weaning from postoperative mechanical ventilation

23
Clinical Decision Support System (CDSS) Sample Scenario © 2011 J. Zaleski

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Weaning from postoperative mechanical ventilation is a common activity in surgical intensive care units. This presentation provides an example of key activities and measures used during the process for clinical decision making.

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Page 1: Weaning from postoperative mechanical ventilation

Clinical Decision Support System (CDSS) Sample Scenario

© 2011 J. Zaleski

Page 2: Weaning from postoperative mechanical ventilation

State of Acute Care• American College of Physicians estimates 500,000 deaths

annually in ICUs (U.S.)• Key Drivers

Patient safety Longitudinal EMR deployment Increase efficiency Staffing shortages Increasing numbers of CC beds

• Larger amounts of hemodynamic, respiratory, I&O information will be automated Motivates enterprise integration Reduces charting workload Improves completeness, accuracy

Page 3: Weaning from postoperative mechanical ventilation

Types of Data Most Used in ICU Clinical Decision Making

Data Type Value

Monitors and monitoring 13%

Observations 21%

Laboratory 33%

Drugs, I&O, IV 22%

Blood gas 9%

Other 2%

Source: E.H. Shortliffe and J.J. Cimino, Biomedical Informatics Computer Applications in Health Care and Biomedicine, page 605.

Page 4: Weaning from postoperative mechanical ventilation

CDSS Sample Case:When to discontinue post-operative mechanical ventilation

• Discontinuation from mechanical ventilation a key activity in surgical intensive care unit (SICU), yet, no guarantees as to outcomes:– When to begin spontaneous breathing trials?– When is patient viable to be extubated?

• Discontinue as quickly as possible– Longer time on ventilator higher likelihood of adverse events

• Ventilator acquired pneumonia• Respiratory distress

– Can exacerbate co-morbidities– Cost

• Candidate patients: Coronary artery bypass grafting (CABG)– Fairly common procedure– Technologically-dependent patients

Page 5: Weaning from postoperative mechanical ventilation

Devices Supporting Acute Care Environment

MechanicalVentilation

InfusionBed

Monitors

Intra-Aortic

BalloonPumps

Anesthesia

Highly Technologically-Dependent Patients

Page 6: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

PatientArrives in

ORInduction

Source: J. Zaleski

On Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Page 7: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Time In: 7:15 Induction: Isoflurane Pt Ht: 157 cm

CABG x 3 40 CCs fentanyl (15 mg/kg) BSA: 1.7 m^215 mg

Pancuronium

Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl mgpancuronium

mglopressor Notes

7:15 76 121/64 98 7 0.5

7:30 83 117/66 99 4.37:40 57 93/52 1007:45 66 100/55 100 300 78:00 61 95/57 100 Swan in place

8:05 62 101/60 100 34.38:10 64 97/58 100 34.4 34.98:25 86 132/78 100 34.3 34.7 298:30 116 116/76 99 34.3 35.2 278:35 98 116/75 99 34.2 35 298:40 92 112/74 100 34.1 34.9 298:45 100 113/70 99 34.1 34.8 298:50 96 112/71 99 34 34.7 299:00 91 97/62 99 34 34.7 319:05 97 109/70 100 33.9 34.5 309:20 93 114/68 100 33.8 34.4 319:30 103 95/61 100 33.7 34.2 32

ContinuousMonitoring

Meds & Drips

Source: J. Zaleski

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Page 8: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl mgpancuronium

mglopressor Notes

9:35 94 93/60 100 33.6 34.2 30Canula placed-

rt. atria; bypassing heart

9:40 94 103/65 100 33.6 34.1 369:45 94 112/67 100 33.6 34.1 36 3 mg (up)9:50 94 113/68 100 33.6 34 339:55 95 103/69 100 33.6 33.9 29

10:00 99 101/68 100 33.6 33.9 28 12 0.48Fibrillation.

Cross-Clamp

10:07 20.8K injection

commenced

10:08 1610:09 12

10:11 10K injection complete

10:15 33 32.510:20 32.8 32.7

10:30 32.9 33Myocard temp:

14

10:35 33.1 3310:45 33 33

10:50 33.3 33.4 Begin re-warm

Core

tem

pera

ture

redu

ction

Heart stoppage

Source: J. Zaleski

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Page 9: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl mgpancuronium

mglopressor Notes

10:55 33.8 33.7 5 mg (up)

11:00 34.9 34.9250 mics

(up)2 mg (up)

11:05 35.4 35.311:10 35.9 35.411:15 36 35.5 Restart / Defib

11:16 36.2 35.911:17 90 79/65 36.3 3611:20 77 107/58 100 4.18 36.2 36 24 Off Bypass

11:25 79 103/56 100 35.9 35.9 2511:30 88 103/52 100 35.5 35.911:35 89 106/55 100 35.4 35.7 2611:40 96 108/61 100 35.2 35.6 2411:45 93 115/64 100 35.1 35.5 2511:50 93 96/53 100 34.9 35.3 2311:55 96 112/65 100 34.8 35.1 2512:00 108 104/62 100 34.7 35 2412:05 105 107/66 100 34.7 34.8 2412:10 88 103/63 100 34.6 34.4 23 2.5 mg12:15 87 99/60 100 34.6 34.912:20 88 121/73 100 34.8 24 Move to SICU

Heart restart

Source: J. Zaleski

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Page 10: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core CVP PAP

12:40 100 99/62 99 5.4 34.8 6 23/10

13:15 99 99/59 100 4.48 35.3 7 24/1413:45 104 115/63 100 5.18 35.7 10 26/1514:15 101 102/54 98 5.18 36.3 9 25/1214:40 98 108/53 100 5.2 36.6 18 31/1414:50 105 128/62 99 5.2 36.6 20 39/1614:55 104 128/62 100 5.2 36.7 19 35/1815:00 101 128/63 100 5.2 36.7 16 35/1715:25 102 110/58 100 5.2 36.7 18 28/1315:50 103 107/57 100 5.2 37 32 28/1516:45 100 107/59 100 5.2 37.1 13 30/1517:00 104 98/56 98 5.2 37.2 13 40/2117:20 103 97/56 97 5.2 37.3 13 32/1817:40 100 98/57 98 5.2 37.3 12 29/1617:45 102 94/54 98 5.2 37.3 12 31/1819:05 104 97/58 97 5.2 37.3 13 30/1820:15 106 99/59 97 5.2 37.5 11 31/1621:15 101 101/60 98 4.8 37.6 15 33/1922:35 Extubated: Vc 1.2 liters

NIF -25 cmH2O

Source: J. Zaleski

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Page 11: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

• Initial blood gas obtained upon patient arrival• Time: 12:45• pH = 7.44• PCO2 = 31 mmHg• PO2 = 100 mmHg

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 12: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

• Patient initially supported by mechanical ventilator on synchronous intermittent mandatory ventilation (SIMV) mode of 12 breaths per minute, tidal volume of 0.85 liters, PEEP of 5 cmH2O

• Patient spontaneous breathing is absent upon arrival due to the anesthesia and paralytic drugs administered during surgery

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 13: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

• Second blood gas obtained• Time: 14:00• pH = 7.41• PCO2 = 29 mmHg• PO2 = 202 mmHg

• Decision made to reduce ventilatory support

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 14: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

• Support reduced to 8 br/min

• Some spontaneous breathing. Clinicians choose to evaluate and await re-warming and third blood gas before attempting spontaneous breathing trial

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 15: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

• Third blood gas obtained• Time: 16:35• pH = 7.40• PCO2 = 37 mmHg• PO2 = 183 mmHg

• Re-warming complete• Decision made to reduce to CPAP in

preparation for spontaneous breathing trials

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 16: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

• Respirations, Rapid-Shallow Breathing Index normal

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 17: Weaning from postoperative mechanical ventilation

Key Parameters Used to Determine Viability for Extubation

Parameter Threshold Value/Range Our PatientVital Capacity, Vc > 10mL/kg

Positive End-Expiratory Pressure, PEEP

5 cm H2O

Negative Inspiratory Force, NIF -20 cm H2O

Inspired Oxygen Fraction, FiO2 < 0.6

Spontaneous Tidal Volume, Vt > 5 mL/kg

Spontaneous Respirations 8 < Rresp < 30

Blood Alkalinity/Acidity 7.32 < pH < 7.48

Partial Pressure of Oxygen, PO2 > 80 mmHg

Partial Pressure of Carbon Dioxide, PCO2

30 mmHg < PCO2 < 50 mmHg

Normal Body Temperature, Tcore ~37 C

Ventilation Mode CPAP

Value Thresholds,Vpthi

Parameters,Pi

Patient Values,Vpti

Page 18: Weaning from postoperative mechanical ventilation

Key Parameters Used to Determine Viability for Extubation

Parameter Threshold Value/Range Our PatientVital Capacity, Vc > 10mL/kg

Positive End-Expiratory Pressure, PEEP

5 cm H2O

Negative Inspiratory Force, NIF -20 cm H2O

Inspired Oxygen Fraction, FiO2 < 0.6

Spontaneous Tidal Volume, Vt > 5 mL/kg

Spontaneous Respirations 8 < Rresp < 30

Blood Alkalinity/Acidity 7.32 < pH < 7.48

Partial Pressure of Oxygen, PO2 > 80 mmHg

Partial Pressure of Carbon Dioxide, PCO2

30 mmHg < PCO2 < 50 mmHg

Normal Body Temperature, Tcore ~37 C

Ventilation Mode CPAP

Clinical Decision Support Systems

Key Parameters Used to Determine Extubation Viability

Page 19: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

• Respirations, Rapid Shallow Breathing Index normal

• Vital capacity & NIF test performed and in normal range

• Vc = 1.2 liters• NIF = -24 cmH2O

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 20: Weaning from postoperative mechanical ventilation

Case Study: CABG Patient

Source: J. Zaleski

12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060

5

10

15

20

25

30

35

40

45

RRm (/min)

RRsp (/min)

Updated real-time knowledge of patient data could have led to earlier extubation

PatientArrives in

ORInduction On

Bypass

Restart Heart /

Off Bypass

Transfer to SICU

Monitoring & Management

Determine Viability

for Weaning

Extubate

Resp

irato

ry R

ate

(br/

min

)

Page 21: Weaning from postoperative mechanical ventilation

Key Parameters Used to Determine Viability for Extubation

Parameter Threshold Value/Range Our PatientVital Capacity, Vc > 10mL/kg 1.2L (70 kg)

Positive End-Expiratory Pressure, PEEP

5 cm H2O 5 cm H2O

Negative Inspiratory Force, NIF -20 cm H2O -24 cm H2O

Inspired Oxygen Fraction, FiO2 < 0.6 0.35

Spontaneous Tidal Volume, Vt > 5 mL/kg 0.55L (70 kg)

Spontaneous Respirations 8 < Rresp < 30 ~20

Blood Alkalinity/Acidity 7.32 < pH < 7.48 7.4

Partial Pressure of Oxygen, PO2 > 80 mmHg 183 mmHg

Partial Pressure of Carbon Dioxide, PCO2

30 mmHg < PCO2 < 50 mmHg 37 mmHg

Normal Body Temperature, Tcore ~37 C ~37 C

Ventilation Mode CPAP CPAP

Data suggest attempts at spontaneous breathing trials could begin much sooner than actually occurred

Page 22: Weaning from postoperative mechanical ventilation

Workflow Considerations• Data show patient meets extubation criteria many hours before

actual extubation– Indicates clear benefit of utilizing these data for patient care– Simple reminders to staff can achieve great benefits for patient

• Notification of readiness to wean important for clinical workflow, patient care management– Is patient viable or is it too early?– Any co-morbidities that can influence the outcome?– All necessary staff so informed and aligned on plans?

• Notification as to life-threatening events requires up-to-date and accurate information– Hemodynamic instabilities/Shock– Respiratory distress

Page 23: Weaning from postoperative mechanical ventilation

THANK YOU!