- Post-Intubation Hypotension: 15% higher in-hospital mortality
- Predictors:
- Pre-intubation shock index (SI ≥ 0.8)*
- Chronic renal disease
- Intubation for acute respiratory failure
- Predictors:
- Push-dose (Bolus-Dose) Pressors:
- Supportive bridge in selected patients:
- Peri-intubation hypotension
- Procedural sedation
- Transporting long-distances from the ED
- Push-dose Pressor Options
- Phenylephrine in pre-mixed “STICK” (most common – be careful in brain injured or heart failure patients)
- Epinephrine – will need to mix yourself
- Supportive bridge in selected patients:
- Pre-oxygenation: Rule of 15’s: Preoxygenation
- Position: Head of bed @ > 15º
- Non-rebreather mask @ 15 L / min
- Nasal cannula @ 15 L / min
- CPAP / BVM + PEEP valve @ 15 cm H2O
- Delayed sequence intubation (DSI) Overview
- “A procedural sedation, where the procedure is pre-oxygenation”
- Basics: Delirious patient with hypoxia -> ketamine 1-2 mg/kg IV -> Preoxygenate (Preferably with CPAP/BiPAP) -> Wait 2 to 3 minutes -> Administer paralytic -> Wait 45 to 60 seconds -> Intubate
- DSI: Safe Apnea
- Safe Apnea = Duration of apnea until a patient reaches a saturation of 88-90%
- Patients with increased metabolic demands and shunting desaturate faster.
- DSI: Who might benefit from it? Patients with vital signs that are unobtainable, or unacceptable:
- “Good Lungs, Bad Brains”: Agitated head injury / ETOH / Psych
- Bad Lungs: Hypoxic COPD, Pneumonia, ARDS
- Apneic Oxygenation:
- Alveoli continue to take up oxygen even without ventilation
- Keep Nasal Cannula in place at 15 L/min during intubation attempt(s) to further prolong duration of safe apnea