Mechanical Ventilation in Post-Op VSD Problems Encountered and Treatment Solutions in Developing Countries

Transcription

1 Mechanical Ventilation in Post-Op VSD Problems Encountered and Treatment Solutions in Developing Countries Casey Culbertson MD Cardiac Intensivist

2 Disclosure #1 Unfortunately Nothing financial

3 Disclosure #2 There is nothings really new, sexy or exciting about mechanical ventilation

4 Disclosure #3 The mind cannot absorb what the butt cannot endure - Joe Perloff MD

5 Simplistic Ventilator Approach Interventional VSD Closure Intubat e Close VSD Extubate

6 Intubate Ventricular Septal Defects (A to Z) Sheraton Hotel. HCMC Vietnam Simplistic Ventilator Approach Surgical VSD Closure Close VSD Ventilate how? Extubate when

7 Simplistic Approach Ventilation What is best?? or What I know / or have done forever Evidenced based medicine

8 Approaches to post OP Ventilation People do have STRONG opinions

9 Simplistic Approach Ventilation What is easiest? O2 In CO2 Out Early Mechanical Ventilation

10 Current Approach Ventilation

11 Complicated Approach Ventilation O2 In PVRC Or PC Or VC CO2 Out

12 Goals of Post-op ventilation (all defects) Make the chest go up and down Work for all ages Be lung protective Allows and encourage spontaneous breathing Augment cardiopulmonary interactions

13 Goals of Post-op ventilation (translated) Ventilate at lowest MAP Reasonable rate to provide normal C02 Non-toxic Fi02 (< 0.6) Extubation when hemodynamically stable Earlier usually = better

14 My VN experiences of Post-op ventilation Vt of > 10cc/Kg Over-inflation on CXR Alveolar capillary compression IMV rates to normalize C02 Air Trapping / CO2 retention Toxic Fi02 (> 0.6) Used when not clinically indicated

15 My VN experiences of Post-op ventilation Extubation delayed Pneumonia Delayed extubation LEADS to pneumonia BAD ASS PSEUDOMONAS C02 retention (metabolic alkalosis) 1º Treatment of Post operative P HTN Vs early addition of prostacyclin analogs

16 Casey s Rules of Post-op ventilation Less is More

17 Casey s Rules of Post-op ventilation When not sure Confuse participant with Lots of confusing studies Lots of graphs (especially tables) Multiple unrelated data points Casey s Favorite (Back of Room) Small Writing Small Writing Small Writing Small Writing Small Writing Small Writing Small Writing

18 Casey s Rules of Post-op ventilation A little evidence based data about Vt 6 ml/kg, permissive hypercapnea 12 ml/kg, pc torr Amato et al. N Engl J Med 1998

19 Casey s Rules of Post-op Ventilation A little data about Vt

20 Casey s Rules of Post-op Ventilation Less is More Vt : 6-8cc/Kg Lower PIP / PEEP (Lower MAP) Avoidance of IMV rates Permissive Hypercapnia Avoidance of Fi02 (> 0.6) Used only when clinically indicated Earlier Extubation Weaning schedule / protocols Extubation readiness test

21 Other Rules of Post-op Ventilation Earlier extubation HemodynamicallyStable No (or controlled) dysrhythmias Not on excessive inotropic support No significant bleeding No significant residual cardiac lesions (ANY QUESTIONS ECHO) No airway / parenchymal disease Trachial bleeding / atelectasis No large pleural effusion No significant pneumonia

22 Post-op Ventilation Earlier extubation Early extubation after pediatric cardiac surgery: systematic review, meta-analysis, and evidence-based recommendations. Alghamdi AA, Singh SK, Hamilton BC, Yadava M, Holtby H, Van Arsdell GS, Al-Radi OO. Department of Surgery, Division of Cardiovascular Surgery, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. CONCLUSION: Early extubation appears safe and is associated with reduction in length of ICU and hospital stay without adverse effects on mortality or morbidity. However, studies to date are poor, heterogeneous, and not suitable to determine a causal effect. Therefore, there is need for a well-designed randomized clinical trial to demonstrate the potential significant benefits of early extubation. J Card Surg 2010

23 So Ventilation for me and my patients What is best?? What I know and Evidenced based medicine

24 Thank You