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Was operated for acute subdural hematoma. Need of Tracheostomy and Gastrostomy tube insertion?

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Neurologist, Surgical
Practicing since : 1997
Answered : 96 Questions
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My 62 year old father was operated for acute subdural hematoma six days back due to a fall. He has been in the ICU under sedation with fentanyl and propofol continuous infusion in addition to a broad spectrum antibiotic, keppra, BP medication plus some other side medication.

From a clinical history standpoint, he has two stents in the heart, has had hypertension, has parkinson's and also had grand mal/focal seizures three months back which he almost recovered from.

He is also on ventilation with 25% oxygen. His ICP and BP are under control and the doctor decided to take the ICP monitors out. On neuro exams, pupil dilation has been reported as normal. When sedation is reduced, he raises his head & moves the body. He opens & blinks the eyes but does not seem to focus his eyesight. Does not follow commands yet. We are told he also tried grabbing the tube when sedation was reduced today.

Looking at the CT, his mid-line shift has reversed to an almost normal position as compared to the original CT. There is a small remaining clot that was not operated on in the original surgery.

The Trauma team tried taking the tube for the ventilator out earlier today. Although his lungs performed well from a breathing perspective, the tube had to be re-inserted almost immediately as his airway closed and tongue (swollen) blocked the airway when the tube was taken out. He is also having excess salivation.

The trauma team requested our permission for Tracheostomy and Gastrostomy tube insertion. We were told that it will make it easier for taking him off the ventilator as well as help reduce the risk of infection. However I have read articles that indicated there are negatives to doing this as well. Also most online references indicate that there is no need for Tracheostomy and Gastrostomy tube insertion before two weeks lapse on the regular ventilator and feeding pipes.

I need your expert opinion on -

1. Whether Tracheostomy and Gastrostomy tube insertion are absolutely needed now.
2. What is the maximum amount of time we can go without Tracheostomy and Gastrostomy tube insertion.
3. Pros and Cons of Tracheostomy and Gastrostomy tube insertion from your personal experience.
Posted Mon, 25 Mar 2013 in Brain Tumor
 
 
Answered by Dr. Visvanathan K 36 minutes later
Hi,

The conventional opinion is that tracheostomy is considered around the 2nd week of being intuited. The pro's are that his ventilation is easy and tracheal toileting i.e. suctioning and bringing out the secretions are easier. The cons are that the work of breathing becomes easy and therefore it may be difficult to wean the patients off the ventilator.

A gastrostomy is indicated if there is concern that the patient may not regain swallowing functions soon.

There are no golden rules with these things. The clinicians directly taking care are in a better position to advice the best course of action.

I would say that waiting for a few more days to see how much neurological improvement occurs and then deciding is also a valid course of action.

Hope this helps.
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