What are the post-intubation orders for a patient?

Post-Intubation Orders

Immediately after successful intubation, initiate continuous sedation with propofol (5-50 mcg/kg/min) combined with fentanyl for analgesia, confirm tube placement with continuous waveform capnography, apply PEEP of at least 5 cmH2O, and begin lung-protective ventilation targeting normocapnia (end-tidal CO2 4.0-4.5 kPa). 1, 2

Immediate Post-Intubation Actions (First 5 Minutes)

Airway Confirmation and Security

• Inflate the endotracheal tube cuff to 20-30 cmH2O immediately after intubation 1
• Confirm tracheal intubation with continuous waveform capnography before starting mechanical ventilation 1
• Watch for equal bilateral chest wall expansion with ventilation (auscultation is less reliable and risks equipment contamination) 1
• If doubt exists about bilateral lung ventilation, obtain lung ultrasound or chest x-ray 1
• Record the depth of tracheal tube insertion prominently in the chart 1
• Secure the tracheal tube with self-adhesive tape (preferred over circumferential ties, especially in head-injured patients to avoid impaired venous drainage) 1

Ventilator Settings

• Apply PEEP of at least 5 cmH2O in hypoxaemic patients 1
• Perform a post-intubation recruitment maneuver in hypoxaemic patients (40 cmH2O CPAP for at least 30 seconds) 1
• Target normocapnia with end-tidal CO2 of 4.0-4.5 kPa 1
• Use lung-protective ventilation strategies, though reduction or removal of PEEP may be necessary in hypovolaemic patients 1
• Consider using transport ventilators rather than hand ventilation to decrease risk of hyperventilation 1

Sedation and Analgesia Initiation

For normotensive/hypertensive patients:

• Start propofol infusion at 5 mcg/kg/min (0.3 mg/kg/h), increasing by increments of 5-10 mcg/kg/min every 5 minutes until desired sedation achieved 2
• Most patients require maintenance rates of 5-50 mcg/kg/min (0.3-3 mg/kg/h) 2
• Do not exceed 4 mg/kg/hour unless benefits outweigh risks 2
• Add fentanyl for analgesia 3

For hypotensive patients:

• Consider midazolam (starting with 2 mg IV bolus, then 1 mg/h infusion) combined with fentanyl 1, 3
• Alternatively, ketamine alone can be used in hypotensive patients 3
• Reduce propofol dosage by approximately 80% in elderly, debilitated, or ASA-PS III/IV patients 2

Additional Immediate Orders

• Pass a nasogastric tube after intubation is complete and ventilation established to minimize need for later interventions 1
• Administer supplemental oxygen, though high-flow oxygen should be titrated against saturations to conserve supplies during transfer 1
• Ensure intravenous cannulae and adequate oxygen supplies are accessible for transport 1

Cardiovascular Management

Fluid and Vasopressor Strategy

• Define conditions for fluid challenge and early administration of catecholamines to decrease cardiovascular complications 1
• Monitor for post-intubation hypotension, which occurs in approximately 15-27% of patients 1
• Small, frequent doses of sedatives minimize haemodynamic side-effects 1

Monitoring Requirements

Continuous Monitoring

• Continuous waveform capnography (mandatory) 1
• Pulse oximetry 1
• Heart rate and blood pressure 1
• Respiratory rate 1
• Level of consciousness 1

Documentation

• Record depth of endotracheal tube insertion prominently 1
• Document rationale for any medication given using specified criteria (e.g., "for accessory muscle use") 1
• Create a visual record of tracheal intubation that should be prominently visible on the patient's chart 1

Sedation Management Principles

Avoiding Awareness with Paralysis

• Accidental awareness is more likely when neuromuscular blocking drugs are used, particularly in emergency patients with high pre-intubation Glasgow coma scores 1
• If rocuronium was used for intubation (duration ~30 minutes vs. succinylcholine ~10 minutes), ensure adequate sedation is established before paralysis wears off 4
• Titrate sedatives against physiological variables with small, frequent doses 1

Sedation Adjustment

• Allow approximately 2 minutes for onset of peak drug effect when titrating propofol 2
• Titrate infusion rates downward in absence of clinical signs of light sedation to avoid excessive administration 2
• Avoid rapid bolus administration, especially in elderly, debilitated, or ASA-PS III/IV patients (increases risk of hypotension and respiratory depression) 2

Special Considerations

High-Risk Populations

Elderly, debilitated, or ASA-PS III/IV patients:

• Reduce propofol dosage to approximately 80% of usual adult dosage 2
• Avoid rapid bolus administration 2
• Expect exaggerated hemodynamic and respiratory responses 2

Traumatic brain injury patients:

• Use propofol and fentanyl combination in normotensive/hypertensive patients 3
• Consider midazolam and fentanyl or ketamine alone in hypotensive patients 3
• Maintain normocapnia (end-tidal CO2 4.0-4.5 kPa) 1

Propofol Infusion Syndrome Warning

• Monitor for metabolic acidosis, hyperkalemia, lipemia, rhabdomyolysis, hepatomegaly, renal failure, and cardiac failure 2
• Major risk factors include: decreased oxygen delivery, serious neurological injury/sepsis, high-dose vasoconstrictors/steroids/inotropes, and prolonged high-dose propofol (>5 mg/kg/h for >48 hours) 2
• If increasing propofol requirements or onset of metabolic acidosis occurs, consider alternative sedation 2

Common Pitfalls to Avoid

• Never start mechanical ventilation before cuff inflation 1
• Do not rely solely on pulse oximetry for monitoring ventilation (it is not designed as a ventilation monitor) 1
• Avoid abrupt discontinuation of sedation, which may result in rapid awakening with anxiety, agitation, and resistance to mechanical ventilation 1, 2
• Do not use propofol vials on more than one person or access more than once (risk of bloodborne pathogen transmission) 2
• Avoid bolus administration of 10-20 mg propofol except to rapidly increase sedation depth in patients where hypotension is unlikely 2
• Do not co-administer propofol through the same IV catheter with blood or plasma (compatibility not established) 2