Post-Intubation Package Checklist As heard on emcrit org



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Post-Intubation Package Checklist

As heard on EMCrit.org




Quick Checklist

  • Waveform Capnography

  • Secure the Tube Well

  • Confirm Lung Protective Vent Settings

  • Achieve Adequate Analgesia and Sedation

  • Raise the Head of the Bed to 30 - 45°

  • Humidify the Air

  • Place In-Line Suction

  • Gastric Tube

  • Cuff Pressure

  • Nebulizers/MDI

  • Prevent Aspiration past the Cuff of the ETT

  • Get a Blood Gas

  • Check Tube Depth

  • Put a BVM at the Bedside ± PEEP Valve

  • Have a Plan for Vent Alarms


Optional

  • Stress Ulcer and DVT Prophylaxis

  • Oral Decontamination


Waveform Capnography

  • Confirms tube placement.

  • Shows tube dislodgement long before O2 saturation falls.

  • Place adapter on the vent side of the HME to protect from moisture.


Secure the Tube Well


Confirm Lung Protective Vent Settings

  • Mode – Assist Control

  • Tidal Volume (Vt) – 6 to 8 cc/kg of ideal body weight.

  • Flow Rate (IFR) – 60 to 80 L/min.

  • Rate (RR) – initially 18, adjust based on CO2 and ventilatory needs.

  • FiO2/PEEP

  • Start at 100% and PEEP of 0 or 5.

  • Wait 5 minutes and then draw an ABG.

  • Then set the FiO2 to 30% and start titrating based on the chart. Go up every 5-10 minutes; quicker if low sats.

      • OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 90-95%

      • Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP combinations such as shown below (not required) to achieve goal.

Lower PEEP/higher FiO2


FiO2

0.3

0.4

0.4

0.5

0.5

0.6

0.7

PEEP

5

5

8

8

10

10

10

FiO2

0.7

0.7

0.8

0.9

0.9

0.9

1.0

PEEP

12

14

14

14

16

18

18-24




  • Check Plateau Pressure

Plateau pressure must be maintained <30 cm H20. Keep lowering the Vt until Plat <30. You may need to go as low as 4 cc/kg.
Achieve Adequate Analgesia and Sedation

Concentration – 1000 mcg in 100 ml D5W or NS (10 mcg/ml)

Starting Dose – 25 mcg/hr

Maintenance Dose – 25 to 150 mcg/hr (Max: 150 mcg/hr)

Titration Dose



        • If above pain or below sedation targets, give 25 mcg IV push over 3 to 5 min and increase infusion rate by 25 mcg/hr, q15 min.

Tapering Dose

        • If above sedation and at or below pain targets, decrease infusion rate by 25 mcg/hr, q 1 hr.

        • If at sedation and at or below pain targets, decrease infusion by 10 mcg/hr, q1h.

        • After interruption, resume at 10 mcg/hr less than previous dose.




  • Morphine Protocol

Concentration - 100 mg in 100mL in NS or D5W (1 mg/ml)

Starting Dose – 0.8 to 10 mg/hr

Maintenance Dose – 0.8 to 150 mg/hr

Titration Dose



  • When pain score is above target or sedation score is below target, you may push 2 mg of morphine over 4-5 mins & increase rate by 2 mg/hr, q 5 mins.

Tapering Dose

  • When sedation score is above target and if pain score is below target, decrease the infusion rate by 2 mg/hr.

  • When sedation score is at target and pain score is below target, decrease the infusion rate by 0.5 mg/hr increments.


Raise the Head of the Bed to 30 - 45°

  • Helps improve lung mechanics.



Humidify the Air

  • Either with a humidification circuit on the vent or a Heat-Moisture Exchanger (HME)


Place In-Line Suction

  • In lieu of In-Line Suction, may use intermittent suction under sterile technique

  • Suction the mouth each time you suction the tube as well


Gastric Tube

  • Empty the stomach to reduce the chances of aspiration


Cuff Pressure

  • The ideal pressure is between 20-30 cm H20.

  • Use a cuffalator.


Nebulizers/MDI

  • If they were intubated for reactive airway disease, then they need frequent nebs. Make sure to remove the HME for nebulizer or MDI treatments.


Prevent Aspiration past the Cuff of the ETT


Get a Blood Gas

  • Arterial or venous.

  • Maintain a sat between 90-95%.


Check Tube Depth

  • Start with 21 cm for women and 23 cm for men.

  • Adjust based on size obviously.

  • Get an ultrasound and/or X-ray.

  • When getting an x-ray make sure the head is in a neutral vertical position (remember the tube follows the nose, nose down-tube deep).


Put a BVM at the Bedside ± PEEP Valve

  • If using PEEP on the vent, use the PEEP valve when bagging the patient.

  • Put the mask on the O2 tubing.


Have a Plan for Vent Alarms

  • Treat them like a cardiac arrest announced overhead.


Stress Ulcer and DVT Prophylaxis

  • Have an institutional plan for which meds and when


Oral Decontamination

  • Chlorhexidine oral swabs



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