Suctioning Stroke Patients: A Delicate Procedure

Suction is a critical tool in treating neurological emergencies, including strokes. Strokes are either hemorrhagic (bleeding in the brain) or ischemic (caused by a clot). Suction can be used to clear a patient's airway or maintain its patency, which may be compromised due to the inability to swallow effectively, cough, or control physical movement after a stroke.

In recent years, a procedure called thrombectomy has emerged as a revolutionary stroke treatment. Thrombectomy involves using suction to literally suck out the offending clot from the patient's brain. This procedure has been shown to be more effective than traditional thrombolysis, which uses clot-busting drugs to dissolve the clot. Thrombectomy has been shown to be particularly effective in treating larger clots and can often be performed even when thrombolysis is contraindicated.

The use of suction in stroke treatment is a rapidly evolving field, with new technologies and techniques being developed and studied. Ultimately, the goal of these treatments is to improve patient outcomes and reduce the devastating effects of strokes.

Thrombectomy: a treatment where the offending clot is sucked out of the patient's brain

Thrombectomy is a treatment used to remove blood clots from arteries or veins. This procedure can be used to restore blood flow to vital organs, such as the brain, and can reduce the risk of death or permanent disability if performed promptly.

During a thrombectomy, doctors use a specially-designed clot removal device that is inserted through a catheter to pull or suck out the clot and restore blood flow. This procedure can be performed as either an open surgery or a minimally invasive surgery. In the former, an incision is made to access the blocked blood vessel, which is then cut open and the clot is removed using a balloon. In the latter, a catheter is inserted into the blood vessel and guided to the location of the clot using continuous imaging scans. The clot is then removed by breaking it up, dissolving it, or sucking it out through a catheter-like vacuum.

Thrombectomy is a treatment for ischaemic stroke, which is caused by a blood clot blocking blood flow to the brain and accounts for around 85% of strokes. It is a powerful intervention that can have a significant impact in preventing and reducing long-term disabilities caused by severe strokes. The procedure should be carried out as soon as possible after the stroke, ideally within the first six hours, but can be performed up to 24 hours after the stroke if deemed beneficial by doctors.

One case study describes a doctor's first-hand experience performing a thrombectomy. The patient, a 42-year-old soldier, had suffered a severe stroke and was administered a clot-busting drug within the critical golden hour, but it had not helped. The doctor performed the thrombectomy procedure, making a small incision near the patient's groin and feeding a catheter along the aorta into the carotid artery in his neck. They then introduced the suction catheter, manoeuvring it into the brain until it reached the clot blocking the middle cerebral artery. Despite initial anxiety about navigating a catheter of that size into a cerebral artery, the procedure was successful, and the patient made a full recovery.

Tracheostomy: a procedure to help stroke patients breathe and protect their airway

Tracheostomy is a procedure that involves creating a small opening in the neck to place a tube into a person's windpipe, allowing them to breathe. It is often performed on stroke patients who have severe dysphagia (difficulty swallowing) or require mechanical ventilation in an intensive care unit (ICU).

Stroke patients may require tracheostomy due to their inability to breathe or protect their airway sufficiently. This can be caused by various types of strokes, such as severe acute ischemic stroke, large or brainstem intracerebral hemorrhage, intraventricular hemorrhage, severe cerebral sinus venous thrombosis, or subarachnoid hemorrhage. The extent of brain damage and its sequelae, such as brain edema and secondary ischemia, are more important factors than the specific type of cerebrovascular pathology.

There are two main scenarios in which tracheostomy is typically considered for stroke patients:

• Stroke unit patients with severe dysphagia: Tracheostomy may be indicated for stroke patients in a stroke unit whose deficits include severe dysphagia that poses a risk of aspiration and cannot be managed effectively with tube feeding and swallowing therapy alone. These patients may require tracheostomy to bridge the gap during rehabilitative care.
• ICU-dependent stroke patients: More often, tracheostomy is performed on stroke patients who are so severely afflicted that they require ICU treatment and mechanical ventilation. In these cases, long-term ventilation and prolonged insufficient airway protection are the main indications for tracheostomy.

Benefits of tracheostomy in stroke patients

Accepted advantages of tracheostomy in stroke patients include:

• Less pharyngeal and laryngeal lesions compared to prolonged orotracheal intubation
• Improved oral hygiene and nursing care
• Higher patient comfort
• Reduced sedation demand
• Easier and faster weaning from the ventilator
• Reduced risk of ventilator-associated pneumonia
• Shorter duration of ventilation and ICU length of stay
• Improved outcome and mortality, although this requires further study

Timing of tracheostomy in stroke patients

The optimal timing of tracheostomy in stroke patients is unclear and varies depending on the patient's condition and the judgment of the treating physicians. However, it is generally recommended to assess the need for further ventilation at the end of the first week of intensive care and proceed with tracheostomy if extubation is not feasible.

Technique for tracheostomy in stroke patients

The tracheostomy procedure can be performed surgically or through a percutaneous dilational tracheostomy (PDT). PDT is a bedside procedure that involves puncturing the trachea and inserting a guidewire, followed by dilation of the tracheal opening and placement of the tracheal cannula. PDT is generally preferred due to its reported advantages, including reduced overall complications, less wound infections, less unfavorable scarring, and higher cost-effectiveness.

Complications of tracheostomy in stroke patients

Tracheostomy is considered a safe procedure, with a low overall complication rate. However, potential complications include venous bleeding, transient desaturations, transient hypotension, skin infections, arterial bleeding, false passage, unintentional decannulation, pneumothorax, esophageal damage, and death.

Decannulation after tracheostomy in stroke patients

Decannulation, or the removal of the tracheostomy tube, should only be performed after reliable confirmation of the patient's ability to swallow and handle their saliva. This confirmation is typically done through clinical swallowing evaluations and/or endoscopic tests, as clinical evaluations alone may be unreliable.

Suction can be used to treat airway compromise in stroke patients

Strokes are either hemorrhagic (bleeding in the brain) or ischemic (caused by a clot) in nature. In the case of an ischemic stroke, thrombectomy is a revolutionary treatment where the offending clot is literally sucked out of the patient's brain. This procedure involves making a small incision near the patient's groin and feeding a catheter along the aorta into the carotid artery in their neck. A suction catheter is then introduced, which is fed inside a larger catheter. With the help of a guide wire, the suction catheter is manoeuvred into the brain until it is in front of the thrombus (clot) that is blocking a large blood vessel in the brain.

The suction thrombectomy technique is a simple, time-saving, beneficial, and safe method for treating acute ischemic stroke with large vessel occlusion. It involves placing a large-bore microcatheter at the proximal part of the thrombi and applying negative suction pressure using a syringe. The thrombi are then sucked out as fragments or captured at the catheter tip by the negative pressure and withdrawn as a single piece.

In the case of a hemorrhagic stroke, suction can also be used to treat airway compromise. As the amount of bleeding increases, more pressure is placed on the brain, and the increase in intracranial pressure (ICP) can begin to press against the brainstem, affecting the patient's respiratory drive. In such cases, rapid sequence intubation should be performed, and supplemental oxygen should be provided if the patient is hypoxic (SaO2 < 94%).

Suction is also useful in the event of spinal cord injuries

Spinal cord injuries can be caused by a wide range of incidents, including automobile collisions, falls, penetrating injuries, blunt trauma, violent attacks, gunshot wounds, shallow-water diving incidents, and sports injuries. These injuries can lead to respiratory emergencies and affect numerous bodily systems, with the respiratory system being the most critical.

Suction is crucial in managing a patient with a suspected spinal cord injury. The injury may impact the patient's ability to cough or swallow effectively, leading to a build-up of saliva, blood, or vomit, which can compromise their airway. A portable suction unit is essential in such cases to remove these obstructions and maintain the patient's airway patency.

The higher the injury on the spinal cord, the greater the potential for paralysis or catastrophic injury. Injuries involving the cervical vertebrae, particularly the midsection (C3-C5), can disrupt the phrenic nerve, rendering the patient unable to breathe on their own. In such cases, suction becomes even more critical, as it helps clear the airway and ensure adequate oxygenation.

Additionally, spinal cord injuries can cause difficulty breathing due to paralysis of the diaphragm and other respiratory muscles. Suction can assist in clearing any secretions or obstructions in the airway, improving the patient's breathing and reducing the risk of respiratory complications such as pneumonia.

Furthermore, spinal cord injuries may result in neurogenic shock, affecting the entire body. Suction plays a vital role in managing this condition by helping to maintain adequate circulation and blood pressure while supporting the patient's vital functions.

In conclusion, suction is invaluable in the event of spinal cord injuries. It helps manage respiratory emergencies, clears airway obstructions, improves breathing, reduces the risk of complications, and supports the patient's overall vital functions. By carrying a portable suction unit to every trauma call and utilizing it effectively, medical professionals can significantly improve patient outcomes in spinal cord injury cases.

Suction can be used to treat head injuries

The first step in treating a head injury is to assess the patient's condition, including their airway, breathing, circulation, disability, and exposure/environment. This involves checking for patency in the airway, listening for noisy ventilations that can indicate obstruction, and using a suction pump to remove any blockages.

The second step is to manage the airway and prevent respiratory emergencies. Patients with traumatic head injuries are prone to respiratory distress due to an unprotected airway, which can be caused by loss of consciousness, tongue obstruction, hemorrhage, or vomiting. A suction pump is a critical tool for managing these tenuous airways and ensuring the patient can breathe.

Additionally, it is important to stay alert for signs of respiratory failure, such as altered mental status, tachycardia, chest tightness, altered breath sounds, decreased oxygen saturation, and pale skin. If respiratory failure occurs, intubation may be necessary, and the suction unit should be kept nearby to maintain patency and ensure the airway remains clear.

Overall, suction plays a vital role in treating head injuries by helping to manage the patient's airway and prevent respiratory complications, which can be life-threatening.

Frequently asked questions