Protective ABG and Vent strats Flashcards
What are TBI Protocol O2 and CO2 goals?
- PaO2 (80-120)
- PaCO2 (35-40…or lower)
- pH 7.4-7.45
- Normal ICP
What can you do to help maintain a patient on TBI protocol until further orders are given?
- Barbiturate’s coma if
necessary - Cooling
- Address other issues and pathologies
- Monitor ICP
- Make sure pt is hemodynamically stable
What are strategies to manage ICP?
- HOB 15-30
- Avoid Hypercarbia
- Ensure adequate BP and oxygenation w/ABG and FiO2
- Provide sedation/analgesia
- Avoid volume overload
- Avoid hyperglycemia
In what situation would you target CO2 goals?
TBI protocol
Is CO2 targetted for COPDers?
No, CO2 is tartgeted for TBI protocol
- pH is targeted for COPD
ABG goals for Cyanotic Heart Defects (ductal dependent) aka NEOS
“Rule of 40s” (7.4/40.40)
- pH = 7.4
- PaCO2 = 40mmhg
- PaO2 = 40mmHg
ABG goals for PPHN aka NEOS
◾pH 7.4-7.45
◾35-40 mmHg PaCO2
◾PaO2 >100mmHg
ARDS Vent Goals (general)
◾ high PEEPs, higher FiO2s
◾ lower tidal volumes (lower ∆P)
◾ Refer to ARDSnet
What values can assess ARDS severity?
PF Ratio and OI
- PF ratio < 300 → Mild
- PF ratio < 200 → Mod
- PF ratio < 100 → Severe
Proning criteria?
PF <150 or OI >20
Pneumothorax goals?
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
How should BVM be performed for pneumothoraxes?
If bagging, smaller breaths and faster RR
Why shouldn’t a pneumothorax patient have 1 lung isolated for care?
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)
General Asthma vent goals?
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
What are general lung protective strategies?
Low Vts and Permissive hypercapnia?
Why would longer Te’s be beneficial for asthma patients?
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
What can you do if dynamic hyperinflation (barrel chest) is observed?
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
What anesthetic agent can be given for bad asthma?
Sevoflurane
Why should you avoid PRVC in asthmatic patients who are able to trigger their own breath?
Not a absolute, but: mode will decrease support in reaction to increased pt effort
What modes are preferred for Mechanical Ventilation of Patients With Smoke Inhalation and Pulmonary Burns
Pressure or volume ventilation
Mechanical Ventilation goals of Patients With Smoke Inhalation and Pulmonary Burns?
- 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
Normal driving pressure target?
Driving pressure < 15
What is PRVC syndrome and why is it a problem?
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
When would Permissive hypothermia be used?
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
