(1) Post intubation care is crucial for critically ill patients in the ED. (2) Proper ventilator settings including low tidal volumes and PEEP can prevent ventilator induced lung injury. (3) Preventing ventilator associated pneumonia requires keeping the head of the bed elevated, maintaining proper cuff pressure, and using chlorhexidine mouthwash. (4) Adequate sedation and analgesia is important to prevent stress responses and immunosuppression in intubated patients.

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