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POSTOPERATIVE RESPIRATORY FAILURE

POSTOPERATIVE RESPIRATORY FAILURE. ARDS Martha Richter, MSN, CRNA. ARDS. Characterized by profound hypoxemia Diffuse alveolar damage b/o noncardiogenic pulmonary edema Increased alveolar-capillary membrane permeability Acute lung injury-direct or indirect. ARDS.

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POSTOPERATIVE RESPIRATORY FAILURE

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  1. POSTOPERATIVE RESPIRATORY FAILURE ARDS Martha Richter, MSN, CRNA

  2. ARDS • Characterized by profound hypoxemia • Diffuse alveolar damage b/o noncardiogenic pulmonary edema • Increased alveolar-capillary membrane permeability • Acute lung injury-direct or indirect

  3. ARDS • Highest progression with sepsis • Acute phase • Rapid progress to refractory hypoxemia • Xrays look like cardiogenic pulmonary edema • May resolve completely OR progress to fibrosing alveolitis • Persistent hypoxemia • Decreased pulmonary compliance Recovery phase resolution hypoxemia, improved lung compliance, resolution CXR abnormalities

  4. ARDS – PULMONARY EDEMA • Hydrostatic-vol overload, LV failure, valvular hrt dis., lymph insufficiency • Permeability pulmonary edema –also alveolar capillary leak-SIRS(systemic inflammatory response syndrome) b/o shock, pulmonary contusion, thermal injury, fat embolism, closed head injury, infections, near drowning, inhaled toxins, pancreatitis, drug ingestion, multiple transfusions, etc. • Mixed-often pts with heart failure and superimposed SIRS

  5. ARDS-treatment • Determine underlying cause • Prevent/early RX nosocomial infections • Adequate nutrition • Prev GI bleed/embolic events • Inhaled B-agonists may fascilitate removal edema fld from alveolik, stim. Surfactant, exert an anti-inflam effect

  6. ARDS-treatment • Initial • Intubation • Mechanical ventilation • FIO2 to maintain PaO2 60-80 • Vt 8-10 ml/kg • Do not exceed PIP 35-40 cm H2O • PEEP to recruit collapsed alveoli, inc. lung vol, improves V/Q matching, dec R L shunt • Used when FIO2>.5 required for prolonged time • Add 2.5-5 cm up to 15 cmH2O • PA cath to monitor intravasc fld replace,myocardial contract, tissue oxygenation (venous partial pressure O2)

  7. ARDS-FLUID MANAGEMENT • Restricted to dec magnitude pulm edema • Urine output 0.5-1ml/kg/hr • Anticipate wt loss .2-.4 kg/day • Drug induced diuresis may be indicated • Improvement=improved oxygenation, resolution infiltrates • Adequate organ perfusion assessed by metabolic acid-base balance & renal function

  8. ARDS-Management • Corticosteroids early – controversial • Corticosteroids late/rescue in severe may have value • Secretions may add to atelectasis-need meticulous management (humidification, PT, suction) • Control of infections • Nutritional support

  9. ARDS-monitoring • Evaluation pulmonary gas exchange • Arterial & venous blood gases • Evaluation of cardiac function • CO, filling pressures, intrapulmonary shunt

  10. ARDS-monitoring RX • Arterial hypoxemia = PaO2 <60mmHg • Principal causes:V/Q mismatch, R-L intrapulmonary shunt, hypoventilation • R to L shunt >30% CO; doesn’t respond to inc. FIO2 • Acute hypoxemia compensation:carotid body-induced inc. alveolar vent; regional pulm art vasoconstriction; inc sympathetic activ to inc CO (inc tissue O2 deliv) • Acute comp occurs at <60mmHg PaO2 • Chronic comp occurs at <50mmHg PaO2 (inc RBC) • PaO2 <30mmHg PaO2 = cell damage likely

  11. ARDS monitoring • Dead space increases (VD/VT ratio) • Normal = <0.3 • May inc to 0.6 • This ratio reflects the adequacy of vent (exchange of CO2) • VD/VT inc with acute resp failure, dec CO, pulmonary embolism • Remember the effects of acute CO2 elevations: inc CBF, inc ICP; >80=seizures, CNS depression

  12. ARDS MONITORING • Mixed venous partial pressures O2 • PvO2 • CaO2-CvO2=reflection of adequacy O2 delivered to tissue relative to extraction by cells. • PvO2 <30mmHg or CaO2-CvO2 >6ml/dl=need to inc CO to inc cell oxygenation • PA cath allows sampling mixed venous blood via distal port

  13. ARDS MONITORING • Arterial pH • Metabolic acidosis=hypoxemia, inadeq deliv O2 to tissues • Assoc with dysrhythmias, inc PVR • Alkalemia=usually iatrogenic b/o mech hyperventilation or drug induced diuresis • May prevent/delay successful weaning

  14. ARDS MONITORING • Intrapulmonary shunt (right to left) • Occurs when alveoli are perfused, not vent • = dec PaO2 • Calculation shunt fraction allows assess of V/Q match during Rx • Normal physiologic shunt =2-5% CO • Degree of R-L shunt “reflects passage of PA blood directly to left side of circ thru bronchial & thebesian v”

  15. OTHER APPROACHES • Exogenous surfactant –improvement in neonates, not adults • Nitric oxide is being investigated for benefits-questionable at this time • Partial liquid ventilation (perfluorocarbons into the tracheobronchial tree). Requires extracorporeal circulatory support • Requires aggressive management with early recognition of contributing events to reduce morbidity & mortality

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