Facilitating intubations

I don't routinely hang a NS bag for intubations, but then again we don't use propofol for intubations either (nor do we bolus it...) so I don't have to worry so much about hypotension.

I usually do the routine stuff....get the intubation kit with meds, pull out the bed, take off the headboard, assure the suction is working and set up, make sure I have a good site, etc, etc...

A couple of liter bags of NS with pressure bags and I ask the MD what vasopressor(s) to have in the room. Usually dopamine first and phenylephrine or norepi 2nd.

RE: "don't usually deal with hypotension".... in general, sedatives can cause hypotension, the positive pressure ventilation also impacts cardiac output, and oddly the laryngeal stimulation of intubation can have a paradoxical effect: hypotension, as there is parasympathetic innervation in that area and can cause a similar vaso-vagal response. I got a nice update from the ICU fellow today on this. in the future, I'm always going to have a liter bolus handy.

1: Know it's comming- better an elective intubation on a patient in distress than an emergent intubation on a patient near arrest.

2: set up a dedicated IV with NS that runs easily when opened. Whe a patient loses the air hunger eather by sedation or with the intubation you are likely to crash the BP and need a fluid bolus until supportive meds can be started. The doc intubating will appriciate an IV to push sedation through, and you don't want to be fretting about "compatabilities " when a patient is being intubated.

3: have your ETT holder ready.

4: have suction set up with an oral suction sevice attached.

5: have a sputum collection trap open and ready- most docs will want a C&S sent once the ET tube is established.

6: make sure the vent, the resp therapist are at the bedside before the doc starts the intubation. Make sure the vent is working with "dummy" settings in appropriate for the patient.

7: do not leave your patient alone or unrestrained until adequare sedation is established. Many meds used for intubation are very short acting. Docs (and patients) hate to have to intubate twice in a hour on the same patient because the patient startled awake and yanked the tube.

8: have a NG/Salem sump set up and ready to go. The patient would prefer to have the gastric tube placed while they are out and your CXR to eval ETT placement can also verify your gastric drain placement.

A couple of liter bags of NS with pressure bags and I ask the MD what vasopressor(s) to have in the room. Usually dopamine first and phenylephrine or norepi 2nd.

For an intubation? Overkill I say.

I want to get some ideas going about making intubations smooth and easy for the patient, doctor (sometimes very nervous resident....; ) ), RT, and nurse.

Today, my patient had to be re-intubated and the doc asked for versed and propofol... started the gtt for propofol and set it up so i could use it to bolus. Versed 5mg/ml- gave 2.

then, i get all set in the room (gown and all) and the doc asks to run saline at 999/hr to keep pressure up, but i had no saline. So should I just anticipate the need for saline bolus next time around.

How else do you facilitate intubating your patients to make it quick and easy?

propofol for intubation? hmmnn..isn't that too much? short acting sedatives and neuromuscular blocking agents (succs) are the usual meds that i encounter during intubation. giving fluids are also usually given first to counteract hypotension.

each doc has their own preference for meds during intubation. some i work with like versed and propofol, some like etomidate and succ.

You should check your States BON about pushing propofol. It is outside the scope of practice in some states and you can't rely on Doc's to know what is legal for you.

propofol for intubation? hmmnn..isn't that too much?

Yes, propofol is used on a routine basis by anesthesia providers for intubation. Some providers will do a RSI and some will not. There are many different drugs that can be used for intubation. Including: fentanyl, midazoam, propofol, etomidate, dexmedetomidine, ketamine, and others. If needed, succ, Nimbex, Zemuron, Norcuron, Pavulon, etc. can be used. It's very provider specific. Etomidate is especially helpful with those that are cardiovascularly compromised at the time of intubation.

Yes, propofol is used on a routine basis by anesthesia providers for intubation.

Yes, by anesthesia providers. In several states it is outside the scope of practice for RN's to push propofol. Which is what it seemed the OP was being asked to do.

thank you, i checked. it is, indeed, within our scope of practice in this state to push propofol if ordered by a licensed provider at bedside.