Protocol for ventilator settings
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1. This document provides protocols for ventilator settings for adults, children aged 1-10 years, and neonates/infants. It includes guidelines for initial settings, adjusting settings based on blood gas results, criteria for weaning and extubation. 2. The protocol outlines steps for changing settings from initial pressure-regulated volume control (PRVC) to synchronized intermittent mandatory ventilation (SIMV) and lists criteria for determining readiness for a spontaneous breathing trial. 3. Special considerations are provided for various clinical situations like post-cardiac surgery patients, pulmonary issues, and open sternum cases.
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![PROTOCOL FOR VENTILATORY SETTINGS
1. First ABG 10min after connecting to ventilator
2. pCO2 value: Increase /Decrease RR
3. Vt: Do not change until mean Paw cross upper limits
4. On PRVC: up to 25 mean Paw is acceptable
Adult Child (1-10yr) Neonate/infant
Vt 8ml/kg 8ml/kg 8ml/kg
I:E 1:2 1:2 1:1.5
PEEP 5 cmH2O 5 cmH2O 3 cmH2O
RR 14 (up to 24) 16 (up to 30) 25 (up to 40)
Initial PRVC settings
SIMV settings
Check-list for early extubation (PRVC SIMV)
1. Stable Hemodynamics (BP, HR, U/O)
2. Rhythm (regular or AF with CVR )
3. Hemostasis (drain output within limits )
4. Neurologic status (awake, oriented)
5. ABG within acceptable range
6. Temperature (Per. temp>30˚c, Core temp- Per. temp ≤ 10)
7. Chest X ray (within normal limits)
• Change from initial PRVC to SIMV
• Initial PS above PEEP- Adults: 7 cmH2O, Infants 10 cmH2O
• Trigger- Adults: Flow ( -2L/min), Infants Pressure (-2cm H2O)
• Reduce RR by 3- 5, PS above PEEP by 2, PEEP by 1 [every 15-30 min]
• Repeat ABG every 30 min after changing settings
• TARGET: PEEP 5, FiO2 0.5, PS above PEEP 5, RR 5 (Minimal SIMV)
Weaning failure signs
Change in
• RR >10
• pCO2 >10
• SaO2 >10](https://image.slidesharecdn.com/protocolforventilatorsettings-200917145941/85/Protocol-for-ventilator-settings-1-320.jpg)
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This document provides information and guidelines for using the Sensormedics 3100A High Frequency Oscillatory Ventilator. It indicates the ventilator is used for neonatal respiratory support between 24-43 weeks gestation weighing 0.54-4.6kg. The document outlines initial settings for frequency, inspiratory time, power, mean airway pressure and guidelines for calibration, treatment initiation, patient management, suctioning, and weaning from the ventilator.
Rescuscitation principles
This document provides guidelines for cardiac resuscitation and emergency cardiovascular care. It outlines objectives such as performing BLS procedures, using an AED, and diagnosing death. It also discusses the chain of survival, including factors like bystander CPR and early defibrillation that impact outcomes. Procedures covered include airway management, IV access, monitoring, and treating reversible causes of cardiac arrest like hypoxia, hypothermia, and electrolyte abnormalities. Indications for starting and stopping CPR are also reviewed.
Pphnhfov
Pulmonary hypertension in neonates (PPHN) occurs when the fetal circulation pattern persists after birth, causing right-to-left shunting of blood and hypoxemia. It has a mortality rate of over 50% without ECMO treatment. Current management involves optimizing oxygenation through various ventilation strategies like hyperventilation, high frequency ventilation, inhaled nitric oxide, and ECMO. While outcomes have improved, PPHN still carries risks of mortality and long-term morbidity so careful monitoring and a multimodal approach are important.
ards-pocket-card-4.7-qr.pdfrespiratory d
resphe inside of the lips, or on the fingernails may happen when a person is not getting as much oxygen as needed. The color of the skin may also appear pale or gray.
Grunting. A grunting sound can be heard each time the person exhales. This grunting is the body's way of trying to keep air in the lungs so they will stay open.
Nose flaring. The openings of the nose spreading open while breathing may indicate that a person is having to work harder to breathe.
Retractions. The chest appears to sink in just below the neck and/or under the breastbone with each breath--one way of trying to bring more air into the lungs.
Sweating. There may be increased sweat on the head, but the skin does not feel warm to the touch. More often, the skin may feel cool or clammy. This may happen when the breathing rate is very fast.
Wheezing. A tight, whistling or musical sound heard with each breath can indicate that the air passages may be smaller, making it more difficult to breathe.
Stridor. An inspiratory sound heard in the upper airway.
Accessory muscle use. The muscles of the neck appear to be moving when your child breathes in. This can also be seen under the rib cage or even the muscles between the ribs.
Changes in alertness. Low oxygen levels may cause your child to act very tired and may indicate respiratory fatigue.
Body positions. Low oxygen and difficulty breathing may force your child to thrust his or head backwards with the nose up in the air (especially if lying down). Or, your child may lean forward while sitting. A child automatically uses these positions as a last attempt to improve breathing.
The signs of respiratory distress may resemble other problems or medical conditions. Always consult your child's healthcare provider for a diagnosis, but if your child is having difficulty breathing, call 911 or go to the closest emergency room.Acute respiratory distress syndrome (ARDS) is the most severe form of acute respiratory failure characterized by diffuse alveolar and endothelial damage. The severe pathophysiological changes in lung parenchyma and pulmonary circulation together with the effects of positive pressure ventilation profoundly affect heart lung interactions in ARDS. The term pulmonary vascular dysfunction (PVD) refers to the specific involvement of the vascular compartment in ARDS and is expressed clinically by an increase in pulmonary arterial (PA) pressure and pulmonary vascular resistance both affecting right ventricular (RV) afterload. When severe, PVD can lead to RV failure which is associated to an increased mortality. The effect of PVD on RV function is not only a consequence of increased pulmonary vascular resistance as afterload is a much more complex phenomenon that includes all factors that oppose efficient ventricular ejection. Impaired pulmonary vascular mechanics including increased arterial elastance and augmented wave-reflection phenomena are commonly seen in ARDS and can additionally affect RV afterload. The use of
ABG.pptx
Arterial blood gas analysis PPT for the cardio student.
Very important topic and concepts that should be clear to those who are dealing with ICU patients
Non invasive ventillation...
A 62-year-old female with a history of hypertension, diabetes, and COPD presented with worsening cough, expectoration, and breathlessness over the past 3 days. On examination, she was drowsy with tachycardia, tachypnea, and low oxygen saturation. Tests showed respiratory acidosis and congestive cardiac failure. She was started on non-invasive ventilation (NIV) with initial settings of IPAP 10 cm H2O and EPAP 4 cm H2O, which were gradually increased. NIV was given for decreasing durations over 4 days as her condition improved before being discontinued.
Mechanical ventilation & Pulmonary Rehabilitation -1.pdf
Mechanical ventilation is used to support patients with respiratory failure by controlling parameters like tidal volume, respiratory rate, and pressure. It requires careful setting and monitoring to prevent complications. Modes include controlled, assisted, and combined settings. Pulmonary rehabilitation uses exercise, education, and breathing techniques to improve symptoms and quality of life for patients with chronic lung disease.
Mechanical ventilation & Pulmonary Rehabilitation -1.pdf
Mechanical ventilation is used to support patients with respiratory failure by controlling parameters like tidal volume, respiratory rate, and pressure. It requires careful setting and monitoring to prevent complications. Modes include controlled, assisted, and combined settings. Pulmonary rehabilitation uses exercise, education, and breathing techniques to improve symptoms and quality of life for patients with chronic lung disease.
Anesthesia during the first year of Life
This document discusses anesthesia considerations for neonates and infants under 1 year of age undergoing surgery. It covers age-specific anatomical and physiological differences, preoperative evaluation and preparation, induction and maintenance techniques, monitoring, fluid management, temperature control, and postoperative care. Special conditions like congenital anomalies requiring surgery are also reviewed.
Mechanical ventilation initiate.ppt
This document provides guidance on mechanical ventilation settings for different clinical situations. It discusses initializing ventilation and monitoring patients on ventilators. Key points include:
- Setting initial parameters like PIP, PEEP, respiratory rate and FiO2 for pressure control mode ventilation
- Understanding how these parameters function, like PIP controlling tidal volume and PEEP preventing atelectasis
- Monitoring for delivered tidal volume, minute ventilation, respiratory rate and oxygenation goals
- Adjusting settings appropriately based on patient's lung health, like using higher PEEP for asthma/COPD to keep airways open
Ventilation
Neonatal ventilation basics focuses on the principles of mechanical ventilation for neonates. It discusses tidal volume ventilation and the differences between anatomical and alveolar dead space. It notes that the neonatal dead space is typically 2.5-3ml/kg. The document also covers the respiratory motion equation, time constants, gestational ages of viability, basic principles of mechanical ventilation including modes of ventilation, commonly used modes on certain ventilators, principles and practical points of HFOV, and NIV options like bipap and HFNC.
BiPAP_many (1).pptx
This document provides information on BiPAP/NIV including definitions, indications, contraindications, equipment, modes, settings, monitoring, complications, and nursing considerations. BiPAP provides positive pressure ventilation via a non-invasive mask to reduce work of breathing and improve oxygenation. It is used for various respiratory conditions like COPD exacerbation and acute respiratory failure. Proper mask fitting and monitoring are important for patient safety and comfort during BiPAP therapy.
BASIC MECHANICAL VENTILATOR cme 2017.pptx
This document provides an overview of mechanical ventilation and strategies for setting a basic ventilator. It discusses respiratory physiology, reasons for needing ventilation, how to set parameters like FiO2, PEEP, tidal volume, and respiratory rate. It also covers topics like lung compliance, ARDS protective strategies, and ventilation in asthma. Two case studies are presented and discussed regarding how to address patients' ventilation needs based on their condition and blood gas results.
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anaesthetic implications of Congenital diaphragmatic-hernia
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Weaning from MECHANICAL VENTILATION
This document discusses weaning from mechanical ventilation. It defines key terms like liberation, extubation, spontaneous breathing trials (SBT), and weaning success and failure. It describes the process of conducting an SBT to assess readiness for extubation. Factors that can lead to weaning failure like respiratory load, cardiac load, neuromuscular issues, and psychological factors are reviewed. Finally, it discusses using different ventilator modes like pressure support ventilation to aid in more difficult weaning cases.
Tracheostomy
Tracheostomy is an artificial opening created in the trachea in the neck to allow access to the lower airway. It has major indications for preventing laryngeal damage from prolonged intubation, managing secretions, and providing stable airway access for prolonged mechanical ventilation. The techniques include open surgical and percutaneous dilatational tracheostomy. Early tracheostomy within 7 days of cardiac surgery has been shown to improve outcomes compared to late tracheostomy by reducing atrial fibrillation, kidney dysfunction, ICU stay, and hospital stay with no increase in mortality or infections. Complications can occur during surgery or post-operatively including hemorrhage, pneumothorax, nerve injury, and infections. Care involves tube
Infective endocardiitis
This document defines infective endocarditis and discusses its pathogenesis, clinical features, diagnosis, treatment and complications. Some key points:
- Infective endocarditis is defined as an infection of the endocardial surface of the heart, including heart valves. It most commonly affects the atrial side of the AV valves and ventricular side of semilunar valves.
- Staphylococcus aureus is now the most common causative organism, whereas streptococci were previously more common. Risk factors include underlying heart conditions, intravenous drug use, and invasive procedures.
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Management of cc tga
1. Congenitally corrected transposition of the great arteries (cc-TGA) involves atrioventricular and ventriculoarterial discordance.
2. Patients often present with ventricular septal defects, heart block, or ventricular dysfunction. The risk of complete heart block increases by 2% each year.
3. Surgical options include repair of associated defects while maintaining discordance, or an anatomic repair to place the morphological left ventricle as the systemic ventricle. The approach depends on the severity of lesions and individual patient factors.
Iabp presentation
This document provides an overview of intra-aortic balloon counterpulsation (IABP). It discusses the history and physiological effects of IABP, including increasing coronary perfusion and decreasing cardiac work. Indications for IABP include acute myocardial infarction and cardiogenic shock. The document reviews IABP instrumentation, monitoring, waveforms, timing, complications, weaning, and removal. IABP is a temporary circulatory support device that aims to improve heart function through counterpulsation.
Coagulation monitoring and teg
This document discusses various laboratory tests used to monitor coagulation, including clotting time, prothrombin time and INR, activated partial thromboplastin time, fibrinogen level, fibrin degradation products, D-dimer, and tests for monitoring anticoagulants like heparin. It provides details on what each test measures, its normal range and clinical uses, and potential causes of abnormal results. It also discusses limitations and factors that can influence certain tests, as well as newer techniques for individualized monitoring and dosing of heparin.
Coronary artery anomalies in chd
This document discusses coronary artery anomalies associated with congenital heart disease. It notes that coronary anomalies can be associated with or due to congenital heart diseases like tetralogy of Fallot, transposition of the great arteries, truncus arteriosus, and pulmonary atresia with intact ventricular septum. It provides details on common coronary artery patterns and surgical management options for addressing anomalous coronary arteries during repair of various congenital heart defects.
Adult ecmo
1. The document describes a case of a 28-year-old female with cyanotic congenital heart disease who underwent an arterial switch operation with integrated ECMO support.
2. ECMO is a form of extracorporeal life support used for both cardiac and respiratory failure in adults. It involves pumping blood out of the body to an artificial lung for gas exchange before returning it to circulation.
3. The key components of an ECMO circuit include a blood pump, membrane oxygenator, tubing, heat exchanger, and monitoring equipment. Proper anticoagulation and flow rates are important for safety and effectiveness.
Evolution of management stratergy for TGA
This document discusses the evolution of surgical management strategies for transposition of the great arteries (TGA). Early palliative procedures like atrial septectomy had high mortality. The atrial switch procedures (Senning and Mustard) developed in the 1950s-60s provided longer term survival but were associated with complications like arrhythmias, systemic ventricular dysfunction, and obstruction of venous pathways. The arterial switch operation developed in 1975 revolutionized treatment by anatomically correcting the defect. However, early attempts were unsuccessful due to technical challenges like coronary artery transfer. The landmark successful case by Jatene in 1975 established the arterial switch as the standard of care for TGA, though early mortality rates were still high at some centers. Long term
Heart transplant guidelines
This document discusses heart transplantation, including indications, donor and recipient criteria. It provides a brief history of heart transplantation from early experiments to modern procedures. Key points include common indications for transplant like dilated cardiomyopathy, the importance of matching donor and recipient size and blood type, and selecting recipients without other medical issues that could impact outcomes. Contraindications and special considerations for procedures like ABO incompatible and pediatric transplants are also summarized.
HYPOPLASTIC LEFT HEART SYNDROME
Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the left side of the heart. It requires multi-stage surgical intervention to establish an adequate circulation. The first stage, known as the Norwood procedure, involves reconstructing the aortic arch and creating a shunt to provide pulmonary blood flow. Subsequent stages include the hemi-Fontan/Glenn procedure and final Fontan completion. Alternative treatments include heart transplantation or hybrid approaches. Long-term survival has improved but remains dependent on surgical expertise and individual patient risk factors. Ongoing management focuses on achieving balanced systemic and pulmonary circulations through each stage of treatment.
Pumps, oxygenators and priming solution
Pumps, oxygenators, and priming solutions are essential components of cardiopulmonary bypass. There are two main types of pumps - roller pumps and centrifugal pumps. Roller pumps work by rolling blood through tubing while centrifugal pumps use centrifugal force to move blood. Membrane oxygenators allow for gas exchange through a semi-permeable barrier, separating blood from gas, and eliminating the damage caused by bubble oxygenators. Proper selection of the components depends on factors such as flow needs, biocompatibility and minimizing trauma to blood during bypass.
Blood presentation
This document discusses red blood cell and component therapy. It covers three pillars of patient blood management: preoperative detection of anemia, intraoperative hemostasis and cell salvage, and postoperative optimization. It then describes the components that make up component therapy, including packed red blood cells (PRBC), platelets, fresh frozen plasma, cryoprecipitate, and leukoreduced and irradiated PRBCs. Indications for transfusion and potential complications are also summarized.
Tga management
1. The document outlines the history and evolution of surgical techniques for treating transposition of the great arteries (TGA).
2. Early techniques included atrial septal defect creation (Blalock-Hanlon) and atrial switch operations by Senning and Mustard using flaps or baffles.
3. The arterial switch operation was first successfully performed by Jatene in 1975 and modified by Lecompte, allowing coronary artery transfer.
4. Advances now allow arterial switch in neonates and extended to 6 months with support like ECMO.
Pediatric ecmo
This document discusses pediatric extracorporeal membrane oxygenation (ECMO) management including:
- Types of ECMO including venovenous and venoarterial
- Ventilator, coagulation, nutrition, inotrope, and sedation management of children on ECMO
- Monitoring of vital signs and investigations including echocardiograms and blood work
- Guidelines for weaning children from ECMO when stable and meeting criteria
- Potential complications of ECMO like bleeding, infection, and neurological injury and their management
- Procedures that can be done while a child is on ECMO
Management of tapvc
This document discusses the diagnosis and management of total anomalous pulmonary venous connection (TAPVC). It covers the types of TAPVC, diagnostic tools including ECG, CXR, echocardiography and catheterization, and surgical and interventional treatment options. The key points are:
1. TAPVC is diagnosed using imaging modalities like echocardiography, CT, and catheterization to identify the anomalous pulmonary vein drainage.
2. Surgical repair is the definitive treatment and involves anastomosis of the pulmonary veins to the left atrium. Factors like age, type of TAPVC, and presence of obstruction determine timing of surgery.
3. Post-operative management focuses on stabil
Constrictive pericarditis pathophysiology
This document discusses the pathophysiology of constrictive pericarditis (CCP). CCP is caused by a thickened and fibrotic pericardium that restricts heart filling. This leads to 4 key hemodynamic changes: 1) impaired diastolic filling, 2) dissociation of intrathoracic and intracardiac pressures with respiration, 3) excessive ventricular coupling, and 4) heart rate dependent filling. The thick pericardium equalizes pressures in all chambers and abruptly halts early diastolic filling. Inspiration decreases left ventricular filling while increasing right ventricular filling via septal shift. Expiration causes the opposite effect.
Mechanical heart valve substitutes
This document discusses the history and evolution of mechanical heart valve substitutes from the 1950s to the present. It describes early ball and cage valves developed by Harken and Starr-Edwards in the 1950s-60s that helped ignite the field of prosthetic heart valves but had limitations. It then covers the development of tilting disc valves including the Bjork-Shiley valve that was later recalled due to failures, and bileaflet valves such as the St. Jude Medical valve made of durable pyrolytic carbon. The document traces the materials, designs and improvements made to mechanical heart valves over decades to increase effectiveness and safety.
Bioprostheic heart valve prosthesis
This document provides a history of heart valve substitutes, beginning with the first implantation of homografts in the 1950s-1960s and moving to the development of xenograft valves fixed with glutaraldehyde in the 1960s-1970s. It discusses the work of Carpentier in developing low-pressure fixation and mechanical protection of valves. Various generations of bioprosthetic valves are summarized, including advances in fixation methods and anti-mineralization treatments. Stentless valves are introduced, providing improved hemodynamics over stented valves but requiring more complex implantation.
PATHOPHYSIOLOGY ,NATURAL HISTORY OF VSD
1. Ventricular septal defects (VSDs) are one of the most common congenital heart defects, accounting for 20-30% of cases in India.
2. The natural history and progression of a VSD depends on factors like its size, location, and the development of pulmonary hypertension.
3. Small VSDs have over a 50% chance of spontaneous closure by age 5, while larger defects often require surgical intervention. Without treatment, complications can include congestive heart failure, pulmonary vascular disease, bacterial endocarditis, and aortic regurgitation.
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Protocol for ventilator settings
- 1. PROTOCOL FOR VENTILATORY SETTINGS 1. First ABG 10min after connecting to ventilator 2. pCO2 value: Increase /Decrease RR 3. Vt: Do not change until mean Paw cross upper limits 4. On PRVC: up to 25 mean Paw is acceptable Adult Child (1-10yr) Neonate/infant Vt 8ml/kg 8ml/kg 8ml/kg I:E 1:2 1:2 1:1.5 PEEP 5 cmH2O 5 cmH2O 3 cmH2O RR 14 (up to 24) 16 (up to 30) 25 (up to 40) Initial PRVC settings SIMV settings Check-list for early extubation (PRVC SIMV) 1. Stable Hemodynamics (BP, HR, U/O) 2. Rhythm (regular or AF with CVR ) 3. Hemostasis (drain output within limits ) 4. Neurologic status (awake, oriented) 5. ABG within acceptable range 6. Temperature (Per. temp>30˚c, Core temp- Per. temp ≤ 10) 7. Chest X ray (within normal limits) • Change from initial PRVC to SIMV • Initial PS above PEEP- Adults: 7 cmH2O, Infants 10 cmH2O • Trigger- Adults: Flow ( -2L/min), Infants Pressure (-2cm H2O) • Reduce RR by 3- 5, PS above PEEP by 2, PEEP by 1 [every 15-30 min] • Repeat ABG every 30 min after changing settings • TARGET: PEEP 5, FiO2 0.5, PS above PEEP 5, RR 5 (Minimal SIMV) Weaning failure signs Change in • RR >10 • pCO2 >10 • SaO2 >10
- 2. 1. Minimal SIMV 2. PS+CPAP (in adults and infants) / CPAP (in adults only) 3. T piece (Briggs) • Trial for 30 min Clinical evaluation, ABG Check list for Successful Spontaneous Breathing Trial • Neurological • awake without stimulation • Eye opening • Tongue protrusion • Good hand grip • Head raise • ABG • SaO2 > 92% • pO2 >80 mmHg (FiO2 ≤ 0.5) • pCO2 : 30-50 mmHg • pH 7.35- 7.45 (Base Excess <4) • Mechanics • Vt >5mL/kg • RR < 24 (adult), <35 (infant) • Stable BP, HR, rhythm • Chest tube drainage within normal limits Extubation • Head end elevation to at least 30˚ • Final suctioning of ET tube • Suctioning of oral cavity • Ask to cough as ET tube is removed in adult patients • Oral lavage following removal of ETT • Put on Humidified O2 by mask 10L/min • Repeat ABG after 30 min Transition ventilation • Post extubation support by CPAP/ BiPAP: If respiratory efforts are borderline and pCO2 retention on ABG or known cases of restrictive airway disease Spontaneous Breathing Trials
- 3. General directions & Special situations • Baer hugger can be applied if there is suspected coagulopathy (on going bleeding) and blood pressure is above normal • Active rewarming can be done if MAP >110 mmHg • Core and peripheral temperature difference >10˚c LCOS • All neonates should have core temp monitoring Rewarming BT shunt • Keep pCO2 40, Hct 40, FiO2 40 (SaO2 ~ 80%) • Any unexplained hypoxia, tachycardia, hypotension note down shunt flow BD Glenn and Fontan • Vt 8mL/kg (increase in intra thoracic pressure impedes venous return) • RR 18-20 • Extubate early as possible • BD Glenn (may keep pCO2 40-50 mmHg i/v/o cerebro-pulmonary circuit) Pulmonary oedema, ETT bleed, Residual LR shunt • Raise PEEP by 1-2 cmH2O (max 10-15 cmH2O) every 15 min, until lower inflection point is reached on flow volume loop • Minimize ET suction if there is no obstruction to airflow (Acute rise in Peak Paw) Bronchospasm in infants • Rule out cardiac cause (MC: volume overload) • Tube hitting carina • Local (secretions, mucus plug) Open sternum • High compliance and risk of barotrauma and volutrauma • Keep normal settings if ventilation parameters and ABG report is good • May need to set higher PEEP (5-7 cmH2O)