2001 OPEN FORUM Abstracts
SUCCESSFULUSE OF HIGH FREQUENCY VENTILATION PROTOCOL IN A PEDIATRIC INTENSIVE CARE UNIT:A CASE REPORT.
Brendak. Batts M.P.H.,RRT, Hughes Spalding Children?s Hospital, James McCrory, M.D.Pediatric Critical Care, MorehouseSchool of Medicine, Hughes Spalding Children?s Hospital, Jean Johnson, B.S.,RRT,Respiratory Clinical Specialist,SensorMedics
Introduction:The 3100A High Frequency Oscillator was introduced in 1991 for rescue and earlyintervention applications in neonatal patients. The benefits of both early interventionand rescue applications of high frequency ventilation have been supported inseveral multi-center randomized control trials and numerous peer reviewed articlesand abstracts. The 3100A has been shown to be effective in the treatment ofnewborns with respiratory distress syndrome, airleak and airleak syndromes,meconium aspiration, pnuemonia, persistent pulmonary hypertension of the newbornand congenital diaphragmatic hernia. Additional benefits include reduced incidencesof chronic lung disease, reduced exposure to high oxygen concentrations, anda reduction in days of mechanical ventilation. In 1995, the 3100A was approvedby the F.D.A. for use on children with severe respiratory failure who, werefailing conventional mechanical ventilation. Failing on conventional ventilationis defined as an oxygen index greater than 13 in two ABG?s during a six hourperiod. We report the use of HFOV protocols which included assessing the oxygenindex as an indicator to determine intervention time. Case Summary: The patientwas an 11 day old male born at 36weeks gestation. Mom required induced laborsecondary to preeclampsia NSVD. BW4lbs, 14oz. Hospital stay 4 days secondaryto hypothermia, hypoglycemia, hyperbilirubinemia. Mom reported patient had a24hour history of panting, and grunting while sleeping, with occasional episodesof slow breathing. While enroute to the emergency center, mom noted blood comingout of mouth, and then patient stopped breathing. She gave rescue breaths, andcalled 911. Patient responded, but required constant stimulation to breath.Patient arrived at the emergency center on 3lpm of oxygen in respiratory distresswith pulse ox saturations 91%, HR 137, RR49, temperature 35.5 rectal. Patientplaced on CPAP via ambu bag with 100%FiO2 sats increased to 94%. Patient stoppedbreathing code called, patient intubated ,and transfered to the Pediatric IntensiveCare Unit. Initially patient was set up on Servo 300 ventilator in SIMV/PC/PSMode, rate 40,. 20/10, 100FiO2, saturations 100% with Paw=11. Day two patienthad sudden deterioration to 80% saturations, required bagging with pressuresof 36/10 to increase sats to low 90's. A CXR revealed total white outof alllung fields. The team elected to place the patient on high frequency ventilation.The patient was placed on HFOV using the SensorMedics 3100A. Initial settingswere Paw=30, Delta P=45, Ti=33%, Fio2=100%, and bias flow=20lpm. Unable to obtainartline ,venous samples revealed hypoxemia with 20-30 Pao2's and saturations93-97%. 12hours later artline obtained, inital oxygen index=40 with a repeatsix hours later = 58. After 36 hours of HFOV at maximum settings, patient developedacute renal failure complicated with his ARDS, and gram negative sepsis. Patientwas successfully transported to an ECHMO center for a trial of ECHMO . CONCLUSION:The use of a high frequency ventilation protocol, helped us to identify earlythat this patient was not responding to the HFOV, and that the underlying etiologymay have been cardiac, and not respiratory. Upon arrival to the ECHMO centeran echo revealed a PDA, which was successfully surgically ligated.
PICU-HFOV VENTILATIONPROTOCOL INITIAL MANAGEMENT
|Intubated and conventionallyventilated patient with an OI of 13 or> for 2 ABGÕs 6hrs apart|
|Mean Airway Pressure(MAP) 4-8cms>than MAP of CMV|
Frequency according to bodysize
|2-12kiloÕs =10Hz,13-20kiloÕs=8Hz, 21-34kiloÕs=7Hz, 35kiloÕs or >=6Hz|
|Power Setting at4.0-Achieve a Chest Wiggle(CF), a visual chest vibration from shouldersto groin|
|Fi02 at 100%, InspiratoryTime%at 33%, Bias Flow at 20LPM or greater|
|Assessment: Pulseoximeter to be maintained between 90-93%|
|Trancutaneous CO2Monitor to stabilize between 50-60 Torr or appropriate Paco2|
|Check ABG/CBG at1Hr to correlate TC CO2, and observe pH. Ph < 7.25 Consult Physician|
|CXR to be obtainedat the 1st hour of stabalization- 9 rib level or better with decreasingopacification|
|Hemodynamics stablewith Mean Arterial Pressure greater than 60mmhg|