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Slide Notes

Does your sick patient require intubation? Protecting their airway requires more than skill with the mechanics of intubation, It requires understanding the physiology of critically ill patients and how it intersects with intubation and mechanical ventilation.

The HOV mnemonic
-Hypotension
-Oxygenation (hypoxia)
-Ventilation (pH)

is a simple way to organize key concepts & skills you need when intubating a critically ill patient.

Review these slides and then ask yourself next time you intubate a sick patient, "are you driving in the HOV lane?"

Is Your Patient in the HOV Lane? Avoid disaster after intubating the critically ill patient.

Published at Dec 20, 2015
Critically ill physiology combined with endotracheal intubation can be a recipe for disaster. Focusing only on the mechanics of intubation and failing to prepare for the effects it will have is heading down a dangerous road. The HOV mnemonic -- Hemodynamics, Oxygenation, Ventilation (pH) is a simple way to organize key concepts and skills needed to intubate a sick patient safely. So be prepared, and next shift ask yourself, "is my patient in the HOV lane?"

PRESENTATION OUTLINE

In the HOV Lane

  • Avoid
Does your sick patient require intubation? Protecting their airway requires more than skill with the mechanics of intubation, It requires understanding the physiology of critically ill patients and how it intersects with intubation and mechanical ventilation.

The HOV mnemonic
-Hypotension
-Oxygenation (hypoxia)
-Ventilation (pH)

is a simple way to organize key concepts & skills you need when intubating a critically ill patient.

Review these slides and then ask yourself next time you intubate a sick patient, "are you driving in the HOV lane?"

Resuscitation

Intubation!

before
Photo by augschburger

Be Prepared

  • Avoid
Sick patients have a high mortality during the peri-intubation period. Endotracheal intubation can be a lifesaving procedure, but the process of intubation and the mechanics of positive pressure ventilation can negatively impact the physiology of the critically ill in three major ways:

-Hemodynamics&Hypotension
-Oxygenation (Hypoxia)
-Ventilation (pH disorders)

The ACTION PLAN
Don't turn a problem into a disaster. Decide if your patient is in one or more of these HOV lanes BEFORE you intubate and be prepared.

Hypotension

    Critically ill patients are often in some form of decompensated shock.

    Intubation and positive pressure ventilation can cause:

    -Elevated intra-thoracic pressure
    - insufficient venous return
    - reduced catecholamines & loss of vascular tone.

    All of which can contribute to significant hypotension.
    Photo by GonchoA

    Fluids

      The ACTION PLAN for Hypotension

      PREVENT intubation-related hypotension by initiating IV fluids prior to the procedure.

      Give 1-2L Normal Saline or Lactated Ringers to assess fluid responsiveness.

      Summary
      Isotonic fluids are a mainstay of treatment for the sick intubated and hypotensive patient. Anyone not already showing signs of hypervolemia will likely benefit from starting fluids early (prior to intubation)
      Photo by Vermin Inc

      Obstruction

        The ACTION PLAN for Hypotension

        START "low & slow" (6cc/kg and low peep)
        AVOID breath stacking
        REDUCE the respiratory rate


        Summary
        Changing from negative to positive pressure ventilation elevates intra-thoracic pressure and reduces venous return.

        Avoid breath stacking and increases in intrinsic PEEP in your obstructive lung disease patients all contribute to hypotension


        -
        Photo by Vvillamon

        Pressors

          The ACTION PLAN for Hypotension

          Have PUSH DOSE EPI at the bedside peri-intubation.

          START Vasopressors before intubation.

          Summary
          Sedation during intubation blunts endogenous catecholamines and reduces vascular tone.

          Induction Agent

            The ACTION PLAN:
            for Hypotension

            Summary
            Reduce induction agent by 50% in shock patient.
            To avoid worsening hemodynamics, use lower doses than usual, regardless of the agent used The dose of any induction agent is more important than the choice of the agent.
            Photo by kevin.hackert

            Oxygenation

              Respiratory failure related to acute hypoxia is caused by fluid (pus, blood, edema) causing shunting of blood and hypoxemia despite 100% FiO2 inspiration.

              Intubating a critically hypoxic patient can transiently worsen atelectasis and alveolar recruitment making the hypoxia worse.

              PEEP

                The ACTION PLAN for Oxygenation

                Assist control mode—volume ventilation

                Begin with tidal volumes 6-8mL/kg & PEEP at 5cm H2O, FiO2 100%

                Increase PEEP by 3-5cm H2O every 2-3minutes to achieve goal oxygen saturation >90%

                LIMIT Plateau Pressure (Pplat) to <30cmH2O Maintain SaO2/SpO2 88%–95% (tidal volume may need to be decreased)

                Summary
                Increasing PEEP enhances alveolar ventilation and recruitment of atelectatic portions of the lung, minimizing V/Q mismatch.
                Photo by wwarby

                Synchrony

                Improve Patient/Ventilator
                The ACTION PLAN for Oxygenation

                Give your patient adequate analgesia and sedation to optimize your lung protective strategy.

                An agitated patient on the vent is an over breathing, and coughing patient Attempting to breath out of sync with the vent will negate any effect increasing PEEP may have.

                Ventilation

                pH & Respiratory Acidosis
                So you placed your endotracheal tube successfully. Five minutes later your patient seizes, develops increasing tachycardia; followed by abrupt bradycardia and subsequent arrest.

                What happened? Worsening acidemia from insufficient ventilation during and after intubation.

                Was your patient tachypneic, prior to intubation? If your patient is compensating for a metabolic acidemia, then your patient is in the HOV LANE and taking away their respiratory drive just made things worse. Here's what to do:
                Photo by garrettc

                Apnea

                Minimize
                The ACTION PLAN for Ventilation

                Attempt to minimize apnea time during intubation. Should be performed by most experienced operator.

                Consider NIV and pressure support during RSI.

                Summary
                Even with the smoothest intubation you've taken away your patient's ability to compensate for their metabolic acidosis and need to compensate for them.

                Imagine sprinting a hundred yards and then being asked t hold your breath for two minutes. Now imagine the metabolic demands on your sick patient.

                Respiratory Rate

                Increase
                The ACTION PLAN for Ventilation

                Once intubated immediately start good ventilatory support with the BVM. Give 20-30 good breaths the first minute before switching to the ventilator.

                Note your patients RR and work of breathing prior to intubation, and match that rate or better after intubation.

                Check an ABG within 5 minutes of intubation.

                Summary
                You've minimized the apnea during the intubation. But you still have to breath for them.

                The HOV Lane

                Now Your Prepared for
                Protecting the airway involves more than just the mechanics of intubation: it requires an understanding of the physiology of your critically ill patient, and preparation for the common hemodynamic, oxygenation and ventilatory consequences of (what is meant to be) a lifesaving procedure.

                Drive Safely

                Now that your ready to deal with Hypotension, Oxygenation issues, and Ventilatory related acidemia (HOV) you can "stay out of the HOV lane" and avoid turning a problem into a disaster.


                Reference
                http://www.ncbi.nlm.nih.gov/pubmed/19464138

                Protected Airway Series

                Part of the
                https://emberproject.org/airway/