Medical Directive to Wean Patient Rapid Anticipated Wean

YES

Total Respiratory Rate > The Set Respiratory Rate And

Patient RASS +2 to -2YES NO

Wean Fi O2 to Maintain Sa O2 ≥95%Wean Fi O2 ≤0,4 switch to PS Mode

Set Resp Rate By 2 Breaths Every 30 Mins Until 8 BPM.

Wean Sedation to a RASS of +2 to -2

Signs of Fatigue

PS by 2 cm every 10 mins untill off

PEEP by 2cm every 10 mins until =5Continue on CPAP 5 cm for 10 mins

Does patient meet extubation criteria

Increase PS to pre wean level

Call Doctor to Review

Extubate as per extubation NPS

NO

Signs of Fatigue

NO

YES

Signs of Fatigue

NO

NO

YES

Obtain ABG and notify MD for extubation

Next SBT in 6 Hours

Tolerates incremental change ?

SBT Assess for 30 mins tolerated ?

Return to prior settings Notify MD failed 2 SBTs Today

Time 07.00-19.00 hrs & Meets SBT Criteria?

Reverse most recent change improveed within 10 mins

Notify MD

Go to SBT

ENROLLMENT CRITERIANo vent discontinuation failure within past 24 hrsPa O2 /Fi O2 ≥ 25 cc/cm H2OMinute volume ≤ 15L/min

Immediate SBT :Ventilated ≤ 72 hrs

Hrs?

SBT CRITERIAGCS ≥ 10 or tracheostomyMAP ≥ 60mmHg, no pressorsGood cough without pain

Place pt on IMVAt prioe rate withPS to keep VT ≥ 5 ml/kg

OXYGEN / VENTILATION WEANINGMaintain Sa O2 ≥92%

Decrease Fi O2 incrementally to ≤ 0,50Decrease PEEP incrementally to ≤ 8 cm H2O

Maintain spontaneous RR ≤ 30 and VT ≥ 5 ml/kg; no IMV or PS changes if respiratory drive abnormal

Decrease IMV rate incrementally to ≤ 6 bpmDecrease PS incrementally to ≤ 8 cm H2O

YES NO

NO

YES

YES

YES YES

YES

YES

NO

NO

NONO

NO

ScvO2

Balance of O2 delivery & consumption

Oxygen Delivery

Oxygen Consumption

Hemoglobin Oxygenation

Hemoglobin Occult Bleeding

Anemia Hemodilution

FiO2

Ventilation

Cardiac Output

Metabolic Demands

FeverPain

AgitationStress/anxiety

SuctioningShiveringTraumaMODSSepsisBurns

Stroke Volume

Heart Rate

AfterloadSVRPVR

Preload CVP

Contractility SWI

Four Components That Effect ScvO2

Vasoactive MedsDysrhythmia

Congestive Heart FailureCardiac Surgery

Arrest

HemorrageOccult BleedingRBC Disorders

AnemiaHemodilution

ScvO2

Hypoxia/HypoxemiaSuctioning,atelectasis

Ventilation/oxygenationLung Disesase

Shunting

SepsisWork of breathing

Fever, shiveringTrauma

Pain/anxiety

C.OC.O

SaO2SaO2

HgBHgB

VO2VO2