New to these boards. We are having a problem with new intensivists on this subject. Our old way of taping is not something they like. They want RT's to do it a way that has tape going on the chin, on the mandible.
Are you all using pediatric holders or tape? If tape-what method are you using?
May 2, '09
There's a thread about this on the NICU forum, I think. Some good answers there.
Our intensivists insist on nasal intubation supposedly because the tubes are more secure. Who cares that the rate of VAP is MUCH higher with nasal intubation? But I digress. We don't use ETT holders at all. Ever. We use adhesive tape or Elastoplast, although that has fallen out of favour because it stretches too much. Of course we're talking apples and oranges here so our taping practice won't be of any use to you. Suffice it to say that I've never seen an ETT taped on the mandible.
May 2, '09
"They want RT's to do it a way that has tape going on the chin, on the mandible. "
I've got to say.... I've never seen this kind of tape job! I'd love see a picture.
May 9, '09
I, too, would love to see the tape job you described. Our RTs use elastoplast to tape to the upper lip. Mastisol is also used to aid in adhesion. We rarely get nasally intubated kids.
May 9, '09
Funny you should say that WarEagle. Last night I had a patient who had been transferred from another hospital who came to us orally tubed with Elastoplast taping. Baby has been on our unit before, a hypoplast who is listed for tx. The mom said to me, "If she self-extubates, could you ask them to reintubate her nasally?" Wha-a-a-a-a-t? (She gave it her best shot... I had to sit on her most of the night... Ativan x 4, fentanyl x 2, chloral hydrate x 2, midazolam and fentanyl infusions and ketamine as a last resort.)
May 9, '09
We rarely have self extubations with our orally intubated patients. They are usually on morphine and versed drips routinely. Some kiddos don't tolerate versed, so we do ativan drips. Then there are those who get fentanyl (our CV side uses more fentanyl than we do). At our facility, RNs are not allowed to administer ketamine IV, only MDs are. In our older patients, we are using diprivan some.
I'm always amazed at the differences in practice - such as the ketamine is a no-no. We had a nurse leave because she administered ketamine. In other places, it's okay for an RN to administer. I'm really not a fan of ketamine (watching my daughter wake up from it was a nightmarish experience), but sometimes it's what the MD ordered!
PS: our VAP rates are pretty low.
May 9, '09
Our practice is pretty similar, Cindy. Most of our kiddos are on morphine and midazolam infusions, plus whatever else we might need to keep them on the bed. Propofol is reserved for the 4-6 hours before extubation. In this province ketamine may be administered by a specially-trained RN, which includes all the nurses on my unit. We are certified in the administration of injectable general anaesthetics (excluding alfentanil and sufentanil) and neuromuscular blockers annually. Emergence reactions are more common in older kids and those who haven't had a benzo administered with it. My little patient from last night is only 5 months old and has never been home. She's been on high doses of opioids and benzos for much of her life, since she's needed long-term intubation. All of our intensivists are methadone prescribers, we use opioids in such high doses!
Our self-extubation rate is really low. It hasn't happened on me in about 8 years. (Better touch wood!) And we've only had 1 VAP in the last 18 months, despite those disgustingly green-slime-producing nasal tubes.
Jun 29, '10
The hospital in which I work does both nasal and oral intubations. We usually prefer nasal because our kiddos seem to have some serious oral secretions and we are continuously retaping the tubes. However some physicians do not like nasal because of the risks. Either way, when we tape we use mastisol and cloth tape. Depending on the size of the patient you use 1 or 2 inch tape and cut two pieces, long enough to go cheek to cheek. We then, split the pieces lengthwise leaving about an inch (give or take) at the end. If OET we place the tape as close to the corner of the mouth and one strip goes over the top lip, while the other strip goes around the tube. Then we use the second piece of tape the same except instead of over the lip we do across the chin. I hope that makes sense. We tried neobars on our little kiddos however some of our docs and nurses did not like them so we continue with tape.
Jul 21, '10
PICURN, we tape the same exact way and I have never once seen a kid in the PICU I work at nasally intubated. We usually have kids on a fentanyl or versed drip. If they have serious lung impairment we paralyze them with vecuronium or cisatracurium. We re-tape often on some kids but we give them .1/kg of vec and get it done in 5-10 mins, I guess our docs weigh the pros and cons and feel that re-taping is much easier than having a nasally intubated kid. Our self extubation rate is also very very low.