But here’s the problem. Why has a tracheostomy not been mentioned and why is the tracheostomy not on the table? This particular patient has a cough, but likely not strong enough to prevent aspiration after extubation. Despite that, no one is talking about a tracheostomy, which is a common next step for patients who are not ready to be exubated, but are also not ready to die.
This man’s family is not ready to give up, and frankly, why should they? He’s breathing spontaneously, maintaining good minute volumes and he’s tolerating minimal ventilator settings, yet the ICU team is pushing to remove life support by doing a one-way extubation without giving him the chance to survive with a tracheostomy without giving him time.
Just for the record, 14 days in the ICU is not a long time. It may be perceived as a long time from an ICU perspective, because for them, they need the bed, they don’t want to spend any more money. For them, it’s a business decision, not a life-saving decision. So, here is one of the many reasons why you need to question the ICU team. Too often ICU teams frame these decisions as “medical futility when in fact, they may be rushing to judgment.
Families need time, the brain needs time, neurological recovery after a hemorrhagic stroke can take weeks to months, not days. What this patient and family really needs now is a tracheostomy to bridge the gap while he continues to recover, possibly a PEG (Percutaneous Endoscopic Gastrostomy) tube if he can’t swallow safely yet, but that could wait another 6 months. More time of sedation to truly assess his neurological function, specialist neurorehabilitation down the line.
Do not let ICU teams push you into a corner. If you’re facing a similar situation and the ICU team is pushing for one-way extubation, while withholding transparency and options like a tracheostomy, you must advocate fiercely, and we are all the way advocating with you. Ask the hard questions. Why isn’t a tracheostomy being offered? Why has it not been mentioned? The family wouldn’t know about a tracheostomy unless we as advocates would have brought it up.
This is why I keep saying over and over again that the biggest challenge for families in intensive care is that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. This is why I also have been saying for many years, ICU teams are not even telling you half of what’s going on. This is exactly one of those situations.
So, is the patient stable enough for the procedure? In this case, yes, he is. What’s the rush in declaring futility after just 14 days? What’s the rush to kill a 51-year-old man? Where’s the rush? Families have the right to say no to one-way extubation and insist on all life sustaining options being considered.
If you’re in a similar situation and you don’t know what to do next, contact me directly here at intensivecarehotline.com. We can help you hold hospitals accountable, navigate the complex ICU system, and give your loved one the best shot at survival and recovery, because you only get one chance to do this right. Take control, speak up, don’t let ICU teams decide it’s “game over” when it’s actually not.
I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy because of our insights. You can verify that on our testimonial section at intensivecarehotline.com. You can verify it on our intensivecarehotline.com podcast section where we have done client interviews because our advice is absolutely life changing.
The biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care.
That’s why we help you to improve your life instantly, making sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always. That’s why you can join a growing number of members and clients that we have helped over the years, saving their loved ones’ lives.
That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. When I talk to families directly, I also talk to doctors and nurses directly, asking all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.
I also represent you in family meetings with intensive care teams.
We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if in case you have unanswered questions, if you need closure, or if you are suspecting medical negligence.
We also have a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded. All of that will help you to improve your life instantly, make informed decisions, have peace of mind, control, power and influence, making sure your loved one gets best care and treatment always.
All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.
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Thank you so much for watching.
This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.
Take care for now.
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