Approach to the patient requiring intubation at Elmhurst (as of 4/4/2020)
By Charles Du
- 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.
- 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)
- 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.
- 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.
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.