2000 OPEN FORUM Abstracts
TIDAL VOLUME BASED THERAPIST DRIVEN PROTOCOL IN THE NEONATAL INTENSIVE CARE UNIT: A 2 YEAR REVIEW
C. Garth Rubins, R.R.T., Sue Ciarlariello, R.R.T., Geoff Peistrup, R.R.T., The Children's Medical Center, Dayton, Ohio
Background: Literature supports overventilation contributes to neonatal lung damage and ultimately chronic lung disease. We felt that a therapist driven ventilator management protocol based on tidal volume monitoring could provide consistent tidal volume delivery and insure timely weaning of ventilator settings. The protocol also allows an easily understood approach to neonatal ventilator management for resident and nursing education.
Method: A protocol was developed emphasizing a tidal volume based approach to ventilator management. Tidal volumes were monitored frequently and inspiratory pressures adjusted to maintained an exhaled volume of 5-6cc/kg and a arterial blood pH>7.25 and a pC02<70. Volumes were calculated using measurements from the Drager Babylog ventilator or the Bicore CP-100 neonatal monitor. Only exhaled volumes from ventilator assisted breaths were used. If the calculated volumes fall out of the desired range the therapist will make peak inspiratory pressure adjustments in increments of 1-2 cmH20. If volumes are appropriate, ventilator rate is adjusted. Inspiratory time is evaluated using flow graphics to maximize volume delivered without providing an inspiratory hold. Fi02 is adjusted to maintain an oxygen saturation of 88-95% based on the gestational age of the patient. A simple flow chart was created and posted in the unit to explain the proper sequence.
Results: Patients on the protocol are reviewed monthly and reported to the NICU quality assurance committee. Documentation, ventilator parameters, ventilator changes, blood gases and complications are reviewed as well as patients requiring re-intubation. Results are as follows
|Number of patients||Ave. Gest. age||Ave. Wt.||# Days on protocol||Patients req. Re-intubation||Complications|
|1998 medical||70||33.5||2.64||1.75 days||11||2*|
|1998 surgical||38||2.15 days||3||0|
|1999 medical||97||31.2||1.71||3.57 days||13||0|
|1999 surgical||28||1.5 days||1||0|
|* 1-Pulmonary interstitial emphysema, 1-Pulmonary hemorrhage|
Experience: All patients requiring re-intubation are reviewed by the neonatologist in the quality assurance committee. No patients have been found to have required re-intubation due to inappropriate weaning. No complications have been attributed to overventilation. Ventilator changes and blood gas results are reviewed with the resident staff daily in rounds to provide learning opportunities. The respiratory therapist also attends patient rounds and discusses management plans for the next 24 hours. The protocol and daily management rounds have provided a systematic approach to ventilator management.
Conclusions: We feel ventilator management has been improved at The Children's Medical Center in our NICU due to implementation of the therapist driven ventilator protocol. The protocol provides safe, prompt weaning 24 hours a day. Weaning of respiratory settings is not delayed during night hours waiting for physician orders. We feel ventilator management protocols work well in the neonatal intensive care environment while still providing opportunities for medical education.