My name is Patrik Hutzel from intensivecarehotline.com, where we instantly improve the lives for families of critically ill patients in intensive care so that you can make informed decisions, have peace of mind, control, power, and influence, even if you’re not a doctor or a nurse in intensive care, making sure your loved one always gets the best care and treatment.

So today I have an email from Donna who says.

“Hi Patrik,

My husband is now in a hospital where he’s on the VV ECMO machine for severe pneumonia, and ARDS (acute respiratory distress syndrome). They’re planning to do a tracheostomy on Tuesday, in two days, if his stats are what they need to be. What numbers should we be looking for?”

Well, thank you so much, Donna, for asking that question. This is an absolutely critical question. I’m so glad you’re asking this before the procedure and actually not after. So, the key numbers to look for, especially since your husband is on VV ECMO (Veno-Venous ECMO), which is used for lung failure, are the following.

Here are the critical parameters the ICU team should be evaluating before proceeding with the tracheostomy.

1. Of course, oxygen parameters such as PaO2 (partial pressure of oxygen), ideally above 60 to 80 mmHg.
2. Oxygen saturation, preferably above 92%.
3. The percentage of oxygen support the ECMO is providing versus what the ventilator is providing i.e. fiO2.
4. ECMO flow rates – are they stable or requiring increases?
5. Sweep gas flow removes CO – is it stable or increasing?
6. The trend over the last 48 to 72 hours – are things improving, stable, or worsening?
7. PCO2 (partial pressure of carbon dioxide) settings on the arterial blood gas, ideally 35 to 45 mmHg.
8. FiO2 (fraction inspired oxygen), ideally weaning down, not maxed out at 100%.
9. PEEP (positive end expiratory pressure) levels should be at lung protective levels, ideally between 5 to 10 cmH20.
10. Plateau pressures should be below 30 cmH20.
11. Driving pressures – lower is better for lung protection.
12. Hemodynamic stability such as blood pressure – stable without vasopressors, or at least minimal vasopressor or inotrope support.
13. Heart function, adequate cardiac output, stable ejection fraction.
14. Normal blood pressure, kidney function, urine output, and creatinine levels.
15. Infection markers, white blood cell count, temperature trends, procalcitonin or CRP levels. Any active infections need to be controlled before an elective tracheostomy procedure.
16. There is the bleeding risk. Platelet count should be adequate, usually above 50,000 for procedures. INR and PTT, coagulation parameters, any bleeding complications while on ECMO anticoagulation.
17. Most patients on ECMO are on a heparin infusion, and it is usually stopped temporarily while doing the tracheostomy.

Here’s what’s absolutely essential and critical for you. You need access to all medical records. Don’t just rely on verbal updates. You need to see the actual numbers, the trends, and the documented assessments. This is exactly where a consulting call with me or intensivecarehotline.com becomes absolutely invaluable. We review all the medical records with you. We can join a call with the ICU team to ask the right questions, advocate for your husband’s best interests, clarify what the numbers actually mean for his specific situation, question the timing of the tracheostomy if the numbers aren’t optimal, ensure the ICU team has considered all factors.

A tracheostomy while on ECMO is not a decision to take lightly. The timing matters enormously. The medical team should not proceed with a tracheostomy just because it’s been a number of days. They should proceed because your husband is stable enough for the procedure. The trajectory is showing improvement or at least stability. The benefits outweigh the risks at this specific time. There’s a reasonable expectation he’ll eventually wean from ECMO.

And now Donna, I also want you to be aware of intensivecareathome.com as a long-term option. If your husband does need long-term ventilation, whether that’s invasive ventilation with a tracheostomy, non-invasive ventilation such as BIPAP or CPAP with a mask, or if he can’t be weaned off the ventilator, or if he does need a tracheostomy long-term, not necessarily a ventilator, Intensive Care at Home can keep him out of ICU predictably and permanently.

This option is also available for palliative care if that becomes the direction you need to consider. Many families don’t know this option exists, but it can be life-changing for both quality of life and outcomes. Something to keep in your back pocket as you navigate this journey. It is way too early to look at Intensive Care at Home, but as time progresses, you might start to think about it.

So also red flags to watch out for:

1. Be concerned if the team is rushing the tracheostomy without clear improvement.
2. Numbers are trending in the wrong direction.
3. There’s active infection or bleeding.
4. ECMO support requirements are increasing, not stable or decreasing.
5. They can’t give you clear answers about the criteria they are using.

Next steps.

Request a family meeting before Tuesday. Ask specifically about each parameter I’ve mentioned. Get copies of all medical records. Leave no stone unturned. Ask what their criteria are for proceeding versus delaying. Consider getting our team involved for a consulting call. I can be there for you and also get the medical records from your previous hospital because I know your husband has been transferred to another hospital for ECMO.

Donna, you’re asking exactly the right questions at exactly the right time. The fact that you’re thinking about this proactively shows you’re advocating effectively for your husband. Don’t be afraid to ask for a delay if the numbers aren’t where they need to be. Tracheostomy can wait if the timing isn’t optimal, but complications from a premature procedure cannot be undone.

If you need my help and the help of my team reviewing the medical records, joining a call with the ICU team, which will be an absolute game changer and will change the dynamics in your favor, or just having someone in your corner who understands ECMO and critical care inside out, reach out to us at intensivecarehotline.com right now, go to the website, call us on one of the numbers on the top of our website or send us an email to [email protected].

We’re here to help families exactly like yours navigate these critical decisions. I’m thinking of you and your husband during this incredibly difficult time. You’ve got this and you don’t have to navigate this alone.

I have worked in critical care nursing for 25 years in 3 different countries where I worked as a nurse manager for over 5 years in intensive care. And I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. And I can very, very, very confidently say that we have saved many lives with our consulting and advocacy, because of our insights and you can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast section where we have done client interviews.

And 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. And 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 the best care and treatment always.

And 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. And that’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. And 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.

And 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, so. 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, and 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 e-books and 21 videos that I’ve personally written and recorded. And 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.

And 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 support at intensivecarehotline.com with your questions. And if you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share the video with your friends and families, and comment below what you want to see next, what questions and insights you have from this video.

I also do a weekly YouTube live where I answer your questions live on a show and you will get notification from the YouTube Live if you are a subscriber to my YouTube channel or if you are a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

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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