DON’T VACILLATE, VENTILATE
DR JUDITH KILLEN
WAGGA WAGGA RURAL REFERRAL HOSPITAL
DON’T VACILLATE, VENTILATE
DR JUDITH KILLEN
WAGGA WAGGA RURAL REFERRAL HOSPITAL
WHY WE HAVE INTENSIVE CARE
• Intensive nursing care
• Advanced ventilatory monitoring & support
• Advanced haemodynamic monitoring and support
• Emergency renal dialysis & haemofiltration
FAILURE OF EXTUBATION
• The decision to ventilate can be thought of as a prediction of failure of extubation
• We have expanding data bases of the size of the issue from closed claim sources, studies such as NAP4, and maternal mortality analyses
AWAKE, BREATHING, PAIN FREE
GENERAL PREOPERATIVE ASSESSMENT
• Nutrition (albumin, urea, white cell count red cell morphology)
• Pre-existing disease – COPD, CCF, liver failure, neurological disease
• Age
• Obesity, OSA
DOES THE PATIENT CONSENT TO POST OPERATIVE VENTILATION?
• Hard to ask once the patient is anaesthetised.
• May not be possible to ask
• Ask about existing forward directives
• Involve family if possible
FORWARD DIRECTIVE
IS THE UPPER AIRWAY PATENT?
• Allergy
• Infection – bacterial or viral eg epiglottitis, croup, quinsy
• Burns – thermal or chemical
• Neoplasm
• Trauma including spinal cord injury
• Swelling associated with the surgical procedure
STARTING FROM THE TOP
AN OBSTRUCTED UPPER AIRWAY
PRE EXISTING UPPER AIRWAY ISSUES
• Obesity
• Obstructive sleep apnoea
• Abnormal anatomy (treacher collins etc)
• Radiotherapy
• Rheumatoid
RADIATION THERAPY
THE GLOTTIS
• Laryngospasm
• Vocal cord paralysis
• Extrinsic compression
VOCAL CORD PARALYSIS
IS THE PATIENT ABLE TO PROTECT THEIR AIRWAY?
• Vocal cord paralysis
• Cough strength
• Secretions
• Bleeding
• Residual paralysis
HAEMATOMA ANTERIOR TO CERVICAL SPINE
CHEST TRAUMA
• Rib fractures
• Pneumothorax
• Haemothorax
• Lung contusion
CHEST WALL INTEGRITY
LUNG INTEGRITY
• Chronic lung disease
• Heart failure
• Infection
• Trauma
COPD / CCF
EMPHYSEMA
BAD COMBINATIONS
• Inadequate respiratory function and thoracic or subdiaphragmatic surgery
• Neck brace plus laparotomy
• Neurological disease plus surgery
IDENTIFIED RISK FACTORS FOR FAILED EXTUBATION
• Age
• Frailty
• Obesity
• OSA
• Delerium
• Haemodynamic instability
• CCF
?AN INCREASING OR DECREASING PROBLEM
EVACUATION
• Children
• Burns
• Spinal Injuries
• For treatments unavailable in your institution such as ECMO
NOT SUITABLE FOR REGIONAL ICU!
PACKAGE YOUR PATIENT
• It may be easier to put lines in in the OR
• What lines are needed?
THANKYOU! & GOODLUCK!