terminal extubation

Question 1

Key components of GOC talk with vent w/d

Answer 1

• cover initiation and what would lead to stopping
• touch base w/ all consultants on prognosis
• SPIKES protocol for family meeting
• Opinion on reintubation
• desire to continue other interventions
• often a terminal event

Question 2

SPIKES protocol

Answer 2

• Setting
• Perception -what do they think is happening
• Invitation -what do they want to knoe
• Knowledge -of disease and care options
• Emotion- respond
• Summarize

Question 3

Family participation acts to encourage

Answer 3

• items from home
• grooming patient
• communication w/ pt
• touching patient
• postmortom care
• religious ritual preferences

Question 4

Med: Laryngeal edema

Answer 4

methylprednisolone 60mg IV x1 day prior to extubation

Question 5

Three classes of meds to have at bedside at time of extubation

Answer 5

opioids, sedatives, anticholinergics

Question 6

Med/Opioid V W/D PCA

Answer 6

Ensure good symptom control and continue same opioid. Ensure enough is available

Question 7

Med V W/D no PCA opiate use

Answer 7

3-5 preloaded syringes of:
* morphine 2-10mg
* fentanyl 25-50mcg

Question 8

Sedative in MV W/D

Answer 8

• if sedated on vent- continue current med
• if on a paralytic discontinue
• if conscious- give sedative to reduce panic/distress
• higher doses in hx of benzo use or alochol use

Question 9

MV W/D sedative meds

Answer 9

3-5 preloaded syringes (order of preference):
* Midazolam 0.2mg/kg
* lorazepam 1-2mg
* pentobarbital 1-2mg/kg

Question 10

MV w/d Anticholinergic

Answer 10

2-3 preloaded syringes of glycopyrrolate 0.2-0.8mg

Question 11

MV W/D Prep Steps

Answer 11

1. stop HD, Tube feeds, paralytics, pressor, abx, fluids, ICD hours before
2. reinforce education that w/d is not cause of death, the disease is
3. contact SW/chaplain
4. RT at bedside
5. RN at bedside and remove restraints
6. Maintain 1 IV access

Question 12

Extubation procedure steps

Answer 12

1. Glyco 0.4mg IV q60min or more prior to extubation
2. IV opioid and sedative 15 min prior to extubation- absent eyelid reflex
3. titrate to comfort with q10 min bolus for IV and q30 min for SC dosing
4. titrate vent settings
5. post ETT removal protocol

Question 13

Vent titration protocol

Answer 13

If symptoms occur, return to prior tolerated settings
1. turn off all alarms
2. towl on chest
3. decrease FIO2 to 21% (room air)
4. turn off PEEP
5. suction ETT
6. remove ETT, deflate cuff, and remove ETT

Question 14

Immediate post ETT protocol

Answer 14

1. suction oropharynx
2. wipe mouth
3. semi recumbent, lateral position
4. NC for cupplimental O2 if requested or medically appropriate

Question 15

Goal vitals post extubation

Answer 15

RR<30
HR <100
Reduced signs of distress:
* grimace
* fear
* agitation
* increased secretions
* accessory muscle use
* nasal flaring
* grunting

Question 16

MV W/D stridor management

Answer 16

racemic epi 2.25% 0.5ml nebulized q3-4 hr prn
monitor for rebound
methylprednisolone use