Mechanical Ventilation 04

8/3/2019 Mechanical Ventilation 04

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Content

y Case background

y Episode 1

y Episode 2

y Nursing Management

y Discussion

y References

y Q & A Session

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Mr. Chans Background

y Male

y 36 years old

y NKDA

y Real-estate agenty Chronic Smoker

y Heavy drinker : 10 cans of beer/Day

Phx:

y Hx of delirium in 2009 when admitted toOrthopedicward for left hand cellulitis Tx

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Admission

Chief complains:y Admitted to AED on 19/10/10 at 0800 because of increased SOB

y Fever + Diarrhea X 3/7 days

y No vomiting

y No abdominal pain

y No URTI

y No UTI symptoms

y TOCC-ve

Vital signs:

y BP:142/79 mmHg, Pulse:146 beat/min, Temperture:39.3,

RR44 /min when on15L O2via non-rebreathing mask

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Physical Examination & Investigation

y CNS : alert and orientated, warm periphery

y Abd: soft, no tenderness

y ECG: SR

y

HS :normal, no murmury Hstix 6.7 mmol/L

y Haemo cue :10.1

y ABG: Type 1 respiratory failure

y CXR : Left lower zone haziness

y Bld C/ST taken given

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ABG interpretation(before giving non-rebreathing mask)

Type 1 respiratory failure

y Hypoxaemic respiratory failure (failure to oxygenate)

y PaO2 < 8 kPa (60 mmHg) and/or PaCO2 < 6.6 kPa (50mmHg).

y Causes:

y Hypoventilation

y Pulmonary Disorders (e.g. ARDS, pneumonia, emphysema)

y

Oxygen Delivery & Uptake Imbalance (DO2/VO2 Imbalance)(e.g. right-to-left shunt, pulmonary embolism)

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pH

pO2

pCO2 Black & Hawks (2005)


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ABG interputation:(Before giving non-rebreathing mask)

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Time 08:12 19/10/10 Normal range

pH 7.43 7.35-7.45

pCO2 3.2 4.7-6.4 kPapO2 8.2 11.0-14.4 kPa

Act. bicarbonate 16 18-23 mmol/L

Total CO2 17 19-24 mmol/LBase Excess -7 -2 - +2 mmol/L

O2 Saturation 0.93

Diagnosis: Type 1 respiratory failure


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Treatment Plan

y O2 15L to keep SpO2 95%

y 1/2:1/2 sol. 70ml/hr

y Keep MAP 65mmHg

y IV A/B

y IV Augmentin

y Septic workup +stool C/ST

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Treatment Plan

Non-rebreathing mask

y Delivers 95% Oxygen at 10-12 L/min

y Two valves added to rebreathing mask prevents:

Entrainment of room air during inspiration Retention of exhaled gases during expiration

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Black & Hawks (2005)


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Mr. Chans progress10

0920 19/10/1015L O2 via

non-rebreathing

mask

1600 19/10/10IntubationPRVC mode

2035 19/10/10Changed PRVC

mode to PS mode

1200 26/10/10Extubated, 6L O2via Hudson mask


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Mr. Chans progress11

0920 19/10/1015L O2 via

non-rebreathing

mask

1600 19/10/10IntubationPRVC mode

2035 19/10/10Changed PRVC

mode to PS mode

1200 26/10/10Extubated, 6L O2via Hudson mask

Episode 115L O2 via Non-rebreathingmaskIntubation(PRVC mode)

Episode 2From PRVCmode PSmade


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Episode 1:Non-rebreathing maskIntubation(PRVC)

Mr. Chans situation before intubation:

y Very distressed and confused later afternoon

y 1600: increased SOB, SpO2 92%, RR 36/min

ySuggestion: Respiratory alkalosis?

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ABG interputation(before intubation)

Time 08:12

19/10/10

09:07

19/10/10

11:42

19/10/10

14:24

19/10/10

Normal range

pH 7.43 7.48 7.50 7.47 7.35-7.45

pCO2 3.2 3.1 3.6 3.6 4.7-6.4 kPa

pO2 8.2 9.5 11.3 7.9 11.0-14.4 kPa

Act.

bicarbonate

16 17 20 19 18-23 mmol/L

Total CO2 17 18 21 20 19-24 mmol/L

Base Excess -7 -5 -2 -3 -2 - +2 mmol/L

O2Saturation

0.93 0.96 0.97 0.93

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15L O2 via non-rebreathing mask

Respirator

alkalosis

Room air

alkalosis

+

pCO2 pH=


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ABG interputation(before intubation)

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Alkalosis

pCO2

pH

respiratory alkalosis

Respiratory

alkalosis

+

=


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Respiratory alkalosis

Cause:

y Extreme anxiety

y Hypoxia

y CHFy Excess Mechanical Ventilation

S&S:

y Dizziness, depressed respiration, disorientation etc.

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Swearingen & Keen (2002)


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Intervention

Intubation at 17:35

y intubation grade 2B larynxonly the arytenoids or the very posterior origin of

the cords visible

y on PRVC mode

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Ventilator PRVC mode

y Pressure RegulatedVolume Control

yAttempt to deliver the desired set tidal volumeusing the lowest possible pressure

y Every breath delivered, either ventilator initiated(control) or patient initiated (assist), are identical

y Peak inspiratory pressure (PIP) will vary

depending ony lung mechanics. (compliance and airway resistance)

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Wiegand & Carlson (2011)


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PRVC

Advantages

y Guarantees delivery of desired tidal volume.

y Minimizes risks of barotrauma due to high peak

pressures.

y Decelerating flow pattern may provide betterdistribution of ventilation and oxygenation.

y

Can better meet patients inspiratory flow demands.

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Setting of ventilator

y FiO2:1.0

y Set Tidal Volume: 380/391

y Set RR30/30, PEEP 10 trigger flow

y Minute Volume 11.0 L/min

y Airway Pressure 23

y Contd sedated with Midazolam 4mg/hr

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Ventilator Setting (PRVC)20

Ventilator mode PR VC

FiO2 1.0

Preset Tidal Volume 380 ml

Preset RR 30 brealth/minPEEP 10 cmH2O

Minute Volume 11.0 L/min

Airway Pressure 23 kPa

Contd sedated with Midazolam 4mg/hr


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Midazolam

y CNS deprssant

y Indications: Induction of general anesthesia

Continuous sedation of intubated and mechanically ventilatedpatients as a component of anesthesia or during treatment inthe critical care setting

May decrease RR, cardiac output and BP Must monitorthe RR, BP, P and conscious level carefully duringadministration

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Onset Peak Duration Metabolism Excretion

Midazolam 1-3min 1-2 hrs Hepatic Urine

(Karch, 2008)


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Metabolic acidosis

Time 14:24

19/10/10

17:46

19/10/10

Normal range

pH 7.43 6.99 7.35-7.45

pCO2 3.6 5.9 4.7-6.4 kPapO2 7.9 24.1 11.0-14.4 kPa

Act.

bicarbonate

19 11 18-23 mmol/L

Total CO2 20 12 19-24 mmol/LBase Excess -3 -20 -2 - +2 mmol/L

O2Saturation

0.93 0.98

n erpre a on a erintubation)


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Causes of Metabolic acidosis

Metabolic acidosis:

excess acidity in the blood

Causes:

1. Diabetic ketoacidosis

2. Impaired Renal function

3. Salicylate Intoxication

4. Lactic acidosis5. HCO3 loss e.g. diarrhea

Preston(2002)


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Episode 2: PRVCPS

y PS mode

y Intact respiratory effort

y Decrease dependence of ventilatiory support

(preparation of wean off)

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Preparation

y Ensure Mr. Chan have spontaneous breathing

y Record the RR, SpO2 etc. as the baseline assessment

y Provide suction and ETT care to maintain airway

patencyy Prepare resuscitation equipments for sudden

changes of patients condition

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Ventilator Setting (PS)26

Ventilator mode PS

FiO2 0.7

PEEP 8 cmH2O

PS 16 cmH2OPatients Tidal Volume 430 ml

Patients RR 25 breaths/min

Patients Minute Volume 10.8 L/min


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Mr. Chans progress

y 20/10/10 1300y Patient awake but agitatedy BP130/60, HR120/miny

Increased midazolan to 12mg/hr + Propofol150mg/hry PS decreased to 12y PEEP 8 flow triggery Pt tidal 429mly Min vol 11.2y RR 24/min

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Propofol

y General anesthetic

y Indications: Induction and maintenance ofgeneral anesthesia

sedation in intubated or respiratory-controlled patients short duration

Side effects:

include direct myocardial depression

reduces cerebral blood flow and may cause mild CNSexcitation activity (e.g., myoclonus, tremors, hiccups)

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Onset Peak Duration Metabolism Excretion

Propofol 30-40sec 2 min 4-8 min Hepatic Urine

Karch (2008) , & Roberts & Hedges (2009)


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Propofol VS Midazolam29


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20/10 1700y BP 100/55 HR 80/minStart Nor-adrenaline infusion to keep MAP >=6522/10/10 1500

y Off midazolan infusiony Decreased propfol to 50mg/hry Nor-adrenaline infusion stopped25/10/10y Off propfoly On PSy FiO2 0.45, PS 10, PEEP 8y Pt Min vol 8.9L, tidal 512ml, RR 19/min

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Prepare to wean off ventilator


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Nursing Management

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Goals of Nursing Management

1. Maintain adequate gaseous exchanges & breathingof patients

2. Prevent development of complications due to

mechanical ventilation and immobility3. Prepare patient to wean offmechanical ventilation

4. Maintain adequate nutrition for hypermetabolicstatus

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Potential Complications

y Pneuomothorax

y Ventilation Acquired Pneumonia (VAP)

y Nosocomial Pneumonia

y ETT Blockage

y Pulmonary edema

y Hypoxemia/Hyperxemia

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Nursing Management

y Provide endotracheal tube care

y Provide ventilator circuit care

y Observe for hemodynamic changes

y Monitor for S&S of acute respratory distress,hypoxemia, hypercarbia and fatigue

y Provide general nursing care:

Positioning

Psychological support to family

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Endotracheal Tube (ETT) Care

y Maintain airway patency

prn suction to remove excess secretions

y Proper placement

reconfirm marking (at incisor) secure or retape the tube

y Suctioning

Suction down the tube and mouth cavity

Monitor the amount and characteristics of secretions

y Oral care alternate ET tube to bilateral mouth corners

protect the mouth corner with duoderm sand note ulcers

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Black & Hawks (2005) & Wiegand & Carlson (2011)


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Ventilator Circuit Care

y Check ventilator settings and alarm limits every shiftand after suctioning or bagging

Settings must be same as physician's orders

y Troubleshooting of ventilator alarmsy Close monitor patients condition after any changes

of ventilator settings

y Proper ET tube care to maintain airway patency

y Never ignore or disable the alarms

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Observe for hemodynamic changes

y May indicate functional changes in circulating volume

y Identify potential of pneumothorax

Report if:

y BP

y Change in heart rate ( or greater than 10% of base line)

y cardiac output

y

mixed venous O2 tension

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Monitor for S&S of acute respratory distress,hypoxemia, hypercarbia and fatigue

Report if:

y Significant changes in pH, PO2, PCO2, or SaO2

y Tachycardia

y or BP

y Sallow/irregular respirations

y Tachypnea, bradypea,/ dyspnea

y

Mental statusy Restlessness, confusion, lethargy

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References

Black, J.M., & Hawks, J.H. (2005). Medical-surgical nursing: clinical management forpositive outcomes (7th ed.). Philadelphia: Elsevier Saunders.

Karch, A. (2008). 2008 Lippincootts nursing drug guide. Philadelphia: Lippincott Wiliams& Wilkins.

Roberts, J.R., & Hedges, J.R. (2009). Clinical procedures in emergency medicine (5th ed.).Philadelphia: Elsevier Saunders.

Preston, R.A. (2002).Acid-Base, Fluids, and Electrolytes: made ridiculously simple. Miami:MedMaster, Inc.

Swearingen, P.L., & Keen, J.H. (2002). Manual of critical care nursing: Nursinginterventions and collaborative management(4th ed.). St Louis: Mosby.

Wiegand, D.L., & Carlson, K.K. (2011).AACN Procedure Manual for critical care (6th ed.).Philadelphia: Elsevier Saunders.

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Q & A Session

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Time 08:12

19/10/10

09:07

19/10/10

11:42

19/10/10

14:24

19/10/10

17:46

19/10/10

18:23

19/10/10

Normal range

pH 7.43 7.48 7.50 7.47 6.99 7.31 7.35-7.45

pCO2 3.2 3.1 3.6 3.6 5.9 4.7 4.7-6.4 kPa

pO2 8.2 9.5 11.3 7.9 24.1 21.6 11.0-14.4 kPa

Act.

bicarbonat

e

16 17 20 19 11 17 18-23

mmol/L

Total CO2 17 18 21 20 12 18 19-24

mmol/LBase

Excess

-7 -5 -2 -3 -20 -8 -2 - +2

mmol/L

O2Saturation

0.93 0.96 0.97 0.93 0.98 0.99

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Mechanical Ventilation 04

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