Post Intubation Checklist

Quick Checklist

• Analgesia & Sedation
• Secure the tube well (use a commercial device)
• Raise head of bed to 30-45°
• Confirm Lung Protective Vent Settings
• Humidify the air (Heat Moisture Exchanger)
• Place Inline Suction (q1h or more)
• End Tidal CO2 Monitor (Pt -> suction -> humidifer -> ETCO2 -> vent)
• Check cuff pressure (20-30 mmH20, use a cuffalator, ask resp Tx)
• Gastric Tube (NG/OG)
• Nebulizers (if any h/o asthma)
• Get an ABG (VBG? only if sat = 90-95% or FiO2 = 30%)
• Check tube depth (CXR)
• Put a BVM at the Bedside ± PEEP Valve
• Run to bed if Vent Alarms

Optional

• Stress Ulcer and DVT Prophylaxis
• Oral Decontamination

Confirm Lung Protective Vent Settings

I: VENTILATOR SETUP AND ADJUSTMENT

1. Calculate predicted body weight (PBW)
   • Males = 50 + 2.3 [height (inches) – 60]
   • Females = 45.5 + 2.3 [height (inches) -60]
2. Set ventilator mode: Assist-Control
3. Set tidal volume: 6-8 ml/kg PBW (start at 8, titrate down to 6 q2h)
4. Set rate: 18 bpm (titrate to pH)
5. Adjust VT and RR to achieve pH and plateau pressure goals below.

II: FiO₂/PEEP

1. Start at 100% and PEEP of 0 or 5.
2. Wait 5 minutes and then draw an ABG.
3. Then set the FiO2 to 30% and start titrating based on the chart. Go up every 5-10 minutes; quicker if low sats. Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP combinations such as shown below (not required) to achieve goal.

OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 90-95%

Lower PEEP/higher FiO2

FiO2	0.3	0.4	0.4	0.5	0.5	0.6	0.7
PEEP	5	5	8	8	10	10	10
FiO2	0.7	0.7	0.8	0.9	0.9	0.9	1.0
PEEP	12	14	14	14	16	18	18-24

Higher PEEP/lower FiO2

FiO2	0.3	0.3	0.3	0.3	0.3	0.4	0.4
PEEP	5	8	10	12	14	14	16
FiO2	0.5	0.5	0.5-0.8	0.8	0.9	1.0	1.0
PEEP	16	18	20	22	22	22	24

III: CHECK PLATEAU PRESSURES (Pplat < 30 cm H2o)

• Plateau pressure must be maintained <30 cm H20.
  • Keep lowering the Vt until Plat <30. You may need to go as low as 4 cc/kg
  • 0.5 second inspiratory pause
  • at least q 4h and after each change in PEEP or VT.
• If Pplat > 30 cm H2O: decrease VT by 1ml/kg steps (minimum = 4 ml/kg).
• If Pplat < 25 cm H2O and VT< 6 ml/kg, increase VT by 1 ml/kg until Pplat>25cmH2OorVT =6ml/kg.
• If Pplat < 30 and breath stacking or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O.

IV: ACIDOSIS MANAGEMENT (pH < 7.30)

• If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25 (Maximum set RR = 35).
• If pH < 7.15: Increase RR to 35. If pH remains < 7.15, VT may be increased in 1 ml/kg steps until pH > 7.15 (Pplat target of 30 may be exceeded). May give NaHCO3
• Alkalosis Management: (pH > 7.45) Decrease vent rate if possible.

Achieve Adequate Analgesia and Sedation

Fentanyl Protocol

• Concentration – 1000 mcg in 100 ml D5W or NS (10 mcg/ml)
  • Starting Dose – 25 mcg/hr
  • Maintenance Dose – 25 to 150 mcg/hr (Max: 150 mcg/hr)
• Titration Dose
  • If above pain or below sedation targets, give 25 mcg IV push over 3 to 5 min and increase infusion rate by 25 mcg/hr, q15 min.
• Tapering Dose
  • If above sedation and at or below pain targets, decrease infusion rate by 25 mcg/hr, q 1 hr.
  • If at sedation and at or below pain targets, decrease infusion by 10 mcg/hr, q1h.
  • After interruption, resume at 10 mcg/hr less than previous dose.

Morphine Protocol

• Concentration – 100 mg in 100mL in NS or D5W (1 mg/ml)
  • Starting Dose – 0.8 to 10 mg/hr
  • Maintenance Dose – 0.8 to 150 mg/hr
• Titration Dose
  • When pain score is above target or sedation score is below target, you may push 2 mg of morphine over 4-5 mins & increase rate by 2 mg/hr, q 5 mins.
• Tapering Dose
  • When sedation score is above target and if pain score is below target, decrease the infusion rate by 2 mg/hr.
  • When sedation score is at target and pain score is below target, decrease the infusion rate by 0.5 mg/hr increments.