Post Intubation Care


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Post Intubation Care

  1. 1. Post Intubation Care. Caring for the Critically Ill Downstairs. By: Kane Guthrie
  2. 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. 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. 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. 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. 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. 7. The Ventilator.
  8. 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. 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. 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 Pnemomediastinum3. Biotrauma: SIRS mediated response from lungs causing MOF.
  11. 11. Preventing VILI – “Lung ProtectiveSettings” 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. 12. Preventing VILI – Measure PlateauPressure 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. 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. 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. 15. We play a crucial role in preventing it!!
  16. 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. 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. 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. 19. Sedation and AnalgesiaPoor sedation and analgesia results in: Increased catecholamine levels Produce immunosupression Hypercoaguability Myocardial ischaemia
  20. 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. 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. 22. Monitoring Circulation! Monitoring the circulation system, focuses on:1. Blood pressure.2. Tissue perfusion.3. Intravascular volume.
  23. 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. 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. 25. Intravascular Volume. CVP unreliable is assessing fluid status & responsiveness. Inferior vena cava assessment- using ultrasound.  Full non-collapsing IVC + Pt adequately filled.
  26. 26. Maintaining Circulation! Fluid resuscitate. Maintain adequate maintenance fluids. Remaining hypotension post this with signs of circulatory compromise? Time for Inotropes/Vassopressors.
  27. 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. 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. 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. 30. Thank-you