2. Focus Conference May 15, 2014 David Chang Professor Cardiorespiratory Care University of South Alabama

3. The normal cerebral perfusion pressure (CPP) is _______. The mortality rate increases by _______ for each 10 mm Hg drop in CPP. A. 8 to 12 mm Hg; 10% B. 8 to 12 mm Hg; 20% C. 70 to 80 mm Hg; 10% D. 70 to 80 mm Hg; 20%

4. An arterial blood gas sample was collected from a patient with COPD 10 minutes after initiation of mechanical ventilation. The results are: pH = 7.47, PaCO 2 = 40 mm Hg, HCO3 - = 28 mEq/L. This ABG most likely represents : A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis E. None of the above

5. The results of an arterial blood gas sample drawn from a mechanically ventilated patient are: pH = 7.47, PaCO 2 = 33 mm Hg, PaO 2 = 68 mm Hg, F I O 2 = 40%. No PEEP. The therapist should: A. decrease the frequency B. increase the F I O 2 C. decrease the frequency and increase the F I O 2 D. increase the frequency and increase the F I O 2 E. increase the frequency or pressure support

6. The pressure / volume loop is typically used to evaluate a patient’s _______ status. A. airflow resistance B. compliance C. oxygenation D. ventilatory

7. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

8. Pleural of Latin datum Related to “give” “something given” Data represent information

9. Pleural of Latin datum Related to “give” “something given” Data represent information (more than numbers) Clinical errors are strongly related to (1) misuse of clinical information, or (2) use of incomplete or invalid clinical information

10. Daily: Time, newspaper, place, people, email, TV Clinical: Breath sounds, vital signs, physical exam

11. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

12. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

13. 1. Decision making (initiate, change, discontinue) 2. Best patient care vs. defensive medicine 3. Errors in health care in the U.S. alone cause between 44,000 and 98,000 deaths every year (Ref: Mechanical Ventilation - H.M. 2011) 4. Non-use of patient clinical data presents a greater risk than misuse (Ref: St. Clair, 2008)

14. 1. Decision making (initiate, change, discontinue) 2. Best patient care vs. defensive medicine 3. Errors in health care in the U.S. alone cause between 44,000 and 98,000 deaths every year (Ref: Mechanical Ventilation - H.M. 2011) 4. Non-use of patient clinical data presents a greater risk than misuse (Ref: St. Clair, 2008)

15. 1. Decision making (initiate, change, discontinue) 2. Best patient care vs. defensive medicine 3. Errors in health care in the U.S. alone cause between 44,000 and 98,000 deaths every year (Ref: Mechanical Ventilation - H.M. 2011) (+100,000s of unreported deaths and injuries) e.g., 3 fetal errors in incorrect breath sound assessment 4. Non-use of patient clinical data presents a greater risk than misuse (Ref: St. Clair, 2008)

16. 1. Decision making (initiate, change, discontinue) 2. Best patient care vs. defensive medicine 3. Errors in health care in the U.S. alone cause between 44,000 and 98,000 deaths every year (Ref: Mechanical Ventilation - H.M. 2011) (+100,000s of unreported deaths and injuries) 4. Non-use of patient clinical data presents a greater risk than misuse (Ref: St. Clair, 2008)

17. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

18. 1. Data from history and admitting workup 2. Ongoing assessment and monitoring 3. Routine and special laboratory data (patient is passive) 4. Data from clinical procedures (patient is active)

19. 1. Data from history and admitting workup 2. Ongoing assessment and monitoring 3. Routine and special laboratory data (patient is passive) 4. Data from clinical procedures (patient is active)

20. 1. Data from history and admitting workup 2. Ongoing assessment and monitoring 3. Routine and special laboratory data (patient is passive) 4. Data from clinical procedures (patient is active)

21. 1. Data from history and admitting workup 2. Ongoing assessment and monitoring 3. Routine and special laboratory data (patient is passive) 4. Data from clinical procedures (patient is active)

22. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

23. 1. Prevent harm (e.g., false-positive, false- negative) 2. Reduce malpractice 3. Reduce healthcare cost 4. Protect professional license 5. Improve professionalism

24. 1. Prevent harm (e.g., false-positive, false- negative) 2. Reduce malpractice 3. Reduce healthcare cost 4. Protect professional license 5. Improve professionalism

25. 1. Prevent harm (e.g., false-positive, false- negative) 2. Reduce malpractice 3. Reduce healthcare cost 4. Protect professional license 5. Improve professionalism

26. 1. Prevent harm (e.g., false-positive, false- negative) 2. Reduce malpractice 3. Reduce healthcare cost 4. Protect professional license 5. Improve professionalism

27. 1. Prevent harm (e.g., false-positive, false- negative) 2. Reduce malpractice 3. Reduce healthcare cost 4. Protect professional license 5. Improve professionalism

28. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

29. 1. Unfamiliar data or procedure 2. Carelessness 3. Incorrect interpretation 4. Incomplete information

30. The normal cerebral perfusion pressure (CPP) is _______. The mortality rate increases by _______ for each 10 mm Hg drop in CPP. A. 8 to 12 mm Hg; 10% B. 8 to 12 mm Hg; 20% C. 70 to 80 mm Hg; 10% D. 70 to 80 mm Hg; 20%

31. The normal cerebral perfusion pressure (CPP) is _______. The mortality rate increases by _______ for each 10 mm Hg drop in CPP. A. 8 to 12 mm Hg; 10% B. 8 to 12 mm Hg; 20% C. 70 to 80 mm Hg; 10% D. 70 to 80 mm Hg; 20% CPP = MAP - ICP

32. 1. Unfamiliar data or procedure 2. Carelessness 3. Incorrect interpretation 4. Incomplete information

33. A 34-year-old woman was incorrectly diagnosed with a rare and aggressive form of neuroendocrine cancer. Her entire lower jaw and teeth were removed and her face was reconstructed with bones taken from lower legs, suffering permanent disfigurement. It turned out that her lab sample was contaminated with another patient’s sample.

34. 1. Unfamiliar data or procedure 2. Carelessness 3. Incorrect interpretation 4. Incomplete information

35. An arterial blood gas sample was collected from a patient with COPD 10 minutes after initiation of mechanical ventilation. The results are: pH = 7.47, PaCO 2 = 40 mm Hg, HCO 3 - = 28 mEq/L. This ABG most likely represents : A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis E. None of the above

36. An arterial blood gas sample was collected from a patient with COPD 10 minutes after initiation of mechanical ventilation. The results are: pH = 7.47, PaCO 2 = 40 mm Hg, HCO 3 - = 28 mEq/L. This ABG most likely represents : acute respiratory alkalosis superimposed on chronic respiratory acidosis. pH PaCO 2 HCO 3 - Chronic respiratory acidosis ↓ NL ↑↑ ↑↑ Acute respiratory alkalosis ↑↑ ↓↓ ↓ NL Combined ↑ NL ↑

37. 1. Unfamiliar data 2. Carelessness 3. Incorrect interpretation 4. Incomplete information

38. The results of an arterial blood gas sample drawn from a mechanically ventilated patient are: pH = 7.47, PaCO 2 = 33 mm Hg, PaO 2 = 68 mm Hg, F I O 2 = 40%. No PEEP, SIMV f = 10/min, total f = 34/min, average spontaneous V T = 120 mL. The therapist should A. decrease the frequency B. increase the F I O 2 C. decrease the frequency and increase the F I O 2 D. increase the frequency and increase the F I O 2 E. increase the frequency or initiate pressure support

39. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

40. 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information - Lab errors 1 to 3% in 1976 (Am J Med Tech, 1976) - Lab errors 3 to 5% in 2006 (Post Gazette, 2006)

41. 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information - Sample mixed up - Analytical/technical errors - Inaccurate calibration and poor quality control - Incorrect auto-interpretation

42. 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information - Maximal Inspiratory Pressure (MIP) - Rapid Shallow Breathing Index (RSBI) - Sputum Gram Stain or Culture -

43. 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information pH = 7.47, PaCO 2 = 40 mm Hg, HCO 3 - = 28 mEq/L Normal: Metabolic alkalosis COPD: Acute respiratory alkalosis superimposed on chronic respiratory acidosis. pH PaCO 2 HCO 3 - Chronic respiratory acidosis ↓ NL ↑↑ ↑↑ Acute respiratory alkalosis ↑↑ ↓↓ ↓ NL Combined ↑ NL ↑

44. 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

45. Sample must be valid - repeat if necessary (change of F I O 2, air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (F I O 2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP)

46. Sample must be valid - repeat if necessary (change of F I O 2, air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (F I O 2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP)

47. Sample must be valid - repeat if necessary (change of F I O 2, air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (F I O 2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP)

48. Sample must be valid - repeat if necessary (change of F I O 2, air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (F I O 2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP)

49. Sample must be valid - repeat if necessary (change of F I O 2, air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (F I O 2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP)

50. Sample must be valid - repeat if necessary (change of F I O 2, air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (F I O 2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP)

51. Sample must be valid - repeat if necessary (change of F I O 2, air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (F I O 2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP) e.g., CPP = MAP - ICP

52. CPP = MAP – ICP Brain occupies ~2% of total body weight Brain uses 15% of energy generated by the body Brain does not hold or store any energy of its own Brain relies on a small amount of glycogen in the astrocytes Low CPP reduces availability of oxygen to the brain Low CPP may lead to hypoxic-ischemic encephalopathy (HIC) e.g., patients with hypotension, CHF, COPD Energy failure (duration sensitive) may result in cerebral cellular injury or death

53. CPP = MAP – ICP CPP: Critical threshold 70 to 80 mm Hg (mortality increases about 20% for each 10 mm Hg drop in CPP below 70 mm Hg) MAP: Keep CPP > 70 mm Hg (keep SBP > 90 mm Hg if MAP not available) ICP: Normal 8 to 12 mm Hg, Clinical critical value < 20 mm Hg

54. The pressure / volume loop is typically used to evaluate a patient’s _______ status. A. airflow resistance B. compliance C. oxygenation D. ventilatory

57. (1) Do not accept clinical data at face value (2) Make sure the data are technically valid and accurate (3) Interpretation must be based on complete data and supporting information (4) Clinical data must match patient’s presentation (5) Use clinical information frequently and wisely