PRESENTOR : CHUA MEI YIN MODERATOR : DR. MOHD RIDHWAN MOHD NOR

CARE PATIENT ON RESPIRATORY SUPPORT

Protocols + Checklist + Physician’s Rounds

PLAY THE IMPORTANT ROLES !!

Reduce errors

Encourages teamwork

Help improves the quality of care received by intensive care patient

Outline of presentation

GoalReview

communications

Check ventilator settings &

mode

Care of ETT

General Care - FAST HUG - FAST HUGSBID

Oral, Eyes & Skin CareSleep

Radiation

Physiotherapy

Monitoring

Infection control

Educate patient &

family

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

REVIEW COMMUNICATIONS

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

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.

Check following settings:

1) Respiratory rate 2) Fraction of inspired oxygen ( fio2)3) Tidal volume4) Peak inspiratory pressure (PIP)

Ventilator mode of patient:- Ventilator itself- Respiratory flow sheet

Care of ETT

Ensuring correct position

Securing the tube

Measuring cuff pressure

Suspecting leak

Suspecting tube blockade

Suctioning

Size of ETT7.0- 7.5mm for

8.0- 9.0mm for

Larger ETT in Asthma, COPD

Tube position, confirmed by: - Clinical examination 5 point auscultation- CXR- Etco2

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

SUCTIONING

General suctioning recommendation:

1) Suction only as needed –not according to a schedule.

2) Hyperoxygenate the patient BEFORE & AFTER suctioning to help prevent O2 desaturation

3) Don’t instill normal saline into the ETT in an attempt to promote secretion removal

2004 American Association for respiratory care CPG

4) Limit suctioning pressure to the lowest level needed to remove secretions

5) Suction for the shortest duration possible

Type of suction

Open suction Closed 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

Open suction

Use in hypoxic patient ( FiO2 >0.6), PEEP > 10

MDR infections

Closed suction

** Combine suction with physiotherapy &

postural drainage

Monitor BP, HR,SPO2 &Arryhtmias

GENERAL CARE

FAST HUG

FAST HUGS BID

FAST

HUG

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.

GENERAL CARE

F = FeedingA = AnalgesicS = SedationT = Thromboembolic prophylaxis

H= Head- of- bed elevationU= Stress Ulcer preventionG= Glucose control

F = Feeding

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 within 24-48hrs icu

admission.

Optimal constituents of feeding solutions remain under debate.

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.

How to assess pain in critically ill patients?

1) Subjective measures of pain- related behaviours ~ facial expression, movement

2) Physiologic indicators ~ Heart rate, blood pressure

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.

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 appropriatelysedated.

Daily discontinuation of sedation may reduce the length of ICU stay & the need for imaging

procedures

Kress et al

T = Thromboembolic prophylaxis

T – Thromboembolic Prophylaxis

Still underused because is still often forgotten and yet

mortality & morbildity rates a/w thromboembolism 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.

The most effective method of prophylaxis still unclear.

The benefit of prophylaxis must be weighed against the risk of complications.

H= Head- of- bed elevation

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.

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

G= Glucose control

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

FAST HUGSBID

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

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.

WEANING: Readiness

All ventilated patients must have “ readiness criteria”

evaluated daily ( after discontinuing sedation)

YES

During weaning trial all patient must be observed Closely to identify the existence of “ distress”

High RRRespiratory patern ( paradox, nasal flaring)Low VT Drop in O2 saturation < 90%Increased hr ( > 20% from baseline)Anxiety, agitation, diaphoresisSomnolence

B = Bowel Care

B = Bowel Care

Disorders of GI motility, including ileus, constipation & diarrhoea are common in critically ill patient & may contribute to additional disease burden.

Institutional guidelines & use of standardized definitions of constipation & diarrhoea may facilitate bowel dysfunction management.

Routine assessment & tx to maintain normal bowel function should be conducted in all critically ill patients.

I = Indwelling Catheter removal

Indwelling catheter including urinary, arterial, central venous, pulmonary artery & dialysis catheters are commonly used in critically ill patients.

Because they penetrate through body’s natural protective mechanism, they are at risk for local & systemic infection.

Early discontinuation & removal, when these catheters are no longer needed, remains an important strategy

to combat catheter-associated infections.

Daily ( @ more frequent) assessment should be performed of the ongoing need for these

catheters, and their removal, when not medically

necessary.

D = De-escalation of Antibiotitcs/Streamlining

Once a pathogen has been identified & antimicorbial susceptibilities have been reported, the regime should be converted to most narrow-spectrum, cost effective& pathogen specific antibiotic.

Minimizes exposure to broad-spectrum antimicrobial therapy.

Same principles can be applied to other pharmacologic treatments which should be regularly re-evaluated for appropriate indications to minimize risk of adverse

effects & medications errors.

Oral, Eyes & Skin care

Oral Care

preferably 8 hourly Remove oral airway Move ET tube to opposite corner Clear mouth of all secretions Paint mouth with 2% chlorhexidine

** Reduces rates of VAP

Eye Care

Moisol eyes drop Tape both eyes in paralysed pt Appropriate antibiotic drops

Skin Care

Daily Bath makes patient comfortable & fresh improves circulation

Observe skin daily for redness, injuries, swelling, rashes or other infections & bony prominences for bed sore.

Cut short the finger & toe nails

Hair care- Shampoo as required

Back care- Apply olive oil from shoulders to buttocks with brisk circular movement

SLEEP IN ICU

Cause of sleep deprivation in ICU:

Environmental factors

Pathophysiological factors

Enviromental factors

Noise Lighting practices Pt care activities Diagnostic procedures Sedatives Analgesics

Pathophysiological factors

Stress Organ dysfunction Inflammatory response Pain Psychosis

Integrated strategy to promote sleep in the intensive care unit:

Noise reduction ( < 50dB)

Diurnal lighting practices

Use of sleep- promoting pharmacologic agent

Minimizing use of pharmacologic agents inhibiting sleep

Uninterrupted time for adequate sleep

Appropriate physiologic support

Active promotion of patient orientation

Patient- ventilator synchrony

Relaxation techniques

RADIATION

A daily CXR is indicated for pt with acute cardiopulmonary problems & for patients on

mechanical ventilation.

In pt with a central venous catheter, a Swan- Ganz catheter, Feeding tube, chest tube placement, only post procedure radiographs indicated.

Stable cardiac monitoring pt & those with purely extrathoracic disease require only admission films upon entry to ICU, unless clinical condition demands.

American College Of Radiology

PHYSIOTHERAPY

Specialized job Round the clock Continuum from preventing respiratory failure, to

managing pt on ventilator to pt who have been

weaned Prevented complications related to MV Percussion, vibration, change of position, postural

drainage ,suction for chest physiotherapy Limb physiotherapy

MONITORING

1) VENTILATION

2) OXYGENATION

3) HEMODYNAMIC

4) URINE OUTPUT

ABG

Infection Control Measures

Control of the reservoirs of infection Interruption of the transmission of bacteria from

person to person Individual device related measures Staff education Surveillance Regular audit

Control of the reservoirs of infection

Disinfection of pt area/bay between pt ( include bed,

monitor, ventilator, other equipment, furniture,

floor , walls)

Appropriate sterilization of reusable equipment

Appropriate disposal of disposable equipment including

sharps

Appropriate surveillance of personnel as reservoirs.

Cross contamination

Put on gloves before handling respiratory secretions @ contaminated objects.

Wash hands with soap & water or an alcohol- based antiseptic hand rub before & after contact with mucous membrane, respiratory secretions, or contaminated objects and before and after contact with pt with respiratory device.

Wear gown when you anticipate being soiled with respiratory secretions and change it before caring for another patient.

Between their uses on different patients, sterilize or

subject to high-level disinfection reusable hand-

powered resuscitation bags ( AMBU)

In addition to routine hand hygiene the following should also be considered in ventilated pt:

Intubation: If elective- standard handwash + sterile gloves Emergency – handrub + sterile glovesSuctioning : Alcohol hand rub before & after

procedure Clean gloveBronch: Surgical hand/forearm scrub Full sterile field, gown & gloves.

Always consider masks, splash guard & eyewear ( PPE)

Full chlorhexidine handwash if accidental exposure to secretions.

Educate family & patient

Seeing a loved one attached to mechanical ventilation

frightening.

To ease distress in pt & family, teach them why mechanical ventilation is needed & emphasize the positive outcomes it can provide.

Explain what you are doing

Communicate desired outcomes so the patient & family can actively participate in the plan of care.

REFERENCE

1) Give your patient a fast hug ( at least) once a day Jean- Louis Vincent, MD, PhD,FFCM

2) [PPT] Care of the ventilated patient: FAST HUG-SBID

3) Critically ill patients need “FAST HUGS BID” ( an update mnemonic)

4) Top 10 Care Essentials for ventilator Patients Evidence-based Interventions and Teamwork are crucial when caring for patients on Mechanical Ventilators, Laura C.

Parker,MSN,RN,CCRN

COMPONENT CONSIDERATIONS

Feeding Can the patient be fed orally, if not enterally? If no, should we start parenteral feeding?

Analgesia The patient should not suffer pain, but excessive analgesia should be avoided

Sedation The patient should not experience discomfort but excessive sedation should be avoided; ‘calm, comfortable, collaborative”

Thromboembolic prevention

Should we give low-molecular weight heparin or use mechanical adjuncts

Head of the bed elevated

Optimally , 300 to 450 ,unless contraindications e.g. threatened cerebral perfusion pressure

Stress ulcer prophylaxis

Usually H2 antagonist: sometimes proton pump inhibitors

Glucose control Within limits defined in each ICU