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Table 1 Processes of care: standards for patients with acuterespiratory failure on mechanical ventilator support

From: Mechanical ventilation in rural ICUs

I.

 

Initial laboratory assessment

 

a.

General screen: phosphate, albumin, calcium, LFTs

 

b.

Prothrombin time/partial thromboplastin time

 

c.

Magnesium

 

d.

CXR

 

e.

Electrocardiogram

 

f.

If phosphate or magnesium ≤ 1.0 mg correct level within 24 h

II.

 

Subsequent laboratory assessment

 

a.

Daily ABG's, CXR first seven days on ventilator

 

b.

Repeat initial panel at ventilation day 5–7

 

c.

Repeat magnesium

 

d.

If phosphate or magnesium ≤ 1.0 mg correct level within 24 h

III.

 

Nursing assessments and care

 

a.

Daily weights

 

b.

Intake and outputs every shift and 24 h

 

c.

Communication with physicians regarding patient condition

 

d.

Pulmonary care: every 2 h repositioning, semi-fowlers

IV.

 

Stress ulcer (initiate by day two in ICU)

 

a.

Use of antacids, H2 blockers, sucralfate or enteral feeding

 

b.

Monitor gastric pH if antacids of H2 blockers utilized

V.

 

Thrombus protection (initiate by day two in ICU)

 

a.

Anticoagulation if no contraindication exists

 

b.

Thigh-high Ted hose and compression stockings if

  

anticoagulation contraindication exists

VI.

 

Dietary management

 

a.

Document dietary assessment (protein/calorie requirements)

  

within 72 h

 

b.

Initiation of feeding with 72 h of ICU admission

 

c.

Verify NG tube position by auscultation, aspiration or CXR

 

d.

If enteral feedings held > 72 h was alternate supplement

  

initiated

VII.

 

Ventilator management

 

a.

Initial tidal volume 8–12 cm3/kg, rate 10–20, A/C mode, 100%

  

FiO2 (unless prior PO2≥ 60)

 

b.

ABG's 30 min after ventilator initiation

 

c.

Prompt (within 60 min) changes for respiratory alkalosis

  

(pH ≤ 7.52 with PCO2 ≤ 35) and/or respiratory acidosis

  

(pH ≤ 7.30 with PCO2 ≥ 55)

 

d.

PaO2 was maintained at ≥ 90% saturation during initial 30 min

  

of treatment

 

e.

Prompt (60 min) ventilator adjustments for sustained

  

desaturations < 90%

 

f.

ABG's 60 min after major ventilator changes; Mode, TV by 100,

  

RR by 4 breaths per min unless set ≤ 10, then by 2 breaths per min

 

g.

Documentation of ET tube size

 

h.

Documentation ET tube cuff pressure at least daily, ideally every

  

8 h

 

i.

Maintain ET tube cuff pressure < 30 mmhg

VIII.

 

Decision to wean

 

a.

Medical stability (no fever, hypotension, arrhythmias)

 

b.

Laboratory stability (Hgb ≥ 10, normal magnesium, phosphate

  

> 1.0, normal calcium (expect decrease by 0.8 mg/dl for each

  

1g/dl decrease in albumin), sodium 130–150, potassium 3–5.5

 

c.

Optimal sedation (absence of neuromuscular blocking agents)

 

d.

Weaning parameters

  

1. PaO2 > 55 mmHg on < 50% fio2

  

2. VE < 12l/min

  

3. Two of the following four: MVV > 2 VE, TV > 5ml/kg, FVC

  

> 10ml/kg, or NIF ≤ 20 cmH20

 

e.

Documentation of intervention of patient anxiety and/or fatigue

 

f.

Documentation of attempts to manage patient pain

 

g.

Successful planned extubation (patient did not require

  

reintubation within 24 h)

  1. Developed by the UIHC multidisciplinary team; data based on [10]. ICU, intensice care unit; A/C, assist control; LFT, liverfunction test; ABG, arterial blood gas; CXR, chest X-ray; NG, nasogastric; ET,endotracheal tube; RR, respiratory rate; MVV, maximum voluntary ventilation;VE, minute ventilation; TV, tidal volume; FVC, forced vital capacity; NIF,negative inspiratory force; Hgb, hemoglobin.