Tracheostomy-Bedside in ICU

 

Policy

Blue surgery (trauma and emergency general surgery) may perform open tracheostomy procedures in the intensive care setting with the required staffing, safety procedures and equipment.   

 

Procedure

1.       Staffing for the tracheostomy must include:

a.       Attending blue surgery faculty

b.      Blue Surgery assistant x2 (fellow, resident, APP): assist procedure-performing provider

c.       Trauma Surgical Services Divisional Charge Nurse (DCN): circulating, and cautery safety ** no patient care, this is a safety supervision role**

d.      Respiratory therapist: airway, ventilator management

e.       ICU nurse: sedation and patient monitoring only

*Procedures must include all required staffing in order to proceed.  If the DCN is unable to be pulled from staffing, the case cannot proceed.

 

2.      Equipment and supplies required: (equipment, trays, consumable supplies)

1.      Equipment

a.       Electrosurgical Unit (ESU)

b.      Headlights x 2

c.       Mayo stand/bedside table

d.      Suction with suction tubing

e.       Trach tray (Resident/fellow/APP/DCN to obtain tray from Central Sterile department)

2.      Supplies (Appendix 1)

 

3.      Confirm the presence of a completed consent prior to the procedure.  Inpatient consents must be done within 48 hours.  Refer to policy #A06-000, Consent to Treatment.

 

4.      All sharps and x-ray detectable sponges shall be counted prior to the procedure and upon skin closure in a consistent and visual manner.  The DCN keeps a running total of the counted items on the count board or count sheet.  All counts are audibly and visually performed by the DCN and the blue surgery assistant/scrubbed team member.  Refer to policy #A08-190, Procedural Counts.  

 

5.      Adhere to proper and safe use of the electrosurgical unit (ESU) per UK policy OR 04-03.  To include safe use of the active electrode, and dispersive electrode during monopolar electrosurgery, and the required EMR documentation.

 

6.      Caution should be used during surgery on the head and neck when using an active electrode in the presence of combustible anesthetic gas and oxygen-enriched environments such as the ICU.  Use the lowest possible concentration of oxygen that provides adequate patient oxygen saturation.  Note: The respiratory therapist (RT) will pre-oxygenate that patient at 100%; decrease to 60% during the pre-procedural time-out; and reduce further to less than 30% while electrosurgical unit (ESU) is in use.  The RT may titrate to 21% if patient is able to tolerate.  Provider will communicate to RT when the ESU is being activated.

 

7.      Follow fire safety measures when electrosurgery is in use according to local, state, federal regulations and UK policy A10-090, Surgical Fire Safety.

a.       The DCN conducts a fire prevention assessment in collaboration with the surgical team, communicates results, and initiates the fire risk protocol accordingly (Appendix 2); document assessment in the EMR

b.      Verify that nonflammable materials (wet towel, sterile water or saline) are available on the field to extinguish a fire should one occur, and monitor that moistened sponges are used near the active electrode tip

c.       Use a water-soluble gel to cover the patient’s facial hair & use water-soluble eye lubricants

d.      Adhere to fire safety strategies related to skin prep, policy OR 03-06, Procedural Skin Prep

                                                              i.      Allow skin antiseptic agents to dry completely before sterile drapes are applied and prior to use of the ESU

                                                            ii.      Adhere to manufacturer’s recommendations for dry time of antiseptic agent.  Maintain strict adherence to recommended dry time of skin preparation; the DCN /APP will use a timer to measure adequate prep dry time prior to activation of the ESU

 

8.      Refer to policy OR10-02, Smoke Evacuation.  The thermal destruction of tissues from the ESU creates a smoke byproduct called plume and must be evacuated with proper smoke evacuation equipment. 

 

9.      Instrument decontamination/sterilization

a.       Reusable trays and instrumentation will be covered and transported to the Central Sterile department for proper cleaning and sterilization as soon as possible after use by the DCN.

b.      In preparation for transport to a decontamination area, sharp instruments must be segregated from other instruments and confined in a puncture-resistant container; to prevent sharps injury, disposable blades will be used and should be discarded accordingly.

c.       Keeps instruments moist until they are cleaned.

d.      The provider or his/her designee will transport soiled instruments to OR Central Sterile in a closed container, leak proof, and labeled with biohazard label.

 

10.  Training and education

a.       The DCN/APPs will complete facility-required education and competency verification activities related to electrosurgery and fire safety/fire reduction strategies, initially and annually thereafter.

 

 

 

References

Association of periOperative Registered Nurses (AORN).  (2020).  Guideline for electrosurgical safety.  In: Guidelines for Perioperative Practice.  Denver, CO: AORN, Inc.

Association of periOperative Registered Nurses (AORN).  (2020).  Guideline for environment of care.  In: Guidelines for Perioperative Practice.  Denver, CO: AORN, Inc.

Managing Agitation and Aggression after Traumatic Brain Injury (TBI)


Background

Definitions
The objective of this guideline is to assist providers in managing acute agitation and aggression in TBI
patients admitted to UK by providing therapies, both environmental/non-pharmacologic and
pharmacologic, to consider based on current level of evidence available. This guideline is not meant to
replace clinical judgement. It does not address chronic TBI/rehab management. Where applicable,
recommendations have been graded to note quality of available evidence for described therapies.

Agitation – disturbed behavior as a result of overactivity; an early symptom occurring as a feature of post-traumatic delirium/confusional state

Aggression – verbal and physical aggression against self, objects, and other people; more likely to be seen late after injury and is often part of a personality change

Impact
  • In the first 6 months after TBI, adults are 3x more likely to show aggression compared to those with multiple traumatic injuries but without TBI
  • Seventy percent of adults experience agitation during inpatient TBI rehab
  • Agitation has been show to negatively affect rate of recovery in acute inpatient rehabilitation
Symptoms
  • Akathisia
  • Disorientation
  • Explosive anger 
  • Irritability
  • Maladaptive behavior
  • Mood lability
  • Physical and verbal aggression
General Principles

  • Continue pre-TBI medication therapies such as antidepressants/psychoactive medications, as abrupt withdrawal may negatively contribute to agitation
  • Limit use of new medication therapy that may contribute to CNS depression (e.g. methocarbamol, gabapentin, etc.), unless clear benefit outweighs risk
  • Optimize pain control (see COM – Adult – Analgesia (Non-Intubated) order-set) Management
I. FIRST LINE THERAPY: Environmental Modifications (High-Quality Evidence)


  • Promote sleep hygiene, reduce noise, reduce interruptions 
    • Reduce stimuli and optimize sleep wake cycle:
    • Consider fatigue and allow patient down time
    • Limit number of visitors at one time
  • Use orientation / memory strategies
    • Ensure the management of anxiety and reassuring [Non-Violent Crisis Intervention training program, for example]
    • Recommended involving family members on the way to react in order to avoid escalation of aggression, how to adopt calming attitudes toward patient
  • Discard all non-essential physical constraints
  • Remove lines/catheters as soon as possible
  • Minimize sources of discomfort
    • Optimize pain control
    • Address GI distress, reflux, constipation
  • Manage drug withdrawal
  • Identify and address seizures (subclinical epilepsy may present as aggression)
  • Limit polypharmacy
    • Eliminate unnecessary medications
    • Medication sassociated with agitation should be used based on risk/benefit analysis (amantadine, levetiracetam, stimulants, benzodiazepines, antihistamines, etc.)
  • Consult PM&R as they could potentially shorten length of stay if agitation is only issue keeping
    patient from discharge
II. PHARMACOLOGIC MANAGEMENT:
Despite the prevalence of agitation following TBI, a limited number of studies have evaluated pharmacological interventions for the management of acute agitation/aggression. Furthermore, even within the limited number of studies evaluated, each study was limited by sample size, heterogeneous patient populations, and an unclear risk of bias. For this reason, this guideline strongly urges the routine use of a comprehensive risk/benefit evaluation when deciding to initiate any pharmacological treatment given limited and/or low-quality evidence.
Recommendations provided in this section are not all inclusive, and alternative therapies may be appropriate. A multi-disciplinary approach, with assistance from clinical pharmacist, consult services (neurology and neurosurgery), and PM&R input should be strongly considered.









References
  1. Luaute J, Plantier D, Wiart L, et al. Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations. Ann Phys Rehabil Med 2016; 59:58-67.
  2. Lombard LA, Zafonte RD. Agitation after traumatic brain injury: considerations and treatment options. Am J Phys Rehabil 2005;84:797-812.
  3. Brooke MM, Patterson DR, Questad KA, Cardenas D, Farrel-Roberts L: The treatment of agitation during initial hospitalization after traumatic brain injury. Arch Phys Med Rehabil 1992; 73:917– 921.
  4. Fleminger S, Greenwood RJ, Oliver DL: Pharmacological management for agitation and aggression in people with acquired brain injury. Cochrane Database Syst Rev 2006; 1:CD003299
  5. Mousavi SG, Amini M, Mousavi SH: Prevention of more complications in patients with head trauma. Int J Preventive Med 2013; 4:1210–1212.
  6. Kim E, Bijlani M. A pilot study of quetiapine treatment of aggression due to traumatic brain injury. J Neuropsychiatry Clin Neurosci 2006;18:547–9.
  7. Mysiw WJ, Bogner JA, Corrigan JD, et al. The impact of acute care medications on rehabilitation outcome after traumatic brain injury. Brain Inj 2006;20:905–11.
  8. Noe E, Ferri J, Trenor c, Chirivella J. Efficacy of ziprasidone in controlling agitation during post- traumatic amnesia. Behav Neurol 2007;18:7-11.

On-Q for Rib Fractures


Methamphetamine-Anesthesia Considerations and Timing of Operation