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Alveolar Equation
Alveolar Equation
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Extubation Protocol
CTICU guidelines:
Extubation Protocol
AIM:
To provide a guideline for extubation of post-operative cardiac surgery patients.
BACKGROUND:
Early extubation of cardiac surgery patients leads to shorter length of ICU stay and reduces the
risks associated with mechanical ventilation. It is our goal to extubate all appropriate patients
within 4-6 hours of ICU admission. This policy is written to facilitate patient selection for early
extubation and direct extubation procedures.
MANAGEMENT:
1. Patients that should be excluded from early extubation:
• Significant post-operative bleeding, >100mls per hour
• Left ventricular ejection fraction <30%
• Signs of worsening cardiovascular dysfunction (eg. rising inotrope
requirements)
• Emergency cases with pre-operative respiratory failure
• High inotrope and vasoconstrictor use (eg. >0.1 mcg/kg/min of both
adrenaline and noradrenaline, or equivalent)
• Persistent acidosis with pH <7.30
• Prolonged high post-operative oxygen requirement (FiO2 >0.5) that does not
respond to recruitment
• Anuric renal failure patients with no dialysis access
• Difficult endotracheal intubation (grade IIIb or IV)
• Patients who require suctioning every hour or more frequently for secretions
• Prolonged cardiopulmonary bypass times (> 180 minutes)
• Aorta surgery (eg. for dissection or thoracic aortic aneurysm)
3. Extubation Procedure
• Prepare and ensure the following equipment is at the bedside prior to extubation and
in good working condition: suction machine, suction catheter, Bag-valve-mask
attached, nasal cannula/ Venturi mask.
• Physician written order required to extubate.
• Sit patient upright, suction oral cavity, hypopharynx and endotracheal tube (ETT).
5. Summary table
• Awake, follows commands, able to • Appropriate gas exchange - PaO2 >60, PaCO2
support upper airway <50 with normal pH, SaO2 ≥96% on FiO2 ≤0.4
• Can take deep breath on command • Inotropes weaning and on minimal levels
• Comfortable respiratory pattern. (adrenaline and noradrenaline <0.05)
• No signs of significant bleeding • Absence of acidosis or alkalosis or severe
• Stable haemodynamically electrolyte disturbances
• No significant CXR changes