to trach or not to trach?

Panacea Financial Contract Review
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
T

turnupthevapor

Full Member
15+ Year Member
Joined
Oct 7, 2008
Messages
186
Reaction score
30
Members don't see this ad.
Surgeon books a 147 KG EF 20% OHS/OSA pt w septic shock 103 fever on 20 ucg levo and primacor with bp 100/60 who is on peep 10 and FIO2 100% with RR 24 TV 600 on the vent for a trach. Surgeon won’t do it bedside (he isn't comfortable). He has been intubated for 20 days and his pulm wants me to do it. My concern is his PO2 will drop like a rock with the transport and eventually the switch leading me to have to recruit him back up w PPV and he will code at that point. Should have been done weeks ago but the wife was refusing.
 
I had to google Primacor as I have never heard of it.
Ok, why not just transport him on the ICU vent and give just a little whiff of versed/fentanyl for procedure, while keeping him on the ICU vent? What's he on for sedation anyway?
But yeah, he may code with a heart and sepsis that bad. Primacor may not be helping your B/P either.
What's his echo show in regards to pulmonary pressures that is?
 
Last edited:
This is a no-go to the OR at the moment with the high fever and borderline hemodynamic instability, but regardless you need to find an ICU doc who knows how to manage an ARDS vent. Unless the person is 6'4" they should likely be on smaller Vt, more PEEP, and lower FiO2
 
I’m curious what the patients condition was 10 days ago when he probably should’ve been trach’d and the family was refusing
 
Twiggidy said:
I’m curious what the patients condition was 10 days ago when he probably should’ve been trach’d and the family was refusing
Click to expand...
Me too.
But doesn't matter now though does it.
He may have missed his window. Maybe this one just needs a tincture of time to see which way he swings.
 
chocomorsel said:
I had to google Primacor as I have never heard of it.
Ok, why not just transport him on the ICU vent and give just a little whiff of versed/fentanyl for procedure, while keeping him on the ICU vent? What's he on for sedation anyway?
But yeah, he may code with a heart and sepsis that bad. Primacor may not be helping your B/P either.
What's his echo show in regards to pulmonary pressures that is?
Click to expand...
This guy is in severe ARDS likely due to a mixture of cardiogenic and septic shock. Even on an ICU ventilator, switching this guy's ETT to a trach and the resultant loss of recruitment is a nightmare. He'll drop like a rock, he weighs a ton so his trach will not be easy and when he codes, there's not going to be a lot of bringing him back. No added mortality benefit of doing the trach at this point and if anything it should be contraindicated in his current state. Hard no.
 
We have M&M's for a reason and I have been to 3 or 4 M&M's of this exact situation over the past thirteen years that went bad, very bad.
 
So for those who haven't looked it up, primacor = milrinone. How much milirinone was this guy on?

Is it common to use a vasodilator with a low SVR state? How bad was this guy's ARDS? Nitric too expensive?? Interested in the disease course....

Not interested in doing this guy's trach.

However, the problem is that everyone else seems to be convinced that a smaller deadspace is going to save his life. How do y'all play this out politically??

FWIW I will consider doing this if PF ratio is at least 80, but I want ecmo (VV bypass) at the same time. If I'm gonna do something to appease people grabbing at straws, might as well give the patient a chance.
 
Last edited:
Ronin786 said:
This guy is in severe ARDS likely due to a mixture of cardiogenic and septic shock. Even on an ICU ventilator, switching this guy's ETT to a trach and the resultant loss of recruitment is a nightmare. He'll drop like a rock, he weighs a ton so his trach will not be easy and when he codes, there's not going to be a lot of bringing him back. No added mortality benefit of doing the trach at this point and if anything it should be contraindicated in his current state. Hard no.
Click to expand...

Or maybe, I am playing devil's advocate here. Yes, he may code due to his above mentioned issues. Or he may not. No one knows for sure until we try right? I honestly don't think that those few seconds where the cuff is down, and the trach is pushed in before balloon up is going to result in such severe de-recruitment/desaturation that he will code if everything goes smoothly. If that was the case, every time he got turned and moved around in bed he would code. I am more concerned about the severe sepsis from whatever source on two cardiac meds and surgery in this state. And yeah, those TVs are too high as well.

I have seen some crazy things in my life. There are a lot of cowboys/cowgirls out there, and I am not one of them. This is not an emergent procedure and yes it could wait.
 
dchz said:
FWIW I will consider doing this if PF ratio is at least 80, but I want ecmo (VV bypass) at the same time. If I'm gonna do something to appease people grabbing at straws, might as well give the patient a chance.
Click to expand...

He's been intubated for 3 weeks, I don't think he's a VV ECMO candidate
 
chocomorsel said:
Or maybe, I am playing devil's advocate here. Yes, he may code due to his above mentioned issues. Or he may not. No one knows for sure until we try right? I honestly don't think that those few seconds where the cuff is down, and the trach is pushed in before balloon up is going to result in such severe de-recruitment/desaturation that he will code if everything goes smoothly. If that was the case, every time he got turned and moved around in bed he would code. I am more concerned about the severe sepsis from whatever source on two cardiac meds and surgery in this state. And yeah, those TVs are too high as well.

I have seen some crazy things in my life. There are a lot of cowboys/cowgirls out there, and I am not one of them. This is not an emergent procedure and yes it could wait.
Click to expand...

The problem with taking this at face value is that there are still unknowns. What are his O2sat/ABG on these current settings? If he's having trouble oxygenating on these settings plus his size, I can see how even the slighest removal of vent support could lead to a rapid desaturation, especially in a septic patient. All of that could lead to a bad code.
 
chocomorsel said:
Or maybe, I am playing devil's advocate here. Yes, he may code due to his above mentioned issues. Or he may not. No one knows for sure until we try right? I honestly don't think that those few seconds where the cuff is down, and the trach is pushed in before balloon up is going to result in such severe de-recruitment/desaturation that he will code if everything goes smoothly. If that was the case, every time he got turned and moved around in bed he would code. I am more concerned about the severe sepsis from whatever source on two cardiac meds and surgery in this state. And yeah, those TVs are too high as well.

I have seen some crazy things in my life. There are a lot of cowboys/cowgirls out there, and I am not one of them. This is not an emergent procedure and yes it could wait.
Click to expand...


A) Absolutely zero chance that this takes a few seconds. He's 147kg, they're going to get into the airway, pull the tube back, put the trach in and switch over the circuit.

B) There is a close to zero mortality benefit associated with placement of a trach in this patient. Continued, severe hypoxia is not an indication for tracheostomy, despite what some pulmonologists/surgeons believe. A tracheostomy assists with weaning from the ventilator, helps suctioning of secretions and facilitates patient comfort. All much lower down on the list of priorities for this patient.
 
From an ICU perspective:
1. No.
2. No.
3. Prop - roc - perc trach (the ICU doc has to step up here)
4. No.

HH
 
chocomorsel said:
Ok, why not just transport him on the ICU vent and give just a little whiff of versed/fentanyl for procedure, while keeping him on the ICU vent? What's he on for sedation anyway?
Click to expand...
Not sure how big your elevators are, but it would not be possible for us to "transport him on the ICU vent" to the OR. ICU vent in the OR is fine, but not for transport.
 
A couple things:

1) this guy’s vent settings are TERRIBLE.
2) what’s his paO2? Just because he is on that much oxygen doesn’t mean he needs it.
3) you’re being a little dramatic when you say it should have been “weeks” ago. He’s only been tubed under 3 weeks....
4) the guy who said only do it if PEG is also booked is nuts. You want to add a PEG on for a fat guy that you’re already worried about? Why on earth would you want that? There’s no reason to think he won’t be able to eat again if he recovers. Just leave in a dobhoff until he gets downsized.
 
chocomorsel said:
I had to google Primacor as I have never heard of it.
Ok, why not just transport him on the ICU vent and give just a little whiff of versed/fentanyl for procedure, while keeping him on the ICU vent? What's he on for sedation anyway?
But yeah, he may code with a heart and sepsis that bad. Primacor may not be helping your B/P either.
What's his echo show in regards to pulmonary pressures that is?
Click to expand...
Because his sat will drop like a rock and then you will be forced to bag him up with high pressure and volume PPV. It’s like kicking a patient hard in the chest. Not a great idea with an EF of 20 severe pulm htn and septic shock....
 
Just do it.

But make sure to place extra pairs of nasal specs set to 4L flow to pre-oxygenate prior to starting.
 
TimesNewRoman said:
A couple things:
4) the guy who said only do it if PEG is also booked is nuts.
Click to expand...

It's an anesthesiologist thing, No one wants to do this trach that won't benefit this patient in their current condition.

However Guillemot speaks a well known general truth (that's why the comment has been liked by so many people), if you do the trach without the PEG they will be calling you tomorrow or the day after to come down for the PEG and you transport a really sick patient to the OR twice rather than once.
 
ProtonPump said:
It's an anesthesiologist thing, No one wants to do this trach that won't benefit this patient in their current condition.

However Guillemot speaks a well known general truth (that's why the comment has been liked by so many people), if you do the trach without the PEG they will be calling you tomorrow or the day after to come down for the PEG and you transport a really sick patient to the OR twice rather than once.
Click to expand...

Yes it is really fing annoying esp if they bring the pt down and there's no consent and no family around so you have to bring them around again.
 
ProtonPump said:
It's an anesthesiologist thing, No one wants to do this trach that won't benefit this patient in their current condition.

However Guillemot speaks a well known general truth (that's why the comment has been liked by so many people), if you do the trach without the PEG they will be calling you tomorrow or the day after to come down for the PEG and you transport a really sick patient to the OR twice rather than once.
Click to expand...

That’s dumb. It’s 2018, PEGs should be few and far between for critically ill patients. The number of PEGs I had placed last year for feeds in a critically ill patient (excluding trauma that has an anatomical reason they can’t get fed from above) was 0. You can get all the nutrition via an NGT or postpyloric tube while the dust settles.
 
TimesNewRoman said:
That’s dumb. It’s 2018, PEGs should be few and far between for critically ill patients. The number of PEGs I had placed last year for feeds in a critically ill patient (excluding trauma that has an anatomical reason they can’t get fed from above) was 0. You can get all the nutrition via an NGT or postpyloric tube while the dust settles.
Click to expand...

Sometimes they need a PEG for rehab/SNF/SAR/LTAC placement :/
 
chocomorsel said:
What's his echo show in regards to pulmonary pressures that is?
Click to expand...

I wonder, at this point, how that information would change anything you'd do or not do. Besides, echo frequently underestimates PAP so its of questionable value here.
 
Not that it in anyway changes the current consensus, but it seems kinda unusual for someone in "septic shock" to be on two inodilators and no vasopressor
 
economycian said:
Not that it in anyway changes the current consensus, but it seems kinda unusual for someone in "septic shock" to be on two inodilators and no vasopressor
Click to expand...

re-read that. levophed. What's the other inodilator?
 
SaltyDog said:
Preeeeetty sure the PEG comment was tongue-in-cheek, but you two go ahead. This debate is amusing.
Click to expand...

Yea 99.3% sure the PEG was sarcasm. That being said, I'd only do this trach is this guy had MRSA. Because if I'm going to do this case, I better be in those plastic gowns, dressed to the nines and feeling FABULOUS!
 
You must log in or register to reply here.

Similar threads

L
Awake trach?
Replies
44
Views
3K
cchoukal
C
Iso4ane
Another victim of hospitals not wanting to pay their group?
Replies
8
Views
2K
MTGas2B
MTGas2B
T
  • Question Question
Reimbursement for same day return to OR cases
Replies
10
Views
2K
nimbus
nimbus
A
proposed legislation to allow CRNA’s to supervise AA’s ?
Replies
44
Views
4K
jwk
jwk
P
Return to OR after Pain Fellowship?
2
Replies
57
Views
9K
NightyNight
N
Top