Ventilation / ICU Overview

VENT BASICS

Modes:

• Assist Control - Every breath the patient gets will be identical and provided by the ventilator.

  • Volume control - have a set volume. (Go to mode).

  • Pressure control - have a set pressure

• SIMV - still input settings, but when pt initiates a breath, ventilator does not provide assistance.

  • Can sometimes have pressure support on top of SIMV - pt initiated breaths will get some pressure to help them.

• Pressure Support - All breaths are patient initiation. Can give some extra support to help patient along.

Making Adjustments

Oxygenation = FIO2 and Mean Airway Pressure (affected by PEEP)

Ventilation = minute ventilation = Tidal Volume * Respiratory Rate

Starting Settings (AC/VC)

• Tidal volume: 6 cc/kg of ideal body weight (NOT ACTUAL WEIGHT)

• PEEP: Flexible, can start at 5 mmHg.

• FiO2: 100% (1.0)

• Respiratory Rate: Something normal (12-18). Try to get close to patient's minute ventilation they had before being intubated.

• Check ABG in 20-30 minutes

ARDS Management (ARDSNet)

FAST HUGS BID: Assess once daily.

Feeding/fluids, Analgesia, Sedation, Thromboprophylaxis, Head up position, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel care, Indwelling catheter removal, Deescalation of antibiotics.

SPONTANEOUS AWAKENING TRIAL

• If patient is responsive to verbal stimuli, go directly to SBT (see ARDSNet above)

• People who should not have SAT – active seizures or receiving sedative for alcohol withdrawal or agitation, receiving neuromuscular blockers, evidence of MI in last 24 hours, elevated intracranial pressure.

• What is an SAT – can you go 4 hours off sedation for 4 hours without anxiety, agitation, pain, RR of 35+ breaths/minute >5 minutes, SpO2 <88% >5 minutes, cardiac arrhythmia, or 2+ signs of respiratory distress (tachycardia, bradycardia, use of accessory muscles, paradoxical breathing, diaphoresis. If yes, go to SBT. If no, restart sedation at half dose, try again tomorrow.

WHAT DO I NEED TO INTUBATE / TO KEEP SOMEBODY ON A VENTILATOR

Pain control – usually a fentanyl drip

Sedation – fentanyl drip as above, or propofol, Precedex (dexmetomadine), Versed (midazolam), ketamine.

Paralysis – After rapid sequence intubation, consider paralysis if somebody has ventilator dyssynchrony (i.e. overbreathing the ventilator).

SYSTEMS BASED PRESENTATION + BUNDLE

Neuro – including pain, sedation

Cardiovascular

Pulmonary

GI/Nutrition

FEN/RENAL/GU

Heme

ID

Endocrine

MSK/Skin

Prophylaxis

End of Rounds Bundle / Checklist

Nursing Concerns

Feeds

Analgesia/Sedation and Delirium Prevention

VTE Prophylaxis

Head of Bed

Ulcer Prophylaxis

Glucose Control

Sore Prevention

Catheter Day and Removal

ETT day and respiratory concerns

Infection Control

Antibiotic day and culture results

Pharmacy Concerns

Restraints

PT/OT

SW / Dispo

Family Updated

Code Status

What are the indications for: (if no indication, discontinue)

Intubation – cannot protect airway, dropping O2 saturation despite non-invasive ventilation (Bipap), worsening respiratory driven acid-base status despite non-invasive ventilation.

Central Line – prolonged need for pressors, poor peripheral access, need for more access.

A-Line – need to check ABGs regularly, close hemodynamic monitoring

Foley Catheter – strict I/O, unable to pee on their own, intubated.

ICU Admission – Requiring titration of bipap, continuous IV drips that need titrating, intubated patients, close neurological checks (q1h or q2h).