INTUBATION AND VENTILATION SUPPORT

Description

• Pressure support ventilation (PSV) is a ventilatory mode in which spontaneous breaths are partially or fully supported by an inspiratory pressure assist above baseline pressure to decrease the imposed work of breathing created by the narrow lumen ETT, ventilator circuit, and demand valve.
• PSV is a form of patient-triggered ventilation (PTV); it may be used alone in patients with reliable respiratory drive, or in conjunction with synchronized intermittent mandatory ventilation (SIMV).

Cycling Mechanisms

Time: Inspiratory time limit is chosen by the clinician.

Flow: Termination of the inspiratory cycle based on a percentage of peak flow. This varies according to both the delivered tidal volume and the specific algorithm of the ventilator in use. For most neonatal ventilators, this occurs at 5% of peak inspiratory flow.

Trigger Mechanisms

• Airway pressure change (minimum 1.0 cm H2O)
• Airway flow change (minimum 0.2 L/min)

Pressure Support Breath

• Pressure support breath is a spontaneous inspiratory effort that exceeds the trigger threshold and initiates delivery of a mechanically generated pressure support breath.
• There is a rapid delivery of flow to the patient, which peaks and then decelerates.
• The airway pressure will rise to the pressure support level, set by the clinician as a value above baseline (positive end-expiratory pressure [PEEP]).
• When the flow-cycling criterion is met (decline to the termination level), the breath will end and flow will cease. If this has not occurred by the end of the set inspiratory time limit, the inspiratory phase of the mechanical breath will be stopped.
• The amount of flow delivered to the patient during inspiration is variable and is proportional to patient effort.
• Patient-controlled variables

1. Respiratory rate
2. Inspiratory time
3. Peak inspiratory flow

• Clinician-controlled variables

1. Pressure support level
2. Inspiratory time limit
3. Baseline flow
4. Baseline pressure (PEEP)
5. SIMV rate, flow, inspiratory time, and tidal volume or pressure limit (if SIMV is used)

HEMODIALYSIS

What Is Dialysis?

Dialysis is a treatment for people whose kidneys are failing. When you have kidney failure, your kidneys don’t filter blood the way they should. As a result, wastes and toxins build up in your bloodstream. Dialysis does the work of your kidneys, removing waste products and excess fluid from the blood.

What Are The Types Of Dialysis?

There Are Two Ways To Get Dialysis:

• Hemodialysis
• Peritoneal dialysis.

What Is Hemodialysis?

With hemodialysis, a machine removes blood from your body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to your body. This 3- to 5-hour process may take place in a hospital or a dialysis center three times a week.

You can also do hemodialysis at home. You may need at-home treatments four to seven times per week for fewer hours each session. You may choose to do home hemodialysis at night while you sleep.

What Happens Before Hemodialysis?

Before you start hemodialysis, you’ll undergo a minor surgical procedure to make it easier to access the bloodstream. You may have:

Arteriovenous Fistula (AV Fistula): A surgeon connects an artery and vein in your arm.

Arteriovenous Graft (AV Graft): If the artery and vein are too short to connect, your surgeon will use a graft (soft, hollow tube) to connect the artery and vein.

AV fistulas and grafts enlarge the connected artery and vein, which makes dialysis access easier. They also help blood flow in and out of your body faster.

If dialysis needs to happen quickly, your provider may place a catheter (thin tube) into a vein in your neck, chest or leg for temporary access.

Your provider will teach you how to prevent infections in your fistula or graft. This provider will also show you how to do hemodialysis at home if you choose to do so.

What Happens Before Hemodialysis?

Before you start hemodialysis, you’ll undergo a minor surgical procedure to make it easier to access the bloodstream. You may have:

Arteriovenous Fistula (AV Fistula): A surgeon connects an artery and vein in your arm.

Arteriovenous Graft (AV Graft): If the artery and vein are too short to connect, your surgeon will use a graft (soft, hollow tube) to connect the artery and vein.

AV fistulas and grafts enlarge the connected artery and vein, which makes dialysis access easier. They also help blood flow in and out of your body faster.

If dialysis needs to happen quickly, your provider may place a catheter (thin tube) into a vein in your neck, chest or leg for temporary access.

Your provider will teach you how to prevent infections in your fistula or graft. This provider will also show you how to do hemodialysis at home if you choose to do so.

CRRT

What Is CRRT, And How Does It Help?

CRRT is a type of blood purification therapy used with patients who are experiencing AKI. During this therapy, a patient’s blood passes through a special filter that removes fluid and uremic toxins, returning clean blood to the body. The slow and continuous nature of the process, typically performed over a 24-hour period, allows patients with unstable blood pressure and heart rates, which is termed hemodynamically unstable, to better tolerate this process.

There Are Six Medical Products Required To Perform CRRT On A Patient:

Blood Purification Machine: the machine pumps the blood, controls the rate of blood flow and includes software to safely monitor therapy delivery

Dialysate: a fluid that carries toxins away from the filter

Replacement Fluid: a specialized, sterile fluid also used to flush toxins from the body but also to replace electrolytes, other blood elements and volume lost during the filtration process

Filter: machine component that removes fluid and uremic toxins

Anticoagulation Method: a type of drug that helps the blood flow through the system, lessening the likelihood that the blood will clot in the filter

Blood Warmer: efficiently maintains a patient’s blood temperature during blood purification therapy

NON INVASIVE VENTILLATION

Introduction

Non-invasive ventilation (NIV) is the delivery of oxygen (ventilation support) via a face mask and therefore eliminating the need of an endotracheal airway

NIV achieves comparative physiological benefits to conventional mechanical ventilation by reducing the work of breathing and improving gas exchange. Research suggests that noninvasive ventilation after early extubation looks helpful in reducing the total days spent on invasive mechanical ventilation.

The intervention is recognised as an effective treatment for respiratory failure in chronic obstructive pulmonary disease, cardiogenic pulmonary oedema and other respiratory conditions without complications such as respiratory muscle weakness, upper airway trauma, ventilator-associated pneumonia, and sinusitis.

NIV works by creating a positive airway pressure – the pressure outside the lungs being greater than the pressure inside of the lungs. This causes air to be forced into the lungs (down the pressure gradient), lessening the respiratory effort and reducing the work of breathing. It also helps to keep the chest and lungs expanded by increasing the functional residual capacity (the amount of air remaining in the lungs after expiration) after a normal (tidal) expiration; this is the air available in the alveoli available for gaseous exchange. There are two types of NIV non-invasive positive-pressure (NIPPV) and Negative-Pressure Ventilation (NPV).

CPAP

CPAP is the most basic level of support and provides constant fixed positive pressure throughout inspiration and expiration, causing the airways to remain open and reduce the work of breathing. This results in a higher degree of inspired oxygen than other oxygen masks. When indicated for home use it is usually via a low flow generator and is commonly used for patients requiring nocturnal CPAP for sleep apnoea. High flow systems used in a hospital environment are designed to ensure that airflow rates delivered are greater than those generated by the distressed patient. As well as having an effect on respiratory function it can also assist cardiac function where patients have a low cardiac output with pre-existing low blood pressure. It is also commonly used for severe obstructive sleep apnoea and also for type 1 respiratory failure, for example, acute pulmonary oedema (by recruiting collapsed alveoli).

Bi pap

NIV is often described as BiPAP, however, BiPAP is actually the trade name. As the name suggests provides differing airway pressure depending on inspiration and expiration. The inspiratory positive airways pressure (iPAP) is higher than the expiratory positive airways pressure (ePAP). Therefore, ventilation is provided mainly by iPAP, whereas ePAP recruits underventilated or collapsed alveoli for gas exchange and allows for the removal of the exhaled gas. In the acute setting, NIV is used in type 2 respiratory failure (for example in a COPD exacerbation), with respiratory acidosis (pH < 7.35).

Negative-Pressure Ventilation (Npv)

Negative-pressure ventilators provide ventilatory support using a device that encases the thoracic cage, such as the iron lung. Although not seen as much in today’s society they were popular in the first half of the twentieth century during the polio epidemic. They work by lowering the pressure surrounding the thorax, creating subatmospheric pressure which passively expands the chest wall to inflate the lungs. Exhalation occurs with passive recoil of the chest wall. Their use is still indicated in chronic respiratory failure. The three types used each with their own advantages and disadvantages[15]:

The earliest version is the tank ventilator, more commonly known as the iron lung. It is a large cylindrical device that encases the patient’s body with only the head visible, a neck collar provides an airtight seal

The poncho-wrap is an airtight bodysuit using a rigid metal framework covered with an airtight nylon parker that surrounds the trunk

The cuirass is made up of a rigid fibreglass shell which fits over the chest wall and upper abdomen

Contraindications Of NIV

• Coma
• Undrained pneumothorax
• Frank haemoptysis
• Vomiting blood (haematemesis)
• Facial fractures
• Cardiovascular system instability
• Cardiac Arrest
• Respiratory Failure
• Raised ICP
• Recent upper GI surgery
• Active Tuberculosis
• Lung abscess
• No additional contraindications in the paediatric population

ECMO SERVICES

Overview

In extracorporeal membrane oxygenation (ECMO), blood is pumped outside of your body to a heart-lung machine that removes carbon dioxide and sends oxygen-filled blood back to tissues in the body. Blood flows from the right side of the heart to the membrane oxygenator in the heart-lung machine, and then is rewarmed and sent back to the body.

This method allows the blood to “bypass” the heart and lungs, allowing these organs to rest and heal.

ECMO is used in critical care situations, when your heart and lungs need help so that you can heal.

Why It’s Done

ECMO may be used to help people who are very ill with conditions of the heart and lungs, or who are waiting for or recovering from a heart transplant. It may be an option when other life support measures haven’t worked. ECMO does not treat or cure a disease, but can help you when your body temporarily can’t provide your tissues with enough oxygen

Some Heart Conditions In Which ECMO May Be Used Include:

• Heart attack (acute myocardial infarction)
• Heart muscle disease (decompensated cardiomyopathy)
• Inflammation of the heart muscle (myocarditis)
• Life-threatening response to infection (sepsis)
• Low body temperature (severe hypothermia)
• Post-transplant complications
• Shock caused by the heart not pumping enough blood (cardiogenic shock)

Some Lung (Pulmonary) Conditions In Which ECMO May Be Used Include:

• Acute respiratory distress syndrome (ARDS)
• Blockage in a pulmonary artery in the lungs (pulmonary embolism)
• Coronavirus disease 2019 (COVID-19)
• Defect in the diaphragm (congenital diaphragmatic hernia)
• Fetus inhales waste products in the womb (meconium aspiration)
• Flu (influenza)
• Hantavirus pulmonary syndrome
• High blood pressure in the lungs (pulmonary hypertension)
• Pneumonia
• Respiratory failure
• Trauma

 BEDSIDE

OVERVIEW

A bedside Cardiac Ultrasound or Echocardiogram is a quick Point of Care Ultrasound (POCUS) that allows you to visualize and evaluate how the heart is functioning. In addition, bedside echocardiography also allows you to evaluate hemodynamic changes and pathological heart diseases.

The Cardiac Ultrasound Procedure is also known as:

Echocardiography, Echocardiogram, or even just “Echo.” They all refer to the same thing.

In addition, you may see cardiac ultrasound referred to as “Transthoracic” or Transesophageal” echocardiography. Transthoracic Echocardiography (TTE) is when a cardiac ultrasound is performed on the patient’s chest. TTE is the most common cardiac ultrasound application and is non-invasive. TTE is what we will be covering in this post. Transesophageal Echocardiography (TEE) is a more specialized cardiac ultrasound with a special probe that is inserted into the patient’s esophagus. TEE requires sedation and is considered more invasive than TTE.

In this Cardiac Ultrasound (Echocardiography) for Beginners Guide, we will be showing you how you can get started on using basic Transthoracic Echocardiography (TTE) right away!

After reading this Echo Tutorial, you will be able to use bedside Cardiac Ultrasound (Echocardiography) to:

• Obtain the 5 Major Cardiac Windows and Views of the Heart (including the Inferior Vena Cava(IVC) View)
• Perform Proper Cardiac Ultrasound (Echocardiography) Technique
• Evaluate for Major Cardiac Ultrasound Pathology:
• Evaluate Left Ventricular Ejection Fraction
• Estimate Central Venous Pressure (CVP) for fluid status/ fluid tolerance using the IVC
• Evaluate for Pericardial Effusion/Tamponade
• Evaluate for Pulmonary Embolism

ARTERIAL PRESSURE MONITORING

OVERVIEW

• arterial catheter connected to a pressure transducer

USES

• blood pressure (systolic, diastolic, mean and pulse pressure)
• arterial blood sampling

Specific indications

• Labile blood pressure
• Anticipation of haemodynamic instability
• Titration of vasoactive drugs
• Frequent blood sampling
• Morbid obesity (unable to fit an appropriately sized NIBP cuff)

DESCRIPTION

• arterial line
• 48 inches of non-compressible rigid-walled, fluid filled tubing
• pressure transducer and automatic flushing system
• pressure bag and automated slow infusion (1-3mL/h) of pressurised saline
• electronic transducer amplifier display

METHOD OF INSERTION AND/OR USE

Mechanism

• fluctuations of vascular pressure cause a pulsation of the saline column
• displaces electromanometer’s diaphragm which has a built in strain gauge (Wheatstone bridge principle)
• deformation leads to a change in resistance of the strain gauge which is sensed electronically
• wave form built up by Fourier analysis from sinusoids or simple wave forms
• wave forms differ depending on where the cannula is inserted

Calibrating (‘zeroing’) 

• ensure the transducer pressure tubing and flush solution are correctly assembled and free of air bubbles
• place transducer at level of the right atrium
• ‘off to patient, open to air (atmosphere)’
• press ‘zero’ -> sets atmospheric pressure as zero reference point
• whenever patient position is altered the transducer height should be altered

Square wave test

• aka fast flush test
• snap flush to generate square wave
• check for oscillations as an indicator of the harmonic characteristics of the system
• usually only 1 oscillation before returning to baseline
• 2 or more oscillations before returning to baseline (underdamped)
• if no oscillations (overdamped – response speed is too slow)

ACCURACY AND MEASUREMENT ERRORS

 Conditions that must be met to ensure accuracy

 cannula properly placed within the lumen of an unobstructed artery (ie. no spasm, thrombus, atheroma proximal to cannula)

• cannula not kinked or obstructed
• cannula connected by short, rigid, wide-bore tubing to the transducer
• no air bubbles in tubing or transducer
• interface from fluid to transducer accurately transmits deflections
• transducer has adequate frequency response (natural frequency > 100Hz)
• transducer is leveled and zeroed to desired point (ie. left atrium)
• no zero drift
• monitor calibrated accurately

Common sources of error

• bubbles in catheter-transducer system -> decreased resonant frequency
• clotting in arterial catheter
• elastic walls causes increased damping
• cannula won’t flush – kinked, clotted, tissued

CENTRAL NURSE SYSTEM MONITORING

Comprehensive Monitoring And Patient Management

Central stations must display comprehensive patient information from bedside monitors in a simple and effective manner for in-depth analysis and in order to increase workflow productivity.

TX Hospital Central Nursing Stations (CNS-9101 and CNS-6201) are a powerful solution designed to ensure simplicity and ease of use. The Central Nursing Station offers multiple review windows, plus an optional dual-display screen that operates separately and displays different sets of information. In addition, the ec1 arrhythmia analysis software helps reduce of false alarms without compromising patient safety.

BENEFITS

• Supports any size of screen, Single screen for monitoring 32 beds and dual screen for monitoring 64 beds, maximum 128 beds
• Powerful anti-interference network signal
• Pure central operating system, no software interference
• Humanized operating interface, simple and clear
• Comprehensive View of Patient Information      

SLEEP STUDY

Polysomnography, called a sleep study, is a diagnostic test used to evaluate sleep disorders, particularly sleep apnea. It involves monitoring multiple physiological parameters, such as brain activity (electroencephalography, EEG), eye movements (electrooculography, EOG), muscle activity (electromyography, EMG), and heart rate (electrocardiography, ECG), while a person is asleep.

Symptoms of sleep disorders that may warrant a polysomnography test include:

• Excessive daytime sleepiness
• Loud snoring
• Observed episodes of stopped breathing during sleep
• Restless tossing and turning during sleep
• Abrupt awakenings with a choking or gasping sensation

Treatment of sleep disorders depends on the specific condition and its severity, but may include:

• Continuous positive airway pressure (CPAP) therapy
• Lifestyle changes (such as losing weight, and avoiding alcohol and caffeine before bedtime)
• Oral appliances to reposition the jaw and tongue
• Surgery to remove tissues blocking the airway.

It is essential to consult a physician for an accurate diagnosis and appropriate treatment.

PICC

What is a peripherally inserted central catheter (PICC)?

A peripherally inserted central catheter or “PICC” is a thin, soft, flexible tube — an intravenous (IV) line. Treatments, such as IV medications, can be given though a PICC. Blood for laboratory tests can also be withdrawn from a PICC.

What are the benefits of using a PICC?

• A PICC is more comfortable compared with the many “needle sticks” that would have been needed for giving medications and drawing blood. The goal is to spare your veins from these frequent “needle sticks.”
• A PICC can also spare your veins and blood vessels from the irritating effects of IV medications.
• A PICC can be used in the hospital setting, nursing facility, or at home and can stay in place for weeks or months, if needed.
• A PICC can be used for many types of IV treatments.
• A PICC can be used to obtain most blood tests.

What are the risks during and after the placement of a PICC?

• There may be slight discomfort during the procedure.
• Bleeding may occur at the insertion site.
• It is sometimes necessary to attempt more than once and it may not be possible to insert the entire length of the PICC.
• During insertion of a PICC, accidental puncture of an artery, nerve, or tendon can occur near the insertion site. However, this is a rare event.
• A clot may form around the catheter in the vein (thrombosis), which can cause swelling and pain in the arm.
• Inflammation in a vein (phlebitis) can develop from the use of all types of IVs, including PICCs.
• An infection may occur at the insertion site or in the bloodstream.
• The PICC can come out, partially or completely, if not well-secured and completely covered.
• The PICC can move out of position in the vein and may need to be removed or repositioned.
• The PICC may become blocked. Medication may need to be used to clear it.

PCDT

• What is Pharmaco mechanical catheter directed therapy (PCDT) includes combined use of Catheter directed thrombolysis and catheter-based suction or mechanical thrombectomy.
• Thrombolysis is a minimally invasive procedure in which we administer clot-dissolving drugs directly into the clot to break it up.
• During thrombectomy we use a catheter tipped with a tool that mechanically breaks up the clot or remove clot by catheter suction.
• These two procedures are sometimes used together, and are useful for very large clots or in people who are at high risk of developing a pulmonary embolism.
• Patients also receive anticoagulation before, during, and after endovascular treatment.