ICU management and referral guidelines for severe hypoxic respiratory failure

Transcription

1 Aim: ICU management and referral guidelines for severe hypoxic respiratory failure 1) To provide a concise management plan Non ventilatory Ventilatory 2) Timeline for referring patient with refractory hypoxic respiratory failure Hypoxic respiratory failure fulfilling ARDS criteria: (Suspected or confirmed Flu) ARDS: Non cardiogenic pulmonary oedema of recognised aetiology i.e influenza. Diagnosis PCWP < 18mmHg or assumed LA pressure <18mmHg. Consider ECHO Bilateral infiltrates on CXR. Consider CT chest to exclude PE, pneumothorax etc. P/F ratio < 200 mmhg (26.7KPa). Measure and document P/F ratios High Risk groups for H1N1: 1. Peri partum 2. Obesity 3. Chronic Lung disease 4. Immuno compromise Non Ventilatory management Sedate and paralyse Microbiology Respiratory Samples Nasopharyngeal swab NBL or BAL Blood cultures Anti microbial Iv antibiotics: Beta lactam and Macrolide for a possible community acquired pneumonia PO Oseltamivir Aerosol precautions for all clinical staff Ventilatory management 0 48 hours Measure and monitor P/F ratio Sedate Paralyse for first 24 48hours, esp. if severe respiratory failure Review daily thereafter Controlled mode of ventilation

2 Oxygenation (see attached algorithm) i) Oxygenation (a) Ideally aim for a PaO 2 8 9kpa, FiO 2 & PEEP titration as per ARDS protocol Reduce FiO 2 if PaO 2 > 9kpa (b) Accept, PaO 2 7 8kpa, if FiO2 > 0.8 and no significant evidence of organ hypoperfusion and no significant history of cardiovascular disease (c) If, PaO 2 <8kpa on FiO 2 > 0.8, consider Xray chest to rule out a pneumothorax and treat as appropriate If in doubt, early referral to respiratory centre ii) Ventilation (CO 2 elimination, see attached algorithm) (a) Measure patients height and calculate ideal body weight (IBW) (b) Tidal volume 4 6mls/kg and plateau pressure < 30cms H 2 O To achieve the above, accept ph> 7.25 regardless of PaCO 2 Aim for the lowest possible tidal volume and plateau pressure, as long as the ph> 7.25 (c) If tidal volume is > 6mls/kg and/or plateau pressure > 30cms of H 2 O and ph<7.25 Consider, Increasing sedation and paralysis Bolus and/ or infusion of NaHCO 3 Accepting ph >7.2, regardless of pc0 2, if the patient is haemodynamically stable If in doubt, early referral to respiratory centre Day 3 onwards Ventilatory management: Principles similar to that as described for the first 24 hours Special considerations: (1) Persistent fever: Co infection esp. Streptococcal infections Review cultures Review antibiotics Chest X ray and/ or USG thorax to rule out a pleural effusion (empyema) Persistent viraemia Review dose of Oseltamivir Discuss with microbiology / virology team Resistance to oseltamivir is reported. Patients failing to respond should be considered for iv Zanamivir. Thromboembolic disease esp. if associated with refractory hypoxia Doppler USG legs, if possible CT pulmonary angiogram Consider anticoagulation Other causes: Line sepsis etc (2) Refractory hypoxia and cardiovascular instability Thromboembolic disease Myocarditis

3 ECG 2D echocardiogram Cardiology review Biventricular failure including pulmonary hypertension ECG 2D echocardiogram Cardiology review (3) Fluid management Aim for an even or a negative fluid balance after the initial resuscitation Consider using diuretics or renal replacement therapy. If in doubt, early referral to respiratory centre Referral to respiratory centre Indications for referral to respiratory centre 1) Age: >16 years, if less liaise with regional PICU centre 2) Oxygenation First 24 hours Unable to achieve a pao 2 > 8kpa, with PEEP > 15 cms of H 2 O and/or FiO 2 > 0.8 Subsequently (day2 7) Unable to maintain a pao 2 > 8kpa, with PEEP > 15 cms of H 2 O and/or FiO 2 > 0.8 3) Respiratory acidosis First 24 hours Unable to maintain tidal volume <6mls/kg and plateau pressure <30 cms of H 2 O and ph >7.2 (if haemodynamically stable) or 7.25 (if haemodynamically unstable) Subsequently (day2 7) Uncompensated respiratory acidosis with a ph <7.2 despite optimum treatment for greater than 48 hours of conventional treatment (may include treatment with NaHCO 3 or CVVH) 4) Associated respiratory complication i.e. bronchopleural fistula, uncontrolled air leak, etc 5) Associated cardiovascular complication: biventricular failure, moderate severe pulmonary hypertension... 6) Associated high risks e.g. pregnancy, haematological malignancy, immunosuppressed,.. 7) Worsening/evolving multi organ failure

4 If in doubt please refer the patient as early as possible. Exclusion: a. Limitations or ceiling of treatment in place. b. High peak inspiratory pressure >30 cm H 2 O or high FiO 2 >0.8 for more than 168 h (7 days) c. > 4 or more organ failure by SOFA score at the time of referral. Referral for ECMO From DGH s Patients meeting the above referral criteria should ideally be referred first to the regional respiratory centre for consideration of rescue therapy. Patients with progressive respiratory failure in spite of rescue therapy (HFOV, NO, prone ventilation) would be considered for ECMO treatment. The regional respiratory centre would act as a triaging centre for ECMO referral. It is hoped that this system would help in appropriately triaging patients to specialist respiratory centres for additional respiratory management and would further assist the ECMO centres in identification of appropriate patients who would benefit from extracorporeal treatment. Repatriation From referral centres back to patient referring hospitals From ECMO centre These centres will also place an invaluable role in the repatriation pathway from ECMO centre

5 Timeline for referral to respiratory centre for Patients wih refractory severe respiratory Failure. Timeline Respiratory failure 0 24hrs Severe respiratory failure Optimise medical, ventilatory and non ventilatory management Failing conventional therapy High risk group esp. peri partum No level 3 beds hours Unable to achieve Oxygenation goals pao 2 > 8kpa, FiO 2 <0.8, PEEP>15cms Ventilation target Tvol.<6mls/kg, Plt pr <30cms, ph>7.2 Persistent air leak, Cardiovascular compromise etc Referral to respiratory centre (Rescue therapy: HFOV, NO, prone ventilation, etc) 3 7 days Any patients with severe respiratory failure for more than 3 days Referral to ECMO capable centre

6 Referral pathway Consultant to consultant referral Referral centre details Critical care department, University health board, Cardiff Hospital switchboard: Consultant bleep no 5490 Direct no. to the unit: / Referral proforma Patient details Name Age Address Date of admission to referring hospital: Date and time admitted to ICU Clinical information Diagnoses: Duration of hypoxic respiratory failure Clinical parameters Ventilatory Cardiovascular Other system review Investigations

7 Referral details Date and Time of referral: Referring consultant: Referring ICU/Hospital: Consultant at UHW: Outcome: Patient accepted for transfer: Yes/ No If No, reason given: Suggestions made for management: Yes/ No