CARE PATIENT ON RESPIRATORY SUPPORT

1. CARE PATIENT ON RESPIRATORY SUPPORT Presentor : chuamei yin Moderator : dr. mohdridhwanmohd nor

2. Protocols + Checklist + Physician’s Rounds

3. PLAY THE IMPORTANT ROLES !! Reduce errors Encourages teamwork Help improves the quality of care received by intensive care patient

5. Goals of Monitoring & Managing the ventilated patient Ensure proper airway Ensure adequate oxygenation & ventilation Maintain hemodynamic stability Interpretation of Ventilator alarms &troubleshooting Prevent infection Prevent complications related to bedridden state

6. REVIEW COMMUNICATIONS

7. 1) Communication among care providers ~Promotes optimal outcome ~ Find out the goal of the therapy for patient ~ Indication for mechanical ventilation ~ Indication for icu admission ~ Do-not–resuscitate status 2) Communication with the patient ~ Provide writing tools or a communication board so pt can express her needs

8. Check Ventilator Settings & Modes Read patient order & obtain in formation about the ventilator. Familiarize with ventilator alarms and the actions to take when an alarm sounds. Keep resuscitation bag at bedside Know how to hyperventilate & hyperoxygenate patient.

9. Check following settings: • Respiratory rate • Fraction of inspired oxygen ( fio2) • Tidal volume • Peakinspiratory pressure (PIP) • Ventilator mode of patient: • Ventilator itself • Respiratory flow sheet

10. Care of ETT Ensuring correct position Securing the tube Measuring cuff pressure Suspecting leak Suspecting tube blockade Suctioning

11. Size of ETT 7.0- 7.5mm for 8.0- 9.0mm for Larger ETT in Asthma, COPD Tube position, confirmed by: • Clinical examination  5 point auscultation • CXR • Etco2

12. Cuff pressure keep < 25mmHg - Inflate cuff to seal - Maintain @ lowest pressure that seal or low leak Every nursing duty check cuff pressure If partial block is suspected.  change ETT **ETT with subglottic suction port- reduced incidence of VAP RCT

14. SUCTIONING General suctioning recommendation: Suction only as needed –not according to a schedule. Hyperoxygenate the patient BEFORE & AFTER suctioning to help prevent O2 desaturation Don’t instill normal saline into the ETT in an attempt to promote secretion removal 2004 American Association for respiratory care CPG Limit suctioning pressure to the lowest level needed to remove secretions Suction for the shortest duration possible

16. Open suction • Fresh cathether with every use • Preoxygenate with 100% o2 • Suction cycle < 20s • Occlude catheter while passing in • Once obstruction is encountered withdraw slightly & suck while coming out • Repeat if required

18. Use in hypoxic patient • ( FiO2 >0.6), PEEP > 10 • MDR infections • Closed suction

19. Monitor BP, HR,SPO2 &Arryhtmias ** Combine suction with physiotherapy & postural drainage

20. GENERAL CARE • FAST HUG • FAST HUGS BID

21. F A S T H U G

22. FAST HUG • A simple, short mneumonic to highlights some keys aspects in the general care of all critically ill patients. • Should be considered at least once a day during rounds • Can be used as mental checklist when individual staff members attending the patients.

23. GENERAL CARE F = Feeding A = Analgesic S = Sedation T = Thromboembolic prophylaxis H= Head- of- bed elevation U= Stress Ulcer prevention G= Glucose control

24. F = Feeding

25. Malnutrition increases complications & worsens outcomes of critically ill patients. In general, 20- 25 kcal/kg/day is acceptable & achievable target intake. Should started early , preferably within24-48hrsicu admission. Optimal constituents of feeding solutions remain under debate.

26. A = Analgesic Pain can effect patient’s psychological & physiological recovery. Critically ill pt feel pain due not only to their illness but also routine procedures e.g. turning, suctioning& dressing changes. One study of 5957 patients , > 63% received no analgesic before painful procedure.

27. How to assess pain in critically ill patients? Subjective measures of pain- related behaviours ~ facial expression, movement Physiologic indicators ~ Heart rate, blood pressure

29. Pharmacological therapies to relieve pain included: opioids non opioids Continuous infusion of analgesic drugs or regularly administered doses are more effective than bolus doses given as “needed” I.V. administration of analgesic allows closer and more rapid titration to patients needs than I.M. or subcutaneous administration. Care should be taken to ensure analgesic is adequate but not excessive.

30. S = Sedation No rules governing how much to give & how often. Sedative administration must be titrated individual. CCC ( Calm, comfortable and collaboration) rule help to determine whether patients are appropriately sedated. Daily discontinuation of sedation may reduce the length of ICU stay & the need for imaging procedures Kress et al

33. T = Thromboembolic prophylaxis

34. T – Thromboembolic Prophylaxis Still underused because is still often forgotten and yet mortality & morbildity rates a/wthromboembolism are considerable & can be reduce by prophylaxis. Among patients who do not received prophylaxis, objectively confirmed rate of DVT range between 13- 31%. It has thus recommended all patients received at least s/c heparin unless CI.

35. The most effective method of prophylaxis still unclear. The benefit of prophylaxis must be weighed against the risk of complications.

37. H= Head- of- bed elevation

38. Several studies demonstrated that having the head of bed inclined at 45 degrees can decrease the risk incidence of gastroesophageal reflux. Patient nurses in semirecumbent reduce rate of nosocomial pneumonia. A randomised trial. Lancet 1999 Raising the head of the bed may not be enough, because patients especially when sedated might slides down in the bed. Attempts must be made to keep head of bed & thorax elevated.

39. U= Stress Ulcer prevention Stress ulcer prevention is important notably for patients who are at risk of developing stress- related gastrointestinal hemorrhages. The optimal medication is still not clear. In 1200 critically ill patients undergoing mechanical ventilation, those treated with ranitidine had significantly lower rates of clinically significant GI bleeding than patients treated with sucralfate although there was no difference in the mortality rates between two groups. Multicenter study by Cook et al

41. G= Glucose control

42. Many units now aim to keep blood sugar levels below 8.3 mmol/L as recommended guidelines for the management of severe sepsis & septic shock. Keeping blood glucose levels < 7.8 mmol/L resulted in 29.3% decrease in hospital mortality rates & 10.8% reduction in length of ICU stay. Krinsley

43. FAST HUGSBID S = Spontaneous Breathing Trial B = Bowel Care I = Indwelling Catheter removal D = De-escalation of Antibiotitcs

44. S = Spontaneous Breathing Trial Daily assessment of SBT has been show to be a safe, effective & highly predictive method for determining which pt will tolerate ventilator separation. Prolonged mechanical ventilation a/w increased rate VAP & in hospital & total mortality. Should be considered at least daily & performed in highly protocolized fashion by well-trained team of nurses & respiratory therapist.

45. WEANING: Readiness All ventilated patients must have “ readiness criteria” evaluated daily ( after discontinuing sedation)

49. YES

50. During weaning trial all patient must be observed Closely to identify the existence of “ distress” High RR Respiratory patern ( paradox, nasal flaring) Low VT Drop in O2 saturation < 90% Increased hr ( > 20% from baseline) Anxiety, agitation, diaphoresis Somnolence