My talk on providing post intubation care to

1. Post Intubation Care.
Caring for the Critically Ill Downstairs.
By: Kane Guthrie

2. Learning Points
 What we need to do post tube!
 Some simple pearls for providing excellent ED critical care
management!
 How to prevent VAP & VILI!
 Some little pearls that can make a big difference to morbidity
and mortality!

3. Case Study
 58 female
 Hx :COPD, smoker
 P/C SOB, febrile,
productive cough
 O/E Severe resp distress
 CRX-severe pneumonia
 Get’s emergently
intubated for resp failure!

4. Ok time for ICU…..
 A call to the ICU
coordinator…..
 Starts ranting there coffee
machines not
working, another nurse has
gone home sick with an
acute hang nail and they
have no bed’s for at least 6
hours.
 Great!!!!!

5. ED Boarding!
 Pt’s spending more time in
ED!
 Lack of higher acuity beds!
 Should patient geography
determine the level of care
they receive?

6. ED Intubations & Mechanical Ventilation
 Make up about .05-1% of presentations.
 Average length of stay between 2-5 hours.
 What we do in this 2-5 hours can have drastic outcomes on
morbidity and mortality.

7. The Ventilator.

8. Managing the Ventilator!
 Most common procedure in managing the critically ill.
The 3 goals of MV:
1. Maintain systemic oxygenation.
2. Improve ventilation.
3. Decrease work of breathing.

9. Adjusting the Ventilator
 A crucial component to managing the critically ill.
Our aim is to:
 Limit ventilator induced lung injury.
 Prevent ventilator associated pneumonia.

10. What is Ventilator Induced Lung Injury?
 VILI = caused by direct damage by the action of MV.
 Results from volutrauma (high tidal volumes) and excessive use of
oxygen.
 Also can cause:
1. Atelectrauma: shear stress and injury to alveolar units.
2. Barotrauma: extra alveolar air – PTX or Pnemomediastinum
3. Biotrauma: SIRS mediated response from lungs causing MOF.

11. Preventing VILI – “Lung Protective
Settings”
 Lower tidal volumes (6ml/kg of ideal body weight) – decrease’s
volutrauma.
 Adding in PEEP to reduce atelectrauma.
 Will need to allow for permissive hypercapnea.
 Elevated Co2 generally well tolerated except in head injury or ACS.
 Monitor Co2 and pH closely.
 pH <7.15 increase RR to max of 30-35 bpm, if fails increase TV by
1ml-kg increments till pH increasing.

12. Preventing VILI – Measure Plateau
Pressure
 Estimate of end-inspiratory alveolar pressure.
 Provides information on lung compliance.
 Goal is to maintain plateau pressure <30 cm H20.
 If > 30cm H20 decrease tidal volume by 1-ml/kg increment
until below <30cm H2O or volume reaches 4ml/kg.
 Patient with obstructive lung disease, decrease RR before TV.

13. Preventing VILI: Dial down the O2!
 Majority of ED patients managed with FiO2 100%.
 Hyperoxia can cause additional lung injury.
 Decrease FiO2 to <60% when clinically feasible- prevent
oxygen toxicity.
 Aim for spo2 >90%
 Use PEEP to assist with oxygenation.

14. Preventing VAP
 Most common complication in ICU patients 27-47% of ICU
acquired infections. .
 VAP results in:
 Prolonged MV.
 Increase ICU & hospital lengths of stay.
 Increased morbidity and mortality.

15. We play a crucial role in preventing it!!

16. Preventing VAP
 Intubated patients lying supine are @ high risk for asp
pneumonia.
 The easiest intervention is to elevated the head of bed 30-45
degrees.

17. Cuff Pressure
 Maintain cuff pressure between 25 -30cm H2O
 Ensure’s adequate cuff seal.
 Measure every 4 hours.
Other things:
 NGT
 Chlorhexadine mouthwash
 Stress ulcer prophylaxis.

18. Sedation & Analgesia
 We’re not that good at it.
 74% received inadequate or no anxiolysis.
 75% of patients received either inadequate or no analgesia.

19. Sedation and Analgesia
Poor sedation and analgesia results in:
 Increased catecholamine levels
 Produce immunosupression
 Hypercoaguability
 Myocardial ischaemia

20. Sedation & Analgesia Tips
 Analgesia first - always.
 Fentanyl – very cardiac stable – provides good analgesia.
 Propofol = excellent sedative but provides NO ANALGESIA!
 Ketamine excellent in the hypotensive patient, @ provides
analgesia as well as disassociation.
 Benzo’s via continuous infusion can accumulate in tissues
prolonging sedative effects.

21. Paralytics
 Provide comfort to us – not the patient.
 Repeated & indiscriminate use NMBAs should be avoided.
 Recurrent use results in “ICU acquired weakness”.
 Majority of patients adequate analgesia & sedation should
suffice.

22. Monitoring Circulation!
 Monitoring the circulation system, focuses on:
1. Blood pressure.
2. Tissue perfusion.
3. Intravascular volume.

23. Blood pressure
 Simplest means of monitoring global circulation.
 Critically ill = ART line!
 Art line essential when giving vasoactive medications.
 Focus on MAP 65mmHg and above.

24. Tissue Perfusion
 Hypoperfusion to tissues is difficult to assess.
Monitor:
 Urinary output
 (0.5mls/kg/hr).
 Lactate level
 >2mmol/litre possibility of circulatory dysfunction.
 Central venous oxygen saturation (ScvO2)
 Surrogate maker of O2 delivery and tissue perfusion.

25. Intravascular Volume.
 CVP unreliable is assessing fluid status & responsiveness.
 Inferior vena cava assessment- using ultrasound.
 Full non-collapsing IVC + Pt adequately filled.

26. Maintaining Circulation!
 Fluid resuscitate.
 Maintain adequate maintenance fluids.
 Remaining hypotension post this with signs of circulatory
compromise?
 Time for Inotropes/Vassopressors.

27. Don’t forget VTE!
 DVT has been shown to develop within the first 24 hours in
critically ill ICU patients.
 13-30% of ICU Pt’s develop DVT during hospital stay.
 The 2 simple things we can do:
1. Heparin 5000U S/C
 TEDs
 Downfall -HITS

28. ABCDon’t Ever Forget the Glucose!
 Stress induced hyperglycaemia is common.
 Associated with increased mortality in ICU pt’s.
 Studies show “tight glucose control” isn’t the answer.
 Aim for a glucose 6-12 mmol.

29. Take Home Points!
 Knowing how to adjust the ventilator, can help adjust
mortality rate in the critically ill!
 Sit the patient up, check the cuff pressure = decreases VAP!
 Analgesia before sedation always!
 DVT prophylaxis downstairs can make a difference upstairs!

30. Thank-you