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Quick Tip for Families in Intensive Care: When Can a Tracheostomy Not Be Done? Or Contraindications of a Tracheostomy!

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

Today’s tip is actually around, “When can a tracheostomy not be done or contraindications for a tracheostomy?” It came up this week because a client who has their mother in ICU wanted to do an early tracheostomy because she felt that her mom won’t come off the ventilator and that a tracheostomy should be done as quickly as possible.

Now, when we looked at the case, when we looked at her mother’s medical records when we spoke to the ICU team, we actually found out that a tracheostomy cannot be done, at least not at this stage.

So, let’s just quickly look at contraindications, and then I’ll break down why this particular lady can’t have a tracheostomy yet. But let’s just talk about what are contraindications for tracheostomy.

So, the first one is an unstable neck fracture. Obviously, if there’s an unstable cervical spine fracture and tracheostomy may pose a risk of exacerbating the injury.

Next, severe coagulopathy. If a patient has a bleeding disorder or severe coagulopathy, the procedure may be contraindicated due to the risk of uncontrollable bleeding.

Next, infection at the site. Active infection or cellulitis at the proposed tracheostomy site increases the risk of complications and may contraindicate the procedure until the infection is controlled.

Number 5, inadequate anesthesia, or sedation. If the patient cannot tolerate or is at high risk of complications from anesthesia or sedation, tracheostomy may be contraindicated.

Next one is, of course, patient refusal. If the patient is competent and refuses the procedure, their wishes should be respected. Of course, each case is unique, and decisions should be made based on careful consideration of the patient’s overall health, clinical condition, and specific contraindications. Of course, healthcare professionals, families, patients always need to be consulted.

But let’s talk about the next big one when a tracheostomy cannot be performed or is contraindicated, which is uncontrolled respiratory distress in some cases, if a critically ill patient in intensive care is in extreme respiratory distress or failure, the time constraints may make tracheostomy impractical compared to other airway management options.

Now, let’s break this down in particular, not only so much airway distress, let’s really be very specific here. So, most contraindications in intensive care from a ventilation side of things happen when FiO2 is about 50% generally speaking and PEEP is about 7 or 8, some people might say about 5, and or if patients are on nitric oxide, for example. Those are the major contraindications in the ICU, why an early tracheostomy often can’t be performed.

Case in point, this week, we are working with a client who has their loved one in ICU. The family wanted an early tracheostomy and the ICU team refused simply because FiO2 has been anywhere between 55% to 80%. Please keep in mind, that room air, the air that you and I are breathing is 21%. So, it’s significantly above room air and her PEEP, which is positive end-expiratory pressure, is 10 and has been up to 12 as well and she’s still in a volume control SIMV ventilation mode which makes it very, very difficult either for a surgeon to perform a tracheostomy, let alone a percutaneous tracheostomy at the bedside in ICU. So, those are the most contraindications.

Another thing that comes into play here is obviously arterial blood gases. If PO2 (partial pressure of oxygen) in the blood gases is around 70% or 80% of FiO2, that’s also a contraindication, or if PCO2 or partial pressure of carbon dioxide is abnormal and above the normal limit, that could be another contraindication because that could simply mean the patient could die during a tracheostomy procedure.

So, what’s the remedy here? The remedy here in this situation is to wait until FiO2 (fraction of inspired oxygen)  is coming down to less than 50%, PEEP (positive end-expiratory pressure) coming down to 8 or less, and arterial blood gases are fine and then, taking all the other contraindications aside, then the tracheostomy should be performed.

The client today is down to 50% but still on the PEEP of 10. But at least it looks like she’s heading in the right direction so she can have a tracheostomy. That’s assuming she’s not waking up and she can be extubated  after sedation has been switched off.

Now, just quickly with coagulopathy and also giving blood thinners, many patients or some patients in ICU are on heparin, which is a blood thinner. If they are especially on IV (intravenous) Heparin, that is a contraindication to do a tracheostomy, but it can be stopped and then the tracheostomy often can be done, just a comment there, but that this is what needs to happen.

I hope that helps you break down when a tracheotomy can and it can’t be done.

That’s my quick tip for today.

If you have a loved one in intensive care and you need help, we have a membership for families of critically ill patients in intensive care. You can get access to it by going to intensivecarehotline.com by clicking on the membership link or by going to intensivecaresupport.org directly. In our membership for families of critically ill patients in intensive care, 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.

Now, I also offer one-on-one consulting and advocacy for families in intensive care. I talk to doctors and nurses directly. I talk to you and your family directly. I ask all the questions to the ICU team that you haven’t even considered asking but must be asked when you have a loved one in intensive care in order for you to make informed decisions, have peace of mind, control, power, and influence.

Now, I also represent you in family meetings with the intensive care team so that you not only have clinical representation and advocacy, it’s also assessing whether you should even go to a family meeting in intensive care. We have a checklist, whether you should or shouldn’t go into a family meeting with the intensive care team so that, once again, you get treated on your terms and your loved one gets treated on your terms and not only the intensive care team terms, especially if you’re not happy with what they’re telling you.

We also offer medical record reviews in real time so that you can get a second opinion in real time. We also offer medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are simply suspecting medical negligence.

All of that, you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or send us an email to [email protected] and it’s all so that you make informed decisions, have peace of mind, control, power, and influence.

Now, if you like my YouTube channel, 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 or what questions and insights you have from this video.

Thanks for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.