Early Extubation Protocol in PEDS/CICU

Esme12, ASN, BSN, RN · Aug 1, 2012

Thread moved to PICU forbetter exposure.

umcRN, BSN, RN · Aug 1, 2012

hmm i can probably help a little bit with this but i am on vacation and don't have access to any of our protocols!

we have"tracks" after surgery, decided by anesthesia, kids come back from surgery with a color, green, yellow, red. pretty self explanatory. kids with "red" really probably shouldn't be coming back from surgery yet anyways and if they're not on ecmo coming up we get ready for it on the unit. "green" kiddos are the wake and wean and yellow is typically to reassess in 4-6 hours post-op.

as far as sedation goes, with the green kiddos they are placed on the fast track with a goal of extubating anywhere from 2-24 hours after surgery. the sedation protocol is as follows:

- wake & wean from vent in 2-24 hrs from admission. goal pain score 4), tylenol q4x48 hrs - standing order, toradol q6 x 48hrs - standing order, oxy 0.1mg/kg q6 when taking po- standing order initially then changes to prn, pca for children >8yrs after extubated.

we do extubation readiness tests prior to all extubations by placing them on cpap for an hour, monitoring their work of breathing, sats, tidal volumes and an abg. the exception to this are the kids trying to climb out of bed that we would rather extubate than sedate and cause longer intubation time (so long as they are hemodynamically stable of course).

i would venture to say most of our patients are extubated within the first 48 hours. the ones that have prolonged intubations are obviously the "red" kiddos - first stage single ventricle, kids that come up open chested, on ecmo, kids who had pretty bad pulmonary hypertension going into surgery and remember how much they love the vent, etc.

older children, once extubated, are out of bed as soon as their la line is out which is typically the morning of post op day 1.

maybe that gave you some starting points? any questions feel free to ask. this is a pedi cardiac icu.

meanmaryjean, DNP, RN · Aug 2, 2012

Had one of those 'climbing out of bed' kids last night. Extubated just a few hours post-op and then somehow managed to do a complete turn (360) while (miraculously) not ripping out his femoral venous and arterial lines.

Mind you - he did this in complete silence, and without setting off the alarms one time.

Pediatric Critical Care Columnist · Aug 3, 2012

We don't have any written protocols and much of the decision-making is left to the surgical team and anaesthesia. We've seen a marked increase in the last couple of years of kids coming back to us extubated. We've also seen a similar upswing in the number of kids extubated later the same day or Day 1 post-op. The ones we don't extubate early are usually the ones with other issues, like sever pulmonary hypertension, renal insufficiency, rhythm issues and the like.

marycarney, don't you just love those little bed snakes? So much easier to deal with when they ARE extubated than when they've got IJ CVLs, chest tubes, and all the rest. A few years ago I had an intubated 12 year old patient with Trisomy 21 who'd had an AVSD repair as an infant who was now having rhythm issues and needing transvenous pacing pending a trip to the OR. It was back at the beginning of the VAP bundle rollout, if memory serves. This kid was a typical T21 sedation sponge and was out of control for the first half of the shift. Had to be kept relatively chill so that the transvenous pacing line didn't get pulled. I'd finally gotten on top of the situation when our medical director strolled by and told me to boost the kid up in the bed and get the HOB up to 30 degrees. I scowled at him and told him I couldn't boost this kid by myself, there was no one available to help me and that I'd just gotten a few moments' peace. You could have heard a pin drop on the unit when he said he would help me boost and we could roc the kid. First and last time he ever did that.

meanmaryjean, DNP, RN · Aug 3, 2012

'sedation sponge' - I am totally stealing that phrase!

Pediatric Critical Care Columnist · Aug 3, 2012

'sedation sponge' - I am totally stealing that phrase!

Help yourself! I've got a million of 'em.

Double-Helix, BSN, RN · Aug 7, 2012

We don't do a huge number of open heart cardiac surgeries in our unit- it's usually about once per week. However, I'd say that maybe one patient every two months will come back to us intubated. It's usually because they had some problems during surgery, trouble weaning, or, like janfrn said, pulmonary HTN or a similar underlying issue. Of those that come back intubated, most of them will be extubated overnight or the following day.

karenychu · Aug 7, 2012

umcrn, do you think you can post your protocols? I am intrigued about the green, yellow, red protocols. Thanks!

Hi I am interested in starting an early extubation protocol in a peds cardiac ICU, anybody have some protocols in their institutions I can bounce some ideas off of? Would greatly appreciate it!!
Research states that early extubation is still not practiced routinely in pediatric ICUs BUT very early exbuation can be accomplished safely after CPB and can take place in the OR or after admission to the ICU. Many children remain intubated for long periods simply because they have had cardiac surgery. (Kloth & Baum, 2002).
Advantages of early extubation include:
Decreased postop pulmonary complications
Decreased length of stay in the ICU
Decreased dependence on mechanical ventilation
Decreased need for additional sedation
Decreased risk of aggravating pulmonary hypertension during ETT suctioning
Decreased costs!

karenychu · Aug 7, 2012

umcrn, do you think you can post your protocols? I am intrigued about the green, yellow, red protocols. Thanks!

umcRN, BSN, RN · Aug 7, 2012

umcrn, do you think you can post your protocols? I am intrigued about the green, yellow, red protocols. Thanks!

I sent you a private message

karenychu · Aug 16, 2012

umcRN,

can you e-mail me at [email protected]? Thanks so much!!