157 lines
3.5 KiB
Markdown
157 lines
3.5 KiB
Markdown
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# Extubation Readiness Checklist
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| Form ID | FRM-VENT-001 | Revision | 1.0 |
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Age/DOB | |
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| Date | |
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| Time | |
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## Pre-Extubation Assessment
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### Clinical Criteria
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#### 1. Underlying Condition Resolved/Improved
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- [ ] Yes
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- [ ] No - Explain: ____________
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#### 2. Hemodynamic Stability
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- [ ] MAP appropriate for age without significant vasoactive support
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- [ ] Heart rate stable
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- [ ] No active bleeding
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**Current Vasoactive Medications:**
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| Medication | Dose |
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|------------|------|
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#### 3. Oxygenation
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- [ ] FiO2 ≤ 0.40 (or ≤ 0.50 for neonates)
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- [ ] PaO2/FiO2 ratio > 200
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- [ ] SpO2 > 90% on current settings
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**Current Settings:**
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- FiO2: ______
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- PEEP: ______ cmH2O
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- Latest ABG: pH _____ pCO2 _____ pO2 _____ HCO3 _____
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#### 4. Ventilation
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- [ ] PaCO2 acceptable for patient
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- [ ] Peak pressure ≤ 20 cmH2O (or age-appropriate)
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- [ ] Spontaneous breathing on minimal support
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**Current Settings:**
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- Mode: ______
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- Rate: ______
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- PIP/PS: ______ cmH2O
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- Spontaneous rate: ______
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#### 5. Spontaneous Breathing Trial (if performed)
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- [ ] Performed
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- [ ] Not performed
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**If performed:**
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- Duration: ______ minutes
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- Mode: [ ] T-piece [ ] CPAP [ ] PS/CPAP
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- Tolerated: [ ] Yes [ ] No
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#### 6. Airway Protection
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- [ ] Adequate cough reflex
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- [ ] Appropriate gag reflex
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- [ ] Manageable secretions
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- [ ] Alert/appropriate neurological status
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**Secretion Description:**
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- Amount: [ ] Minimal [ ] Moderate [ ] Copious
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- Character: ____________
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#### 7. Sedation Status
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- [ ] Minimal or weaning sedation
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- [ ] Able to follow commands (if age-appropriate)
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**Current Sedation:**
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| Medication | Dose | Last Given |
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|------------|------|------------|
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#### 8. Metabolic Status
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- [ ] Adequate nutrition
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- [ ] No significant electrolyte imbalances
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- [ ] Normal temperature
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**Latest Labs:**
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- Na: _____ K: _____ Cl: _____ HCO3: _____
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- Ca: _____ Mg: _____ Phos: _____
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#### 9. Post-Extubation Plan
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- [ ] Non-invasive support planned: ______
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- [ ] High-flow nasal cannula available
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- [ ] Room air trial planned
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- [ ] RT available at bedside for extubation
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### Special Considerations
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#### For Neonates:
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- [ ] Caffeine on board (if applicable)
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- [ ] Weight > 500g (or institution-specific threshold)
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- [ ] Postmenstrual age considerations addressed
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#### For Long-Term Ventilation:
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- [ ] Airway evaluation performed (if >7 days intubated)
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- [ ] Consider subglottic edema risk
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- [ ] Dexamethasone considered (if appropriate)
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## Contraindications to Extubation
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- [ ] Active seizures
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- [ ] Neuromuscular blockade
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- [ ] Recent airway surgery
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- [ ] Significant facial/airway trauma or edema
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- [ ] Other: ____________
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## Physician Review
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**Attending Physician Notified:** [ ] Yes [ ] No
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**Extubation Approved:** [ ] Yes [ ] No
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**If No, reason:** ____________
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## Extubation Procedure
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**Extubation Date/Time:** ____________
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**Post-Extubation Support:**
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- [ ] Room air
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- [ ] Nasal cannula: ______ L/min
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- [ ] High-flow nasal cannula: ______ L/min, FiO2: ______
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- [ ] CPAP: ______ cmH2O
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- [ ] BiPAP: IPAP ______ EPAP ______
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**Immediate Post-Extubation Assessment (within 1 hour):**
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- SpO2: ______ %
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- RR: ______ breaths/min
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- HR: ______ bpm
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- Work of breathing: [ ] Minimal [ ] Moderate [ ] Severe
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- Stridor: [ ] None [ ] Mild [ ] Moderate [ ] Severe
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## Signatures
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| Role | Name | Signature | Date/Time |
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|------|------|-----------|-----------|
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| RN | | | |
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| RT | | | |
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| MD/NP | | | |
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---
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*Form FRM-VENT-001 Rev 1.0*
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