post-intubation
Table of Contents
Mx of the newly intubated patient in ED - post-intubation
immediate tasks
- initial confirmation of successful intubation of the trachea
- end-tidal CO2 (EtCO2) determination (either colorimetric or quantitative) is the most accurate means of confirming ETT placement in most circumstances and should be used for every intubation
- EtCO2 methods may not be useful in patients in cardiac arrest if CO2 is not detected
- traditional clinical indicators as below cannot be relied upon alone:
- visualization of the ETT through the cords
- misting of the tube with ventilation
- auscultation of breath sounds over the lung fields
- check that ETT has not been inserted too far and has gone into R main bronchus:
- most adults should have a lip level of ~21cm
- check for breath sounds on L chest
- CXR confirmation once NGT has been placed
- inflate ETT cuff
- check cuff pressure and ensure no air leak
- ventilate patient
- initially via bag unless ventilator has been set up prior
- secure tube
- commence ongoing sedation infusion
- consider longer acting muscle relaxant
- place nasogastric tube
- CXR to confirm ETT depth, NGT position and evidence of pneumothorax or aspiration
- blood gases to confirm adequate ventilation
hypotension post-intubation
aetiology
- persisting hypotension from induction agents
- Rx with iv fluids, consider metaraminol (Aramine) 0.5mg iv doses
- hypotensive effect of sedative infusion
- consider changing from propofol to morphine/midazolam
-
- paralysis is often followed by a period of hypotension, consider iv fluid bolus +/- metaraminol (Aramine)
- reduced venous return from mechanical ventilation
- check airway pressures and PEEP
- patients with obstructive airways disease such as asthma need prolonged expiratory phase and slow respiratory rate to avoid excessive pressures do not cause impaired venous return and asystole
- tension pneumothorax due to mechanical ventilation
- reduced venous return from intra-abdominal gas due to BVM ventilation or ETT cuff failure
- ensure NGT is placed, draining and correctly position in stomach
- re-check ETT cuff for air leak
- underlying hypovolaemia
- give iv fluids, or if blood loss, give blood transfusion
- cardiac ischaemia
- depletion of endogenous catecholamines in the critically ill patient
- commence inotropes such as noradrenaline / norepinephrine
- could it be due to underlying disease process causing the shocked hypotensive patient
declining oxygen saturation
- re-check ETT placement
- check EtCO2 trace and level
- re-check ETT depth
- re-check ETT cuff air leak
- abrupt changes in the airway pressure in a patient receiving volume limited ventilation, or in tidal volumes in a patient receiving pressure limited ventilation, should prompt an immediate search for a cause of an acute change in compliance
- is the endotracheal tube obstructed
- suction it
- is there a tension pneumothorax caused by mechanical ventilation
- is there a tense air-filled abdomen splinting the chest
- ensure NGT position, draining and no air leaks from ETT cuff
- is patient fighting against ventilation
- ensure adequate sedation +/- paralysis
- when in doubt, take patient off ventilator and hand ventilate with bag to better assess situation
- those with bronchospasm need this treated
- nebulisers
- ensure prolonged expiratory phase and slow resp. rate
- see also: managing ventilator problems
Mx of the ventilated patient
- ongoing sedation infusion
- eg. morphine/midazolam infusion or propofol infusion
- consider longer acting muscle relaxant
- neuro-muscular blockers such as bolus dose vecuronium 10mg for adults
- consider particularly prior to inter-hospital transfer
- lung protective ventilator settings
- most now recommend initial tidal volumes of 8ml/kg ideal body weight for height
- for average height 5'7“ man, this is 550ml (700ml if 6'4”)
- for average height 5'5“ woman, this is 480ml (390ml if 5'2” or 550ml if 5'10“)
- if using Pressure Support Ventilation (PSV) then aim for plateau pressure - PPlat <30 cmH2O
- head up 30-45°
- warmed humidified air (HME filter)
- suction including mouth
- at least hourly
- stress ulcer prevention
- DVT prophylaxis
- treat underlying illness
- eg. nebulisers if asthma/exacerbation COPD
post-intubation.txt · Last modified: 2016/03/27 22:14 by 127.0.0.1