Approach to the patient requiring intubation at Elmhurst (as of 4/4/2020)
By Charles Du
Pre-intubation:
- Page respiratory therapy: amion login: EHC. Ask them to bring a vent, suction, intubation tray.
- Page anesthesia (amion), tell them last K.
- Place transfer order in Epic to ICU/step down bed. Call bedboard x45245 to inquire about bed availability. If no beds, call crit care consult fellow (amion) to help find a bed.
Order:
- Fentanyl continuous (not titrated) @150 mcg/hr
- Midazolam continuous @ 2 mg/hr. If Elmhurst is out of midazolam, can use propofol continuous @ 30mcg/kg/min.
- Norepinephrine titrated 1-30 mcg/min starting at 5 mcg/min (on standby)
- 1L LR (free-flowing, on standby)
Getting Ready:
- Ask one RN to get everything ready but the fentanyl, ask a second RN to pick up the fentanyl from the basement pharmacy (MD’s cannot pick up fentanyl).
- Place patient on telemetry (portable monitor if tele not available), continuous pulse ox, BP cuff on.
- If patient on the floors, ask RN to call RRT (NPs) for backup.
- Ensure patient has 2 working PIVs. Set up 2 suctions.
- Calculate patient’s IBW and multiply by 6 for LTVV (6cc/kg). Note patient’s weight if dosing propofol.
Post-intubation:
- Leave patient on FiO2 100%. Increase PEEP as needed if hypoxemic.
- Ask RNs to start sedative drips. May need to uptitrate sedation and start fluid / pressors following intubation, see Elmhurst management guide for further information.
Patient transport:
Patients at Elmhurst are not transported on ventilators, nor are there portable ventilators available. Therefore, the patient must be bagged during transport.
- Page respiratory therapy to accompany transport, ask for Ambu bag with PEEP valve and HEPA filter. ARDS patients oxygenate poorly with 0 PEEP.**
- Call for transport and make sure they have the elevator ready (protocol for transporting COVID patients)
- Maintain sedation running. Make sure IVs don’t get ripped out during transport or the patient will wake up.