From Ordinary to Extraordinary - Dr. Pearson

• Post-Intubation Hypotension: 15% higher in-hospital mortality
  • Predictors:
    • Pre-intubation shock index (SI ≥ 0.8)*
    • Chronic renal disease
    • Intubation for acute respiratory failure
• 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
• 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

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