...Introduction/Problem Identification Mechanical ventilation is one of the most commonly used interventions in the Intensive Care Unit. It has been found that more than half of patients are ventilated within the first 24 hours of admission to the ICU. Most of these patients are placed on mechanical ventilation due to acute respiratory failure, lung infection, difficulty breathing, or because they are unable to protect their airway. (http://www.aast.org/generalinformation/mechanicalventilation.aspx) Although the intervention of mechanical ventilation is important to allow the patient to improve gas exchange, the intervention often causes anxiety in patients. Patient’s receiving mechanical ventilation often deal with pain, fear, lack of sleep,...
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...common nosocomial infection in Critical Care units. VAP is linked with high mortality rates, increased hospital stays, longer mechanical ventilation and increased costs to hospitals and patients (Rosa, Hernandez, Carillo, Fernandez, & Valles, 2012). Patients who have an endotracheal tube (ETT) with mechanical ventilation are more likely to develop VAP. These patients have a poor cough reflex due to a decreased level of consciousness and diminished movement of the respiratory tract mucocila, leading to the inability to clear secretions. These contaminated secretions will then sit on top of the ETT cuff and eventually leak down and invade the lungs. Also aiding as a reservoir for microbes is a biofilm that can form on the ETT and enter the lungs causing infection (Mietto, Pinciroli, Patel, & Berra, 2013). Nurses are responsible for applying pharmacological and non-pharmacological measures to help prevent VAP which poses a very difficult challenge. Nurses must research and incorporate the use of evidence-based practice into their daily care of patients on mechanical ventilation (Sedwick, Lance-Smith, & Nardi, 2012). This paper will look closely at the evidence-based research and protocols implemented which best prevent ventilator-associated pneumonia. To help prevent further complications and improve outcomes in patients on mechanical ventilation, a standard of care was created by the Institute for Health Care Improvement (IHI) in 2004 called the Ventilator Bundle. These...
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...Background: Mechanical ventilation is an invasive procedure which could be painful and may cause agitation, anxiety and stress for the child (1). Usually critically ill children are often ventilated mechanically and remain at paediatric intensive care unit (PICU). The unfamiliar environment of PICU with presence of medical gadgets, bright light and frequent noise may frighten the child. Moreover, such critically ill children require recurrent interventions by the medical care team where they usually do not cooperate or not want to understand the necessity of medical instrumentation and interventions like adults (2). Using sedation and analgesia in this situation can help the child to reduce their anxiety and agitation and also relief the pain caused by this invasive procedure. However, proper sedation requires for its optimal outcome. Dose should be accurate and individually titrated, based on sedation assessments. Both inadequate and excessive sedation may have deleterious effects. Inadequate sedation can lead to increase distress and fighting the ventilator, interference with effective mechanical ventilation, myocardial and cerebral ischemia, and potentially dangerous outcomes such as self-extubation or removal of other mechanical devices (3). On the other hand, excessive sedation, which is a common problem in critically ill children receiving...
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...Case Study for Final Exam Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal (voluntary) muscles of the body. The name myasthenia gravis, which is Latin and Greek in origin, literally means "grave muscle weakness." With current therapies, however, most cases of myasthenia gravis are not as "grave" as the name implies. In fact, for the majority of individuals with myasthenia gravis, life expectancy is not lessened by the disorder. The hallmark of myasthenia gravis is muscle weakness that increases during periods of activity and improves after periods of rest. Certain muscles such as those that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are often, but not always, involved in the disorder. The muscles that control breathing and neck and limb movements may also be affected. Myasthenia gravis is caused by a defect in the transmission of nerve impulses to muscles. It occurs when normal communication between the nerve and muscle is interrupted at the neuromuscular junction - the place where nerve cells connect with the muscles they control. Normally when impulses travel down the nerve, the nerve endings release a neurotransmitter substance called acetylcholine. Acetylcholine travels through the neuromuscular junction and binds to acetylcholine receptors which are activated and generate a muscle contraction. ...
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...C. L., Wilde, C. D., Pellizzari, S. J., Chebbo, A., Song, J., & ... Meyer, T. (2012). Reduction in the Incidence of Ventilator-Associated Pneumonia: A Multidisciplinary Approach. Respiratory Care, 57(5), 688-696. Abstract BACKGROUND: We report the process implemented in our institution by a task force focused on the reduction of ventilator-associated pneumonia (VAP). METHODS: Retrospective cohort study of all adults admitted to one of our 4 adult ICUs, intubated on invasive mechanical ventilation. We implemented a ventilator bundle in April of 2007; we report the incidence of VAP in 2008, and, after adjustment in the process (oral care performed by respiratory therapists), the incidence in 2009. The primary outcome was reduction of the microbiologically confirmed VAP rate over a 2 year period. Other outcomes were duration of mechanical ventilation, antibiotic days, ICU and hospital stay, and mortality. RESULTS: During the study period, 2,588 patients received invasive mechanical ventilation in the adult ICUs. The VAP rate during 2008 was 4.3/1,000 ventilator days, and the 2009 rate was 1.2/1,000 ventilator days. The 2008 to 2009 VAP rate ratio was significantly greater than 1 (rate ratio 3.6, 95% CI 1.8-8.0, P < .001). Antibiotic days were less in 2009 versus 2008 (Hodges-Lehmann estimate of difference between 2008 and 2009, 1.0, 95% CI 0.0 -1.0, P = .002). The median stay in the ICU was unchanged, and in the hospital was decreased in 2009 (Hodges- Lehmann estimate...
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...Ventilator Associated Pneumonia and Guidelines VAP: Definition • Pneumonia in patients receiving invasive mechanical ventilation for at least 48 hours • Early VAP: < 4 days in the ICU • Late VAP: > 4 days in the ICU VAP: Incidence US National Nosocomial Infection Surveillance Type of ICU Mean VAP Rate (Cases/1000 vent days) Trauma 15.1 Neurosurgical Surgical Burn Cardiothoracic 12.9 9.9 9.6 7.9 Data from January 2002 – June 2003 Reported as VAP rates/1000 vent days VAP: Burden of Illness • Incidence 10-20% of patients receiving mechanical ventilation > 48 hours • Increased ICU Mortality (2-4 times) • Increased ICU LOS (5-7 days) • Increased hospital costs (>$10,000 US in additional costs) Safdar et al, Crit Care Med, 2005; 33: 2184 VAP: Healthcare Cost Burden of Illness Canada (per year) (10.6 cases/1000 Vent days) Excess Vent days Excess Deaths1 16,000 days (55 ICU beds) 216 Excess Cost2 $46,000,000 1Based on attributable mortality of 5.8% cost cost methodology 2Ontario Clinical Criteria for Suspicion of VAP • New or persistent infiltrate on CXR without another cause • Plus any 2 of the following: • • • • Purulent endotracheal secretions Increasing oxygen requirements Core temperature > 38.0o C WBC < 3.5 or > 11.0 Adapted from N Engl J Med 2006;355:2619-30. Host Risk Factors for VAP • Underlying pulmonary disease (e.g. COPD) • • • • • Sepsis ARDS ...
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...consciousness and confusion. The patient had gone through her fifth cycle of chemotherapy when she became very confused today. She was then brought to the emergency room where she was evaluated and had testing done. A CT scan of the patients head showed no signs of acute abnormalities. The chest x –ray re-demonstrated the pan coast tumor with possible underlying infection. Sinuitis also was noted on the CAT scan. The patient was admitted to the floor because of her shortness of breath and level of confusion. Antibiotics were administrated for the pneumonic process and Neupogen was given. The patient was put on oxygen therapy and aerosol treatments and later was transferred to the ICU because of respiratory failure. The patient was placed on a mechanical ventilator when sent to ICU with the new status of DNRCC-A and was extubated on 3/6/10 and died. Past Medical History The patient has a history of depression and acute mental status change. The patient has a surgical history of an A-port insertion. History of Present Illness The patient came into the emergency room complaining of confusion and weakness after her fifth cycle of chemotherapy was done earlier that day. Physical Exam on Admission Vital Signs | Actual Values | Reference Values | Temperature | 98.7F | 97.0- 99.5F | Respiratory Rate | 20 bpm | 12- 20 bpm | Pulse | 121 bpm | 60- 100 bpm | Blood Pressure | 151/79 mm Hg | 60-90/90-140 mm Hg | Weight | 85 lbs | 115 lbs | HEENT: No abnormalities Neck: No...
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...caused by unilateral or bilateral membraneous or bony occlusion. Diagnosis can be confirmed by the inability to pass a catheter through the nares, by cessation of air movement when the mouth is held closed, and by X-ray. Persistent Pulmonary Hypertension of the Neonate (PPHN)- ADA Persistent Fetal Circulation (PFC) - characterized by pulmonary vasoconstriction which results in high pulmonary vascular resistance; this pulmonary hypertension in turn keeps open (or reopens) the fetal cardiac shunts (the foramen ovale and/or the ductus arteriosis). The end result is right-to-left shunting and hypoxemia. Nitric Oxide therapy new treatment for PPHN. Bronchopulmonary Dysplasia (BPD)- BDP is applied to those infants who require mechanical ventilation during their first week of life, who remain dependent on supplemental O2 for more than 28 day, and who have characteristic areas fo increased density on their CXR 1. The Stages of BPD- (identified by CXR) a. Stage I-Indistinguishable from RDS, including diffuse alveolar atelectasis, formation of hyaline membranes, etc. “Ground Glass” appearance b. Stage II-Increase opacification or “white out” of the lungs on X-ray...
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...Research Article: Standard Tracheal Secretion Assessment versus an acoustic Secretion Detector Endotracheal intubation and mechanical ventilation are life-saving procedures in patients with respiratory insufficiency. But this can profoundly impair the defensive mechanisms which keep the lower respiratory tract sterile, increasing the risk of bacterial colonization and ventilator-associated pneumonia. Although endotracheal suctioning is a standard of care in all mechanically ventilated patients, clear guidelines regarding the technique and timing of suctioning are lacking. The applicable American Association for Respiratory Care (AARC) guideline suggests that endotracheal suctioning should be performed at some minimum frequency or when clinically indicated. Since endotracheal suctioning can cause hypoxemia, mechanical trauma, bronchospasm, and hemodynamic instability, an accurate assessment of the need for suctioning might decrease the frequency of suctioning complications. TBA Care is a novel device designed to generate a signal when secretions are present in the respiratory tract of an intubated patient, indicating the need for endotracheal suctioning. This is the first prospective randomized trial to compare different indications for endotracheal suctioning. This study compares the efficacy of TBA Care in detecting the presence of secretions in the airways to standard indications, and tested the hypothesis that different suctioning indications could impact the incidence of...
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...ARDSnet OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 88-95% Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP combinations such as shown below (not required) to achieve goal. Lower PEEP/higher FiO2 FiO2 0.3 0.4 0.4 PEEP 5 5 8 0.5 8 0.9 16 0.5 10 0.9 18 0.6 10 1.0 18-24 0.7 10 0.7 12 NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary FiO2 PEEP 0.7 14 0.8 14 0.9 14 INCLUSION CRITERIA: Acute onset of 1. PaO2/FiO2 ≤ 300 (corrected for altitude) 2. Bilateral (patchy, diffuse, or homogeneous) infiltrates consistent with pulmonary edema 3. No clinical evidence of left atrial hypertension PART I: VENTILATOR SETUP AND ADJUSTMENT 1. Calculate predicted body weight (PBW) Males = 50 + 2.3 [height (inches) - 60] Females = 45.5 + 2.3 [height (inches) -60] 2. Select any ventilator mode 3. Set ventilator settings to achieve initial VT = 8 ml/kg PBW 4. Reduce VT by 1 ml/kg at intervals ≤ 2 hours until VT = 6ml/kg PBW. 5. Set initial rate to approximate baseline minute ventilation (not > 35 bpm). 6. Adjust VT and RR to achieve pH and plateau pressure goals below. Higher PEEP/lower FiO2 FiO2 0.3 0.3 0.3 PEEP 5 8 10 FiO2 PEEP 0.5 18 0.5-0.8 20 0.3 12 0.8 22 0.3 14 0.9 22 0.4 14 1.0 22 0.4 16 1.0 24 0.5 16 __________________________________________________________ PLATEAU PRESSURE GOAL: ≤ 30 cm H2O Check Pplat (0.5 second inspiratory pause), at least q 4h and after each change in PEEP or VT. If Pplat > 30 cm H2O: decrease...
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...by gradually reducing the FIO2 and/or the mandatory ventilator rate, leading to the progressive development of hypoxemia and hypercarbia. · The principle advantage of terminal wean is that patients do not develop any signs of upper airway obstruction during the withdrawal of ventilation. If the wean is performed slowly with the administration of sedatives and analgesics, they do not develop symptoms of air hunger. These advantages not only promote the comfort of the patient but reduce the anxiety of the family and caregivers. · Terminal extubations have the principal advantages that they do not prolong the dying process and that they allow the patients to be free from and unnatural endotracheal tube. The process of terminal extubation also...
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...Ambu Bag (Artificial Manual Breathing Unit), is a hand-held device mostly used to create positive pressure ventilation for patients who are not breathing well, or not breathing at all. The ambu bag should be part of resuscitation kits for trained professionals not only out-of-hospital settings but also in hospitals as part of standard equipment which is found in emergency rooms. Manual resuscitators are used within the hospital usually for temporary ventilation of patients dependent on mechanical ventilators when the mechanical ventilator needs to be examined for malfunction, or when these patients are transported within the hospital. Two principal types of manual resuscitator exist, one version is self-filling with air, which can work without...
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...|CognitiveLevel||3rd Ed. Page References| |Recall|Application|Analysis|Totals|| I. PATIENT DATA EVALUATION AND RECOMMENDATIONS|11|14|1|26|| A. Review Data in the Patient Record|4|||4|| 1. Patient history e.g.,• present illness• admission notes• respiratory care orders• medication history• progress notes• diagnoses• DNR status• patient education (previous)|||||pp 33, 82, 47| 2. Physical examination relative to the cardiopulmonary system e.g., vitalsigns, physical findings|||||pp 33-35, 35-45, 47, 151-153, 153-155, 155-156, 156-158, 158-163, 175-177| 3. Laboratory data e.g.,• CBC• electrolytes• coagulation studies• culture and sensitivities• sputum Gram stain|||||pp 45-47| 4. Pulmonary function results|||||pp 47, 151-153, 153-155, 155-156, 156-158, 158-163, 191-194, 194-196, 197| 5. Blood gas results|||||pp 47, 124-126, 126-127, 127-128, 151-153, 153-155, 156-158, 158-163| 6. Imaging studies e.g.,• radiograph• CT• MRI|||||pp 33-45, 47, 151-153, 175-177| 7. Monitoring data|||||| a. fluid balance|||||pp 139-140| b. pulmonary mechanics e.g., maximum inspiratory pressure, vitalcapacity|||||pp 47, 139, 191-194, 194-196| c. respiratory e.g.,• rate• tidal and minute volume• I:E|||||pp 47, 139, 191-194, 194-196| d. pulmonary compliance, airways resistance, work of breathing|||||pp 47, 137-139, 141-143| e. noninvasive e.g.,• pulse oximetry• VD/VT• capnography• transcutaneous O2 / CO2|||||pp 20-21, 47, 137-139, 167-172, 172-175| 8. Cardiac monitoring|||||pp 35-45, 158-163| ...
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...Journal of Intensive Care Medicine http://jic.sagepub.com/ The Impact of a Simple, Low-cost Oral Care Protocol on Ventilator-associated Pneumonia Rates in a Surgical Intensive Care Unit Carrie S. Sona, Jeanne E. Zack, Marilyn E. Schallom, Maryellen McSweeney, Kathleen McMullen, James Thomas, Craig M. Coopersmith, Walter A. Boyle, Timothy G. Buchman, John E. Mazuski and Douglas J. E. Schuerer J Intensive Care Med 2009 24: 54 originally published online 17 November 2008 DOI: 10.1177/0885066608326972 The online version of this article can be found at: http://jic.sagepub.com/content/24/1/54 Published by: http://www.sagepublications.com Additional services and information for Journal of Intensive Care Medicine can be found at: Email Alerts: http://jic.sagepub.com/cgi/alerts Subscriptions: http://jic.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://jic.sagepub.com/content/24/1/54.refs.html >> Version of Record - Jan 14, 2009 OnlineFirst Version of Record - Nov 17, 2008 What is This? Downloaded from jic.sagepub.com at UNIV OF THE INCARNATE WORD on April 15, 2013 Original Research The Impact of a Simple, Low-cost Oral Care Protocol on Ventilator-associated Pneumonia Rates in a Surgical Intensive Care Unit Journal of Intensive Care Medicine Volume 24 Number 1 January/February 2009 54-62 # 2009 SAGE Publications 10.1177/0885066608326972 http://jicm.sagepub...
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...Case Study Three 1. What is the definition of ARDS? Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. More fluid in your lungs means less oxygen can reach your bloodstream. This deprives your organs of the oxygen they need to function. Acute Respiratory Distress Syndrome (ARDS) is also known as shock lung, wet lung, post perfusion lung and a variety of other names related to specific causes. What are the associated clinical indicators? The first signs and symptoms of ARDS are feeling like you can't get enough air into your lungs, rapid breathing, and a low blood oxygen level. Other signs and symptoms depend on the cause of the ARDS. They may occur before ARDS develops. Sometimes, people who have ARDS develop signs and symptoms such as low blood pressure, confusion, and extreme tiredness. This may mean that the body's organs, such as the kidneys and heart, aren't getting enough oxygen-rich blood. 2. What conditions did this patient experience that are common risk factors ssociated with ARDS? Brain present with near drowniess syndrome that lead to his diagnosis of ARDS. 3. Describe the major pathophysiological alterations in ARDS. Increased capillary permeability is the hallmark of ARDS. Damage of the capillary endothelium and alveolar epithelium in correlation to impaired fluid remove from the alveolar space result in accumulation of protein-rich fluid inside the...
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