ventilator management in complex congenital heart disease - a case-based review

Ventilator Management In Complex Congenital Heart

Disease: A Case-Based Overview

Natasha Lavin, B.S., R.R.T.-N.P.S., C.P.F.T.Geoffrey L. Bird, M.D., M.S.I.S., F.A.A.P.

CHOP Respiratory Care ConferenceOctober 2013

Nothing to disclose

Not even tired jokes about disclosures

Under Pressure• You have a fresh post-op patient who just

got back after a Fontan procedure.

• All was going well for the OR team, until

efforts to open up and augment the distal

branch PAs were followed by blood in the

ET Tube. A decent amount of blood

actually.

• CT Anesthesia and the Surgeon head

back to the OR for the transplant who’s on

the table for organs on the way in by

helicopter.

Under Pressure• The Attending has gone to catch a few zzzz’s.

It is apparent she is not the lite sleeper you were hoping and is not answering her pages so it is up to you and the Fellow to manage the patient.

• Coags have been sent and FFP and platelets are on the way from blood bank.

• The patient is coughing and desating and trying to reach for his blood filled ET tube.

Anyone seen this scenario?

• Plan “A”: The Critical Care fellow, who just took care of six bad pulmonary hemorrhages in the PICU last month insists this patient is bleeding to death and CLEARLY needs more “P’s!” • In addition to Platelets, Plasma, Packed

cells, he asks for Paralysis, higher PIP, and more PEEP.

• Plan “B”: You suggest different “P’s:” Power wean and pull the tube

•

Oh Crap, which one is the FontanProcedure again?

SpontaneousOr NPV

Fontan Physiology

• With no right ventricle, pulmonary blood flow (PBF) is entirely a passive diastolic phenomenon.

• And, with or without a fenestration, PBF is the major determinant of cardiac output.

• With spontaneous or NPV, PBF is enhanced.

• With PPV, PBF can trend towards zero.

• 1mmHg = 1.4cmH2O

Anyone seen this scenario?

• Plan “A”: The senior PICU Fellow, who just took care of six bad pulmonary hemorrhages in the PICU last month insists this patient is bleeding to death and CLEARLY needs more “P’s!” • In addition to Platelets, Plasma, Packed

cells, he asks for Paralysis, higher PIP, and lots more PEEP.

• Plan “B”: You suggest different “P’s:” Power wean and pull the tube

Accentuate The Positive?• 4mo patient returns to CICU after Tetralogy of Fallot

repair.• Reconstruction was somewhat cumbersome with a

second bypass run to revise the VSD patch and resectmore obstructing muscle.

• Team Anesthesia recommends putting the warmer on since the patient seems to be a bit chilly from the walk down the hallway (hrmmm).

• As soon as they head back to the OR, your febrilepatient, who’s chilly around the edges, begins having periods of a common & potentially dangerous arrhythmia, JET.

• Palpitations are contagious and the new Attending passes out on the floor.

Accentuate The Positive?

• From the floor the Attending mumbles something about Tets needing knee-chest, 100% blow-by O2, morphine, and a fluid bolus, so try that…

• Security takes the Attending to the ER (out of your hair)

• The new NP wants to go up on the dopamine and keep the angry flailing Tet “light and dry,” (cut back on the sedation and the IV fluid volume) so “we don’t get into more trouble.”

• You offer a different plan.•

Accentuate The Positive?

• From the floor the Attending mumbles something about Tets needing knee-chest, 100% blow-by O2, morphine, and a fluid bolus, so try that…

• Security takes the Attending to the ER (out of your hair)

• The new NP wants to go up on the dopamine and keep the angry flailing Tet “light and dry,” (cut back on the sedation and the IV fluid volume) so “we don’t get into more trouble.”

• You offer a different plan.

Slow Down, You Move Too Fast

• Anesthesia brings a 6kg 6mo back from the OR after Bidirectional Glenn and requests the following vent settings: Rate 20, VT 70mL, PEEP 3, FIO2 100%.

• First ABG: pH 7.52, CO2 28, PaO2 42.• Hoping to avoid any “PVR issues” the visiting NICU

fellow doesn’t ask for any vent changes• Over the next hour or two, your patient becomes

cyanotic with sats that keep getting lower and lower.• NICU Fellow reaches for the bag and begins to

aggressively hand ventilate to attempt to improve oxygen saturation….


• You ever so gently takeover the bag from said NICU Fellow’s greedy little hands.

• After confirming that the recent postop chest film is okay, you back off on hand ventilation until your patient is breathing spontaneously with a little CPAP and oxygen.

• As the saturations rise, you fill the NICU Fellow in on why the easiest way to keep this patient’s sats up might be to pull the tube.

HeartLungs BodyHeart

Heart

Head

Lungs


• You ever so gently takeover the bag from said NICU Fellow’s greedy little hands.

• After confirming that the recent postop chest film is okay, you back off on hand ventilation until your patient is breathing spontaneously with a little CPAP and oxygen.

• As the saturations rise, you fill the NICU Fellow in on why the easiest way to keep this patient’s sats up might be to pull the tube.

Get By With A Little Help From My Friends

• An adolescent with cold symptoms for the past few days arrives in the ER after passing out at school.

• Patient is noted to be tachycardic and mildly tachypneic with a gallop, frequent PVC’s, soft pressures, and abdominal pain.

• The physician in the ER calls for a fluid bolusand a cardiology consult, but decides in the meantime he would like to intubate the patient.

Get By With A Little Help From My Friends

• The new RT grad who just got hired to the ED calls you with the story, and ends with “I don’t get it – just not sure what the docs are thinking.”

• “You mean the fluid bolus? Me neither!”• “No,” says the new hire, “the intubation for

mild tachypnea.”• Tipping off your ECMO friends on the way

down to the ED, you fill them in on why you agree with the need for a tube.

120/80

-5 vs+15

Positive Pressure Ventilation

• Can reduce oxygen consumption and doesreduce LV afterload

• Useful for poor ventricular function (acute myocarditis and cardiomyopathies)

• Also useful in other hemodynamic problems made worse by increased afterload

– Significant aortic valve insufficiency

– Significant AV valve insufficiency

Intubation

• Can be an exciting procedure

• Especially with shifts in loading conditions (preload and afterload) in a sick heart with limited data (on volume status) and limited access (periph IV vs central line)

• Not needed for CPAP or BiPAP – these can help too!!

• Consider preparing for ECMO while preparing for endotracheal intubation

Trade the Blower for a Vacuum

• Patient is a post op Fontan with marginal hemodynamics and a less than sunny disposition receiving mechanical ventilation.

• Unlike most Fontans, volume just doesn’t seem to be fixing the usual postop soft BPs

• As the patient gets more peripheral edema, the lab just sent back blood gas results with a mixed acidosis.


• With minor atelectasis on the film, the team reaches for more opiates, “in case pain is an issue,” and asks you to dial up the ventilatorsettings.

• Excited by memories of watching the recent “Natasha and Geoff” show, you suggest tape remover and plans to extubate.

• With the medical team eager to hear more, you expound upon your excellent suggestion.

Cardiopulmonary Interactions After Fontan

Operations: Augmentation of Cardiac Output Using

Negative Pressure Ventilation

by Lara S. Shekerdemian, Andrew Bush, Darryl F. Shore, Christopher Lincoln, and

Andrew N. Redington

Circulation

Volume 96(11):3934-3942

December 2, 1997

Copyright © American Heart Association

A, Qp was measured in a cardiorespiratory steady state during IPPV (IPPV1) and after 15

minutes of NPV (NPV1).

Shekerdemian L et al. Circulation 1997;96:3934-3942


Stroke volume index during standard studies.



Qp for all Fontan patients during standard studies increased by a mean of 42% after 15

minutes of NPV. The increase was independent of baseline values for Qp during IPPV1.



Subgroup 1: Qp for patients in whom a third measurement was made after reinstitution of

IPPV (IPPV2) at the end of a standard study.



Subgroup 2: Qp for patients in whom the period of NPV was extended after completion of a

standard study.




• With minor atelectasis on the film, the team reaches for more opiates, “in case pain is an issue,” and asks you to dial up the ventilatorsettings.

• Excited by memories of watching the recent “Natasha and Geoff” show, you suggest tape remover and plans to extubate.

• With the medical team eager to hear more, you expound upon your excellent suggestion.

Miscellanea

• Volume control rather than pressure control

• Risk of routine NIF (negative inspiratory force) assessment

• Uncuffed tubes with no leak

Take home points

• In acute postoperative CHD care, the best ventilator management can often be less ventilator management – or extubation.

• Take it from another “Dr. Bird:” PPV/ventilators aren’t all bad! Great tools for:– Paralyzed patients with open chests

– Helping a sick left ventricle

– Helping leaky mitral and aortic valves

– Significant atelectasis and paralyzed diaphragms

Take home points

• For the postop cardiac patient who’s acting up on a ventilator, always ask if the vent is making the patient feel better, or the doctor feel better

• Usually the right answer is tracheal extubation, but always good to anticipate the cardiac effects of extubation (and these will be magnified by stridor/edema).

ventilator management in complex congenital heart disease - a case-based review

Health & Medicine

mo patient

febrile patient

different plan

plan b

attending mumbles

new attending

different ps

pulmonary blood flow