management during neonatal ventilation
TRANSCRIPT
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Mohamed KhashabaMohamed KhashabaProfessor of Pediatrics, Professor of Pediatrics,
NeonatologyNeonatologyHead of NICUHead of NICU
Mansoura Faculty of MedicineMansoura Faculty of Medicine
Care of Ventilated BabyCare of Ventilated Baby
Prof. M Khashaba,MDProf. M Khashaba,MD 11
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.
2.2. Raise HcT.Raise HcT.
3.3. Reposition the baby.Reposition the baby.
4.4. Change ETT to a larger size.Change ETT to a larger size.
5.5. Suctioning.Suctioning.
6.6. Infection control.Infection control.
7.7. Consider diuretics.Consider diuretics.
8.8. Drugs. Drugs.
9.9. Nutrition.Nutrition.
10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 22
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.
2.2. Raise HcT.Raise HcT.
3.3. Reposition the baby.Reposition the baby.
4.4. Change ETT to a larger size.Change ETT to a larger size.
5.5. Suctioning.Suctioning.
6.6. Infection control.Infection control.
7.7. Consider diuretics.Consider diuretics.
8.8. Drugs.Drugs.
9.9. Nutrition.Nutrition.
10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 33
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Clinical applicationsClinical applications
Accept modest hypercarpia (50 -55 Accept modest hypercarpia (50 -55
mmHg) if modest changes are mmHg) if modest changes are
unsuccessful.unsuccessful.
Avoid high PiP > 30 unless Avoid high PiP > 30 unless
manipulation of other variables fail.manipulation of other variables fail.
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby.Reposition the baby.4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Drugs.Drugs. 9.9. Nutrition.Nutrition.10.10. Consider EchocardiographyConsider Echocardiography..
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OO22 Transport to Transport to TissuesTissues
Depends uponDepends upon
1.1. OO22 carrying capacity of blood. carrying capacity of blood.
2.2. Rate of blood flow.Rate of blood flow.
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CaOCaO22 = = HB x 1.34 xSaO HB x 1.34 xSaO22 + 0.003x PaO + 0.003x PaO22..
Optimal HcT is 45 % or Hb 13 -16 Optimal HcT is 45 % or Hb 13 -16
gm/dl.gm/dl.
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Clinical applicationsClinical applications
Rise of Hb by packed cell Rise of Hb by packed cell
transfusion is more effective in transfusion is more effective in
improving tissue oxygen than raising improving tissue oxygen than raising
FiO2.FiO2.
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Oxygen is more readily released to the tissues with Oxygen is more readily released to the tissues with acidosis, increased body temperature, increased acidosis, increased body temperature, increased PaCOPaCO22, and increased 2,3-DPG levels, and increased 2,3-DPG levels..
Oxygen is less available to the tissues in alkalosis, Oxygen is less available to the tissues in alkalosis, hypothermia, decreased PaCOhypothermia, decreased PaCO22, and decreased , and decreased
2,3-DPG2,3-DPG. .
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby. Reposition the baby. 4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Drugs.Drugs. 9.9. Nutrition.Nutrition.10.10.Consider Echocardiography.Consider Echocardiography.
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PositioningPositioning
1.1. Prone position alters physiologyProne position alters physiology
improves compliance , oxygenation, improves compliance , oxygenation,
Wagaman et al 1979Wagaman et al 1979..
2.2. Avoid abdominal distensionAvoid abdominal distension
3.3. Reduces energy requirements.Reduces energy requirements.
4.4. Allow ventilation of dependant areas.Allow ventilation of dependant areas.Prof. M Khashaba,MDProf. M Khashaba,MD 1111
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby.Reposition the baby.4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Vasopressors.Vasopressors.9.9. Nutrition.Nutrition.10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 1212
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Air Way CareAir Way Care
Suctioning every 2-3 hours.Suctioning every 2-3 hours. Suctioning not frequently needed in the first Suctioning not frequently needed in the first
48 hrs.48 hrs. Copious secretions may necessitate more Copious secretions may necessitate more
frequent care.frequent care. Sudden deterioration may indicate need for Sudden deterioration may indicate need for
suctioning.suctioning. No suctioning after surfactant administration.No suctioning after surfactant administration.
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.
2.2. Raise HcT.Raise HcT.
3.3. Reposition the baby.Reposition the baby.
4.4. Change ETT to a larger size.Change ETT to a larger size.
5.5. Suctioning.Suctioning.
6.6. Infection control.Infection control.
7.7. Consider diuretics.Consider diuretics.
8.8. Drugs. Drugs.
9.9. Nutrition.Nutrition.
10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 1414
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Infection ControlInfection Control Sources of infectionSources of infection
1.1. Contaminated circuits.Contaminated circuits.
2.2. Humidification systems.Humidification systems.
3.3. Medical gas source.Medical gas source.
4.4. Others e.g suctioning, sampling Others e.g suctioning, sampling and infused fluidsand infused fluids
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Clinical interventions and Clinical interventions and applicationsapplications
1.1. Bacterial filters in both inspiratory and expiratory limbs.Bacterial filters in both inspiratory and expiratory limbs.
2.2. Use only sterile water for humidification.Use only sterile water for humidification.
3.3. Change circuits weekly.Change circuits weekly.
4.4. Periodic draining of condensed fluid in circuits.Periodic draining of condensed fluid in circuits.
5.5. Single use suction cath. and sterile technique.Single use suction cath. and sterile technique.
6.6. Orotracheal rather than Nasotracheal tubeOrotracheal rather than Nasotracheal tube
7.7. Sterile punctures.Sterile punctures.
8.8. Disinfect probes.Disinfect probes.
9.9. Barrier precautions.Barrier precautions. Prof. M Khashaba,MDProf. M Khashaba,MD 1616
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.
2.2. Raise HcT.Raise HcT.
3.3. Reposition the baby.Reposition the baby.
4.4. Change ETT to a larger size.Change ETT to a larger size.
5.5. Suctioning.Suctioning.
6.6. Infection control.Infection control.
7.7. Consider diuretics.Consider diuretics.
8.8. Drugs. Drugs.
9.9. Nutrition.Nutrition.
10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 1717
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.
2.2. Raise HcT.Raise HcT.
3.3. Reposition the baby.Reposition the baby.
4.4. Change ETT to a larger size.Change ETT to a larger size.
5.5. Suctioning.Suctioning.
6.6. Infection control.Infection control.
7.7. Consider diuretics.Consider diuretics.
8.8. Drugs. Drugs.
9.9. Nutrition.Nutrition.
10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 1818
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DrugsDrugs
Respiratory stimulants may prevent Respiratory stimulants may prevent post extubation apneas in preterm.post extubation apneas in preterm.
Dopamine for hypotensive baby, rate Dopamine for hypotensive baby, rate is individualized.is individualized.
Dobutamine is more effective in Dobutamine is more effective in increasing LV output.increasing LV output.
Combination appears promising Combination appears promising (dobut.+ low dose dobam.).(dobut.+ low dose dobam.).Prof. M Khashaba,MDProf. M Khashaba,MD 1919
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DopamineDopamine
Avoid use in hypovolemic babyAvoid use in hypovolemic baby..Dose tapered to response Dose tapered to response
(1-20ug/kg/min)(1-20ug/kg/min)..
Extravasation may cause tissue Extravasation may cause tissue necrosisnecrosis..
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StabilityStability
— — Protect from light; solutions that Protect from light; solutions that are darker than slightly yellow should are darker than slightly yellow should not be usednot be used ; ;
incompatible with alkaline solutions or incompatible with alkaline solutions or iron salts; compatible when iron salts; compatible when coadministered with dobutaminecoadministered with dobutamine
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DobutamineDobutamine
2-152-15 mcg/kg/minute, titrate to desiredmcg/kg/minute, titrate to desired ResponseResponse
Stimulates beta1-adrenergic receptors, Stimulates beta1-adrenergic receptors, causing increased contractility and causing increased contractility and heart rate, with little effect on beta2heart rate, with little effect on beta2 - -
Stable in various parenteral solutions Stable in various parenteral solutions for 24 hours; incompatible with for 24 hours; incompatible with
alkaline solutionsalkaline solutions , ,
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Pharmacological Agents Pharmacological Agents CorticosteroidstsCorticosteroidsts
Pharmacological Agents Pharmacological Agents CorticosteroidstsCorticosteroidsts
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Suggested Protocol for Suggested Protocol for Dexamethasone for WeaningDexamethasone for WeaningSuggested Protocol for Suggested Protocol for Dexamethasone for WeaningDexamethasone for Weaning
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Pharmacological AgentsPharmacological AgentsCorticosteroidsCorticosteroids
Pharmacological AgentsPharmacological AgentsCorticosteroidsCorticosteroids
Peri-extubation corticosteroid treatmentPeri-extubation corticosteroid treatment
received repeated or restrict its use to infants at received repeated or restrict its use to infants at increased risk for airway edema and obstruction, increased risk for airway edema and obstruction,
such as those who have prolonged intubationsuch as those who have prolonged intubation
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complex Fluid balancecomplex Fluid balance
11..immature kidneys have limited immature kidneys have limited concentrating abilitiesconcentrating abilities
22..insensible losses vary with insensible losses vary with gestational age, use of radiant heaters gestational age, use of radiant heaters and phototherapy, and the water and phototherapy, and the water content of inspired aircontent of inspired air . .
Fluids should be adjusted to maintain Fluids should be adjusted to maintain neutral or slightly negative water neutral or slightly negative water balancebalance..
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excessive fluid increases the risk of excessive fluid increases the risk of patent ductus arteriosus, necrotizing patent ductus arteriosus, necrotizing enterocolitis (NEC), pulmonary edema, enterocolitis (NEC), pulmonary edema, and death. Excessive fluid may also and death. Excessive fluid may also increase the risk of BPDincrease the risk of BPD..
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Pharmacological AgentsPharmacological Agents
DiureticsDiuretics
Pharmacological AgentsPharmacological Agents
DiureticsDiuretics
The use of diuretics for RDS has no effect on The use of diuretics for RDS has no effect on mortality, CLD, duration of mechanical mortality, CLD, duration of mechanical ventilation and oxygen supplementation, and ventilation and oxygen supplementation, and
length of hospitalizationlength of hospitalization
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DIURETICSDIURETICS
no evidence to support the routine no evidence to support the routine use of diuretics in preterm infants with use of diuretics in preterm infants with
RDSRDS
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby.Reposition the baby.4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Drugs.Drugs.9.9. Nutrition.Nutrition.10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 3030
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Nutritional ManagementNutritional Management
Nutritional compromise leads to muscle Nutritional compromise leads to muscle atrophy , pulmonary changes and atrophy , pulmonary changes and difficulty in weaning.difficulty in weaning.
Initiation of enteral feeds is based on the Initiation of enteral feeds is based on the degree of stress , perfusion and gut status.degree of stress , perfusion and gut status.
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Successful weaning occur more Successful weaning occur more
frequently in those on adequate frequently in those on adequate
nutrition compared to malnourished nutrition compared to malnourished
babies.babies.
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Contraindications to Contraindications to feedingfeeding
1.1. Unstable baby.Unstable baby.
2.2. 24 hours before extubation.24 hours before extubation.
3.3. Marked abdominal distensionMarked abdominal distension..
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Management Management considerationsconsiderations
1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.
2.2. Raise HcT.Raise HcT.
3.3. Reposition the baby.Reposition the baby.
4.4. Change ETT to a larger size.Change ETT to a larger size.
5.5. Suctioning.Suctioning.
6.6. Infection control.Infection control.
7.7. Consider diuretics.Consider diuretics.
8.8. Drugs. Drugs.
9.9. Nutrition.Nutrition.
10.10. Consider Echocardiography.Consider Echocardiography.Prof. M Khashaba,MDProf. M Khashaba,MD 3434
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Role of Role of EchocardiographyEchocardiography
Essential in hypoxemic respiratory failure.Essential in hypoxemic respiratory failure.
Follow up suspected PDA, PPH and LV Follow up suspected PDA, PPH and LV
dysfunction.dysfunction.
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