MEDICAL CITY CONGENITAL HEART SURGICAL UNIT VENTILATOR AND SUPPORT WEANING PROTOCOL

Transcription

1 MEDICAL CITY CONGENITAL HEART SURGICAL UNIT VENTILATOR AND SUPPORT WEANING PROTOCOL Purpose To provide consistent clinical practice and timely interventions in in the management of patients requiring mechanical ventilation in the Congenital Heart Surgical Unit (CHSU). This protocol establishes criteria for support and weaning of mechanical ventilation for patients in the CHSU. The Respiratory Therapist will initiate this protocol upon receipt of a Medical Staff s written order (e.g. Ventilation Support and Weaning Protocol). The provider will (1) review the default goals and either accept or modify them within the order, (2) select the fast track option if they anticipate the patient will require less than 12 hours of mechanical ventilation. Thereafter, no other ventilator orders or blood gas orders related to this protocol will need to be ordered in the electronic medical record for subsequent parameter changes unless said changes fall outside protocol guidelines. Responsibility Respiratory Therapists who have completed training and verified skills annually. The protocol will be reviewed and approved annually by the medical staff service line. PROTOCOL Inclusion Criteria The CHSU ventilator management protocol is indicated for patients who are mechanically ventilated for reasons related to their disease or following corrective or palliative repair of their CHD. Exclusion Criteria This policy is not indicated for: patients who are receiving alternative medical gas therapy (e.g. CO2, Nitrogen) or alternative modalities of ventilation (e.g. HFV, APRV, ECMO)

2 Clinical Ventilation and Oxygenation Goals Unless otherwise ordered, the clinical goals for patients of this protocol are: Pressure To maintain a plateau pressure < 30 or Peak Inspiratory Pressure (PIP) 35 cm H20 Tidal Volumes (all volumes should be assessed on ideal body weight) To maintain a targeted effective tidal volume of 6-8 ml/kg for mechanical breaths. For patient with ARDS 6 ml/kg. To maintain a targeted effective tidal volume of 4-6mL/Kg for supported breaths. For patients with large ETT leak chest rise and fall and gas exchange will be the primary tools of assessment. > 30% leak will be brought to the medical teams attention. Acid-base balance (ph) To maintain an arterial ph within range or capillary/venous ph Ventilation (CO2) To maintain End-tidal Carbon Dioxide (ETCO2) 35-55mmHg and/or PCO mmHg. In patients with poor pulmonary perfusion, significant dead space, or large ETT leaks the ETCO2 may read significantly lower or may be less reliable. In these patients the ETCO2 will be used for trending and clinical assessment and PCO2 will be the primary assessment tool. Oxygenation For patients without Single Ventricle Physiology, maintain SpO2 92% on < 0.5 FIO2 For patients with Single Ventricle Physiology, maintain SpO % Monitoring and Patient Assessment The Respiratory Therapist will assess and document the patient ventilator interaction with every intervention and minimum of twice a shift. After any change in the patient s ventilation, the Respiratory Therapist is expected to: Evaluate the patient s response to ventilation or oxygenation support changes Make adjustments to achieve clinical goals as defined by this protocol Assess Breath sounds and physical appearance Assess Data from non-invasive and invasive patient monitors, including but not limited to: o Heart Rate, Blood Pressure, NIRS, SpO2, ETCO2, or TcPCO2 where applicable o Blood gas analysis results if obtained Assess Chest radiographs if obtained Assess and document Ventilator settings Assess Ventilator graphics (waveforms and loops) Assess for Dysynchrony where applicable Assess for Intrinsic PEEP where applicable

3 INITIAL SETTINGS Mode: SIMV (PRVC) with PS Rate: The below are good initial settings: unless otherwise ordered by Physician or NP o Infant 25 bpm o Child 20 bpm o Adolescent 15 bpm Vt Set: 6-8 ml/kg. If PIP > 35 or plateau > 30 consider suctioning and/or lowering tidal volume target. If patient develops ARDS, consider recruitment maneuvers per policy and lower tidal volumes to 6 ml/kg. Ti: PS: PEEP: FIO2: seconds for infants seconds for child seconds for adolescent Flow graphics will be used to optimize To achieve tidal volumes of 4-6 ml/kg 5 cm H2O unless patient was requiring more in the O.R. or during manual ventilation or non-invasive support. 0.5 unless patient required more or less in the O.R. or during manual ventilation. TITRATION PHASE For patients in whom the provider has selected the fast track option, please proceed to the extubation readiness test phase. If the patient is excluded, please continue down the titration phase and reassess Q2 hours for eligibility. OXYGENATION FIO2 n-single Ventricle Physiology The FIO2 will be titrated in increments of to achieve the clinical goal for oxygenation. If SpO2 falls below 92%, but > 88% for greater than 15 minutes, increase FIO2 to achieve goal. Once the SpO2 increases to 96%, titrate the FIO2 down to achieve goal. If the patient spontaneously desaturates < 88% increase the FIO2 until the patient s SPO2 recovers to >88%. Assess for reasons for desaturation and consider suctioning or reposition. tify the team if the patient does not return to baseline FIO2 within an hour or if the patient is unable to meet the oxygenation goals on FIO2 of 1.0.

4 Shunted Single Ventricle Physiology The FIO2 will be titrated in increments of to achieve the clinical goal for oxygenation. If SpO2 falls below 75%, but > 70% for greater than 15 minutes, increase FIO2 to achieve goal. Once the SpO2 increases to 85%, titrate the FIO2 down to achieve goal. If the patient spontaneously desaturates < 70% increase the FIO2 until the patient s SPO2 recovers to >85%. Assess for reasons for desaturation and consider suctioning or repositioning. tify the team if the patient does not return to baseline FIO2 within an hour or if the patient is unable to meet the oxygenation goals on FIO2 >30% above baseline. PEEP PEEP will be titrated to prevent atelectasis without creating cardiac compromise and improve VQ mismatch to achieve the clinical goals, if not otherwise specified (per providers order). PEEP will be increased by 1 cm H2O when FIO2 > 0.6 for greater than 30 minutes to achieve the clinical goal for oxygenation. PEEP > 8 cmh2o will require approval by the medical team. The RT will document this approval in the EMR. Once clinical goal for oxygenation has been reached on FiO2 < 0.5 for 2 hours, PEEP should be decreased by 1 cm H2O every 6 hours until 5cm H2O has been reached. Single Ventricle Physiology PEEP should be used judiciously in patients with Single Ventricle Physiology; increases in PEEP > 6 cm H2O should only be performed with orders from NP, Fellow or Attending physician Changes to a patient s NIRS should be assessed with any increase in PEEP VENTILATION Tidal Volume (Vt) Adjust control (mandatory breaths) settings (volume or pressure) to maintain a targeted effective tidal volume of 6-8 ml/kg; 6 ml/kg for patients with ARDS or if PIP > 35 or plateau > 30. Adjust support (spontaneous breaths) settings (volume or pressure) to maintain a targeted effective tidal volume of 4-6 ml/ kg. Respiratory Rate (f) The set respiratory rate will be adjusted to achieve the clinical goals for ventilation. The medical team will be notified if the patient has a metabolic acidosis (HCO3 < 18). Increase the set respiratory rate (by 4 breaths per minute) if the ETCO2 or PCO2 increases 55mm Hg and/ or the arterial ph decreases to < 7.30 (venous/capillary < 7.25), unless otherwise ordered. Decrease the set respiratory rate (by 4 breaths per minute) if the ETCO2 or PCO2 decreases to 35mmHg and/ or the arterial ph increases to > 7.40 (venous/capillary > 7.35), unless otherwise ordered. Blood gases will be drawn on admission and schedule by the prescriber. If necessary an RT can place an order for a PRN blood gas Use of blood gases can be utilized at the therapist discretion

5 ALL CHANGES WILL BE REASSESSED WITHIN AN HOUR OF TITRATION. Extubation Readiness Test (ERT): Once a shift or upon physician request (i.e. selection of the fast track option), mechanically ventilated patients will be assessed by the bedside nurse and RCP to determine clinical stability and assess whether they meet the inclusion criteria for ERT. 1 ERT Inclusion Criteria: Air leak 25 cm H2O (please notify provider if > 25) Spontaneous respiratory effort planned procedure requiring anesthesia or significant sedation in next 24 hours. PEEP 7 ( 6 for single ventricle physiology), FiO2 0.6 and no escalation in the previous 4 hours. Dopamine 10mcg/kg/min, Epinephrine 0.03 mcg/kg/min and no other signs of hemodynamic instability Gag or cough present with suctioning neuromuscular blockade Sternum Closed Appropriate Sedation Level ERT Exclusion Criteria: spontaneous respiratory effort Planned procedure requiring anesthesia or significant sedation in next 24 hours Escalation of ventilator support within the last 4 hours PEEP > 7 (> 6 for single physiology), FiO2 > 0.6 gag or cough with suctioning Neuromuscular blockade Open Sternum Provider Approval Required for ERT if: Air leak > 25 cm H2O if intubated > 48hours (please notify Physician or NP). However this may not exclude this patient from being extubated 7. Dopamine >10mcg/kg/min, Epinephrine > 0.03 mcg/kg/min or other signs of hemodynamic instability (e.g., hypotension requiring fluid administration, An ERT may still be performed in these instances with approval of Physician or NP as these are not absolute contraindications for extubation) Patient is at risk for congestive heart failure following extubation ERT PROCEDURE: 1. Decrease FiO2 to 0.5 or leave at current setting if < 0.5. If on lower FIO2, FIO2 can be increased to a max. of 0.5 to achieve oxygenation goals. 2. Decrease PEEP to 5 or leave at current setting if < 5 3. Place patient in minimal pressure support, adjusted for ETT size: a cm = 10 cm H20 b cm = 8 cm H2O c. 5 cm = 6 cm H20

6 4. Respiratory Therapist must remain at bedside for minimum of 15 min to ensure tolerance of ERT and reset alarms appropriately. 5. Patients will be monitored by the bedside clinicians during the test for 2 hours but it can be stopped at any time during the test if the patient is classified as failing (see below) or the medical team decides it is appropriate to attempt extubation earlier. 6. If patient is passing ERT at 15 min into test, the RCP should notify the Physician or NP to obtain orders in preparation for potential extubation (eg, NPO, IVF, sedation). 7. A decision to obtain a blood gas specimen is at the discretion of the respiratory therapist and bedside nurse during the ERT. 8. As soon as criteria for failure are met, patient should be placed on minimum amount of support that alleviates distress and achieves clinical goals. The team will be notified and a plan to retest will be determined. 9. At the end of 2 hours, if the patient has passed the ERT, the medical team will be notified and the patient will be returned to minimal support settings. 10. ERT pass or fail will be documented in the ventilator flowsheet. ERT failure: SpO2 less than clinical goal Effective Tidal Volume < 5ml/kg ideal body weight End-tidal CO2 greater > 50 mmhg, unless compensated metabolic alkalosis. In this case we will use a delta change of 10 mmhg. Respiratory rate outside acceptable range for age or signs of respiratory distress: < 6 months, breaths/min 6 months-2 years, breaths/min 2 years-5years, breaths/min > 5 years, breaths/min Heart rate increase by more than beats per minute or arrhythmias Cerebral NIRS decrease > 10% te: Provider may shorten testing time and choose to extubate prior to completion of the ERT. This is particularly important to note when they anticipate a short ventilation course. Post-extubation Care If the patient passes the ERT or the provider determines the patient is eligible for extubation to low flow nasal cannula oxygen to achieve oxygenation goals. If a patient fails their extubation readiness test and the order is received to extubate the Respiratory Therapist will contact the Physician or NP to discuss alternative modes of respiratory support, such a Nasal CPAP, Heated Nasal Cannula. For patients who fail extubation all traditional interventions such as reintubation, NIV, HFNC will be considered and ordered by the core team. For those patients extubated with an Air Leak > 25 cm H2O a dose of nebulized Racemic Epinephrine should be immediately available for administration in case of signs of upper airway obstruction

7 Timing of blood-gas sampling following extubation will be at the respiratory therapist and bedside nurse s discretion but should be obtained no more than 1 hour following extubation. References 1. Saura, P; Blanch, L; Mestre, J; Vallaes, J; Artigas, A; Fernaandez, R. Clinical consequences of the implementation of a weaning protocol. Intensive Care Medicine. October 1996, 22(10): Wratney AT, Cheifetz IM. Extubation criteria for infants and children. Respiratory Care Clinics of rth America. 2006;12(3): Ely, EW; Bennett, PA; Bowton, DL; Murphy, SM; Florance, AM; Haponik, EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. American Journal of Respiratory and Critical Care Medicine, February 1999, 159(2): Manthous, CA; Schmidt, GA; Hall, JB. Liberation from mechanical ventilation: a decade of progress Chest, September 1998, 114(3): Horst, HM; Mouro, D; Hall-Jenssens, RA; Pamukov, N. Decrease in ventilation time with a standardized weaning process. Archives of Surgery, May 1998, 133(5):483-8; discussion Marx, WH; DeMaintenon, NL; Mooney, KF; Mascia, ML; Medicis, J; Franklin, PD; Sivak, E; Rotello, L. Cost reduction and outcome improvement in the intensive care unit. Journal of Trauma, April 1999, 46(4):625-9; discussion Wratney, AT. MD; Benjamin, JR. DK; Slonim, AD, Hamel DS, Cheifetz IM. The endotracheal tube air leak test does not predict extubation outcome in critically ill pediatric patients. Pediatric Critical Care Medicine 2008, 9, N5, Pgs Esteban, A; Alaia, I; Tobin, MJ; Gil, A; Gordo, F; Vallverdau, I; Blanch, L; Bonet, A; Vaazquez, A; de Pablo, R; Torres, A; de La Cal, MA; Macaias, S. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. American Journal of Respiratory and Critical Care Medicine, February 1999, 159(2): Marelich, GP; Murin, S; Battistella, F; Inciardi, J; Vierra, T; Roby, M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest, August 2000, 118(2): Randolph, AG; Wypij, D; Venkataranman, ST; Hanson, JH; Gedeit, RG; Meert, KL; Luckett, PM; Forbes, MA; Liley, M; Thompson, J; Cheifetz, IM; Hibberd, P; Wetzel, R; Cox, PN; Arnold, JH. Effects of Mechanical Ventilator Weaning Protocols on Respiratory Outcome in Infants and Children. JAMA, vember 2002, 288(20):

8 11. Butler, R; Keenan, SP; Inman, KJ; Sibbald, WJ; Block, G. Is there a preferred technique for weaning the difficult-to-wean patient? A systematic review of the literature. Critical Care Medicine, vember 1999, 27(11): Approved CHSU Medical Director Date Medical Director of Respiratory Care Date Originator/Director, Respiratory Care Date

9 Oxygenation Active Weaning Phase Ventilation Decrease RR by 4 Decrease FiO2 until 0.5 Is Set RR 10 Is Peep 7 ( 6 for single ventricle physiology) Decrease RR by 4 Decrease Peep by 1 Q 15 min until Peep 7 ( 6 for single ventricle physiology) Is CO2 < 55 SpO2 within Desirable parameters? Return to Ventilator Adjustment Phase Return to Ventilator Adjustment phase te if at any point in the active weaning phase the Oxygenation/Ventilation goals are not met- proceed to the Ventilator Adjustment Phase Proceed to ERT Extubation

10 Readiness Test Algorithm Assess the patient during AM & PM vent checks *Acceptable Resp Rates (BPM) < 6 months, months-2 years, years-5years, > 5 years, Air leak 25 cm H2O (please notify NP or fellow if > 25) Spontaneous respiratory effort planned procedure requiring anesthesia or significant sedation in next 24 hours. PEEP 7 ( 6 for Single Ventricles), FiO2 0.6 and no escalation in the previous 4 hours. Dopamine 10mcg/kg/min, Epinephrine 0.03 mcg/kg/min and no other signs of hemodynamic instability Gag or cough present with suctioning neuromuscular blockade Sternum Closed Appropriate Sedation Level Repeat assessment in hours Decrease FiO2 to 0.5 or leave at current setting if < 0.5. If on lower FIO2 patient can be titrated to a max. of 0.5 without this be considered a failure. Decrease PEEP to 5, or leave at current setting if < 5 Place patient in minimal pressure support adjusted for ETT size: cm = 10 cm H cm = 8 cm H2O 5 cm = 6 cm H20 RCP must remain at bedside for 15 min to ensure tolerance of ERT Pass/Fail SpO2 within clinical goal Effective Tidal Volume 5ml/kg ideal body weight End-tidal CO2 50 mmhg, unless chronic respiratory acidosis Respiratory rate within acceptable range for age and no signs of respiratory distress: Heart rate did not increase by more than beats per minute or arrhythmias Cerebral NIRS did not decrease by more than 10% Resume previous settings May extubate at discretion of the NP or Physician Leave on PS/CPAP for up to 2 hours Patient MUST continue to pass same criteria At 15 minutes contact NP or Physician for NPO, IVF and sedation orders in preparation for extubation Does patient continue to meet ERT criteria? Contact NP or Physician to arrange for extubation time Return patient to previous setting unless the provider orders something different

11 CVICU Ventilator Support and Weaning Protocol Badge Buddy CVICU Ventilator Support And Weaning Protocol- Clinical Goals Ventilation Oxygenation ph (art) (cap/ven) SpO₂ 92 % ETCO₂ or PCO₂ mmhg Shunted Single Ventricles 70-85% Rate changes by 4 Peep by 1 for FiO₂ >.60 or Vt 6-8cc/kg Mand. Breaths FiO₂ <.5 for 2 hours, PEEP or PS for Spont Vt of 4-6 cc/kg Call Provider for PEEPS > 6 Maintain PIP < 35 or Plat < 30 Monitor NIRS, CXR, MAP for PEEP s Consider PC for PIP > 35 or Plat >30 Call provider for PEEP > 6 Call provider for Metabolic Acidosis Consider Recruitment Maneuver Call Provider for leaks of > 30 % Vti Call Provider if of.3 of FiO₂ ERT Criteria All Patients on Protocol will have an ERT performed once a shift or on Physician request unless : PEEP > 7, FiO 2 > 0.6, Open Sternum, cough or Gag tify Provider prior to ERT if any of the following: Dopamine >10mcg/kg/min, Epinephrine > 0.03 mcg/kg/min Other signs of hemodynamic instability Air leak of > 25 cmh₂o & tubed > 48h Setting- PS/CPAP PS 10 for ETT 3.0 or 3.5, PS8 for , PS6 for 5.0 PEEP 5, FiO₂ 0.5, Call Provider after 15 min if PASS is suspected PASS = Vt 5cc/kg, ETCO₂ <50, HR, NIRS stability, RR in range <6m= 20-60bpm, 6m-2y=15-45 bpm, 2y-5y = 15-40bpm, >5y=10-35bpm