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Airway Management For Intubated Patients in the PICU/CICUStandard Work Modified: December 2015Owner(s): William Harmon, Tim Hicks, Barbara CastroPerformed By: PICU/CICU and Anesthesia Teams Version: 2.1Revised by: Harmon/LeeTrigger: Admission/Ongoing Care of an Intubated Patient in the PICU/CICUScope: Addresses ETT Securement and Sedation Standards for intubated patients in the PICU/CICU Maintaining a secure airway is a primary focus for all intubated patients. Note that the time surrounding PICU admission is a high-risk period for airway loss. Confirmation of ETT position, secure placement and clarification of airway concerns must be focus of any team handoff and initial plan of care. ALL TEAM MEMBERS (LIP, RN, RT, House Staff) ARE EMPOWERED TO RAISE AN ALERT AND TO HALT ANY PATIENT ACTIVITY IF THE AIRWAY HAS YET TO BE EVALUATED AND SECURED, OR IF IT IS POORLY SECURED.LIPs and RTs will follow established pediatric ETT securement techniques as described in Respiratory Therapy Care Guideline # 211. This mandates the hands-on presence of 2 airway-focused providers when securing/retaping an endotracheal tube. The broad team is empowered to halt the procedure if the 2-person standard is not being followed. If the patient has a critical airway then refer to and follow the “PICU Critical Airway Practice Guideline.”For Newly Admitted / Newly Intubated Patients: A portable chest X-ray will be ordered and called for when the OR to PICU page is received for CICU patients, or immediately upon PICU arrival/intubation for all other patients. When the CXR is taken the ETT position will be immediately evaluated by an LIP and confirmed with the RN/RT team. ETT tip position will be targeted to mid to lower third portion of the trachea. All endotracheal tubes will be secured per unit standards, by default, in all patients unless it is agreed that immediate extubation (within 15 minutes) is planned after evaluating the patient’s extubation readiness. For OR cases and newly admitted patients, a transitional sedation plan will be discussed during patient handoff. Short term Propofol, paralytic, or other appropriate bolus sedation will be utilized until sedation drips are available at the bedside and titrated to effect.The use of muscle relaxation (rocuronium IV 0.6 mg/kg), after assuring full mechanical ventilatory support and appropriate sedation/analgesia, is the PICU/PCICU standard prior to re-securing or repositioning the endotracheal tube during this transitional phase. If there is a reason to not provide muscle relaxation, document a care note in the chart.Established Patients:Endotracheal tube securement should be evaluated by both RTs and RNs as part of daily safety checks.A daily morning chest x-ray will be obtained for all intubated patients and reviewed by the overnight team. If repositioning is required the LIP will immediate notify the RT/RN team using closed loop communication.The PICU sedation protocol should be used by default for intubated patients. This provides titration of morphine/versed infusions per sedation score targeted to 2 or less, depending on the clinical situation. Other sedation agents may be used as clinically appropriate with the same sedation score targets. Prior to ETT re-securement or repositioning assess the patient’s sedation score and clinical status. Strongly consider the use of muscle relaxation (bolus Rocuronium or Cisatracurium) after assuring full ventilator support. Capnography with waveform analysis remains the gold-standard for assessing airway patency and correct ETT placement. As such, capnography will be available for all intubated patients. Colorimetric ETC02 detection is less reliable and can provide both false positive and false negative results. Anesthesiology will be immediately paged for backup support (PIC # 1311) in the event of airway loss (or concern thereof) in an acute postoperative patient (CICU or PICU services). Anesthesia back-up support is always available at the discretion of the PICU physician. ................
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