Thursday, April 20, 2017 Critical care units HIKMET QUBEILAT

Thursday, April 20, 2017 HIKMET QUBEILAT

Thursday, April 20, 2017                                                                                            HIKMET QUBEILAT

An Intensive Care Unit (ICU) or Critical Care Unit (CCU Thursday, April 20, 2017 An Intensive Care Unit (ICU) or Critical Care Unit (CCU ) is a specialised facility in a hospital that provides intensive care medicine. Many hospitals also have designated intensive care areas for certain specialities of medicine, as dictated by the needs and available resources of each hospital. The naming is not rigidly standardized. HIKMET QUBEILAT

Specialized types of ICUs include Thursday, April 20, 2017 Specialized types of ICUs include : Neonatal intensive care unit (NICU) Special Care Baby unit (SCBU) Pediatric Intensive Care Unit (PICU) Psychiatric Intensive Care Unit (PICU) Coronary Care Unit (CCU) for heart disease Medical Intensive Care Unit (MICU) Surgical Intensive Care Unit (SICU) Cardiac Surgery Intensive Care Unit (CSICU) Neuroscience Critical Care Unit (NCCU) Overnight Intensive Recovery (OIR) Neuro Intensive Care Unit (NICU) Burn Wounds Intensive Care Unit Trauma Intensive care Unit (TICU) Shock Trauma Intensive care Unit (STICU) HIKMET QUBEILAT

Thursday, April 20, 2017 Equipment and systems Common equipment in an ICU includes mechanical ventilator; dialysis equipment for renal problems; equipment for the constant monitoring of bodily functions; a web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains and catheters; and a wide array of drugs to treat the main condition(s), induce sedation, reduce pain, and prevent secondary infections HIKMET QUBEILAT

Mechanical ventilation Thursday, April 20, 2017 Mechanical ventilation HIKMET QUBEILAT

Mechanical ventilation Thursday, April 20, 2017 Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing when patients cannot do so on their own, and must be done so after invasive intubation with an endotracheal or tracheostomy tube through which air is directly delivered (in contrast to noninvasive ventilation). HIKMET QUBEILAT

Common indications for mechanical ventilation Thursday, April 20, 2017 Common indications for mechanical ventilation Apnea with respiratory arrest Acute lung injury Respiratory rate >30 breaths per minute Chronic obstructive pulmonary disease (COPD) Clinical deterioration Respiratory muscle fatigue Obtundation or coma Hypotension Tachypnea or bradypnea Blood gases showing persistent hypoxemia Acute partial pressure of carbon dioxide (PCO2) of >50 mm Hg with pH <7.25 Neuromuscular disease HIKMET QUBEILAT

A mechanical ventilator Thursday, April 20, 2017 A mechanical ventilator is a machine that generates a controlled flow of gas into a patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine, and delivered to the patient using one of many available modes of ventilation. HIKMET QUBEILAT

Thursday, April 20, 2017 HIKMET QUBEILAT

ways to ventilate a patient? Thursday, April 20, 2017 ways to ventilate a patient? There really is only two ways to ventilate a patient, using (conventional) positive pressure or negative pressure. Some of the earliest ventilators were negative pressure chambers (iron lungs). HIKMET QUBEILAT

Thursday, April 20, 2017 Mode or Breath Pattern CMV = Conventional controlled ventilation, without allowances for spontaneous breathing. Many anesthesia ventilators operate in this way. Assist-Control = Where assisted breaths are facsimiles of controlled breaths. Intermittent Mandatory Ventilation = Which mixes controlled breaths and spontaneous breaths. Breaths may also be synchronized to prevent "stacking". Pressure Support = Where the patient has control over all aspects of his/her breath except the pressure limit.) HIKMET QUBEILAT

Thursday, April 20, 2017 Modes of ventilation Assist Control (AC). In this mode the ventilator provides a mechanical breath with either a preset tidal volume or peak pressure every time the patient initiates a breath. Traditional assist-control used only a preset tidal volume--when a preset peak pressure is used this is also sometimes termed Intermittent Positive Pressure Ventilation or IPPV HIKMET QUBEILAT

Thursday, April 20, 2017 HIKMET QUBEILAT

Thursday, April 20, 2017 HIKMET QUBEILAT

Synchronized Intermittent Mandatory Ventilation (SIMV). Thursday, April 20, 2017 Synchronized Intermittent Mandatory Ventilation (SIMV). In this mode the ventilator provides a preset mechanical breath (pressure or volume limited) every specified number of seconds (determined by dividing the respiratory rate into 60 - thus a respiratory rate of 12 results in a 5 second cycle time). Within that cycle time the ventilator waits for the patient to initiate a breath using either a pressure or flow sensor. When the ventilator senses the first patient breathing attempt within the cycle, it delivers the preset ventilator breath. If the patient fails to initiate a breath, the ventilator delivers a mechanical breath at the end of the breath cycle. Additional spontaneous breaths after the first one within the breath cycle do not trigger another SIMV breath HIKMET QUBEILAT

Controlled Mechanical Ventilation (CMV). Thursday, April 20, 2017 Controlled Mechanical Ventilation (CMV). In this mode the ventilator provides a mechanical breath on a preset timing. Patient respiratory efforts are ignored. This is generally uncomfortable for children and adults who are conscious and is usually only used in an unconscious patient. It may also be used in infants who often quickly adapt their breathing pattern to the ventilator timing. HIKMET QUBEILAT

Pressure Support Ventilation (PSV). Thursday, April 20, 2017 Pressure Support Ventilation (PSV). This was developed as a method to decrease the work of breathing in-between ventilator mandated breaths. Thus, for example, SIMV might be combined with PSV so that additional breaths beyond the SIMV programmed breaths are supported. However, while the SIMV mandated breaths have a preset volume or peak pressure, the PSV breaths are designed to cut short when the inspiratory flow reaches a percentage of the peak inspiratory flow (e.g. 10- 25%). Also, the peak pressure set for the PSV breaths is usually a lower pressure than that set for the SIMV breath. PSV can be also be used as an independent mode.. HIKMET QUBEILAT

Continuous Positive Airway Pressure (CPAP). Thursday, April 20, 2017 Continuous Positive Airway Pressure (CPAP). A continuous level of elevated pressure is provided through the patient circuit to maintain adequate oxygenation, decrease the work of breathing, and decrease the work of the heart (such as in left-sided heart failure - CHF). Note that no cycling of ventilator pressures occurs and the patient must initiate all breaths. In addition, no additional pressure above the CPAP pressure is provided during those breaths. CPAP may be used invasively through an endotracheal tube or tracheostomy or non-invasively with a face mask or nasal prongs HIKMET QUBEILAT

Positive End Expiratory Pressure (PEEP) Thursday, April 20, 2017 Positive End Expiratory Pressure (PEEP) is functionally the same as CPAP, but refers to the use of an elevated pressure during the expiratory phase of the ventilatory cycle. After delivery of the set amount of breath by the ventilator, the patient then exhales passively. The volume of gas remaining in the lung after a normal expiration is termed the functional residual capacity (FRC). The FRC is primarily determined by the elastic qualities of the lung and the chest wall. In many lung diseases, the FRC is reduced due to collapse of the unstable alveoli, leading to a decreased surface area for gas exchange and intrapulmonary shunting), with wasted oxygen inspired. Adding PEEP can reduce the work of breathing (at low levels) and help preserve FRC. HIKMET QUBEILAT

Initial ventilator settings Thursday, April 20, 2017 Initial ventilator settings Tidal Volume, Rate, Pressures and Initial FiO2 For adult patients and older children without existing lung disease -- a tidal volume of 12 mL per kg body weight is set to be delivered at a rate of 12 a minute (12-12 rule). with COPD -- a reduced tidal volume of 10 ml/kg is to be delivered 10 times a minute to prevent overinflation and hyperventilation (10-10 rule). with acute respiratory distress syndrome (ARDS) -- an even more reduced tidal volume of 6-8 mL/kg is used with a rate of 10-12/minute. This reduced tidal volume allows for minimal volutrauma but may result in an elevated pCO2 (due to the relative decreased oxygen delivered) but this elevation does not need to be corrected (termed permissive hypercapnia) HIKMET QUBEILAT

Thursday, April 20, 2017 Alarms Mechanical ventilators are equipped with alarms to notify you of any changes in their ventilation status. Here are some of the most common causes of low and high pressure alarm situations HIKMET QUBEILAT

Low-Pressure Alarms Patient disconnection Circuit leaks Airway leaks Thursday, April 20, 2017 Low-Pressure Alarms Patient disconnection  Circuit leaks  Airway leaks  Chest tube leaks  HIKMET QUBEILAT

High-Pressure Alarms Patient coughing Thursday, April 20, 2017 High-Pressure Alarms Patient coughing  Secretions or mucus in the airway  Patient biting tube  Airway problems  Reduced lung compliance (eg. pneumothorax)  Increased airway resistance  Patient fighting the ventilator  Accumulation of water in the circuit  Kinking in the circuit  Problems with inspiratory or expiratory valves  HIKMET QUBEILAT