1 / 33

Special Procedures

Special Procedures. Fred Hill, MA, RRT. Surfactant Replacement. Composition Phospholipids (90%) phosphatidylcholine (PC) (85%) - dipalmitoyl phosphatidylcholine (DPPC) (60%) Phosphatidylglycerol (PG) Phosphatidylinositol (PI) Cholesterol Proteins (5-10%): SP-A, SP-B, SP-C, SP-D.

ginny
Download Presentation

Special Procedures

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Special Procedures Fred Hill, MA, RRT

  2. Surfactant Replacement Composition • Phospholipids (90%) • phosphatidylcholine (PC) (85%) - dipalmitoyl phosphatidylcholine (DPPC) (60%) • Phosphatidylglycerol (PG) • Phosphatidylinositol (PI) • Cholesterol • Proteins (5-10%): SP-A, SP-B, SP-C, SP-D

  3. Surfactant Replacement Indications • Prophylactic administration (high risk for developing RDS) • <32 weeks gestational age • <1300 grams • L/S ratio <2:1 • Absence of PG • Therapeutic (rescue) administration • ↑WOB (grunting, retractions, nasal flaring) • ↑ O2 requirements • RDS on CXR

  4. Surfactant Replacement Types of Surfactant • Exosurf (colfosceril palmitate): synthetic, 5 ml/kg • Survanta (beractant): calf lung, 4 ml/kg • Infasurf (calfactant): calf lung, 3 ml/kg • Curosurf (poractant alfa): pig lung, 2.5 ml/kg

  5. Surfactant Replacement Adverse Effects • Bradycardia, desaturation • ETT reflux, ETT obstruction • Barotrauma Benefit • Decreased mortality rates • Decreased morbidity rates, reduction in: • Severity of RDS • Pulmonary air leaks • Incidence of BPD

  6. High –Frequency Ventilation Introduction • Delivery of small tidal volumes at very high rates (usually >150/min.) • Rates may be expressed in hertz (Hz) (1 Hz = 60/min.) • Amplitude = ΔP, determines PCO2 • Mean airway pressure determines PO2

  7. High –Frequency Ventilation Indications • Respiratory failure unresponsive to conventional methods • Pulmonary air leaks • Congenital diaphragmatic hernia

  8. High –Frequency Ventilation Hazards • Gas trapping & hyperinflation • Necrotizing tracheobronchitis (especially with HFJV) • Chest assessment is difficult • Obstruction • Malposition of ETT

  9. High –Frequency Ventilation Types • High-frequency positive pressure ventilation (HFPPV) • High-frequency jet ventilation (HFJV) • High-frequency Oscillatory Ventilation (HFOV)

  10. High –Frequency Ventilation High-Frequency Positive Pressure Ventilation (HFPPV) • 60 to 150 bpm • Tidal volume exceeds dead space • Possible advantages: • ↓ pneumothoraces • ↓ asynchrony with ventilator

  11. High –Frequency Ventilation High-Frequency Jet Ventilation (HFJV) Bunnell Life Pulse High Frequency Ventilator

  12. High –Frequency Ventilation High-Frequency Jet Ventilation (HFJV) • 240-660 bpm • Passive exhalation • Requires special ETT or adapter • In tandem with conventional ventilator • Occasional sighs • PEEP • Continuous gas flow for entrainment

  13. High –Frequency Ventilation High-Frequency Oscillatory Ventilation (HFOV) Sensormedics 3100A

  14. High –Frequency Ventilation High-Frequency Oscillatory Ventilation (HFOV) • 8 to 30 HZ (480 – 1800) • Active inspiration and exhalation

  15. Inhaled Nitric Oxide Action • Causes smooth muscle relaxation in vascular walls of pulmonary vessels • Improves oxygen delivery due to dilation of vessels in ventilated areas of lung

  16. Inhaled Nitric Oxide Applications • PPHN – most important • MAS • RDS • Pneumonia, sepsis • Congenital diaphragmatic hernia

  17. Inhaled Nitric Oxide Hazards • Nitrogen dioxide (NO2) • Methemoglobinemia

  18. Inhaled Nitric Oxide Application • INOvent Delivery System • 8 – 20 ppm

  19. INOvent

  20. Extracorporeal Membrane Oxygenation (ECMO) History • 1950’s: short-term (hours) in open heart surgery • 1960’s: long-term (days to weeks) • 1971: first use in infants

  21. Extracorporeal Membrane Oxygenation (ECMO) Exclusion Crtieria • Gestational age <35 weeks • Pre-existing IVH • Significant coagulopathy or uncontrollable bleeding. • No major (>grade 1) intracranial hemorrhage • Irreversible lung injury • Major congenital/chromosomal anomalies or severe encephalopathy • Major cardiac malformation • Mechanical Ventilation : >7days • Cardiac arrest other than immediately at birth

  22. Extracorporeal Membrane Oxygenation (ECMO) Inclusion Criteria • 80% mortality risk if no ECMO intervention • Oxygenation Index (OI)>40: OI =(Mean Airway Pressure [cmH20] x FiO2 x 100) which in turn is divided by the Post ductal PaO2 [mmHg] • OI = Paw x FIO2 x 100 PaO2 • Gestational Age >35 weeks • Weight >2 kgs • Reversible lung disease • No major (>grade 1) intra-cranial hemorrhage • No lethal congenital abnormalities

  23. Extracorporeal Membrane Oxygenation (ECMO) Mechanisms of Bypass • Venoarterial: blood drawn from right atrium via right internal jugular vein, returned to the aortic arch via right common carotid artery • Takes over function of heart and lungs • Venovenous: blood drawn from right atrium via right internal jugular vein, returned to right atrium via femoral vein • Takes over function of lungs

  24. Extracorporeal Membrane Oxygenation (ECMO)

  25. Extracorporeal Membrane Oxygenation (ECMO)

  26. Advantages of Venovenous ECLS • Sparing of carotid artery • Preservation of pulsatile flow • Normal pulmonary blood flow • Perfusion of lungs with oxygenated blood • Perfusion of coronaries with oxygenated blood • Avoidance of infusion of possible emboli into arterial circulation • Central venous pressure accurate • Selective limb perfusion does not occur

  27. Disadvantages of Venovenous ECLS • No cardiac support • Lower systemic PaO2 • Recirculation issues

  28. Advantages of Venoarterial ECLS • Provides cardiac support • Excellent gas exchange • Rapid stabilization

  29. Disadvantages of Venoarterial ECLS • Carotid artery ligation • Nonpulsatile flow • Reduced pulmonary blood flow • Lower myocardial oxygen delivery • Direct infusion of possible emboli into arterial circulation • Central venous pressure inaccurate

  30. Extracorporeal Membrane Oxygenation (ECMO) Components of ECMO Circuit • Venous blood drainage reservoir • Blood roller pump • Membrane oxygenator • Heat exchanger

  31. Extracorporeal Membrane Oxygenation (ECMO) Physiologic Complications • Bleeding • Volume problems • Blood pressure problems • Hematologic problems (anemia, leukopenia, thrombocytopenia) • Infection

  32. Extracorporeal Membrane Oxygenation (ECMO) Technical Complications • Pump failure • Rupture of tubing • Membrane failure • Cannula problems • Other mechanical failures

  33. Extracorporeal Membrane Oxygenation (ECMO) Overview • Early method of rescue • Less important today with advent of SRT, HFOV, and iNO • Still an important life support option in some centers

More Related