Intubation in critical care setting

DAS guidelines for icu intubation

1. INTUBATION IN CRITICAL CARE SETTING DR.MALAKA MUNASINGHE 2018.11.29

2. 6% of ICU patients- predicted difficult airways Severe hypoxaemia ( SPO2< 80%)- 25% during ICU intubations NAP 4 STUDY - 60% of air way incidents in ICU DEATH OR PERMANENT NEUROLOGICAL INJURY

3. Increased airway difficulty in ICU??? Multifactorial!!! Patient related Environment related Staff related

4. Staff related lack of patient preparation equipment check failure protocol deviation poor decision-making loss of situation awareness Lack of experience in airway management Lack of senior help( out of hour intubations) Poor team work

5. Patient related physiologically and /or Anatomically difficult airways- burns/ cervical spine injuries Physiologically difficult airways Increased risk of aspiration Airway assessment difficult- Poor cooperation/low GCS Collars/masks Limited time

6. E nvironment related Limited access to the patient( monitors/ equipment) Monitors in head end Suboptimal lighting Access to advanced airway devices/ monitoring( Capnography/ End tidal O2) limited Complex equipment or devices - cognitive overload and poor decision making Non-availability of surgical staff

7. Predicting difficult airway in ICU Only validated assessment tool available currently- MACOCHA score SCORE 0- EASY > 3-DIFFICULT AIRWAY 2017 American Thoracic Society . De Jong et al.54 Factors Points Factors related to patient   M allampati class III or IV 5  Obstructive sleep  A pnoea syndrome 2  Reduced mobility of  C ervical spine 1  Limited mouth  O pening <3 cm 1 Factors related to pathology   C oma 1  Severe  H ypoxaemia (SpO 2  <80%) 1 Factor related to operator  Non- A naesthetist 1 Total 12

8. Difficult Airway Society( DAS) guidelines

9. DAS guidelines T eam

10. Intubation check list

11. Patient preparation

12. Preparation of equipment

13. Preparation of the team

14. Preparation for difficulty

15. Air way management plan

16. PLAN A

17. PLAN B/C

18. PLAN D

19. FRONT OF NECK ACCESS( FONA)

20. Priming of FONA G etting the FONA set to the bedside after one failed intubation attempt Opening the FONA set after one failed attempt at facemask or SGA oxygenation Immediate use of the FONA set at CICO declaration

21. ISSUES AWAKE INTUBATION in ICU? WHAT TO USE DURING INDUCTION? WHAT IS DELAYED SEQUENCE INDUCTION? Can you wake up the patient if intubation fails?

22. Post intubation Complications are common- 80% of airway problems occur after intubation Continuous monitoring continued Care of the tube/ adequate sedation/ physiotherapy CXR- to exclude endobronchial intubation/aspiration If patient haemodynamically stable but hypoxaemic - recruitment maneuvers performed

23. SUMMARY Morbidity and mortality during ICU intubations are significantly high compared to elective surgical intubations Patient related, staff and environment related factors are contributory factors Simplified, protocolized approach would reduce detrimental outcomes during these airway interventions