Protective ABG and Vent strats

Question 1

What are TBI Protocol O2 and CO2 goals?

Answer 1

• PaO2 (80-120)
• PaCO2 (35-40…or lower)
• pH 7.4-7.45
• Normal ICP

Question 2

What can you do to help maintain a patient on TBI protocol until further orders are given?

Answer 2

• Barbiturate’s coma if
  necessary
• Cooling
• Address other issues and pathologies
• Monitor ICP
• Make sure pt is hemodynamically stable

Question 3

What are strategies to manage ICP?

Answer 3

• HOB 15-30
• Avoid Hypercarbia
• Ensure adequate BP and oxygenation w/ABG and FiO2
• Provide sedation/analgesia
• Avoid volume overload
• Avoid hyperglycemia

Question 4

In what situation would you target CO2 goals?

Answer 4

TBI protocol

Question 5

Is CO2 targetted for COPDers?

Answer 5

No, CO2 is tartgeted for TBI protocol

• pH is targeted for COPD

Question 6

ABG goals for Cyanotic Heart Defects (ductal dependent) aka NEOS

Answer 6

“Rule of 40s” (7.4/40.40)

1. pH = 7.4
2. PaCO2 = 40mmhg
3. PaO2 = 40mmHg

Question 7

ABG goals for PPHN aka NEOS

Answer 7

◾pH 7.4-7.45
◾35-40 mmHg PaCO2
◾PaO2 >100mmHg

Question 8

ARDS Vent Goals (general)

Answer 8

◾ high PEEPs, higher FiO2s
◾ lower tidal volumes (lower ∆P)
◾ Refer to ARDSnet

Question 9

What values can assess ARDS severity?

Answer 9

PF Ratio and OI

• PF ratio < 300 → Mild
• PF ratio < 200 → Mod
• PF ratio < 100 → Severe

Question 10

Proning criteria?

Answer 10

PF <150 or OI >20

Question 11

Pneumothorax goals?

Answer 11

Insert chest tube for removal of
pneumothorax.

• Limit the pressures (Plat < 30, Vt lower level of normal that achieves goals (6-8mL/kg) (look at PC CMV for pressure delivery)
• Higher FiO2
• Normal PEEP
• potentially permissive hypercapnia if pressure requirements are high

Question 12

How should BVM be performed for pneumothoraxes?

Answer 12

If bagging, smaller breaths and faster RR

Question 13

Why shouldn’t a pneumothorax patient have 1 lung isolated for care?

Answer 13

Isolation of affected lung is not
recommended because:

• Atelectasis causes large V/Q mismatch
• Can increase the size of the pneumothorax, and impair gas exchange)

Question 14

General Asthma vent goals?

Answer 14

Lung protective strategies (Low vt and permissive hypercapnia)

• Long Tes (may need to increase PIPs)
• Observe for dynamic hyperinflation
• PEEP w/caution (target PEEP total of 5 cmH2O), kyrsta said ideally keep peep at 0 since they have trouble getting air in and out = lots of air trapping.
• Consider anesthetic agents for bronchodilation effects

Question 15

What are general lung protective strategies?

Answer 15

Low Vts and Permissive hypercapnia?

Question 16

Why would longer Te’s be beneficial for asthma patients?

Answer 16

Longer exhalation times allow for adequate exhalation (watch for air trapping)

• PIP may need to be higher (greater than 30); Ensure plats < 30
• Higher PIPS reduce air trapping and help overcome high resistance

Question 17

What can you do if dynamic hyperinflation (barrel chest) is observed?

Answer 17

If no air movement with a barrel chest appearance, consider disconnecting from vent and pushing on chest (carefully) before reconnection

• Rescue method, reconnect post procedure

Question 18

What anesthetic agent can be given for bad asthma?

Answer 18

Sevoflurane

Question 19

Why should you avoid PRVC in asthmatic patients who are able to trigger their own breath?

Answer 19

Not a absolute, but: mode will decrease support in reaction to increased pt effort

Question 20

What modes are preferred for Mechanical Ventilation of Patients With Smoke Inhalation and Pulmonary Burns

Answer 20

Pressure or volume ventilation

Question 21

Mechanical Ventilation goals of Patients With Smoke Inhalation and Pulmonary Burns?

Answer 21

• Tidal volume: 4–8 mL/kg PBW
• Inspiratory time 0.6–1.0 s
• Plateau pressure: Less than 28 cm H2O unless chest wall compliance decreased
• If compliance decreased, plateau pressure should exceed 28 cm H2O
• Measure end inspiratory transpulmonary pressure to determine acceptable plateau
  pressure
• Driving pressure equal to or less than 15 cm H2O
• Rate only limited by the development of auto-PEEP
• Minute volume to maintain normal PaCO2
• PEEP 5–10 cm H2O, unless ARDS
• FiO2 1.0 initially because of concern for CO poisoning
• If ARDS, manage as any other ARDS patient

Question 22

Normal driving pressure target?

Answer 22

Driving pressure < 15

Question 23

What is PRVC syndrome and why is it a problem?

Answer 23

PRVC targets a volume and the vent attempts to achieve by altering pressure admin.

• PRVC syndrome occurs when the pts WOB increases, the vent eases off of pressure because the vent finds it easier to obtain the Vt set so it reduces the admined pressure
• Results Decrease pressure from vent further increases Pts WOB = increasing O2 demand and could result in resp failure

Question 24

When would Permissive hypothermia be used?

Answer 24

Used in the acute phase of severe TBI to optimize cerebral perfusion and reduce ICP. used to mitigate brain injury following trauma

• Decreases cerebral metabolic rate
• Reduces cerebral blood flood
• Reduces inflammatory response in brain