Mohammad Irfan Akhtar
Assistant Professor, Department of Anesthesiology, Aga Khan University, Hospital, Karachi
1. Patient Information Communication Form; Fill with the following details and send to CICU at least 45 minutes before patient shifting; patient’s demographics, diagnosis / procedure, ventilator settings (e.g. SIMV 12-14 cmH2O, TV 6-8 ml/kg, FiO25-0.6, PS 12-15 cmH2O, PEEP of 5 cmH2O, monitoring, inotropes, sedation, extubation plan
2. Handover of the patient from OR Anesthesia team to CICU team (Consultant, resident, attending nurse)
a. Patient Handover details:
- Diagnosis/ Procedure.
- Angiography findings (EF), Echo report (EF, valve functions, valve area, pulmonary hypertension)
- Airway assessment
b. Significant intraoperative events (e.g. hypotension, arrhythmias, blood transfusions etc.)
c. I/V access
d. Monitoring lines, If PA (indication)
e. Last lab reports (Hb, ABGs, K)
f. Ionotropic support, vasopressor use
g. Pacing (indication, rate, mode)
h.Temperature on shifting
i. Extubation plan; fast track or conventional
j. (Fast track: Extubation within 6 hours of arrival at CICU)
3. Warming measures (K+, normothermia, fluid warmer, room temp 22○C) activated.
4. Observation for two hours for chest tube output for weaning readiness.
5. Readiness testing:
a. Stable hemodynamics SBP > 90 mm/Hg with minimal Ionotropic support (Epinephrine < 0.08 μg/kg/minute, Norepinephrine < 0.05 μg/kg/min, Dopamine < 10 μg/kg/min), HR < 110.
b. Stable ABGs, (P/F ratio > 200 on FiO2 of 0.5), pH > 7.30.
c. Chest tube output < 100 ml/h for two consecutive hours. Hb > 8 gm/dl.
d. Peripheral Temp > 35.5 ºC
a. Sedation off, after patient has some spontaneous breathing efforts
b. Adequate analgesia supplementation (multi-modal approach)
c. Reduce FiO2 to 0.4 if PO2 > 60 and oxygen saturation > 94%.
d. Reduce SIMV slowly by 1-2 breaths every 10-15 min with close watch on patient’s hemodynamics, respiratory parameters (R/R, SpO2, TV).
e. Put patient on spontaneous breathing with pressure support and monitor RSBI.
f. Reduce PS to 8 slowly provided RSBI < 80.Do ABGs to see adequacy of oxygenation/ ventilation/metabolic status.
7. Extubation: if patient fully awake, cooperative, adequate cough and gag reflexes, adequate hand grip, minimal bronchial secretions.
Caution: Extubation in the presence of anesthesia resident/consultant.