Post Intubation Care.Caring for the Critically Ill Downstairs.

By: Kane Guthrie

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!

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!

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!!!!!

ED Boarding!

Pt’s spending more time in ED!

Lack of higher acuity beds!

Should patient geography determine the level of care they receive?

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.

The Ventilator.

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.

Adjusting the Ventilator

A crucial component to managing the critically ill.

Our aim is to:

Limit ventilator induced lung injury.

Prevent ventilator associated pneumonia.

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.

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.

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.

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.

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.

We play a crucial role in preventing it!!

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.

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.

Sedation & Analgesia

We’re not that good at it.

74% received inadequate or no anxiolysis.

75% of patients received either inadequate or no analgesia.

Sedation and Analgesia

Poor sedation and analgesia results in:

Increased catecholamine levels

Produce immunosupression

Hypercoaguability

Myocardial ischaemia

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.

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.

Monitoring Circulation!

Monitoring the circulation system, focuses on:

1. Blood pressure.

2. Tissue perfusion.

3. Intravascular volume.

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.

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.

Intravascular Volume.

CVP unreliable is assessing fluid status & responsiveness.

Inferior vena cava assessment- using ultrasound. Full non-collapsing IVC + Pt adequately filled.

Maintaining Circulation!

Fluid resuscitate.

Maintain adequate maintenance fluids.

Remaining hypotension post this with signs of circulatory compromise?

Time for Inotropes/Vassopressors.

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

ABC Don’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.

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!

Thank-you