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CASE PRESENTATION

Case 1: ICU Patient with Acute Respiratory Failure, Now Requiring Intubation

A previously well 55-year-old, 90 kg man presented to hospital 3 days earlier with fever, muscle aches, and mild respiratory symptoms. He spent the first 48 hours of his hospital stay in the ward before being admitted to intensive care with increasing oxygen requirements and progressive respiratory symptoms. Due to worsening oxygen saturation and fatigue, the intensive care team determined that he required intubation.

The intubation team was assembled, comprising a staff anesthesia practitioner, airway assistant, personal protective equipment (PPE) spotter, and the patient’s bedside nurse in intensive care unit (ICU). The patient was moved to a negative pressure isolation room in the ICU for intubation.

The intubation team donned airborne level PPE, including a fit-tested respirator mask, goggles, face shield, full-length gown, and two pairs of gloves. An intubation pack for a male patient (including an 8.0-mm ID endotracheal tracheal [ETT], anesthesia mask, size 4 and 5 extraglottic airway devices [EGDs], Guedel and nasopharyngeal airways, and disposable hyperangulated blades for the video laryngoscope [VL]) was brought into the negative pressure room, which already had a prepared VL with a stand-alone monitor screen. Only the intubation team were present in the room, with the doors closed.

At the time of intubation, the patient had oxygen saturations of 92% on 10 L oxygen via a non-rebreathing mask. His BP was 150/75 and HR 110. An intravenous cannula and arterial line were both in-situ. Following adequate denitrogenation using a tight-fitting face mask and self-inflating bag, apneic oxygenation using humidified high-flow nasal oxygen (HFNO) was used due to the potential for severe hypoxemia. To reduce the risk of hypotension, intravenous fluids are administered at the time of induction and vasopressors are prepared. The chosen induction drugs were midazolam 2 mg, ketamine 150 mg, and rocuronium 100 mg. Cricoid pressure was applied, and the patient was intubated swiftly on the first attempt. The ETT cuff was inflated and the ICU ventilator connected, with in-line suction. Once the ETT position was confirmed with ETCO2 and by observing equal chest movement, cricoid pressure was removed and lung protective ventilation commenced. The single-use airway equipment was immediately disposed of into a plastic bag along with the outer pair of gloves for the airway operator and assistant.

One at a time, the intubation team left the room, doffing their gown and gloves in the negative pressure room and entering the anteroom. Within the anteroom, after performing hand hygiene, the eye shield and goggles were removed. Hand hygiene was repeated and the respirator mask removed. Hand hygiene was performed again before leaving the room.

After completion of the room resting time, the patient was moved out of the negative pressure room and into a COVID-designated ICU bay. The negative pressure room was thoroughly cleaned and reset for ...

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