4.3.24

Caring for the Ventilated Patient: an update from acute management to weaning

Suzanne M. Burns, RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM

Session Objectives:

1. Describe the rationale and use of selected ventilator parameters, modes and mode options, and the prone position in the management of ARDS patients.

2. Discuss the ventilatory management of status asthmaticus and the use of PEEP. 3. Discuss the use of strategies such as protocols for ventilator and sedation

weaning, and system initiatives, to improve outcomes in the long-term ventilated patient.

4. Identify the “best-practice” related to other key aspects of care of the ventilated patient such as nutrition, mobility, and “prophylaxis interventions”.

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Caring for the Ventilated Patient: an update from

acute management to weaning

Suzanne M. Burns RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM

(3/15/04)

Session Objectives

Describe the rationale and use of selected ventilator parameters, modes, and mode options, and the prone position in the management of ARDS patients.Discuss the ventilatory management of status asthmaticus and the use of PEEP. Discuss the use of strategies such as protocols for ventilator and sedation weaning, and system initiatives, to improve outcomes in the long-term ventilated patient. Identify the "best-practice" related to other key aspects of care of the ventilated patient such as nutrition, mobility, and "prophylaxis interventions".

“Managing” ventilated patients

The longer you are on the ventilator…..

the longer you are on the ventilator!

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Outcomes of Long-term Mechanical Ventilation

CostMorbidity and MortalitySatisfaction: patients families & staff

Acute Management: Case Study

Mr X, 59 year old, admitted for a community acquired pneumonia three days ago.Now on 100% non-rebreather, short of breath, confused and agitated.ABG: 7.36/38/55. Chest x-ray: bilateral diffuse white-out, no increase in heart size.Sent to MICU where he is intubated and ventilated.

Case continued:

Vent settings: FiO2=80%, Mode=A/C, tidal volume (Vt)=840ml (12 ml/kg), rate (fx)= 15 (patient fx=25), Ti=0.5 sec, PEEP=5cm H2OABG after 30 min: 7.30/35/57.PaO2/FiO2 (P/F ratio)= 71Still agitated and thrashing!

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What’ wrong with Mr. X?

How do you know?

Which of these choices would be reasonable?

increase FiO2 to 100%increase PEEP: 14-16 range.decrease Vt to 6 ml/kgincrease set fxchange modeincrease Tisedate and consider paralytics

“Volu-Press” Trauma

Large Vt’s create high pressuresInjury to the stiff lung at plateau pressures > 35 cm H2O for > 72 hoursAlveolar fractures and edema : non-ARDS, ARDS (Dreyfuss et al)

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Plateau Pressure(a.k.a. static, distending and alveolar pressure)

Measure with an end-inspiratory hold maneuver on vent.Plateau pressure is the pressure required to hold the lung open. Difference between Peak and Plateau Pressures is 10-15 cm H2O.

Peak and Plateau Pressures

Repetitive Opening Injuries

Stiff lungs: damaged with repetitive opening and closing.Concept of recruitment/de-recruitment.Keep the lung open to prevent further injury.PEEP, PEEP, PEEP….

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“Baby-lung”syndrome

ARDS lung not homogeneousSome air spaces are open, others not.Areas that are aerated are the “baby-lung”.Prone to injury from the distending forces of a big breath.

So what do we know in humans?

Hickling et al: low volume/low mortalityNHBLI NIH ARDS Network study: 800 patients with ARDS (P/F<200, non-cardiac, bilateral infiltrates) randomly assigned to 6 versus 12 ml/kg (lean body weight) volume ventilation. FiO2 and PEEP assigned in an algorithmic approach.

Humans continued:

ARDS Net Study stopped early: smaller Vtresulted in 25% lower mortality! (NEJM 2000)

Sub-analysis: those in the low volume group had plateau pressures < 35 (around 26), those in the traditional (also < 35).High breathing rates tolerated in study may have contributed to auto-PEEP (so what was the role of PEEP in this study?)

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Humans continued:

Amato et al (NEJM 1998): higher PEEP levels associated with improved outcomes.Recruitment versus de-recruitment.Inflection pressures….higher PEEP levels necessary.“Keeping the lung open” is difficult.

So how do we manage and what have we learned? Two major concepts…...

Lower Vts are better Keep the lung open (recruit and keep open)

Lower Tidal Volumes

6 ml/kg (don’t know about 7,8,9,10,11)pressure is important…..but we don’t know what pressure…even 35 may be too high.and,….if we lower volume and/or pressure, patient will be hypercarbic!

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Permissive Hypercarbia

Keep pH > 7.2well tolerated except in elevated ICP and in those with acute cardiac problemssome evidence that hypercarbia may be beneficial (lung protective).

PEEP (keep the lung open)

Amato et al: higher levels of PEEP are necessary (14-16 cm H2O) range.

Recruitment Maneuvers

Recruitment is an “inspiratory maneuver”.60/60, 40/40…can be dangerous.De-recruitment happens quickly…within 15 minutesAre there other ways to open and keep the lung open (modes, inspiratory/expiratory ratios, prone positioning)?

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Modes of ventilation

Volume modes assure the desired volumePressure modes assure the pressure (plus decelerating flow pattern is attractive).PC/IRV, Pressure Release Ventilation? The verdict isn’t in…. Need to measure Vts!High Frequency Oscillation: may have a place but little experience yet (reports are good…MOAT II study)…use of paralytics?

Prone Positioning

What does it do (recruitment)?Why does it work?Does it change outcomes?How do we do it? Gattanoni et al, Albert et

Putting it all together!

Mr X was sedated and paralyzed.Switched to PC/IRV ratio mode (1:1), fx: 30, IPL: 38 (mean Vt= 8 ml/kg), PEEP 14, FiO2: 80%ABG: 7.27/59/80

What else could you do?

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Status AsthmaticusCase Study

28 year old female admitted to ER with c/o wheezing and chest tightnessdiaphoretic, unable to say a whole sentence, pulse 140, peak flow 80ml, pulsus paradox 20 mmHg

Status (continued)

put on 100% non-rebreatheralbuterol and ipratropriumnebs given with no reliefpatient intubated

Asthma Case (continued)

On vent: A/C of 20, PEEP of 5 cm H20, FiO2 of 100%, Vt : 10ml/kg, Ti=1.2 secs, PIP= 65 cmH20, spontaneous rate= 30BP is 80/40, pulse=140, O2 sat= 98%ABG= pH=7.33, PaCO2= 45mmHg, PaO2= 102 mmHgPatient is agitated and thrashing

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Which Are Appropriate???

1. Sedate and paralyze2. Shorten inspiratory time3. Lower vent rate4. Measure auto-PEEP5. Increase set PEEP

Clinical Assessment of Resistance

resistance: how easily gases flow down airwaysmeasure with end- inspiratory holddifference between peak and plateau pressures normal gradient: 10-15 cm H20

Morbidity associated with the mechanical ventilation of patients with asthma

Dynamic hyperinflation and auto-PEEPHypotension, effect on venous return and wedge pressures Barotrauma

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Asthma and W.O.B.

Mechanical disadvantage

DynamicHyperinflation

Increased W.O.B.

Dynamic Hyperinflation and auto-PEEP: contributing factors

Caused by inadequate exhalation time. Expiratory resistance, low elastic recoil, high MV, short expiratory time contribute.Mucus hyper-secretion, increased wall thickness and airway closure or collapse.Mechanical factors.

Auto-PEEP: how do we find it?

Auto-PEEP: difference between set PEEP and total PEEP.Auto-PEEP measured during an end-expiratory hold maneuver. difficult to do on spontaneously breathing patient

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Auto-PEEP and Patient-ventilator “triggering”

Self-initiated inspiratory airflow occurs when alveolar pressure is less than ambient .Ventilator sensitivity adjusted relative to set PEEP.Auto-PEEP is not sensed! Example: sensitivity of - 2, PEEP of 5, auto-PEEP of 5, means patient needs to generate - 7 cm H2O to trigger…dyssynchrony, dyspnea, discomfort results!).

Hemodynamic Compromise?

consider brief cessation of mechanical ventilation!!!

Putting the Pieces Together

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Lung Protective StrategiesFor Asthma

use volume modes low ratesshort inspiratory timeslong expiratory timesassume DH and auto-PEEP!!!

Protective Strategies (continued)

applied PEEP (may prevent early airway closure and gas trapping...allow for better emptying)permissive hypercarbia may be necessary outcome of these maneuvers!

Weaning the Ventilated Patient

Management strategies for success

(a.k.a. “it’s not just what you do with the ventilator”)

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Weaning: art or science?

Weaning Case Study:

Mr Z is 8 days s/p CABGPMH includes Type 2 diabetes, COPD and PVD.Course complicated by 3 unsuccessful extubation attempts. The last resulted in a code. Chest tube placed for pneumothoraxfollowing central line placement. Transferred to the MICU for weaning.

Case continued:

Vent settings: A/C mode, FiO2=50%, Vt= 600ml (10 ml/kg), fx=20 (total rate is 25), Ti=1.2 sec, PEEP=5 cm H2O.

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Case continued:

On sliding scale insulin (glucose range: 100-350), albumin=1.8, nutrition via TPN (had diarrhea and had high residuals with enteralfeedings), weight=up 7 kg, agitated, in pain, nervous, has not slept in days. Has not been mobilized. Auto-PEEP is 10, MV=15 L.NIP= -55, PEP= +50, SVt= 200ml

Which of the following would be reasonable?

Do weaning parameters againExtubate if parameters goodDo a full assessment: BWAP or otherCheck for auto-PEEPChange mode and settings

Reasonable….?

Pain, nutrition and PT consultsTight glucose control: insulin infusionCheck for c-diffAnxiolyticsConsider tracheostomy

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What About Standard Weaning Predictors?

NIP: < - 20 cmH20PEP: > +30 cmH20SVt: 5 ml/kgVC: 15 ml/kgOther: Fi02 <50%, secretions etc

And non-pulmonary factors to assess wean-ability?

Morganroth et al ’84, Goodnough-Hanneman ‘94, Burns ’94Comprehensive systematic assessment important to determine outcome.

Criticism of Predictors

Pulmonary specific, no inclusion of non-pulmonary factors.Predictors don’t change over time. How can they be predictive?Lack of stratification.

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What do we know?

Prediction is difficult (predictors don’t predict... but help to point to what needs improvement).Traditional Predictors are pulmonary specific (NIP, PEP, Vt, VC etc.).Non-pulmonary factors important.Important to assess all systematically.

Weaning Predictors and Weaning Methods

2 large scale reviews (Cook et al, McIntyre et al) note that predictors to date fall short!!!Little evidence exists related to specific modes for weaning. However methods, specifically protocols and multidisciplinary approaches…... appear to work!Attention to clinical factors prior to weaning!

So How Does a Multidimensional Predictor

Perform?

A Preliminary Evaluation of the BWAP

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Questions

Does the BWAP score change over time?Is the BWAP score predictive of weaning potential?Do different populations of patients perform differently? Are any of the individual factors important to weaning outcome?

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Design

Prospective data collection on all patients requiring LTMV (> 3 days) in 5 adult ICUs between 3/1/2001 and 12/31/2003. Data part of an on-going quality project using APNs as “Outcomes Managers” to manage and monitor the patients.Burns SM, Earven D, Fisher C, Lewis R, Merrel P, Schubart J, Truwit JD, Bleck T. Implementation of an Institutional Program to Improve Clinical and Financial Outcomes of Patients Requiring Mechanical Ventilation: One year outcomes and lessons learned. CCM 2003

Materials and Methods

BWAP at regular intervals. -two to three times weekly to assess factors for intervention and to track progress.-within 24 hours of wean.-within 24 hours of failure.

BWAP Assessments

• 989 BWAP measurements made immediately prior to a successful wean attempt.

• 158 BWAP measurements made immediately prior to an unsuccessful wean attempt (unsuccessful extubation).

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Days On Vent By Patient Group

1312141912Mean

989148Median

142849413397704N (cases)

OverallDiedDisch, W/O Wean

Weaned, Alive, Un-successful

Weaned,Alive, Successful

Group 4Group 3Group 2Group 1

LOS by Patient Group

2723323828Mean

2015232721Median

142849413397704N (cases)

OverallDiedDisch, W/O Wean

Weaned, Alive, Un-successful

Weaned,Alive, Success-ful

Group 4Group 3Group 2Group 1

Questions

Does the BWAP score change over time?Is the BWAP score predictive of weaning potential?Do different populations of patients perform differently?Are any of the individual factors important to weaning outcome?

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What Does the Weaning Trajectory Look Like?

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Questions

Does the BWAP score change over time?Is the BWAP score predictive of weaning potential?Do different populations of patients perform differently?Are any of the individual factors important to weaning outcome?

BWAP Scores by Group: Comparison Between Successful and

Unsuccessful Wean Attempts

415537544357-55Mean<.0001<.0001< .0001P value:

WilcoxonRank Sum

425438584258-54Median

16598851106114101-781BWAPs

ALLN

ALLY

DeadN

DeadY

A/USN

A/USY

A/SN

A/SY

Group>Wean>

Questions

Does the BWAP score change over time?Is the BWAP score predictive of weaning potential?Do different populations of patients perform differently? Are any of the individual factors important to weaning outcome?

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BWAP Scores by Units: Comparison Between Successful and

Unsuccessful Wean Attempts

<.0001<.00010.00030.021<.0001P-ValueWilcoxonRank Sum

41553957455742493855Mean

42543858425842503854Median

15694347117342823816237329BWAPs

ALL

N

ALL

Y

CCU-TCV

N

CCU/TCV

Y

SICU

N

SICU

Y

NICU

N

NICU

Y

MICU

N

MICU

Y

Group

Wean?

Questions

Does the BWAP score change over time?Is the BWAP score predictive of weaning potential?Do different populations of patients perform differently? Are any of the individual factors important to weaning outcome?

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Binary Logistic Regression Model

Resulting coefficients provide estimate of effects of each individual predictor – all others being held constant.

Summary of the Nine Most Predictive BWAP Factors

0.0007PaO20.04pH0.01Airway (size)0.0000Rate and pattern0.003Strength 0.001Bowel0.03Anxiety (subjective)0.01Rest (subjective)0.04HemodynamicsP value

Modes for Weaning: a tale of two studiesBrochard AJRCCM ’94 and Esteban NEJM ’95

Criteria for entry (ready to wean).Trial of spontaneous breathing.Successful for 2 hours, extubated(20% re-intubation rate).Those who failed, randomly assigned to a mode for weaning.Studies demonstrated disparate results.But protocols safe?

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Case Study (continued)

Mr Z does better on PSV ventilation, and is rested for 24 hours on PSV max. PEEP is increased to 7 cm. Nutrition sees patient and enteral feedings are initiated. An insulin infusion is initiated for “tight” glucose control. Patient is ambulated in the hallway by PT. C-diff titers are sent (negative) and by day 3, BWAP score is 50% (meets entry criteria for protocol assignment).

Weaning Protocols: the science

Ely NEJM ‘96Kolleff CCM ‘97Brochard AJRCCM ’99Vitacca AJRCCM ‘01 (COPD)Positive Outcomes: duration of ventilation, complications, cost of care.No change in mortality.

Sedation: too much?The case for protocols continues...

Brook et al (CCM 1999)Kress et al. (NEJM 2000)Outcomes: decrease in vent time and LOS but not mortality.

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Improved Outcomes of Protocols for Weaning and Sedation

(prospective randomized trials, *sign)

NoYes*Yes*Yes*Brook CCM ’99 (sedation)

NoNoYes*Yes*Kress NEJM ’00 (sedation)

NoNoNoYes*Ely NEJM ’96 (wean)

NoNoNAYes*Kollef CCM ’97 (wean)

MortalityHosp-LOSICU-LOSVent Duration

Protocols:are NOT

“cookbook medicine”!!!

They decrease variation in practice!

However…….

Protocols are not automatic!Ely et al AJRCCM ’99: “Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning”.Buy-in and systematic attention to assuring that process is adhered to is essential. Easy to “drop the ball”!

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Protocols

Putting them into practice!

Some Concepts

Respiratory muscle fatigue.Work, rest, and conditioning.

Respiratory Muscle Fatigue

All muscles can be made to fatiguehypermetabolic, weak, poor nutritional stateonce fatigued, takes 12-24 hours to restmode and method important

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Fatigue: Signs and Symptoms

dyspneatachypneachest/abdominal asynchronyelevated PaCO2 (late)

Respiratory Muscle Rest

Volume modes: cessation of spontaneous effortPressure Modes: dependent on level….RR< 20/min, Vt 8-12 ml/kg, absence of accessory muscle use12-24 hours to rest

Conditioning

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“Sprints”

strengthening conditioninghigh pressure-low volume workshort duration, full restCPAP, T-piece, low IMV rates

“Gentle Wean”

endurance conditioninglow pressure-high volume workconditioning episodes longer durationpressure support ventilation

Protocols: the essentials“when to go, when to stop”

Criteria for entry (ready to “go”).Signs of intolerance (time to “stop”…..generally non-invasive measures).Defined work intervals.Defined rest and how to rest. Not complicated, everyone involved!One shoe…does not fit all!

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Daily Screen: example

Hemodynamic stabilityFIO2 < 50%PEEP < 5BWAP > 45%5 min. CPAP trial without signs of intoleranceProtocol assignment

Signs Of Intolerance

RR>35 for 5 min.0xygen saturation < 90%.HR>140 or 20% change in either direction.Systolic BP>180 or <90mm Hg.Excessive anxiety or agitation.Diaphoresis

Definition Of Rest

PSV Max: RR<20 and Vt 8-12ml/kg.Volume modes: cessation of spontaneous effort.

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CPAP Protocol

1 trials attempted daily. Last no more than 2 hrs.Rest with any signs of intolerance.1 sustained trials, approach team about extubation.Full muscle rest at night.

PSV Protocol

Activated after no progress in CPAP trial noted, and in very weak or debilitated.Start at PSV max.Decrease PSV by 2-5 increments twice in 8 hours.

PSV (continued)

If no signs of intolerance during first two hours decrease again for remaining 6 hours.Return to previous level with signs of intolerance.PSV 5cm/H20 sustained for 4 hours ...approach team for extubation.

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A word on “mixing modes”

Esteban et al. Chest ’94Survey of hospitals to determine prevalence of weaning modes.T-piece: 24%SIMV: 18%PSV: 15%SIMV + PSV: 9%Weaning time longer with SIMV + PSV: 20 vs 5 days)!

System Initiatives

Burns et al. AJCC 1998Smyrnios et al. CCM 2002Henneman et al. CCM 2001, AJCC 2002Burns et al CCM 2003Outcomes: vent duration, LOS, complications, mortality, cost

System Initiatives Outcomes (*sign)

YesYes*Yes*Yes*Yes*Burns CCM’03, 5 ICUs (prospective)

YesYes (NS but close)

Yes*Yes*Yes*Smyrnios CCM ’02 (M/S/C ICUS, prospective)

NoNoNoYes*Yes*Henneman CCM ’01, AJCC’02 (MICU, pre-post design)

CostMortalityH-LOSICU-LOS

Vent Time

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An Example: Process and Outcomes

Systematic, Comprehensive Multidisciplinary Approach to Assuring Good Outcomes for

Long-Term Ventilated Patients

Project Background

Institution interested in improving clinical and financial outcomes of patients requiring prolonged mechanical ventilation (>3 days) in adult ICU’s.

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Components

Multidisciplinary inputEvidence-based clinical pathwayOutcomes Managers (APN’s)Outcomes to be managed and monitored.BWAP at regular intervals for assessment and tracking.

The Data: All Units

Pre-OM (18 months)N = 595Mean age = 57.3N (%) weaned = 333 (57.0%)

Post-OM(12 months)N = 502Mean age = 56.4N (%) weaned = 331 (65.9%)

Pre- and Post -Outcomes Management (OM) outcomes: all units combined

P= 0.0231%38%Mortality

P=< 0.000125/2030/22Hosp-LOS

P=< 0.000816/1222/15ICU-LOS

P=< 0.000112/914/10Vent duration

SignificancePost-OM mean/median

Pre-OM mean/median

Outcomes

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Per Patient Cost: All Patients(TCS: $4,084,858, DCS: $2,430,120)

$72,000$74,000$76,000$78,000$80,000$82,000$84,000$86,000$88,000

pre-OM post OM

Per-patient Cost

And remember…..

Other factors are important…. we need to be systematic about the

assessments!

Nutrition Connection

Some Food for Thought!

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Goals of Nutrition Support

Provide adequate energy and protein for wound healing, acute phase reactants and antimicrobial functions.Preserve lean body mass.Avoid overfeeding!

Benefits of Enteral Feeding

Stimulates immune barrier functions.Maintains gut mucosa (prevents bacterial translocation ?)and many others…..

Benefits (cont.)

Simplifies fluid/electrolyte management.More “complete” nutrition.Less infectious complications.Less expensive (product and complication costs).

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Glucose Control

Infectious complications increase 5 fold with glucose > 220 mg %Decreased phagocytosisPoor wound healingGastroparesisPoor utilization of nutrition supportTo name just a few...

Control Glucose!!!“Tight glucose control”

“Intensive Insulin Therapy in Critically Ill Patients”Van den Berghe et al.

NEJM Nov 2001

How Much Tube Feeding is Your Patient Receiving?

Ordered vs Delivered

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Enemies of Full Enteral Dose Delivery

Bowel soundsResidual volumesProcedures and “road trips”

Residual Volumes

• Consider:• normal secretions• cascade effect

• What is a gastric “residual”?

• How much is too much?

Data Supporting the Routine Monitoring of Residual Volumes

1)2)3)

Did you check yourresidual today?

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Stepwise Approach to “Treat” Residuals

Place patient on right side x 15 minutes before checking RV.Switch to calorically dense formula. Seek transpyloric access.Add prokinetic (erythromycin, metaclopramide etc.).

Treating Residuals (cont.)

Use narcotic alternative.Avoid hyperglycemia (tight glucose control may be best!).HOB > 30 degrees.Quit checking so often!Etc.

Some Conclusions:

Initiate feedings within 48 - 72 hours; earlier if malnourished. Avoid overfeeding. Glucose control!Use enteral over parenteral.Monitor actual tube feedings delivered (pad hourly to account for losses, tube feed-free intervals).Rethink how you evaluate residuals!

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A case for reconditioning and how to approach it!

Maximizing Mobility in the ICU Patient

Time Line of Changes

Within 2-3 days of recumbency• skeletal muscle atrophies, balance

difficulties

Condition but don’t wear ‘em out!!

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Mobility and Exercise

Exercise even with an ETT (i.e. not to wait until received tracheostomy).Safe but confident and aggressive physical therapy…may need a consult with PT for those with deficits or myopathies.Re-conditioning: weight bearing is important to recruit muscle.De-conditioning begins early…

Philosophy

While exercising, our patients shouldn’t have to struggle to breath.Better gains in conditioning if not short of breath.Full support while exercising!Reconditioning of the respiratory muscles will happen concurrently.

Preventing Iatrogenesis

DVTSinusitisGIVAP

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DVT Prophylaxis

25% of ICU deaths from unknown reasons are PE!Guidelines: suggest that SCD plus heparin are better that either alone. Need to assure that prophylaxis is present!Assess risk!

Stratification for Risk of VTEClaggett et al.

High risk>60 yearsmajor surgery, with no other risk factorsmyocardial ischemiamedical patients with risk factors

Highest riskmajor surgery >40, previous VTE, cancer, hypercoagulablitymajor orthopedic surgelective neuro surgmultiple trauma/acute spinal cord injury

DVT Prophylaxis

Mild-mod risk: LDUH as good as SCD’sCombination better in high risk patientsNeurologic injury patients: heparin may be dangerous.LDMH: enoxaparin good but lasts longerLow dose coumadin: high risk and special situations …lasts longer.

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Sinusitis: No Nasal Tubes!!!!

Sinusitis continued:

If sinusitis is present, risk of VAP or sepsis increases.Nasal tubes increase likelihood of sinusitisTreatment: saline, neosynephrine, nasal steroids, antibiotics (if infected).Sinus films are not reliable to detectCT may demonstrate air-fluid level or consolidation, aspirate is definitive.

GI Prophylaxis

Risk factors for GI bleed: mechanical ventilation, history of bleeding, anticoagulation or coagulopathies, steroids, MV plus renal failure.H2 receptor antagonists (e.g. ranitidene) better than cytoprotective agents (e.g. sucralfate)Association between H2 receptor antagonists and increased mortality and VAP rates.PPI’s (omeprazole etc) Enteral feeding may be equally as effective.

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VAP Prophylaxis

Avoid re-intubationHOB> 30 degreesPrevent sinusitisType of GI prophylaxis may be important (H2 antagonist versus sucrafate, PPI)Jejunal vs gastric tube placement

VAP continued:

Enteral feeding “free” time?Continuous Subglottic Suctioning HandwashingLimit vent tubing changes, HME etcOral decontamination (chlorhexidine etc)

Lessons Learned: Science and Practice

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Lessons Learned

Recognize those at risk of LTMV!Comprehensive approach to assessment and care (pathways, evidence based approaches, multidisciplinary input)…..appear effective.Unlikely that sustained changes will occur unless attention paid to process over time.

Lessons Learned (continued)

Protocols for early removal of sedation and for weaning. Avoid… “plan du jour”!Many physiologic and psychologicfactors contribute to wean success!Consistency in managing and monitoring the process.

WHAT A GREAT POPULATION……..

For NP Management!!!!!

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Enjoy the Conference!!!

Bibliography

Albert RK, Lesa D, Sanderson M, Robertson HT, Hlastala MP. The prone position improves arterial oxygenation and reduces shunt in oleic-acid-induced acute lung injury. Am Rev Respir Dis 1987; 628-633.Amato MBP, Barbas CSV, Bonassa J, Saldiva PHN, Zin WA, de CarvalhoCR. Volume-assured pressure support ventilation. Chest. 1992;102:1225-1234.Amato MBP, Barbas CSV, Medeiros DM, et.al. Beneficial effects of the “open lung approach” with low distending pressures in acute respiratory distress syndrome. Am J Respir Crit Care Med. 1995; 152:1835-1846Brochard L, Ranes A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilators. Amer Resp Crit Care Med 1994;150:896-903.Brook AD, Ahrens TS, Schaff R, Prentice D, Sherman G, Shannonn W, Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999; 27: 2609-2615.

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Bib: continued

Burns SM, Burns JE, Truwit JD. Comparison of Five Clinical Weaning Indices. AJCC. 1994;3:332-352.Burns SM, Marshall M, Burns JD, Ryan B, Wilmoth D, Carpenter R, Aloi A, Wood M, Truwit JD. Design, Testing and Results of An Outcomes Managed Approach To Patients Requiring Prolonged Ventilation. AJCC 1998 (Jan/Feb in press)Chastre J, Fagon J. State of the art: ventilator –associated pneumonia. Am J Respir Crit Care Med. 2002; 165: 867-903.Cohen IL, Bari N, Strosberg MA, Weinber PF, Wacksman RM, Millstein BH, Fein IA. Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatorymanagement team. Critical Care Medicine. 1991;19:1278-84.Cook DJ, Reeve BK, Guyatt GH et al. Stress ulcer prophyllaxis in crotoca;;y ll patients. Resolving discordant meta-analyses. JAMA. 1996; 275: 308-314.

Bib: continued

Daly B, Rudy ER, Thompson KS, Happ MB. Development of a special care unit for chronically ill patients. Heart and Lung. 1991;20:40-51.Deutscj,am CS, Wilton P, Sinow J et al. Paranasel sinusitis associated with nasotraceal intubation: a frequently unrecognized and treatable source of sepsis. Critical Cae Medicine. 1986; 14: 111-114.Ely EW, Baker AM, Dunagan DP, Burke HC, Smith AC, Kelly PT, Johnson MM, Browder RW, Bowton DL. Haponik EF. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J. Med 1996;335:1964-1969.Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponick EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am Jour of Respir and Crit Care Med. 1999; 159: 439-436.Esteban A, Alia I, Ibanez J, Benito S, Tobin MJ. Modes of mechanical ventilation and weaning a national survey of Spanish hospital. Chest.1994;106:1188-93.

Bib: continued

Esteban A, et al. (Spanish Lung Failure collaborative Group). A comparison of four methods of weaning patients from mechanical ventilation. NEJM1995;332:345-350.Gattinoni L, Tognoni G, Pesenti A et al. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 2001; 345: 68-573.Geerts WH. Heit JA. Clagett GP. Pineo GF. Colwell CW. Anderson FA Jr. Wheeler HB. Prevention of venous thromboembolism Chest. 2001, Jan. 119(1 Suppl):132S-175S Hickling KG, Henderson SJ, Jackson R. Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med. 1990;16:372-377Holzaphel L, Chastang C, Demingeon G, et al. A randomized study assessing the systematic search for maxillary sinusitis on the occurrence of ventilator-associated pneumonia. Am J Respir Crit Care Med 1999; 159: 695-701.

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