Adverse effects of Endotracheal Intubation

OVERVIEW

  • Can be classified anatomically or into immediate, short and long term complications.
  • Below is anatomically.

AIRWAY

  • Dental Trauma
  • Failure to intubate
    • careful assessment of risk factors (history, examination, previous intubations)
    • optimal positioning
    • having a back up plan to provide oxygenation (bagging, LMA, guedels, nasopharyngeal airways, trans-tracheal airways)
  • Failure to Ventilate or Oxygenate (see above)
  • Damage to airway (cord injury, false passage creation)
    • multiple laryngoscopies
    • intubation for a prolonged length of time
    • limit laryngoscopies
    • have a back up plan
    • gentle manipulation with airway devices
  • Oesophageal intubation
    • ETCO2 use
  • Subglottic stenosis
    • assessment for early extubation
    • vigilant cuff pressure measurement
    • early tracheostomy
  • Tracheo-oesophageal Fistula (see subglottic stenosis above)

RESPIRATORY

  • Endobronchial intubation
    • careful attention on insertion
    • clinical assessment after intubation
    • CXR
  • Aspiration
    • aspiration of N/G tubes
    • starve if able
    • prokinetics
    • rapid sequence induction
  • Bronchospasm
    • if occurs can treat with: salbutamol, adrenaline, ketamine, Mg
  • Hypoxia from de-recruitment of lungs
    • conversion from spontaneous ventilation -> positive pressure ventilation results in de-recruitment when patient apnoeic
    • preoxygenation
    • quick securement of airway
    • increasing PEEP on ventilator
  • Sputum retention + pneumonia
    • head up
    • suction
    • chest physio
    • early antibiotics
  • Barotrauma
    • protective lung ventilation

CARDIOVASCULAR

  • Hypotension (cardiovascular collapse)
    • multi-factorial: drug induced, patient often have high sympathetic tone which is obtunded with induction of anaesthesia
    • use of balanced, haemodynamically stable agents for induction
    • judicious use of vasoactive medications
    • assess for tension pneumothorax and decompress if indicated
  • Hypertension and Myocardial Ischemia
    • from laryngoscopy and tracheal stimulation
    • balanced anaesthetic on induction

NEUROLOGICAL

  • Increased ICP
    • obtund haemodynamic response to laryngoscopy with hypnotic and fasting acting opioid
  • Potential spinal cord injury on laryngoscopy in patient with an unstable cervical spine
    • inline immobilisation
    • awake fiber-optic intubation
  • Requirement for sedation and analgesia

OTHER

  • Adverse drug reactions
  • Bacteraemia
  • Requirement for close monitoring (one-one nursing care)

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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