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You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO Center Emory University Hospital

You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

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Page 1: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

You Snooze, You Lose

James M. Blum, MD, FCCM

Chief of Critical Care

Emory University Department of Anesthesiology

Medical Director, Emory ECMO Center

Emory University Hospital

Page 2: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Disclosure

• Consultant for CLEW medical

Page 3: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Overview

• Understand the history of post-cardiac surgery sedation

and ventilator management

• Discuss reasons to change from prior practices

• Understand changes to anesthetics that impact the ability

to “fast-track” patients

• Tips and techniques to extubate the challenging patient

• Discuss when the “slow-track” is being on the right-track

Page 4: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 5: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 6: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 7: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 8: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 9: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 10: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 11: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Post-cardiac surgery sedation and ventilator management

Page 12: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Why were inhalational anesthetics so bad?

Page 13: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Why were inhalational anesthetics so bad?

Myocardial depressants and vasodilators

Page 14: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Why were inhalational anesthetics so bad?

Page 15: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Why were inhalational anesthetics so bad?

Page 16: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Why were inhalational anesthetics so bad?

Page 17: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

So we have the perfect storm:

Page 18: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

So we have the perfect storm:

Short acting things (inhalational anesthetics) tend to result in worse

outcomes

Page 19: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

So we have the perfect storm:

Short acting things tend to result in worse outcomes

Long acting things (opiates) result in better outcomes

Page 20: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

So we have the perfect storm:

Short acting things tend to result in worse outcomes

Long acting things result in better outcomes

All it takes is some mechanical ventilation and we should be fine!

Page 21: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 22: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

There is only one problem

Page 23: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

There is only one problem

Awareness

Page 24: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

There is only one problem

Awareness

Page 25: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

There is only one problem

3% - 10%

Page 26: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

How do we deal with this?

Page 27: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

How do we deal with this?

Benzodiazepines

Page 28: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What’s the problem with this combination?

Page 29: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What’s the problem with this combination?

Benzodiazepines

Page 30: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What’s the problem with this combination?

Benzodiazepines + Opiates =

Page 31: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What’s the problem with this combination?

Benzodiazepines + Opiates = Synergistic Sedation

Page 32: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 33: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

Page 34: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

better for patients

Page 35: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

better for patients

-DVT

Page 36: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

better for patients

-DVT

-pneumonia

Page 37: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

better for patients

-DVT

-pneumonia

-pressure ulcers

Page 38: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

better for patients

-DVT

-pneumonia

-pressure ulcers

-stress ulcers

Page 39: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

These do not happen overnight

Page 40: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

better for patients

-DVT

-pneumonia

-pressure ulcers

-stress ulcers

one major incentive - $

Page 41: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reasons to Change Practice and Try to Wake Early

one major incentive - $

Page 42: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Show Me the Money!!!

Page 43: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

There is nothing wrong with saving some $

Page 44: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Show Me the Money!!!

EMORY UNIVERSITY HOSPITAL MIDTOWN 550 PEACHTREE ST NE GA - Atlanta $91,988.10 $25,335.59 $23,607.39

DRG 236 - CABG W/O Cath or MCC

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient2015.html

Page 45: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Show Me the Money!!!

EMORY UNIVERSITY HOSPITAL MIDTOWN 550 PEACHTREE ST NE GA - Atlanta $91,988.10 $25,335.59 $23,607.39

DRG 236 - CABG W/O Cath or MCC

Page 46: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Show Me the Money!!!

EMORY UNIVERSITY HOSPITAL MIDTOWN 550 PEACHTREE ST NE GA - Atlanta $91,988.10 $25,335.59 $23,607.39

DRG 236 - CABG W/O Cath or MCC

Assume OR Costs are fixed

Things you can modify:

Medical supplies

Medications used

Duration of stay

Page 47: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Show Me the Money!!!

EMORY UNIVERSITY HOSPITAL MIDTOWN 550 PEACHTREE ST NE GA - Atlanta $91,988.10 $25,335.59 $23,607.39

DRG 236 - CABG W/O Cath or MCC

Assume OR Costs are fixed

Things you can modify:

Medical supplies - $

Medications used - $

Duration of stay - $$$$

MV

Page 48: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What if we use super short acting dope?

Page 49: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What if we use super short acting dope?

Page 50: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What if we use super short acting dope?

Page 51: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What if we use dedicated post-op recovery units?

Page 52: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

What if we use dedicated post-op recovery units?

Page 53: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 54: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 55: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Any model can help you extubate early

Page 56: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Page 57: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Low-dose opiate (fentanyl ≤ 20 μg/kg or equivalent) or short-acting opioid supplemented with propofol or

etomidate, or volatile anaesthesia with or without a protocol for early extubation within eight hours.

Conventional cardiac anaesthesia was defined by the use of high-dose opioids (fentanyl ≥ 20 μg/kg or

equivalent) with propofol or etomidate, or volatile anaesthesia with or without a protocol for extubation

within a specified time after surgery.

Page 58: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Page 59: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Page 60: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Page 61: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

How to Fast Track

Change opiate

Reduce opiate dose

Change paralytic

Extubation in OR

Protocolized Extubation

Page 62: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Page 63: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Fast-tracking saves

you 7.4 hours on

the ventilator

Page 64: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Page 65: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Fast-tracking starts in the operating room

Fast-tracking saves

you 4.5 hours in the ICU

Page 66: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

How to Fast Track

Change opiate

Reduce opiate dose

Change paralytic

Extubation in OR

Protocolized Extubation

Page 67: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

How to Fast Track

Change opiate

Reduce opiate dose

Change paralytic

Extubation in OR

www.extubateme.com

http://www.extubateme.com
Page 68: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

How to Fast Track

Wake

Warm

Whip it Out

Page 69: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Waking

Page 70: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Waking

Physiologic

Pharmacologic

Pathologic

Page 71: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Waking

Physiologic

Page 72: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Waking

Pharmacologic

Page 73: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Waking

Pathologic

Page 74: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems waking?…the Workup!

Page 75: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Weaning

Page 76: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Page 77: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Page 78: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Page 79: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Page 80: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Failed ventilator weaning assessment by protocol?

Page 81: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Failed ventilator weaning assessment by protocol?

Go ahead a make a full assessment

Page 82: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Failed ventilator weaning assessment by protocol?

Go ahead a make a full assessment

Make a decision

Page 83: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Failed ventilator weaning assessment by protocol?

Go ahead a make a full assessment

Make a decision….perhaps with a friend

Page 84: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Failed ventilator weaning assessment

Failed ventilator weaning assessment by protocol?

Go ahead a make a full assessment

Make a decision….perhaps with a friend….and a number of resources

Page 85: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Whipping it Out

Sedation mechanism

Page 86: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Problems Whipping it Out

Sedation Dexmedetomidine vs. Propofol

Page 87: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Sedation Dexmedetomidine vs. Propofol

Page 88: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Sedation Dexmedetomidine vs. Propofol

Page 89: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Sedation Dexmedetomidine vs. Propofol

Page 90: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Sedation Dexmedetomidine vs. Propofol

Page 91: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Sedation Dexmedetomidine vs. Propofol

Page 92: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Sedation Dexmedetomidine vs. Propofol

Page 93: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Sedation Dexmedetomidine vs. Propofol

Page 94: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Reintubation…what to do?

Page 95: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 96: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 97: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

1. Failure of a spontaneous breathing trial, defined as arterial

oxygen saturation (SaO2) less than 90%with 12 L of oxygen

during a T-tube trial or PaO2 less than 75mmHg with a fraction

of inspired oxygen (FIO2) of at least 50% during lowlevel

pressure support

2. Successful spontaneous breathing trial in patients with any

of the following preexisting risk factors for postextubation

acute respiratory failure: body mass index greater than 30,

left ventricular ejection fraction less than 40%, and failure

of previous extubation

3. Successful spontaneous breathing trial followed by failed

extubation, defined as at least 1 of the following: PaO2:FIO2

ratio less than 300, respiratory rate greater than 25/min for

at least 2 hours, and use of accessory respiratory muscles

or paradoxic respiration.

Eligibility

Page 98: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 99: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 100: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 101: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO
Page 102: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

Concerns about loss of airway

Page 103: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

Concerns about loss of airway

Do not fast-track the difficult airway

Page 104: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Page 105: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Page 106: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Page 107: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Extubated after 5 hours in ICU after meeting all protocol metrics

Page 108: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Extubated after 5 hours in ICU after meeting all protocol metrics

Develops respiratory stridor

Page 109: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Extubated after 5 hours in ICU after meeting all protocol metrics

Develops respiratory stridor

Attempt by APP to reintubate

Page 110: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Extubated after 5 hours in ICU after meeting all protocol metrics

Develops respiratory stridor

Attempt by APP to reintubate

Failed….Anesthesia called

Page 111: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Extubated after 5 hours in ICU after meeting all protocol metrics

Develops respiratory stridor

Attempt by APP to reintubate

Failed….Anesthesia called

Difficult bag mask

Page 112: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Extubated after 5 hours in ICU after meeting all protocol metrics

Develops respiratory stridor

Attempt by APP to reintubate

Failed….Anesthesia called

Difficult bag mask

Cardiac arrest

Page 113: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory67 yo M s/p elective CABG for CAD

Intubated using glide scope with difficulty in OR

Uneventful OR course

Extubated after 5 hours in ICU after meeting all protocol metrics

Develops respiratory stridor

Attempt by APP to reintubate

Failed….Anesthesia called

Difficult bag mask

Cardiac arrest

Devastating neurologic injury

Page 114: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

Sometimes the “slow-track” is the right track

Page 115: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

Sometimes the “slow-track” is the right track

Difficult Airway

Page 116: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

Sometimes the “slow-track” is the right track

Difficult Airway

Marginal pulmonary status

Page 117: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

Sometimes the “slow-track” is the right track

Difficult Airway

Marginal pulmonary status

Concerns about bleeding

Page 118: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Snatching Defeat from the Jaws of Victory

Sometimes the “slow-track” is the right track

Difficult Airway

Marginal pulmonary status

Concerns about bleeding

Marginal pulmonary status

High-dose pressors

Page 119: You Snooze, You Lose · 2018. 5. 4. · You Snooze, You Lose James M. Blum, MD, FCCM Chief of Critical Care Emory University Department of Anesthesiology Medical Director, Emory ECMO

Conclusions

• Fast-track extubations start in the OR, but require the ICU

team to execute the pivotal move

• Primary reasons for fast-track are financial, but overall

may improve patient care

• Use of pharmacy and high flow NC and NIV can bridge the

failing patient

• Trail of extubation is reasonable in controlled situations

• Don’t be afraid of the "slow-track"


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