immediate post-intubation care for critically ill covid-19 ... · immediate post-intubation care...
TRANSCRIPT
![Page 1: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/1.jpg)
Immediate Post-Intubation Care for Critically Ill COVID-19 Patients
Idris Chikophe
Anesthesiologist & Critical Care Practitioner
17TH April 2020
![Page 2: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/2.jpg)
What Could Go Wrong Immediately After Intubation?
• Desaturation • Hypotension
![Page 3: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/3.jpg)
Desaturation: Functional Reserve
![Page 4: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/4.jpg)
Desaturation: Functional Reserve
• P: Ratio & Shunt Fraction
• 400 - 500 mmHg -> 2-3%
• 300 - 399 mmHg -> 7-10%
• 200 - 299 mmHg ->10-20%
• 100 - 199 mmHg ->20-40%
• <99 mmHg -> >40%
![Page 5: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/5.jpg)
Desaturation: Mechanisms of Hypoxemia
• Poor functional reserve
• No bagging approach Time to Hemoglobin Desaturation
COVID-19
![Page 6: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/6.jpg)
Desaturation: Mechanisms of Hypoxemia
• Atelectasis
• Supine position & FRC
• Muscle relaxants & FRC
• Difficult Airway
• Esophageal intubation
![Page 7: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/7.jpg)
Dealing With Desaturation
• Start ventilation with FiO2 100%
• Check for chest rise
• Capnography?
• Suction?
![Page 8: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/8.jpg)
Informal Lung Recruitment Maneuver & and Initial PEEP Selection
• Initial Ventilation with a high transpulmonary pressure
Initial PEEP2 cmH2O above upper P flex
![Page 9: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/9.jpg)
Optimum PEEP
• Gives:• The best oxygenation (best shunt
reduction)
• Minimum dead space
• The best lung compliance
• Without adverse cardiopulmonary effects • Hypotension
• Acute LV Failure
![Page 10: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/10.jpg)
Optimum PEEP
![Page 11: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/11.jpg)
Optimum PEEP
![Page 12: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/12.jpg)
Hypotension
• Resulting from:
• Vasodilation & Myocardial depression from induction agents
• Pre-existing hypovolemia
• Septic shock
• Myocarditis
• Adverse cardiopulmonary interactions
• Dealing with Hypotension• 4 cc/kg of RL• Any of:
• Adrenaline 100 mcg• Phenylephrine 5 mcg/kg• Ephedrine 3 mg• May be repeated every 5 minutes• Remember to set NIBP cycling at 3
minutes initially
• Noradrenaline (long term)
![Page 13: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/13.jpg)
Dealing with Hypotension
• Check tidal volume
• Check PEEP/ auto-PEEP
• POCUS
![Page 14: Immediate Post-Intubation Care for Critically Ill COVID-19 ... · Immediate Post-Intubation Care for Critically Ill COVID-19 Patients Idris Chikophe Anesthesiologist & Critical Care](https://reader033.vdocument.in/reader033/viewer/2022060603/6058104d36faba01a402fd44/html5/thumbnails/14.jpg)
• The end……..