ABCDEFG: Daily Checklist

Airway:
A • Tube position
• Cuff pressure

Breathing:
• Ventilator setting – focus on safety
• Mode (synchronised, non-synchronised?)
1. RR
2. Pressures
B 3. PEEP
4. FiO2
• Blood gases: pH, PaO2, PaCO2
• Secretions Daily Reassess care plan
• Lung sounds
1. Resuscitation status
Cirulation: 2. Sedation
• Capillary refill time
• Arterial blood pressure 3. GI prophylaxis
• Heart rate 4. DVT prophylaxis
C • Central Venous Pressure CVP
• ScvO2 (venous blood gas) 5. Fluids and electrolytes
• Lactate 6. Nutrition
• Urinary output, fluid balance/24h
7. Intravenous and other
Disability: accesses
• GCS
D • RASS status
8. Duration of antibiotics and
• CAM-ICU / delirium steroid use
• Pupil size and reactiveness to light
9. Delirium prevention
Exposure:
Check access sites
Check skin colour and pathologies
E Drains, tubes, lines
Body temperature
Lab results – pathological values

Feeding:
• Blood glucose
F • Enteral feeding tolerance
• Bowel movements

General other aspects:

• Gastric ulcer prophylaxis
G • VAP prophylaxis
• Positioning, mobilisation and physical therapy
 Hypoxemia in the ventilated patient

1 Call for help and bring the airway trolley

2 Increase FiO2 to 100% oxygen

Assess and treat the cause of desaturation:

3 Airway? BreathingCircuit? Lungs?

Airway
• Rule out accidental extubation. Confirm endotracheal tube position with
EtCO2.
4 • Attempt suctioning to rule out obstruction of endotracheal tube.
• Rule out esophageal placement of endotracheal tube.
• Check for air leak from the mouth or neck.
• If in doubt, consider reintubation.

Circuit
• Check for disconnection of the circuit and equipment failure.
5 • Rule out air-trapping by disconnecting patient from ventilator to allow
exhalation.
• Consider manually bagging the patient with 100% oxygen at 10-12
breaths/minute.

Lungs
• Listen for pathological lung sounds (pneumothorax, obstruction,
secretions…) and subcutaneous crepitus.
6 • Look for pathological waveforms and values on the ventilator screen.
Consider the following: bronchospasm, worsening of ARDS, ventilator
asynchrony, pneumothorax.
 Ventilator Troubleshooting
BRONCHOSPASM, ASTHMA EXACERBATION

VENTILATOR SCREEN

FINDINGS
V ENTILATOR :
• ↑ inspiratory pressures in VCV / ↓ Vt in PCV

• Dynamic hyperinflation

• Typical EtCO2 waveform

P HYSICAL EXAMINATION :
• Wheezing

• In severe disease, silent chest can be present

VENTILATOR MANAGEMENT TREATMENT

If haemodynamic collapse: disconnect circuit to allow Nebulised β2-agonist – e.g. salbutamol

for expiration
Nebulised anticholinergics – e.g. ipratropium bromide
• Synchronised VCV regime
Corticosteroids – e.g. methylprednisolone
• ↓ respiratory rate (start at 10)

• ↑ flow rate (60-80 L/min) If not responding to initial therapy:

Magnesium sulphate
• reasonable Vt (start at 8 mL/kg IBW)
Ketamine
• ↓ I:E ratio (start at 1:3)
Aminophylline
• Do not increase PEEP Parenteral beta-agonists – e.g. terbutaline

• If air trapping on flow graph, ↓respiratory rate or Consider adrenaline 200-500ug s.c. if in extremis
further decrease I:E

• If plateau pressure > 30cmH20, increase I:E

 Ventilator Troubleshooting
CIRCUIT OBSTRUCTION

VENTILATOR SCREEN
FINDINGS

VENTILATOR:
• Sawtooth pattern on flow graph (secretions)
• High airway pressures
• Low Vt

PHYSICAL EXAMINATION:
Depending on the cause:

• Suction of mucus from endotracheal tube

• Obstruction of endotracheal tube (e.g. mucus)

VENTILATOR MANAGEMENT TREATMENT

• Suction airway
• Check the endotracheal tube
None
• Consider reintubation
• Bronchoscopy?
 Ventilator Troubleshooting WORSENING OF ARDS

VENTILATOR SCREEN FINDINGS

VENTILATOR:
• Reduced lung compliance
• ↑ inspiratory pressures in VCV / ↓ Vt in PCV

PHYSICAL EXAMINATION:
• Bilateral chest infiltrates on CXR
• Reduced oxygenation (desaturation,
reduced PaO2)

VENTILATOR MANAGEMENT TREATMENT

• Keep plateau pressure below 30cm2 H20 • Check for possible underlying causes
- Keep low Vt (start at 6ml/kg IBW) (ventilator acquired bacterial superinfection,
- Increase respiratory rate to keep aspiration…). Check if it is adequately
pH=7.3-7.45 treated (ABX?)
- ↑ I:E ratio
• If hypoxemia persists despite increasing
• Increase PEEP and FiO2 to maintain oxygenation FiO2 and PEEP, or if PaO2/FiO2<150,
between 88-95% consider prone positioning

PEEP matching to FiO2 suggested by the ARDSNET

protocol (simplified)

FiO2 0.4 0.5 0.6 0.7 0.8 0.9

% O2
PEEP 5 8 10 10 12 14
cm H2O
 Physiology of Prone Positioning

Supined Positioning
Ventral Alveoli Overdistended
VENTRAL
GRAVITY

BLOOD
DORSAL FLOW
Dorsal Alveolus Collapsed

Proned Positioning
Dorsal Alveoli Decreased Collapse

DORSAL
GRAVITY

BLOOD
FLOW
VENTRAL
Ventral Alveolus decreased overdistention
 MANAGEMENT OF UNDIFFERENTIATED HYPOTENSION

Rule out artifacts: check arterial pressure and SpO2 curve,

1
flush arterial line
2 Call for help

3 Assess ABCDE

4 Secure airway if compromised

5 Pulsation on large arteries is absent, start CPR

6 Give adequate FiO2 to SpO2 > 90%

Secure i.v. access and start empiric fluid resuscitation

7 with regard to fluid responsiveness (consider passive leg
raise test or fluid challenge)

8 If not fluid responsive, consider vaspressor infusion

Obtain ECG, blood chemistry and lactate,

9
consider Trans Thoracic Echocardium (TTE)

Think about the probable cause of shock and treat the

problems requiring immediate attention:
• Hypovolaemic: haemorrhagic, dehydration
10 • Cardiogenic: left ventricular failure, arrythmias
• Obstructive: pulmonary embolism, tension
pneumothorax, cardiac tamponade
• Distributive: anaphylaxis, sepsis
 Recommendations for sepsis:
the 1 hour sepsis bundle

1 Measure lactate level

2 Obtian bloodcultures before administering antibiotics

3 Administer broad spectrum anitibiotics

Begin to rapidly administer 30mL/kg crystalloid for

4
hypotension or lactate > 4 mmol/L

Apply vasopressor if hypotensive during or after fluid

5 resuscitation to maintain a mean arterial pressure of >
65mmHg

6 Remeasure lactate if initial lactate elevated >2 mmol/L