Beruflich Dokumente
Kultur Dokumente
1
15/03/2018
2
15/03/2018
3
15/03/2018
4
15/03/2018
5
15/03/2018
6
15/03/2018
7
15/03/2018
A -a
(alveolar) (arteriol) oxygen gradient
8
15/03/2018
PaO2/FiO2 ratio
A normal PaO2/FiO2 ratio is 300 to 500
mmHg
less than 300 mmHg indicating
abnormal gas exchange
less than 200 mmHg indicates severe
hypoxemia
Normal Values
• pH = 7.35 – 7.45
• pCO2 = 35 – 45 mmHg lungs
(Reference Value = 40)
9
15/03/2018
10
15/03/2018
Normal Values
(Harrisons)
CHECK THE
COMPENSATORY RESPONSE
11
15/03/2018
MIXED DISORDER
• difficult and it is important to look at all the parameters
• If compensation calculations are not compatible with one
primary disorderr
• if the respiratory and metabolic parameters are both changed
in the same direction (acidic, alkaline),
• if the pH is changed in the opposite direction from what is
expected for a primary disorder (eg, the lactate is high but the
pH is alkaline), or when pCO2 and HCO3- change in opposite
directions from what is predicted
ANION GAP
Na – (HCO3 + Cl) = 10-12 mmol/L
Atau 12-14 mEq/L
Na = 135 HCO3 = 15
Cl = 97 RBS = 100 mg%
AG = 135 – 112 = 23
12
15/03/2018
ANION GAP
Na – (HCO3 + Cl) = 10-12
Na = 135 HCO3 = 15
Cl = 97 RBS = 500 mg%
ANION GAP
13
15/03/2018
ANIONS CATIONS
Proteins 15 Calcium 5
ANIONS CATIONS
Organic acids 5 Magnesium 1.5 Cl- + HCO3- =
Na+ = 140
128
Phosphates 2 Potassium 4.5
Sulfates 1
Difference (cations -
Chloride 104 anions) = 140 - 128 = 12
TOTAL 151 TOTAL 151
14
15/03/2018
15
15/03/2018
• Metabolic Alkalosis PaCO2 will increase 0.75 mmHg per meq/L increase in
HCO3
• Respiratory Acidosis
Acute HCO3 will increase 1 meql/L per 10 mmHg increase in
PaCO2
Chronic HCO3 will increase 4 meq/L per 10 mmHg increase in
PaCO2
• Respiratory Alkalosis
Acute HCO3 will decrease 2 meq/L per 10 mmHg decrease in
PaCO2
Chronic HCO3 will decrease 4 meq/L per 10 mmHg decrease in
PaCO2
COMPENSATORY RESPONSE
METABOLIC ACIDOSIS
PaCO2 = (1.5 X HCO3) + 8
16
15/03/2018
COMPENSATORY RESPONSE
METABOLIC ALKALOSIS
PaCO2 will increase 0.75 mmHg per
meq/L increase in HCO3
COMPENSATORY RESPONSE
17
15/03/2018
COMPENSATORY RESPONSE
RESPIRATORY ALKALOSIS
Acute: HCO3 will decrease 2 meq/L per 10 mmHg
decrease in PaCO2
18
15/03/2018
19
15/03/2018
DETERMINE CLUES
FROM THE
CLINICAL SETTING
20
15/03/2018
U Uremia
D Diabetic Ketoacidosis
P Paraldehyde
I Isoniazid, Iron
L Lactic Acidosis
S Salicylates
A Acetazolamide
D Diarrhea
U Ureteropelvic shunt
P Post Hypocapnia
21
15/03/2018
METABOLIC ALKALOSIS
Vomiting Remote
diuretic use Post
hypercapnea
Chronic diarrhea
Cystic fibrosis
Acute alkali administration
METABOLIC ALKALOSIS
Bartter’s syndrome Severe
potassium depletion
Current diuretic use
Hypercalcemia
Hyperaldosteronism
Cushing’s syndrome
Gastric aspiration
22
15/03/2018
RESPIRATORY ACIDOSIS
CHRONIC: COPD, intracranial tumors
ACUTE: pneumonia, head trauma, general
anesthetics, sedatives
RESPIRATORY ALKALOSIS
Hyperventilation, Pregnancy, Liver failure,
Methylxanthines
CASE 1
56F with vomiting and diarrhea 3 days ago
despite intake of loperamide. Her last urine
output was 12 hours ago.
23
15/03/2018
CASE 1
serum Na = 130 pH = 7.30
K = 2.5 pCO2 = 30
Cl = 105 HCO3 = 15
BUN = 42 pO2 = 90
crea = 2.0
RBS = 100
CASE 1
serum Na = 130 pH = 7.30
K = 2.5 pCO2 = 30
Cl = 105 HCO3 = 15
BUN = 42 pO2 = 90
crea = 2.0
RBS = 100
24
15/03/2018
CASE 1
serum Na = 130 pH = 7.30
K = 2.5 pCO2 = 30
Cl = 105 HCO3 = 15
BUN = 42 pO2 = 90
crea = 2.0
RBS = 100
Compensated
pCO2 = 15 x 1.5 + 8 = 30.5 Metabolic
Acidosis
CASE 1
serum Na = 130 pH = 7.30
K = 2.5 pCO2 = 30
Cl = 105 HCO3 = 15
BUN = 42 pO2 = 90
crea = 2.0
RBS = 100
25
15/03/2018
CASE 2
19F, fashion model, is surprised to find her K=2.7
mmol/L because she was normokalemic 6
months ago. She admits to being on a diet of
fruit and vegetables but denies vomiting and
the use of diuretics or laxatives. She is
asymptomatic. BP = 90/55 with subtle signs of
volume contraction.
CASE 2
Plasma Urine
serum Na 138 63
K Cl 2.7 34
HCO3 96 0
pH 30 0
pCO2 7.45 5.6
45
26
15/03/2018
COMPENSATORY RESPONSE
METABOLIC ALKALOSIS
PaCO2 will increase 0.75 mmHg per
mmol/L increase in HCO3
VENTILATOR
27
15/03/2018
Pengertian
Pemberian oksigen kejalan nafas pasien melalui
mesin:
• Invasif(Ventilator)
• Non Invasif(NIV)
Invasive
28
15/03/2018
29
15/03/2018
30
15/03/2018
Evita
31
15/03/2018
32
15/03/2018
Savina
33
15/03/2018
Galileo
Raphael
34
15/03/2018
Servo
35
15/03/2018
36
15/03/2018
37
15/03/2018
Indikasi
Persiapan: obat, alat
Intubasi/NIV
Setting awal ventilasi mekanik
Evaluasi: fisiologis, klinis
Penyesuaian (adjustment)
38
15/03/2018
Indikasi Pemasangan
• Gangguan Ventilasi Paru :
– Disfungsi otot nafas :
kelelahan otot nafas, kelainan dinding torax, penyakit
neuromusculer (GBS, poliomyelitis, myastenia)
– Peningkatan tahanan jalan nafas (COPD, severe astma)
– Gangguan kendali nafas (intoxikasi obat / overdosis,
trauma capitis )
– ARDS/ALI
– Pneumonia/infeksi
77
Indikasi Pemasangan
• Gangguan Oksigenasi :
– Hypercapnic Respiratory Failure: PaCO2 > 50 mmHg
– Hypoxemic Respiratory Failure: PaO2 < 60 mmHg
– Hipoksik hipoksia : disebabkan oksigen yang masuk kurang
mis. menghirup CO2 pada kebakaran, pneumoni, contusio
paru
– Stagnan hipoksia : o.k gangguan pada jantung menyebabkan
edema paru : AMI,cardiomyopathy, hypertensi heart
disease.
– Anemia hipoksia : pada perdarahan hebat dimana belum
ada tindakan tranfusi.
– Histotoksik hipoksia: disebabkan pemakaian oksigen yang
tinggi pada psn sepsis.
78
39
15/03/2018
Indikasi Lain
• pemberian sedasi berat / obat pelumpuh otot
• menurunkan kebutuhan oksigen
• mencegah atelektasis
• menurunkan TIK
• anestesia
• Stabilisasi dinding dada
79
MenurunkanWOB
•Tidak meningkatkan beban otot-otot pernapasan
40
15/03/2018
41
15/03/2018
83
•A/C: Assist-Control
•IMV: Intermittent Mandatory Ventilation
•SIMV: Synchronized Intermittent
Mandatory Ventilation
•Bi-level/Biphasic: Non-inversed Pressure Ventilation
with Pressure Support (consists of 2 levels of
pressure)
42
15/03/2018
86
43
15/03/2018
44
15/03/2018
45
15/03/2018
MODES of VENTILATION
Control Mode
Delivers pre-set volumes at a pre-set rate and
a pre-set flow rate.
The patient CANNOT generate spontaneous
breaths, volumes, or flow rates in this mode.
46
15/03/2018
Control Mode
Assist/Control Mode
•Delivers pre-set volumes at a pre-set rate and a pre-
set flow rate.
•The patient CANNOT generate spontaneous
volumes, or flow rates in this mode.
•Each patient generated respiratory effort over and
above the set rate are delivered at the set volume
and flow rate.
47
15/03/2018
Assist-control
Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, &
Wood LDH(eds.): Principles of Critical Care
A/C cont.
Negative deflection,
triggering assisted
breath
48
15/03/2018
SYCHRONIZED INTERMITTENT
MANDATORY VENTILATION
(SIMV):
IMV
Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, &
Wood LDH(eds.): Principles of Critical Care
49
15/03/2018
SIMV
SIMV
Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, &
Wood LDH(eds.): Principles of Critical Care
50
15/03/2018
SIMV cont.
Machine Breaths
Spontaneous Breaths
51
15/03/2018
PRVC
52
15/03/2018
PEEP cont.
53
15/03/2018
HIGH FREQUENCY
VENTILATION
TROUBLESHOOTING
Anxious Patient and/or dis-synchrony on the ventilator:
Could be secondary to overall discomfort
Increase sedation
Can be due to a malfunction of the ventilator
Patient may need to be suctioned
Could be secondary to feelings of air hunger
Options include increasing tidal volume, increasing flow rate,
adjusting I:E ratio, increasing sedation
54
15/03/2018
55
15/03/2018
Effusion
56
15/03/2018
57
15/03/2018
Accidental Extubation
• Role of the Nurse:
58
15/03/2018
OTHER
59
15/03/2018
VAP DIAGNOSIS-CPIS
VAP BUNDLE
1. Elevation of HOB to between 30-
45° (RN / RT)
2. Daily sedative interruption and
daily assessment of readiness to
extubate (RN / RT /MD)
3. DVT prophylaxis (MD / RN /
Pharmacy)
4. Stress ulcer disease prophylaxis –
including initiation of safe enteral
nutrition within 24-48 hours of ICU
admission (MD / RN / Pharmacy)
5. Daily oral care and
decontamination with
Chlorhexidine (added in 2010) (RT /
RN / MD)
60
15/03/2018
Libatkan pasien
61
15/03/2018
HOB 30-45°
Adverse efffects
• HOB 30-45° unless Meta analysis: 45° :
venous stasis,
contraindicated hemodynamic
instability-
• Especially inconclusive
recommended for
Neuro population
• To prevent aspiration
during enteral feeding
62
15/03/2018
OVERSEDATION
predisposes pts to: OVERSEDATION predisposes
pts to:
• Thromboemboli
• Pressure ulcers • Difficulty in monitoring
• Gastric neuro status
regurgitation and • Increased use of diagnostic
aspiration procedures
• VAP
• Increased ventilator days
• Sepsis
• Prolonged ICU and Hospital
stay
Daily Wake-up
• Every pt must be awakened
daily unless contraindicated
• Daily weaning assessments
reduce the duration of MV
• If pt becomes symptomatic
– rebolus and restart
infusion at lower dose than
original dose
• Goal is to decrease
sedation
63
15/03/2018
Enteral Feedings
• Initiation of safe
enteral nutrition within
24-48 hours of ICU
admission
• Early initiation
decreases bacterial
colonization
• HOB 30-45°
• Routinely + PRN
verification tube
placement
64
15/03/2018
Additional Evidence-Based
Component of Care:
Deep venous
thrombosis (DVT)
prophylaxis (unless
contraindicated)
• TED stockings
• SCD machine
• Heparin S/C
65
15/03/2018
66
15/03/2018
67
15/03/2018
68
15/03/2018
69
15/03/2018
70
15/03/2018
71
15/03/2018
ET Tube Care
• Cuff pressure
(between 20-30cm
H2O)
• Oral intubation
preferred
• Pengaman ETT
72
15/03/2018
ET Tube Care
• Continuous or intermittent sub-glottic
aspiration
• Avoid unnecessary
disconnection of MV
circuit
73
15/03/2018
• Integrated suction
line
Subglottal Suctioning • Increased pressure
distribution and
effective sealing
Should be done using a
14 French sterile
suction catheter
• Prior to ETT
suctionning
• Prior to pt change of
position
Subglottic
secretions
• Prior to extubation
* Continuous subglottic
ETT with dedicated
lumen above cuff may
reduce risk of VAP
ET Tube Care
• Open vs close
suctioning… benefits
is not demonstrated
yet
74
15/03/2018
75
15/03/2018
76
15/03/2018
77
15/03/2018
78
15/03/2018
79
15/03/2018
Evaluasi-monitoring
• Look at the patient
• Listen to the patient
• SpO2–SaO2
• AnalisaGas Darah
• End Tidal CO2
• CXR
• Ventilator : PIP, VT, exp, Alarm.
80
15/03/2018
Waveforms Analysis
• Scalars are waveform representations of pressure,
flow or volume on the y axis vs time on the x axis
• Loops are representations of pressure vs
volume or flow vs volume
81
15/03/2018
Scalar Waveforms
Loop
82
15/03/2018
Common problems
that can be diagnosed
by analyzing
Ventilator waveforms
Lung Mechanics
• Use Scalar
• Pressure Time Waveform with a square wave
flow pattern
83
15/03/2018
Flow-time waveform
• Flow-time waveform has both an inspiratory and an expiratory
arm.
84
15/03/2018
PEARL: Think of
low lung compliance (e.g. ARDS),
excessive tidal volumes,
right mainstem intubation etc
time
Note: Patient effort must be absent
85
15/03/2018
Pressure-volume loop
Compliance (C)
is markedly reduced in the
injured lung on the right as
compared to the normal lung
Normal
on the left
lung
86
15/03/2018
Overdistension
Peak
inspiratory
pressure
Upper
inflection
point
Note: During normal ventilation the LIP cannot be assessed due to the effect of
the inspiratory flow which shifts the curve to the right
Recognizing Auto-PEEP
87
15/03/2018
88
15/03/2018
Detecting Auto-PEEP
Recognize
Auto-PEEP
when
89
15/03/2018
Lluis Blanch MD, PhD et al: Respiratory Care Jan 2005 Vol 50 No 1
90
15/03/2018
91
15/03/2018
Recognize
airway obstruction
when
PATIENT-VENTILATOR INTERACTIONS
Wasted efforts
Double triggering
Flow starvation
Active expiration
92
15/03/2018
93
15/03/2018
94
15/03/2018
95
15/03/2018
PEARL: This is a high drive state where increased sedation/paralysis and mode
change may be appropriate for lung protection.
Recognizing
Airway Secretions
&
Ventilator Auto-Cycling
96
15/03/2018
97
15/03/2018
Pulse Oximetry
• A non-invasive method of measuring arterial
oxygen saturation
• Monitor sharp fall in PaO2
– Accurate in mild to moderate hypoxia
– SaO2<75%not reliable
– Other conditions
• Vasoconstriction
• Poor peripheral perfusion
• Severe hypotension
• shock
98
15/03/2018
99
15/03/2018
Alarm
• Lakukan kaliberasi
• •Test lung
• •Setting alarm –periksa setiap 4 –6 jam
• •Periksa parameter, apakah frekwensi, volume
atau tekanan yang ditetapkan sudah sesuai.
• •Fungsi humidifier
• •Sirkuit / pipa pernapasan ( breathing circuit ):
kebocoran, timbunan air, letak.
alarm
•Butuh perhatian segera
•Lihat pasien: ABC: airway, tubing connect, dada
naik turun? Warna pasien? Saturasi?
•Pasien distress, masalah tidak ditemukan,
disconnect, ventilasi di berikan secara manual
•Jika pasien stabil, lihat ventilator
100
15/03/2018
Terimakasih
101