Correspondence

Local practice checklist for handover/weaning/extubation of postoperative adult open heart cardiac surgery patients on mechanical ventilation shifted from operating room to cardiac intensive care unit

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:

  •   Demographics
  •   Diagnosis/ Procedure.
  •   Angiography findings (EF), Echo report (EF, valve functions, valve area, pulmonary hypertension)
  •  Airway assessment
  •  Comorbids

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

6. Weaning:

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.