Ventilator Management Orders

Ventilator Management Orders

For Consented Organ Donors

______BiLevel Set Up

·  Initial FiO2 40%

·  Rate 8 - 20

·  PEEP Low 10 – 18 cm H2 : Adjust to maintain PaO2 > 100 mm Hg on FiO2 40%

·  PEEP High to obtain Vt 6 - 10 ml/kg ideal body weight

·  Adjust TH (time at PEEP high) to maintain an initial I:E 1:1

·  Monitor closely, maintaining PIPs < 38 cm H2O

·  Keep I:E ratio as close to 1:1 as possible while avoiding Auto peep

BiLevel Ventilation Changes – as indicated per ABG’s

·  To increase ventilation (ie decrease PaCO2) while maintaining MAP

·  Increase rate: Adjust TH (time at PEEP High) to maintain 1: 1 ratio

·  OR Increase PEEP High keeping Vt 6-10 ml/kg ideal body weight

·  To decrease ventilation (ie increase PaCO2) while maintaining MAP

·  Decrease rate: Adjust TH (time at PEEP High) to maintain 1:1 ratio

·  OR Reduce PEEP High keeping Vt 6-10 ml/kg ideal body weight

·  To increase oxygenation (ie increase PaO2) Keeping FiO2 at 40%

·  Raise Peep Low and raise the PEEP High by the same amount keep PIP’s < 38

·  OR Increase the I:E ratio (lengthen the TH)

DO NOT inverse I:E ratio without speaking to LifeShare Coordinator

______Pressure Control Set Up (for Transport Ventilators or when BiLevel is not available)

·  Initial FiO2 40%

·  Rate 8 – 20

·  PEEP 10 – 18 cm H20: Adjust to maintain PaO2>100 mm Hg on FiO2 40%

·  Inspiratory Pressure set to obtain Vt 6 - 10 ml/kg ideal body weight

·  Adjust Inspiratory time to maintain an initial I:E 1:1

·  Monitor closely, maintaining PIPs < 38 cm H2O

·  Keep I:E ratio as close to 1:1 as possible while avoiding Auto peep

Pressure Control Ventilation Changes as indicated per ABG’s

·  To increase ventilation (ie decrease PaCo2) while maintaining MAP

·  Increase rate: Adjust I time to maintain 1:1 ratio

·  OR Increase Inspiratory pressure keeping Vt 6 - 10 ml/kg ideal body weight

·  To decrease ventilation (ie increase PaCO2) while maintaining MAP

·  Decrease rate: Adjust I time to maintain 1:1 ratio

·  OR Decrease Inspiratory pressure keeping Vt 6-10 ml/kg ideal body weight

·  To increase oxygenation (ie increase PaO2) keeping FiO2 at 40%

·  Increase PEEP keeping the PIP’s<38

DO NOT inverse I:E ratio without speaking to LifeShare Coordinator

______Respiratory Therapy Orders

·  Verbally report all ABG results, documenting MAP and Plateau Pressure, and ventilator changes to LifeShare Coordinator

·  Use a heated circuit and DO NOT disconnect patient from ventilator without LifeShare notification

·  Place an end tidal CO2 or transcutaneous CO2 monitor and correlate with ABG’s

·  Transport ventilator to be used for all trips

·  In the event a transport ventilator is not available, manual ventilation with a PEEP valve is REQUIRED

·  Verify respiratory therapy orders on Adult Order Set and confirm chest PT

Oxygen Challenge (complete as ordered)

·  Obtain a baseline ABG prior to making ventilator changes for O2 challenge, documenting MAP and Plateau Pressure

·  Maintain BiLevel or PCV mode during challenge

·  Increase FiO2 to 100%

·  Decrease PEEP Low to 5 cm H2O

§  BiLevel - decrease PEEP High to maintain Vt prior to O2 Challenge

§  Pressure Control - adjust inspiratory pressure to maintain Vt prior to O2 Challenge

·  Maintain setting for 15 minutes

·  Draw ABG, documenting MAP and Plateau Pressure, then immediately return to previous settings

·  Verbally report to LifeShare Coordinator ABG’s and then make changes as indicated by previous ABG

Signature:______per LifeShare Standing Orders/Protocol

LifeShare Organ Recovery Coordinator

Date:______Time:______

Lung Management Guidelines for LifeShare Coordinators – pg 1

Not part of order set

·  Upon consent and prior to ANY vent changes, consider a baseline ABG and O2 challenge

·  Initiate Ventilator Management Orders for ALL consented brain dead organ donors

·  In DCD, the attending physician has to sign the order for vent changes, but we do recommend it

·  Verify orders placed for:

1.  Stat chest x-ray now and q 6 hours

·  Lung measurements of initial CXR and hard copy of terminal chest x-ray

2.  ABG’s/O2Challenge

·  prn with initial changes and then q 2 hours

·  As directed by LifeShare

·  ALL ABG’s verbally reported to LifeShare Coordinator

3.  Bronchoscopy for both anatomical and therapeutic evaluation

·  Minimal lavage

·  Separate culture and smears from each lung, if possible

·  Repeat O2 Challenge 1 hour after bronchoscopy

4.  Echocardiogram

·  Consider reducing the low PEEP to 8 for ECHO and returning to previous settings when complete

·  Question if a poor echo is due to increased intrathoracic pressures if Peep >10

·  Verify medications ordered on Routine Deceased Donor Orders:

1.  Narcan 8 mg IVP – USE EARLY/USE ALWAYS

2.  SoluMedrol 2 gm and repeat 1 gm q 12 hours

3.  Zosyn 4.5 gms IV STAT and repeat q 6 hours

·  Consider use of these additional medications as indicated:

1.  Bronchodilators - Combivent MDI or Albuterol MDI 10-12 puffs every 2-4 hours

·  Avoid nebulizers, they place a break in the circuit

2.  Vasopressin infusion titrated to desired urine output

·  Wean Levophed off first, titrating Neosynephrine and Dopamine down as tolerated

·  Consider d/c if hemodynamically stable 1-2 hrs prior to OR to allow natural diuresis

3.  Dopamine – recommended/”acceptable” dose 3 mcg/kg/min

·  If pt requires pressor support, this is first line preference of transplant surgeons in general

4.  Mannitol 25-50 gm bolus, then consider infusion of 3-6 gm/hr

·  Mechanism allows for “third space” fluid to be diuresed and protection of lungs

·  Closely monitor/achieve/maintain hourly:

1.  CVP 4-8 mmHg

2.  I and O status

3.  Adjust fluids as necessary to maintain CVP and clear lung fields

·  Avoid albumin

·  Remain conscious of vasopressin dosing

·  Verify orders and review with RN and respiratory therapy for aggressive pulmonary toileting, which may include any or all of the following:

1.  Module bed with rotation and percussion

·  Percussion 15 min q 1 hours (minimum)

·  Manually Rotate pt > 45 degrees q 1 hour

·  Module bed rotation q 15 minutes

2.  Manual percussion/pulmonary therapy (consider if module not available)

·  Percussion q 2 hrs – consider LINK vest

·  Manually rotate hourly

3.  Suction with gentle quad cough

·  If you auscultate sounds after percussion, suction

·  If no sounds or secretions, suction q 4 hrs

4.  Auscultate q 2 hours

5.  HOB elevated @ 30° (except during manual CPT and suctioning ® trendelenburg)

·  Adjust vent setting per ABG’s, as indicated

·  Correlate ABG’s with end tidal CO2 device

·  Expect a 7 point variation, anything greater is indicative of how sick your patient may be

Lung Management Guidelines for LifeShare Coordinators – pg 2

Not part of order set

·  After evaluating social/medical history, ABG’s, chest x-rays and bronchoscopy, consider chest CT

·  ONLY after discussion with AOC and Intensivist consult

·  Verify pt has not already had one done upon admission

·  Allocation decision:

1.  If Pa02 >350 and CXR clear or improving

·  Begin placement

2.  If Pa02 <350 and/or CXR not clear, worsening:

·  Reconsider:

a.  Bronchodilators every 1 hour X 2

b.  Mannitol bolus/gtt

c.  Aggressive pulmonary toilet

d.  Ventilator manipulation and/or other recruitment maneuvers

e.  Repeat therapeutic bronchoscopy

·  Discuss with AOC and Intensivist stopping pursuit of lungs

·  If lung allocation stopped:

·  D/C serial CXR’s and ABG’s except as needed for overall management

IMPORTANT/FYI:

Sputum Gram Stain
Characteristics / Clinical Interpretation
Large number of squamous cells, few to moderate PMN’s (polymorphonuclear cells), mixed flora / Saliva, possibly mixed with purulent bronchial secretions
Large number of PMNs; gram positive diplococci / Pneumococcal infection
Large number of PMNs; gram negative organisms / Haemophilis infection
Large number of PMNs; gram positive cocci in clusters / Staphylococcal infection
Large number of PMNs; no organisms seen

·  Transport ventilators are necessary for all “trips” and settings should be discussed with intensivist, respiratory therapist, anesthesia and LifeShare Coordinator if BiLevel is not available

·  Avoid disconnecting patient from ventilator or any interruptions in the circuit

·  The Ventilator Management Orders is acceptable in pediatrics. You may need to reevaluate the Rate, PEEP and PIP. The acceptable parameters will be established on a case by case basis.

Reviewed Date 02/22/2010