Wednesday, February 13, 2019

Pitfalls of Protocols: Pushing the Limits of Extubation

A recent post described extubating an asthmatic patient with very bad weaning parameters, and I promised to provide a followup telling whether he "flew" or not.

He flew.

It was a nail-biting experience and for the first hour it was unclear if he was going to make it.  His respiratory rate settled down into the teens which was reassuring, but he did not gain lucidity for quite a while and was intermittently midly "combative" and uncooperative.  He was on HFNC with oxygen saturations in the high 80s and low 90s, and he remained tachycardic and was wheezing.  His wife and the nurse were continuously in the room reassuring him, as were several doctors during the first hour or two.  During the course of several hours, he was able to be weaned to simple face mask and then nasal cannula and the next day he was discharged from the ICU.

If we had followed some sort of "weaning protocol" with blind faith, I don't know how long it would have been before he would have "passed" the protocol's tests and been extubated.  At some point, somebody would have said, "Hey, we better stray here, or we'll never get him extubated."