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Final case pediatric mechanical ventilation
- A 9-year-old girl with beta thalassemia major was admitted to the PICU for respiratory distress following an allogenic stem cell transplant. She required intubation and mechanical ventilation support. - Various ventilation modes were trialed, including PCV, HFOV, PSV and NIV. Weaning attempts were made but oxygen requirements increased, requiring reintubation. Bilateral infiltrates were seen on chest x-rays. - After 19 days in the PICU receiving respiratory support and undergoing further weaning trials on various modes, the patient's condition remained critical with ongoing respiratory distress and oxygen needs.
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Final case pediatric mechanical ventilation
- 1. Pediatric Mechanical Ventilation ACase Presentation Ahmed Al Gahtani, BSRC, RRT
- 2. Case Introduction • ChiefComplaint: Beta Thalassemia Major. • HPI: Patient is 9 y/o girl suffering from Beta Thalasemia Major since infancy. She was admitted for ALLOSCT. • Family History: Her sister suffers from same disease, received allogenec stem cell transplantation 12 years ago. • Weight: 23 Kg.
- 3. Physical Examination • Vitals:Temp 36.7, HR 81, RR 20, SpO2 98%. • General: Alert and oriented, no acute distress. • HENT: Normocephalic. • Respiratory: Normal respiration, clear breath sounds. • CVS: Regular rate and rhythm, S1+S2, normal peripheral perfusion. • Abdomine: Soft.
- 4.
- 5. Physical Examination • Impression& Plan: Patient stable, to receive ALLOSCT, to be discharged 30 days after the procedure. • The procedure was done on 26/9/2011 with no complication.
- 6. RRT Activation 13/10/2011 •RRT was activated due to increased oxygen requirement, decreased LOC, and bleeding. • Vitals: • VBG: • CXR ordered, patient received one dose of lasix. • RRT decided to admit patient to PICU. GCSSpO2RRHRBPTemp 15/1595%/10L72148137/8637.6 SvO2tHbBEHCO3PO2PCO2pH 66%/10L1240.127.238537.31
- 7. CXR • Bilateral diffused opacities. •Mild cardiomegaly. • Bilateral pulmonary edema. • Mild pleural effusion.
- 8. PICU Admission • Patientadmitted on SFM 10 LPM. • Vitals: • Patient continued to have respiratory distress require high oxygen, tachypenic, with patchy opacities on CXR. • Patient was intubated with ETT size 6.0 with no complication. SpO2RRHRBPTemp 93%/10L54133117/6837.1
- 9. Initiation of Mechanical Ventilation 0620 PCVMode 30/ 36Rate (Set/Meas) 100% / 93%FiO2/SpO2 ----- / 135Vt (Set/Exh) 5.2MV (Exh) 20 / 37PC (Set/PIP) 23MAP 15PEEP 0.62Ti V 3Trigger 0657 ABG (AL)Type 7.21pH 73.5PCO2 mmHg 126PO2 mmHg 29.6HCO3 - 0.2BE 130tHb 93% / 98%SaO2/SpO2
- 10. Patient Assessment • Vitals: •CNS: Pt on Fentanyl and Midazolam. • CVS: Sinus Tachycardia, S1+S2, capillary refill ˂ 3 sec, with flat neck veins. No inotrops. • Resp: Pt on MV (PCV), symmetrical chest rise, acyanotic, high PIP, large amount of thick bloody secretion, good A/E with bilateral coarse crackles. • Renal: Fluid balance +200, on Lasix 5 mg/hr. SpO2/FiO2RRHRBPTemp 94%/100%54137127/7138
- 11. CXR Post Intubation •Persistent increased opacification of both lungs. • Worsening mild-to- moderate pleural effusion. • ETT high.
- 13. Initiation of HFOV 0835 HFOVMode 7HzFreq 100% / 92%FiO2/SpO2 28MAP 60Amp 25Flow 33%Ti % 18 / 39Alarms 0921 ABG (AL)Type 7.47pH 44.3PCO2 mmHg 205.5PO2 mmHg 29.1HCO3 5.0BE 122tHb 99% / 100%SaO2/SpO2 Appearance Good Chest Wiggle Symmetrical Acyanotic
- 14. Respiratory Care Plan •Wean MAP to 26 cm H2O if CRX shows adequate expansion. • Then wean MAP by 1 cm H2O Q6 hours. • Obtain CXR. • ABG Q6 hours + PRN. • Targeting normal pH and SpO2 ≥ 90%.
- 15. CXR post HFOV •Good expansion. • Improved aeration. • Bilateral diffused infiltration. • ETT high.
- 16. HFOV Alteration 1209 HFOVMode 7 HzFreq 40%/ 92%FiO2/SpO2 26MAP 60Amp 25Flow 33%Ti % 18 / 39Alarms 1247 ABG (AL)Type 7.42pH 46.5 / 42PCO2/TCOM mmHg 99.8PO2 mmHg 29.8HCO3 4.6BE 109tHb 94% / 100%SaO2/SpO2
- 17. Day 4 inPICU • Vitals: • CNS: Pt on Fentanyl, Midazolam, and Atracurium. • CVS: Sinus Tachycardia, S1+S2, capillary refill ˂ 3 sec, with flat neck veins. On levophed & dopamine. • Resp: Pt on HFOV, good chest wiggle, acyanotic, with moderate amount of thick brown secretion, targeting pH 7.30 & SpO2 ≥ 90% . • Renal: Fluid balance - 500, on Lasix 5 mg/hr. SpO2/FiO2RRHRBPTemp 95%/40%HFOV115100/6536.5
- 18. CXR • Good expansionwith bilateral infiltration shows improvement. • Bilateral mild pleural effusion. • Mild cardiomegaly. • ETT slightly high.
- 19. Mechanical Ventilation 1300 HFOVMode 9 HzFreq 40%/ 92%FiO2/SpO2 20MAP 55Amp 25Flow 33%Ti % 15 / 25Alarms 1429 ABG (AL)Type 7.35pH 49.5 / 47PCO2/TCOM mmHg 85PO2 mmHg 27.1HCO3 1.2BE 95tHb 94% / 95%SaO2/SpO2
- 21. Mechanical Ventilation 19301630Time PCVPCVMode 16 /1630 / 30Rate (Set/Meas) 50% / 96%50% / 100%FiO2/SpO2 ----- / 188---- / 250Vt (Set/Exh) 3.19.9MV (Exh) 18 / 3024 / 34PC (Set/PIP) 1618MAP 1110PEEP 0.970.79Ti V 3V 3Trigger 21201736Time ABG (AL)ABG (AL)Type 7.417.64pH 5422PCO2 mmHg 6755PO2 mmHg 3225HCO3 53.2BE 10385tHb 90% / 95%90% / 94%SaO2/SpO2
- 22. Day 5 inPICU • Vitals: • CNS: Pt on Fentanyl & Midazolam. • CVS: Sinus Rhythm, S1+S2, capillary refill ˂ 3 sec, with flat neck veins. On dopamine. • Resp: Pt on CMV (PCV), symmetrical, acyanotic, with large amount of thick brown secretion, good A/E clear breath sounds, targeting pH 7.30 & SpO2 ≥ 90% . • Renal: Fluid balance - 521, on Lasix 2 mg/hr then off. SpO2/FiO2RRHRBPTemp 99%/45%1610099 / 6836.4
- 23. Mechanical Ventilation 08450815Time SPRVCPCVMode 14 /1416/ 16Rate (Set/Meas) 40% / 99%45% / 98%FiO2/SpO2 180 / 177---- / 206Vt (Set/Exh) 2.73.6MV (Exh) ---- / 2717 / 28PC (Set/PIP) 12 / ---------PS (Set/Meas) 1315MAP 911PEEP 0.960.97Ti V 3V 3Trigger 1030 ABG (AL)Type 7.41pH 55PCO2 mmHg 80PO2 mmHg 34HCO3 8.9BE 95tHb 92% / 97%SaO2/SpO2
- 24. Day 13 inPICU • Vitals: • CNS: Pt on Fentanyl, GCS 13/15. • CVS: Sinus Rhythm, S1+S2, capillary refill ˂ 3 sec, with flat neck veins. No inotrops. • Resp: Pt on CMV (PSV), symmetrical, acyanotic, with moderate amount of thick white secretion, good A/E clear breath sounds, targeting pH 7.28 & SpO2 ≥ 90% . • Renal: Fluid balance – 1.4 L. SpO2/FiO2RRHRBPTemp 97%/35%2897101 / 5937.2
- 25. CXR • Bilateral infiltration. •Good expansion. • Mild pleural effusion. • ETT in good position.
- 26. Mechanical Ventilation 1135Time PSVMode 27Rate (Meas) 35%/97%FiO2/SpO2 145Vt(supported) 4.0MV (supported) 10PS (Set/Meas) 7MAP 5PEEP V 3Trigger 1416 VBGType 7.38pH 53PCO2 mmHg 40PO2 mmHg 32HCO3 5.6BE 102tHb 75% / 99%SaO2/SpO2
- 28. Day 13 inPICU • Patient was extubated @ 1445 to NC 3 LPM with no complication. • Vitals: HR 104, BP 93/60 (66), RR 30, SpO2 100% • B/S: clear bilateral, with good A/E. • Potential Risks: Stridor, atelectasis, or difficulty clearing secretions. • Plan: Racrmic Epi, CPT (IS), NTS as needed
- 29. Day 13 inPICU • Oxygen requirement increased. • Respiratory rate in the 30s and 40s. • Patient on SFM 8 to 10 LPM. 1600 VBGType 7.43pH 50PCO2 mmHg 38PO2 mmHg 32.5HCO3 7.2BE 104tHb 69% / 99%SaO2/SpO2
- 31. Day 14 inPICU • Vitals: • CNS: Pt on Midazolam & Precedex. • CVS: Sinus Rhythm, S1+S2, capillary refill ˂ 3 sec, with flat neck veins. No inotrops. • Resp: Pt on 8 LPM SFM, symmetrical, acyanotic, with decreased A/E and clear breath sounds, targeting pH 7.28 & SpO2 ≥ 90% . • Renal: Fluid balance – 183 cc. SpO2/FiO2RRHRBPTemp 92%/10 LPM3593121 / 6037.8
- 32. CXR • Good expansion. •Mild cardiomegaly. • Bilateral infiltration.
- 33. Initiation of NIV 1000Time NIV(PS)Mode 30Rate (Meas) 35%/98%FiO2/SpO2 160Vt (supported) 4.8MV (supported) 10PS (Set/Meas) 5PEEP 1345 VBGType 7.40pH 47PCO2 mmHg 40PO2 mmHg 29.1HCO3 3.7BE 95tHb 76% / 100%SaO2/SpO2 • Patient continue on SFM 8LPM, SpO2 89%, RR in the 40s, with increased WOB. • Team decided to start the patient on NIV as follow:
- 34. Plan • To maintainpatient on NIV (PS), 4 hours on then 2 hours off.
- 35. Day 19 inPICU • Vitals: • CNS: no sedation, GCS 15/15, agitated & anxious. • CVS: Sinus Tachycardia, S1+S2, capillary refill ˂ 3 sec, with flat neck veins. No inotrops. • Resp: Pt is alternating on and off NIV (PS 12/ PEEP 7 with FiO2 60%), with increased oxygen requirement and tachypenia with increased WOB, targeting pH 7.28 & SpO2 ≥ 90%. • Impression: pulmonary hemorrhage with respiratory distress. SpO2/FiO2RRHRBPTemp 93% / 60%45120130 / 8538
- 36. CXR • Bilateral congestion. •Bilateral diffused infiltration. • Pneumonia or ARDS can not be exluded.
- 38. Day 19 inPICU • Patient was reintubated @ 2200 due to moderate- to-severe distress. • B/S: equal bilateral with coarse crackles. • No complication. • CXR ordered.
- 39. CXR • Bilateral congestion. •Bilateral diffused infiltration. • ETT high • Compared with previous CXR there are more diffused opacification Rt ˃ Lt.
- 40. Mechanical Ventilation 23002200Time PCPRVCMode 30 /3030 / 30Rate (Set/Meas) 100% / 87%100% / 91%FiO2/SpO2 ---- / 193180 / 176Vt (Set/Exh) 6.86.2MV (Exh) 26 / 35---- / 37PC (Set/PIP) 2021MAP 88PEEP 0.790.79Ti V 3V 3Trigger 2325 ABG (AL)Type 7.25pH 60PCO2 mmHg 55PO2 mmHg 21.5HCO3 - 5.9BE 95tHb 82% / 87%SaO2/SpO2 Sedation Fentanyl Midazolam
- 42. Day 19 inPICU 04582345Time HFOVHFOVMode 6 Hz8 HzFreq 70% / 94%100% / 84%FiO2/SpO2 3527MAP 7555Amp 3025Flow 33%33%Ti % 33 / 4220 / 32Alarms 0550 ABG (AL)Type 7.40pH 35PCO2 mmHg 79PO2 mmHg 24HCO3 - 3.8BE 92tHb 95% / 97%SaO2/SpO2
- 44.