INTENSIVE CARE MEDICINE

DEPARTMENT

Intubation Protocol

September, 2023

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Patient Safety during Intubation

Introduction
As you know, we ICU nurses, doctors, and respiratory therapists work hard to keep our
patients safe by carefully monitoring them and doing our best to prevent secondary injuries.

In this video, we are going to present to you the best care practices for your patient who is
about to be intubated or extubated.

As we all know, many ICU patients get intubated. If you are assigned to care for that patient
you must be particularly aware of certain things during this critical procedure. Failure to
follow a few important things during intubation can put your patient at risk of serious injury
or even death.

Intubating your Patient

When the decision is made to intubate your patient due to impending respiratory failure or
airway protection, be sure the following items are first addressed:

Compassionate Patient Preparation

If the patient is awake and lucid, be sure a senior compassionately informs the patient about
the procedure. Give the patient a chance to ask any questions. Let the patient know that they
will not be able to speak after the intubation but that he will regain his ability to speak once
the ETT is removed. Also, inform them that the tube will come out when the original issue
has resolved.

Finally, let them know that they might have a sore throat but that too will resolve.

If the patient is anxious, be sure to calm him and assure him that he will get your best care.

Unless it is an emergency intubation and the patient’s life depends upon immediate action, be
sure an informed consent has been obtained; Show consent form

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Equipment Preparation

 Be sure that your patient’s IV cannulas are working well. (Show flushing) If the IV
does not flush well or is leaking, be sure a new line is placed.
 Be sure the suction device has strong suction. Test it yourself. (show testing of
machine)
 Be sure you have either a flexible suction catheter or a Yankauer hard tip attached to
the suction tubing. A 14 or 12 French size for adults is standard. The 16fr ones (red
hub) are usually too large and may get stuck inside an ETT. (Show difference)
 Your unit’s laryngoscope should be checked every shift to be sure it is ready any
moment. re-check it to be sure the light is bright. If it is dim, it may weak batteries or
a weak bulb. (Show strong light and weak light)

Be sure the Patient Monitor is properly displaying heart rate, saturation, and BP. Be sure the
saturation probe and ECG electrodes are producing good waveforms. (show artefact and on
sat probe, and then good waveform) If the waveforms are proper this usually means the
vital sign numbers are reliable. If the monitor is not working properly, it is important to take
the time to troubleshoot the issues.

 It is likely, the patient will get pre-oxygenated by ambu-bag and bag-valve mask. Be
sure it is connected to an oxygen source. (Show this)

The clinician who will be intubating will decide which size ETT to prepare. You may be
asked to remove it from the pack and inflate the cuff for any leaks. Occasionally, a cuff may
leak. If so, the ETT must be replaced. (show inflating cuff)

A Stylet or Bougie should also be readily available (show)

Drug Preparation

If the person who is going to intubate the patient has not prepared induction drugs, ask him
what he needs. In most setups, it will be one of the following:

 Ketamine
 Succinocholine
 Propofol
 Vercuronium
 Atropine
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  Adrenaline
You should be familiar with the following most common side effects;

Ketamine is a dissociative anesthetic can cause mild to moderate transient increases in blood
pressure, heart rate, and cardiac output. Typically dose is 1-4.5 mg/kg.

Succinocholine is a neuromuscular blocking agent which results in total paralysis. As with

all neuromuscular blocking agents, Succinocholine must never, I repeat must never be given
before a sedative is given. This is because Succinocholine has no effect on consciousness or
pain. Also, if a patient has high potassium, a different paralytic may be chosen, especially if
the patient is a burn patient. Typical induction dose is 1mg/kg

Propofol is sedative-hypnotic agent that is used for sedation and anesthesia.

Typically, it causes hypotension with an average dose of 0.5 to 1.5 mg/kg. But a number of
factors should be considered when determining the best dose. The elderly, those who are
hypovolemic, or have ASA-PS III or IV patients may have exaggerated hemodynamic and
respiratory responses to rapid bolus doses.

Vercuronium is another neuromuscular blocking agent which results in total paralysis. The
typical dose is 0.1-0.2 mg/kg.

Atropine is an anticholinergic drug. It is often used as premedication for intubating pediatric

patients but typically not for adults. If a vial is not available, obtain a vial if you are
intubating a child.

Adrenaline, an adrenergic agonist, should be on hand in the event of a cardiac arrest.

*Important Point

Before the procedure check the monitor and make a mental note of the Heart Rate and
Sao2. We can call these the Baseline Vital Signs. Now, if there are changes, you’ll know
the direction or trend of the changes. (Show monitor)

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After Drug Administration

Let’s now discuss what activities will promote the best patient safety once the drugs have
been administered.

Remember, the clinician intubating often cannot see the monitor. It is usually behind him or
in back. So, you are the eyes and ears of the person intubating. And it is your careful
monitoring of the patient that can optimize success.

Let’s Consider this Situation:

Before your patient intubation, you checked the monitor to see the Baseline Vital signs,
specifically the Heart Rate and SaO2.

For example, let’s say your patient’s heart rate is 120 at the start of the intubation.
Commonly, there may be some small change in heart rate during the procedure.

But… if the patient’s heart rate begins to drop, you must begin to loudly call out the trend.
A falling heart rate may be a sign of increasing hypoxia or excessive vagal stimulation.

You may say:

(Second actor calls out off camera)

“Doctor, the heart rate is now 110. Heart rate now 102. Doctor, heart rate is dropping!”

Don’t be afraid to use a strong voice because often the area is very noisy.

Some of you may be wondering why we are so concerned about a heart rate, for example, of
100bpm. After all, we are all taught that a normal adult heart rate 60-100 is normal.

But the problem is not the number of 100bpm, but it’s the downward trend that is the
problem.

We could call this 100bpm a relative bradycardia because the patient started with a heart
rate of 120. And now there is a definite downward trend, or slowing of the heart.

If it is not recognized early, the patient’s heart rate may continue to fall, even to the point of
severe bradycardia and asystole. And should that happen, it suddenly becomes a case of
resuscitation emergency.

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So, when you call out the numbers, the person intubating has the information he needs to
decide what’s the best thing he can do…whether he will continue to intubate, or perhaps to
pull out and ambu-bag the patient.

Remember, as long as the heart rate remains steady, the intubating clinician knows he
has time during the procedure. But if it starts to fall, you must begin to call the
numbers!!
REMEMBER, it’s not the actual number that counts, but the downward
movement or Trend that is critical to recognize and call out.

No let’s talk about the SaO2.

As you already know, all patients should be pre-oxygenated before intubation unless it is an
emergency intubation. And, if the procedure is quick, the SaO2 will probably remain stable.

But, just like with the heart rate, if the SaO2 does begin to trend downward, you must call it
out…

For example: “95%....94%....93%....92%..Saturation dropping.”

As the SaO2 falls below 90%, it may then begin to fall more quickly.

And just like with the heart rate, if you wait too long to notify the intubator, the SaO2 will
keep dropping risking patient arrest.

Remember….Waiting too long to re-oxygenate will make full resuscitation increasingly

difficult to achieve.

After the Intubation

Once the ETT has been inserted, the clinician will inflate the balloon and then check for
correct ETT placement.

At this time, the heart rate and SaO2 should be stablilizing.

But, if either heart rate or saturation had been trending downward toward the end of the
intubation, it’s critical to watch those two parameters to be sure they do not continue to
drop. If they do, the senior must act aggressively to prevent possible cardiac or
respiratory arrest.

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Ambu-bagging

Be sure the person using the ambu-bag is using it properly. Do not over-ventilate, or under-
ventilate. Also, feel for any resistance when squeezing the bag. And be sure it is connected to
the oxygen source. (show this).

Your patient may require some over ventilation at this time if the intubation was difficult and
took extra time. If so, ventilate about every 1 second (show this)

But if it was a smooth intubation, squeezing every 5 or 6 seconds, half bag, should be fine.
Squeeze over 1 second, and then release the bag to allow it to re-inflate. (Show this)

THE BP

It is also important to check the BP once heart rate and SaO2 are stable. It is not unusual that
the BP can drop significantly once a patient is intubated, especially if the patient had been in
great distress or hyper-dynamic beforehand, or was given too much sedative.

Once all vital signs are stabilized:

a. recheck breath sounds

b. note the position of the ETT at the lip line
c. secure the ETT
d. check the cuff balloon pressure. Too much cuff pressure can lead to post extubation
stridor and tracheal necrosis.
e. Connect to the circuit and adjust vent parameters according to patient need.

Finally, set the head of bed at least 30 degrees as part of the VAP prevention bundle. (show
gauge)

Also, if the patient needs an NGT, this is the best time to insert it while the patient is still
under the effects of the induction drugs.

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