Trouble shooting-Case scenarios

1. Trouble shooting-Case scenarios Kishore P. Critical Care Conference

2. Case 3 • 18 yr old man intubated for organophosphorus poisoning and intermediate syndrome was on the foll settings (see ventilator). • He suddenly desaturates. You notice that his resp rate is 35/min, heart rate is 120/min, BP is 90/70mmHg. • Auscultation reveals equal vesicular breath sounds. What would you do? Kishore P. Critical Care Confernce

3. Case 4 • A 35 yr old man with status epilepticus following organochloride ingestion is being ventilated in the ICU. You are called because of desaturation and persistent low pressure alarms. How would you tackle the situation? Kishore P. Critical Care Confernce

4. Case 5 • 50 yr old man being ventilated for hepatic coma. Noticed by nursing staff to be gasping and desaturating. Ventilator has been showing high pressure alarms. What is your approach to this patient? Kishore P. Critical Care Confernce

5. Case 3 • 18 yr old man intubated for organophosphorus poisoning and intermediate syndrome was on the foll settings (see ventilator). • He suddenly desaturates. You notice that his resp rate is 35/min, heart rate is 120/min, BP is 90/70mmHg. • Auscultation reveals equal vesicular breath sounds. What would you do? Kishore P. Critical Care Confernce

6. Approach to Hypoxia on the ventilator Increase FiO2 to 100% Examine patient Chest X-Ray ABNORMAL NORMAL HYPOVENTILATION Low pressure alarms Check machine and connections • UNILATERAL • Collapse • Atelectasis • Infarction • AIRWAY OBSTRUCTION • High pressure alarms • Tube block • Secretions • bronchospasm • BILATERAL • Bronchopneumonia • ARDS • Cardiogenic edema • Volume overload PULMONARY EMBOLISM PNEUMOTHORAX ET TUBE MALFUNCTION Tube leak Bronchial displacement Kishore P. Critical Care Confernce

7. Case 4 • A 35 yr old man with status epilepticus following organochloride ingestion is being ventilated in the ICU. You are called because of desaturation and persistent low pressure alarms. How would you tackle the situation? Kishore P. Critical Care Confernce

8. Consider the following • Cuff leak. • Leak in the circuit • Loose connections • ET tube displacement • Disconnection • Inadequate flow • Low supply gas pressures Kishore P. Critical Care Confernce

9. Low pressure alarm • FiO2 to 100% • Check all connections for leaks. Start from ventilator inspiratory outlet—humidifier—inspiratory limb—nebulizer—Y junction—dead space—et tube cuff—expiratory limb—expiratory valve. • If inspiratory effort excessive-inadequate flow—increase inspiratory flow, decrease Ti, increase TV • Check gas pressures • If all normal and problem persists, change ventilator Kishore P. Critical Care Confernce

10. Case 5 • 50 yr old man being ventilated for hepatic coma. Noticed by nursing staff to be gasping and desaturating. Ventilator has been showing high pressure alarms. What is your approach to this patient? Kishore P. Critical Care Confernce

11. Consider the following Secretions in airway Tube block Kinking of tube Biting the tube Water in the tube Cuff herniation Rt. bronchial intubation Fighting the ventilator Cough Increased airway resistance Bronchospasm Decreased compliance Atelectasis Fluid overload Pneumothorax Kishore P. Critical Care Confernce

12. High pressure alarm • FiO2 to 100% • Look at chest movement, auscultate air entry. Kishore P. Critical Care Confernce

14. Low pressure- “leak” • High pressure- “block” Kishore P. Critical Care Confernce

15. Other alarms • Apnoea alarm • Low and high minute volume • High frequency • Low inlet gas pressures Kishore P. Critical Care Confernce

16. Default settings • Varies to requirement Kishore P. Critical Care Confernce

17. Case 1 • 25 year old lady with acute severe asthma is admitted into the ICU from emergency. She was intubated in the emergency department. On admission, she seems to be gasping on the tube. The ventilator has been giving high pressure alarms since it was connected. The SpO2 is 99%. Body weight 50kgs. Set the ventilator for this patient. Kishore P. Critical Care Confernce

18. Case 2 • A 40 yr old man from Chittoor, who was being treated for malaria developed progressive breathlessness and hypoxia requiring intubation in the ward. X-ray done is suggestive of ARDS. He is being shifted into the ICU. Body weight 60kgs. Set the ventilator for this patient. • One hr later ABG done-pH 7.20, PCO2 65, PaO2 55, HCO3 25, BE 1.0, SaO2 86%. What changes would you make. Kishore P. Critical Care Confernce

19. Status asthmaticus • Low TV-6ml/kg • High I:E ratio – low rate (8-10/min) • Ti = 1-1.2 sec • Pramp = 100-200msec • PEEP = 7-8 cm H2O • Permissive hypercapnia Kishore P. Critical Care Confernce

20. COPD • High I:E ratio – low rate (8-10/min) • Ti = 1-1.2 sec • Pramp = 100-200msec • PEEP = 7-8 cm H2O • Permissive hypercapnia Kishore P. Critical Care Confernce

21. ARDS • Low TV: 6ml/kg • Peak pressures<35 cm H2O • Rate 20-30/min (max 35/min) to maintain pH>7.30 • If pH<7.30 inspite of max rate, start NaHCO3 • PEEP 10-20 cm H2O • Paralyze the patient if PEEP > 10cm H2O Kishore P. Critical Care Confernce