Sedation hold algorithm 2

[Pages:5] Every 24 hours

Restart sedatives at 1/2 dose and titrate to RASS

prescribed

Reinstitute previous ventilatory support

- Sedation bolus

- Period of

mandatory ventilation

- May need bolus

NMB to gain control and rerecruit

- Catch up NG

feed

Sedation Hold Algorithm COVID 19

SAT Safety screen

Fail

Physiotherapy

Perform SAT

Fail

Pass if eyes

open to voice

SBT Safety screen

Fail

Perform SBT

SAT SAFETY SCREEN No agitation No muscle relaxants HR < 100 BPM (sinus rythm) Noradrenaline < 10ml/hr (4/50) Suitable for spontaneous mode of ventilation (>12 hours with):

- Plateau pressure < 30cmH20 - DeltaP (Pmax-PEEP) < 15 - FiO2 < 50%

SAT CONSIDERATIONS Availability of personnel

Grade of intubation (if Grade 3 or more ensure airway doctor aware)

Suitability for SBT (see SBT safety screen)

SAT FAILURE Anxiety, agitation or pain

Respiratory rate > 35/min

Oxygen saturation < 88%

Respiratory distress

Cardiac arrhythmia

SBT SAFETY SCREEN Oxygen saturation 88%

FiO2 50%

PEEP 8-10 cmH2O

Established on spontaneous mode

HR < 100 bpm

Noradrenaline 10ml/hr (4/50)

No agitation / obeys commands

Is clinical team aware?

Fail

SBT CONSIDERATIONS

Pass if manages

Availability of personnel

30-60 minutes

Equipment for extubation or re-

intubation

PSV 5/PEEP on PSV

Consider

extubation

? Cough strength

? Sputum load

? Risk of

supraglottic

oedema

? Conscious level

? Ease of re-

intubation

? RR/Vt < 105

? NG feed stopped

during SBT

SBT FAILURE Respiratory rate > 35/min

Respiratory < 8/min

SaO2 < 88%

Respiratory distress

Mental status change

HR increase by 25% or rhythm change

RR/Vt (RSBI) > 105 min/L

Extubation Algorithm COVID 19

Re-recruit on

YES

NO

Has the patient

ventilator for 1 hour.

passed a SBT?

REF A

Prepare for extubation.

REF B

Medical team agree extubation appropriate

YES

Passed SBT with SPONT mode setting of Pi 5 PEEP 5 with FiO2 < 30%

- Switch ventilator into

standby mode just prior to extubation or put patient on Water's Circuit

- Extubate on peak

inspiration and quickly apply facemask to catch any droplets

- Extubate onto

Hudson mask 6-8L/ min flow rate

- Re-assess in 30

mins time

- If RR < 20 and SaO2

94-98% decrease flow rate by 2L/min

- Once < 4L/min

switch to nasal cannula with surgical mask unless 2 x negative swabs

Passed SBT with SPONT mode setting of Pi5 PEEP

5-10

- Switch ventilator into

standby mode just prior to extubation or put patient on Water's Circuit

- Extubate on peak

inspiration and quickly apply facemask to catch any droplets

- Extubate onto non-

rebreathe mask with flow rate of 10L/min

- As soon as possible

following extubation commence on CPAP hood using CPAP valve 10cmH20

- Review in 6 hours

and reduce CPAP valve by 2,5cm H20

- Do not reduce CPAP

after 20:00

- Further reductions to

be guided by the clinical team

REF C

Postextubation care

- Assess cough

strength, stridor and voice

- Swallow assessment

- Delirium assessment

and re-orientation

- Continue to wean

oxygen as able

- Discharge planning

Passed SBT with SPONT mode setting of Pi5 PEEP 10-15

- Switch ventilator into

standby mode just prior to extubation or put patient on Water's Circuit

- Extubate on peak

inspiration and quickly apply facemask to catch any droplets

- Extubate onto non-

rebreathe mask with flow rate of 10L/min

- As soon as possible

following extubation commence on CPAP hood using CPAP valve 10cmH20

- Review in 6 hours

and reduce CPAP valve by 2,5cm H20

- Do not reduce CPAP

after 20:00

- Further reductions to

be guided by the

REF C

REF A

Ventilator re-recruitment:

- Use spontaneous mode.

- Pi 20cmH20

- Use patient maintenance PEEP value

- Small bolus of short acting sedation (propofol and alfentanil) infusion may be required.

REF B

Steps to take prior to extubation

- Nursing team in pod aware

- Airway doctor informed

- Aspirate NG tube

- Oxgen delivery equipment checked and ready

- Pre-oxygenate with 100% O2 for at least 3 minutes

- Suction applied through ETT and to oropharynx

- Sub-glottic suction port aspirated

- Consider switching to Water's Circuit to avoid excessive aerosolisation on tube removal

- Deflate pilot balloon slowly

If you are unsure at any point please STOP and ask a trained member of staff

REF C

Quick Reference Guide for CPAP Hood use with the FD140

Equipment Needed 1. StarMed hood labelled NIV (NOT CPAP) Select helmet ? measure around neck and these are the sizes below ? X Small 17-27cm ? Small 27-34cm ? Medium 34-41cm ? Large 41-47 cm ? X Large 47-52cm ? XXX Large 52-60cm 2. 1 X yellow clear guard filter 3. Armstrong CPAP system, HOOD ? contains 5cmH2O PEEP valve,

FD 140 SeSngs ? Turn on FD140 ? Select Helmet (screen will turn green) ? Select flow 60L (reduced to 40l/min aQer hood placed on paSent) ? Select oxygen requirement (FiO2)

Flow- MINIMUM FLOW 40L PEEP 2.5,5,7.5,10 Oxygen 21%-100% Exclusion criteria Unstable C-Spine, No bone flap, or FloaSng bone flap, base of skull fracture

1. Collar with pressure

2. Place filter here

ApplicaSon of Hood

1. Select collar out of the box, a`ach clear pressure tube through green port on collar.

3&4. Connect circuit, and check anS-asphyxiaSon valve

2. Select hood and a`ach PEEP valve, connector and yellow clear guard filter to right side of hood

3. Connect tubing from FD140 to leQ side of hood

4. Check jam jar lid on hood pull blue tab to ensure movement (anS-asphyxiaSon valve), take off and replace

5&6. Ear plugs and collar

5. Place ear plugs in paSent's ears

6. Use 2 members of staff to place collar over paSents head

7. Press start on FD140 and place hood over paSents head and click into place

7. Press start and place hood over head

8. A`ach arm straps under the arm pits and Sghten

9. Use port to inflate neck support with black pump (does not affect seal purely to support neck)

9&10. Inflate neck support for comfort and Strate flow to achieve PEEP

8. A`ach arm straps and Sghten

Hood access opened

Jam Jar lid can be taken off to give medicaSon, drinks and nutriSon whilst sSll delivering high flow oxygen.

Removing jar jam lid is an AEROSAL generaVng procedure.

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