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

Abstract

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.