CCM MECHANICAL VENTILATION PROTOCOL

       

                   

 

Absolute Contraindications to Prone Treatment:

! Massive hemoptysis requiring immediate surgical or interventional radiology procedure

! Tracheal surgery or sternotomy in the previous 15 days ! Unstable spine, pelvic, or femur fracture ! Lung transplant < 15 days prior

Relative Contraindications to Prone Treatment:

! Intracranial pressure (ICP) >25mmHg or cerebral perfusion pressure (CPP) <60mmHg

! Burn Location ! Serious facial trauma or facial surgery in the previous 15 days ! Anterior chest tubes with air leak – attempt to reposition the

chest tube laterally then prone ! Pregnancy > 24 weeks – consideration of emergent delivery

prior to prone positioning, emergent OB consultation ! Open abdomen or open abdomen with wound vac

Criteria to Stop Prone Treatment:

! PaO2:FiO2 ratio ≥ 150mmHg with PEEP ≤ 10 and FiO2 < 0.6 after 4 hours in the supine position

! Drop in PaO2:FiO2 ratio of > 20% relative to the supine position

! Complications occurring during a prone session and leading to its immediate interruption such as bradycardia (<30bpm for > 1min), cardiac arrest, hypotension (SBP < 60 for > 5 min), or elevated ICP > 25mmHg for > 5 minutes

*Goals: • PaO2 55-80 • SaO2 88-95% • pH 7.30-7.45 • Plat <30 • Poor grade SAH and TBI with GCS < 8: goal PaO2 > 70 and

SaO2 > 90%

**High PEEP + FiO2 • PEEP ≥ 10 • FiO2 ≥ 0.6 • Respiratory therapy is to notify the MD and obtain an ABG to

determine PaO2:FiO2 ratio

*** Paralyze Prone Algorithm • If pt’s PaO2:FiO2 ratio remains <150 mmHg on PEEP > 10 and

FiO2 > 0.6, allow a 12-24 hr stabilization period. MD then has option to:

1. Start paralysis and prone positioning OR

2. Start paralysis and wait for a subsequent 12 hours. If PaO2:FiO2 remains < 150 on > 10 PEEP and > 0.6 FiO2, then begin prone positioning. If PaO2:FiO2 is > 150 on PEEP < 10 and FiO2 < 0.6 continue paralysis for full 48 hour period and re-assess.

! For pts on neurosurgery service: neurosurgery attending must be contacted at the beginning of the 12-24hr stabilization period

CCM MECHANICAL VENTILATION PROTOCOL NOTES

Relative Contraindications to Paralysis: ! ICP >25mmHg or CPP <60mmHg

Criteria to Stop Paralysis:

! Clinical judgment at > 48hrs of Nimbex based on patient response to therapy

! Persistent Bradycardia

ECMO Criteria: ! Reached appropriate step on protocol ! Age < 60yrs old ! PaO2<55mmHg, pH<7.20, Sats<88% on

FiO2=100% ! Attempt at temperature control < 38.5C ! Transfusion to Hgb > 12 ! Recruitment maneuver ! Optimal PEEP trial

Rescue Therapies:

! Diuresis or Ultrafiltration ! Drain pleural effusions ! Transfusion to Hb > 12 ! Consider use of Inverse Ratio Ventilation such as

APRV or BiLevel ! Consider inhaled flolan ! Consider aborting pressure limited volume control

and use elevated pressures ! Reconsider any contraindications to prone or

paralysis treatment ! Evaluate goals of care with family and consider

change in code status to DNR if appropriate  

The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-1308 Guerin C, Reignier J, Richard J-C, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-2168 Papazian L, Forel J-M, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010;363:1107-1116 Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009;374:1351-1363

ARDSnet Protocol Titration & Goals (PEEP/FiO2 Algorithm)

PaO2 = 55 mmHg – 80 mmHg

SpO2 = 88% – 95% Tidal Volume = 6mL/kg PBW