Weaning from postoperative mechanical ventilation

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Weaning from postoperative mechanical ventilation is a common activity in surgical intensive care units. This presentation provides an example of key activities and measures used during the process for clinical decision making.

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Weaning from postoperative mechanical ventilation

  1. 1. Clinical Decision Support System (CDSS) Sample Scenario © 2011 J. Zaleski
  2. 2. State of Acute Care• American College of Physicians estimates 500,000 deaths annually in ICUs (U.S.)• Key Drivers  Patient safety  Longitudinal EMR deployment  Increase efficiency  Staffing shortages  Increasing numbers of CC beds• Larger amounts of hemodynamic, respiratory, I&O information will be automated  Motivates enterprise integration  Reduces charting workload  Improves completeness, accuracy
  3. 3. Types of Data Most Used in ICU Clinical Decision Making Data Type Value Monitors and monitoring 13% Observations 21% Laboratory 33% Drugs, I&O, IV 22% Blood gas 9% Other 2% Source: E.H. Shortliffe and J.J. Cimino, Biomedical Informatics Computer Applications in Health Care and Biomedicine, page 605.
  4. 4. CDSS Sample Case: When to discontinue post-operative mechanical ventilation• Discontinuation from mechanical ventilation a key activity in surgical intensive care unit (SICU), yet, no guarantees as to outcomes: – When to begin spontaneous breathing trials? – When is patient viable to be extubated?• Discontinue as quickly as possible – Longer time on ventilator higher likelihood of adverse events • Ventilator acquired pneumonia • Respiratory distress – Can exacerbate co-morbidities – Cost• Candidate patients: Coronary artery bypass grafting (CABG) – Fairly common procedure – Technologically-dependent patients
  5. 5. Devices Supporting Acute Care Environment Anesthesia Intra- Aortic Balloon MonitorsMechanical PumpsVentilation Highly Technologically-Dependent Patients Bed Infusion
  6. 6. Source: J. Zaleski Case Study: CABG Patient Restart Determine Patient On Heart / Transfer Monitoring & ViabilityArrives in Induction Extubate Bypass Off to SICU Management for OR Bypass Weaning
  7. 7. Source: J. Zaleski Case Study: CABG Patient Restart Determine Patient On Heart / Transfer Monitoring & Viability Arrives in Induction Extubate Bypass Off to SICU Management for OR Bypass WeaningTime In: 7:15 Induction: Isoflurane Pt Ht: 157 cmCABG x 3 40 CCs fentanyl (15 g/kg) BSA: 1.7 m^2 15 mg Pancuronium pancuronium Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl g lopressor Notes mg 7:15 76 121/64 98 7 0.5 7:30 7:40 83 57 117/66 93/52 99 100 4.3 Meds & Drips 7:45 66 100/55 100 300 7 8:00 61 95/57 100 Swan in place 8:05 62 101/60 100 34.3 8:10 8:25 64 86 Continuous 97/58 132/78 100 100 34.4 34.3 34.9 34.7 29 8:30 116 Monitoring 116/76 99 34.3 35.2 27 8:35 98 116/75 99 34.2 35 29 8:40 92 112/74 100 34.1 34.9 29 8:45 100 113/70 99 34.1 34.8 29 8:50 96 112/71 99 34 34.7 29 9:00 91 97/62 99 34 34.7 31 9:05 97 109/70 100 33.9 34.5 30 9:20 93 114/68 100 33.8 34.4 31 9:30 103 95/61 100 33.7 34.2 32
  8. 8. Source: J. Zaleski Case Study: CABG Patient Restart Determine Patient On Heart / Transfer Monitoring & Viability Arrives in Induction Extubate Bypass Off to SICU Management for OR Bypass Weaning pancuroniumTime HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl g lopressor Notes mg Canula placed-9:35 94 93/60 100 33.6 34.2 30 rt. atria; bypassing heart9:40 94 103/65 100 33.6 34.1 36 Core temperature reduction9:45 94 112/67 100 33.6 34.1 36 3 mg (up)9:50 94 113/68 100 33.6 34 339:55 95 103/69 100 33.6 33.9 29 Fibrillation.10:00 99 101/68 100 33.6 33.9 28 12 0.48 Cross-Clamp K injection10:07 Heart stoppage 20.8 commenced10:08 1610:09 12 K injection10:11 10 complete10:15 33 32.510:20 32.8 32.7 Myocard temp:10:30 32.9 33 1410:35 33.1 3310:45 33 3310:50 33.3 33.4 Begin re-warm
  9. 9. Source: J. Zaleski Case Study: CABG Patient Restart Determine Patient On Heart / Transfer Monitoring & Viability Arrives in Induction Extubate Bypass Off to SICU Management for OR Bypass Weaning pancuroniumTime HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl g lopressor Notes mg10:55 33.8 33.7 5 mg (up) 250 mics11:00 34.9 34.9 2 mg (up) (up)11:05 35.4 35.311:10 35.9 35.411:15 Heart restart 36 35.5 Restart / Defib11:16 36.2 35.911:17 90 79/65 36.3 3611:20 77 107/58 100 4.18 36.2 36 24 Off Bypass11:25 79 103/56 100 35.9 35.9 2511:30 88 103/52 100 35.5 35.911:35 89 106/55 100 35.4 35.7 2611:40 96 108/61 100 35.2 35.6 2411:45 93 115/64 100 35.1 35.5 2511:50 93 96/53 100 34.9 35.3 2311:55 96 112/65 100 34.8 35.1 2512:00 108 104/62 100 34.7 35 2412:05 105 107/66 100 34.7 34.8 2412:10 88 103/63 100 34.6 34.4 23 2.5 mg12:15 87 99/60 100 34.6 34.912:20 88 121/73 100 34.8 24 Move to SICU
  10. 10. Source: J. Zaleski Case Study: CABG Patient Restart Determine Patient On Heart / Transfer Monitoring & ViabilityArrives in Induction Extubate Bypass Off to SICU Management for OR Bypass WeaningTime HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core CVP PAP12:40 100 99/62 99 5.4 34.8 6 23/1013:15 99 99/59 100 4.48 35.3 7 24/1413:45 104 115/63 100 5.18 35.7 10 26/1514:15 101 102/54 98 5.18 36.3 9 25/1214:40 98 108/53 100 5.2 36.6 18 31/1414:50 105 128/62 99 5.2 36.6 20 39/1614:55 104 128/62 100 5.2 36.7 19 35/1815:00 101 128/63 100 5.2 36.7 16 35/1715:25 102 110/58 100 5.2 36.7 18 28/1315:50 103 107/57 100 5.2 37 32 28/1516:45 100 107/59 100 5.2 37.1 13 30/1517:00 104 98/56 98 5.2 37.2 13 40/2117:20 103 97/56 97 5.2 37.3 13 32/1817:40 100 98/57 98 5.2 37.3 12 29/1617:45 102 94/54 98 5.2 37.3 12 31/1819:05 104 97/58 97 5.2 37.3 13 30/1820:15 106 99/59 97 5.2 37.5 11 31/1621:15 101 101/60 98 4.8 37.6 15 33/1922:35 Extubated: Vc 1.2 liters NIF -25 cmH2O
  11. 11. Respiratory Rate (br/min) 10 15 20 25 30 35 40 45 0 5 OR12:44:18 Patient Arrives in12:57:3313:35:5213:47:4213:59:3214:11:23 RRsp (/min)14:23:13 Induction14:35:03 RRm (/min)14:46:5314:58:4315:10:3415:22:2415:34:15 On15:46:05 Bypass15:57:5516:09:45 • pH = 7.4416:21:35 •Time: 12:4516:33:2516:45:1616:57:07 Off17:08:57 Bypass Heart / Restart • PO2 = 100 mmHg • PCO2 = 31 mmHg17:20:4717:32:3717:44:2717:56:1718:08:0718:19:5718:31:48 to SICU18:43:38 Transfer18:55:2819:07:1819:19:0819:30:5919:42:4919:54:3920:06:29 • Initial blood gas obtained upon patient arrival20:18:2020:30:11 Monitoring & Management20:42:0120:53:5121:05:4121:17:3121:29:2221:41:12 for21:53:02 Viability Weaning Determine Case Study: CABG Patient Extubate Source: J. Zaleski
  12. 12. Source: J. Zaleski Case Study: CABG Patient Restart Determine Patient On Heart / Transfer Monitoring & Viability Arrives in Induction Extubate Bypass Off to SICU Management for OR Bypass Weaning • Patient initially supported by 45 mechanical ventilator on synchronous 40 RRm (/min) intermittent mandatory ventilation 35 RRsp (SIMV) mode of 12 breaths perRespiratory Rate (br/min) (/min) 30 minute, tidal volume of 0.85 25 liters, PEEP of 5 cmH2O 20 • Patient spontaneous breathing is absent upon 15 arrival due to the anesthesia and paralytic drugs 10 administered during surgery 5 0 12:44:18 12:57:33 13:35:52 13:47:42 13:59:32 14:11:23 14:23:13 14:35:03 14:46:53 14:58:43 15:10:34 15:22:24 15:34:15 15:46:05 15:57:55 16:09:45 16:21:35 16:33:25 16:45:16 16:57:07 17:08:57 17:20:47 17:32:37 17:44:27 17:56:17 18:08:07 18:19:57 18:31:48 18:43:38 18:55:28 19:07:18 19:19:08 19:30:59 19:42:49 19:54:39 20:06:29 20:18:20 20:30:11 20:42:01 20:53:51 21:05:41 21:17:31 21:29:22 21:41:12 21:53:02
  13. 13. Respiratory Rate (br/min) 10 15 20 25 30 35 40 45 0 5 OR12:44:18 Patient Arrives in12:57:3313:35:5213:47:4213:59:3214:11:23 RRsp (/min)14:23:13 Induction14:35:03 RRm (/min)14:46:5314:58:4315:10:3415:22:2415:34:15 On15:46:05 Bypass15:57:5516:09:4516:21:3516:33:2516:45:1616:57:07 Off17:08:57 Bypass Heart / Restart17:20:4717:32:3717:44:2717:56:1718:08:0718:19:5718:31:48 • pH = 7.41 to SICU •Time: 14:0018:43:38 Transfer18:55:2819:07:1819:19:08 • PO2 = 202 mmHg • PCO2 = 29 mmHg19:30:5919:42:4919:54:3920:06:29 • Second blood gas obtained20:18:2020:30:11 Monitoring & Management20:42:0120:53:5121:05:4121:17:3121:29:2221:41:12 for21:53:02 Viability Weaning Determine Case Study: CABG Patient • Decision made to reduce ventilatory support Extubate Source: J. Zaleski
  14. 14. Respiratory Rate (br/min) 10 15 20 25 30 35 40 45 0 5 OR12:44:18 Patient Arrives in12:57:3313:35:5213:47:4213:59:3214:11:23 RRsp (/min)14:23:13 Induction14:35:03 RRm (/min)14:46:5314:58:4315:10:3415:22:2415:34:15 On15:46:05 Bypass15:57:5516:09:4516:21:3516:33:2516:45:1616:57:07 Off17:08:57 Bypass Heart / Restart17:20:4717:32:3717:44:2717:56:1718:08:0718:19:5718:31:48 to SICU18:43:38 Transfer18:55:2819:07:1819:19:0819:30:5919:42:49 breathing trial19:54:3920:06:2920:18:2020:30:11 Monitoring & Management20:42:0120:53:5121:05:4121:17:3121:29:22 • Support reduced to 8 br/min21:41:12 • Some spontaneous breathing. for21:53:02 before attempting spontaneous Viability Weaning Determine Case Study: CABG Patient Clinicians choose to evaluate and await re-warming and third blood gas Extubate Source: J. Zaleski
  15. 15. Source: J. Zaleski Case Study: CABG Patient Restart Determine Patient On Heart / Transfer Monitoring & Viability Arrives in Induction Extubate Bypass Off to SICU Management for OR Bypass Weaning 45 • Third blood gas obtained 40 RRm (/min) •Time: 16:35 35 RRsp • pH = 7.40Respiratory Rate (br/min) (/min) 30 • PCO2 = 37 mmHg • PO2 = 183 mmHg 25 20 • Re-warming complete 15 • Decision made to reduce to CPAP in 10 preparation for spontaneous breathing 5 trials 0 12:44:18 12:57:33 13:35:52 13:47:42 13:59:32 14:11:23 14:23:13 14:35:03 14:46:53 14:58:43 15:10:34 15:22:24 15:34:15 15:46:05 15:57:55 16:09:45 16:21:35 16:33:25 16:45:16 16:57:07 17:08:57 17:20:47 17:32:37 17:44:27 17:56:17 18:08:07 18:19:57 18:31:48 18:43:38 18:55:28 19:07:18 19:19:08 19:30:59 19:42:49 19:54:39 20:06:29 20:18:20 20:30:11 20:42:01 20:53:51 21:05:41 21:17:31 21:29:22 21:41:12 21:53:02
  16. 16. Respiratory Rate (br/min) 10 15 20 25 30 35 40 45 0 5 OR12:44:18 Patient Arrives in12:57:3313:35:5213:47:4213:59:3214:11:23 RRsp (/min)14:23:13 Induction14:35:03 RRm (/min)14:46:5314:58:4315:10:3415:22:2415:34:15 On15:46:05 Bypass15:57:5516:09:4516:21:3516:33:25 Breathing Index normal16:45:1616:57:07 • Respirations, Rapid-Shallow Off17:08:57 Bypass Heart / Restart17:20:4717:32:3717:44:2717:56:1718:08:0718:19:5718:31:48 to SICU18:43:38 Transfer18:55:2819:07:1819:19:0819:30:5919:42:4919:54:3920:06:2920:18:2020:30:11 Monitoring & Management20:42:0120:53:5121:05:4121:17:3121:29:2221:41:12 for21:53:02 Viability Weaning Determine Case Study: CABG Patient Extubate Source: J. Zaleski
  17. 17. Key Parameters Used to Determine Viability for Extubation Parameter Threshold Value/Range Our Patient Vital Capacity, Vc > 10mL/kg Positive End-Expiratory 5 cm H2O Pressure, PEEP Negative Inspiratory Force, NIF -20 cm H2O Inspired Oxygen Fraction,FiO2 < 0.6 Spontaneous Tidal Volume, Vt > 5 mL/kg Parameters, Spontaneous Respirations Value Thresholds, 8<Rresp< 30 Patient Values, Pi Vpth Vpti Blood Alkalinity/Acidity 7.32 < pH <i 7.48 Partial Pressure of Oxygen, PO2 > 80 mmHgPartial Pressure of Carbon Dioxide, 30 mmHg < PCO2 < 50 mmHg PCO2 Normal Body Temperature,Tcore ~37 C Ventilation Mode CPAP
  18. 18. Key Parameters Used to Determine Viability for Extubation Parameter Threshold Value/Range Our Patient Vital Capacity, Vc > 10mL/kg Positive End-Expiratory 5 cm H2O Pressure, PEEP Negative Inspiratory Force, NIF -20 cm H2O Inspired Oxygen Fraction,FiO2 P1 < 0.6 Spontaneous Tidal Volume, Vt > 5 mL/kg P2 Spontaneous Respirations Parameters Used to 30 Key 8<Rresp< Determine Extubation Viability P3 Blood Alkalinity/Acidity 7.32 < pH < 7.48 … Partial Pressure of Oxygen, PO2 Clinical Decision Support Systems > 80 mmHgPartial Pressure of Carbon Dioxide, 30 mmHg < PCO2 < 50 mmHg PCO2 Normal Body Temperature,Tcore <Vpt1 Vpt2 < C ~37 … Vpti < Action Vpth1 Vpth2 Vpthi Ventilation Mode CPAP
  19. 19. Respiratory Rate (br/min) 10 15 20 25 30 35 40 45 0 5 OR12:44:18 Patient Arrives in12:57:3313:35:5213:47:4213:59:3214:11:23 RRsp (/min)14:23:13 Induction14:35:03 RRm (/min)14:46:5314:58:4315:10:3415:22:2415:34:15 On15:46:05 Bypass15:57:5516:09:4516:21:3516:33:25 Breathing Index normal16:45:1616:57:07 • Respirations, Rapid Shallow Off17:08:57 Bypass Heart / Restart17:20:4717:32:3717:44:2717:56:1718:08:0718:19:5718:31:48 to SICU18:43:38 Transfer18:55:2819:07:1819:19:0819:30:5919:42:4919:54:3920:06:2920:18:2020:30:11 Monitoring & Management20:42:0120:53:5121:05:41 • Vc = 1.2 liters21:17:3121:29:22 and in normal range21:41:12 • NIF = -24 cmH2O for21:53:02 Viability Weaning Determine Case Study: CABG Patient • Vital capacity & NIF test performed Extubate Source: J. Zaleski
  20. 20. Respiratory Rate (br/min) 10 15 20 25 30 35 40 45 0 5 OR12:44:18 Patient Arrives in12:57:3313:35:5213:47:4213:59:3214:11:23 RRsp (/min)14:23:13 Induction14:35:03 RRm (/min)14:46:5314:58:4315:10:3415:22:2415:34:15 On15:46:05 Bypass15:57:5516:09:4516:21:3516:33:2516:45:1616:57:07 Off17:08:57 Bypass Heart / Restart17:20:4717:32:3717:44:2717:56:1718:08:0718:19:5718:31:48 to SICU18:43:38 Transfer18:55:2819:07:1819:19:0819:30:5919:42:4919:54:3920:06:2920:18:2020:30:11 Monitoring & Management20:42:0120:53:5121:05:4121:17:31 could have led to earlier extubation21:29:2221:41:12 for21:53:02 Updated real-time knowledge of patient data Viability Weaning Determine Case Study: CABG Patient Extubate Source: J. Zaleski
  21. 21. Key Parameters Used to Determine Viability for Extubation Data suggest attempts at Threshold Value/Range trials could begin much Parameter spontaneous breathing Our Patient Vital Capacity, Vc sooner than 10mL/kg occurred > actually 1.2L (70 kg) Positive End-Expiratory 5 cm H2O 5 cm H2O Pressure, PEEP Negative Inspiratory Force, NIF -20 cm H2O -24 cm H2O Inspired Oxygen Fraction,FiO2 < 0.6 0.35 Spontaneous Tidal Volume, Vt > 5 mL/kg 0.55L (70 kg) Spontaneous Respirations 8<Rresp< 30 ~20 Blood Alkalinity/Acidity 7.32 < pH < 7.48 7.4 Partial Pressure of Oxygen, PO2 > 80 mmHg 183 mmHgPartial Pressure of Carbon Dioxide, 30 mmHg < PCO2 < 50 mmHg 37 mmHg PCO2 Normal Body Temperature,Tcore ~37 C ~37 C Ventilation Mode CPAP CPAP
  22. 22. Workflow Considerations• Data show patient meets extubation criteria many hours before actual extubation – Indicates clear benefit of utilizing these data for patient care – Simple reminders to staff can achieve great benefits for patient• Notification of readiness to wean important for clinical workflow, patient care management – Is patient viable or is it too early? – Any co-morbidities that can influence the outcome? – All necessary staff so informed and aligned on plans?• Notification as to life-threatening events requires up-to- date and accurate information – Hemodynamic instabilities/Shock – Respiratory distress
  23. 23. THANK YOU!

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