WEANING LONGER TERM PATIENTS

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WEANING LONGER TERM PATIENTS

• Keep It Simple!
• By
• David Quayle Paul Hinchley
• Charge Nurses
• Cardiothoracic Critical Care Unit,
• John Radcliffe Hospital, Oxford

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The Big Issues!

• Weaning is a complex multifactorial issue
• Different experiences offer varied solutions
• Patient tolerance is variable
• Assessment of progress/tolerance is often
  subjective
• Practitioners have different skill levels
• Prolonged stay in critical care can be
  detrimental to patients
• Financial implications

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What Do We Do as Practitioners?

• Too much information
• Nurse Unfriendly!
• Break it down to basics
• Respiratory Mechanics
• Oxygen Uptake
• Tissue Perfusion

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Rapid Shallow Breathing Index

• RSBi Respiration Rate
• Tidal Volume (Litres)
• Index of gt105 indicating intolerance (Jurgen
  Tobin, 1997 and Krieger et al, 1997)
• Early indication of an increase in a patients
  respiratory Effort
• Prior to such changes impacting onto arterial
  blood gases

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Oxygen Uptake

• Shunt Chart
• Is there evidence of VQ disassociation?
• PaO2 / FiO2 Graph

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Tissue Perfusion

• Hmm Problem!
• Increasing Lactate indicates poor tissue
  perfusion
• Also possible in renal function
• ? Graph which relates the 2

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What Next?

• Colour Coding
• Red
• Amber
• Green
• Stop
• Caution
• Go!

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Case Study 1

• 76 YO Lady post CABG x3
• Reopened for Bleeding
• Remained ventilated due to CVS instability
• 10 days post op on ASB FiO2 .55, Peep 7
  Pressure Support 22 Plan for Tracheostomy

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Potted History

• Began to cautiously reduce PS
• Graph 1 showed green increased rate of
  reduction
• Sat out hair washed
• Graph 1 showed amber recent change in activity
  so wait see

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• Issue with sputum retention. Moved into red zone
  graph 1 2
• Rested as per flowchart then weaning recommenced
• PS FiO2 gently reduced

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• Graph 1 showed green so recommenced reducing PS
• Graph 2 showed green so reduced Peep to 5
  remained green

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• Remaining in the green zone so weaning rate
  increased
• Extubated within 48 hours without tracheostomy!

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Case Study 2

• 72 YO Gentleman post Tissue AVR
• Obese smoker developed respiratory failure
• Reintubated
• 8 days post op on ASB FiO2 .45, Peep 5
  Pressure Support 22

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Potted History

• Gradual reduction in pressure support Graph 1
  into the red zone
• Patient assessed by Anaesthetist NAD
• Graph 2 into red zone - ? Why shunting

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• FiO2 increased gradually to .7
• Rise in temperature noted cultures taken
• 1st line IVABs commenced
• Weaning held due to deterioration

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Case Study 3

• 67 YO Gentleman post CABG x2
• Poor LV required IABP post op
• Bleeding
• Chest infection
• 3 days post op on SIMV FiO2 .45, Peep 5
  Pressure Support 18

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Potted History

• Persistent BDef
• Graph showed amber zone
• Rising urea noted triggering Anaesthetic R/V
• Fluids Px

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• Graph moving into red zone
• Other renal indicators increasing
• Commenced haemofiltration

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• With CVVH in green zone for all indicators
• Weaning restarted and accelerated
• Extubated within 48 hours

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Future Plans

• Validation Study
• Action Research with implementation

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Any Questions?