Tag: ICU

The Only intro to gases you’ll need in four parts

Thanks to Dr Jasmine Poonian for this comprehensive introduction to gases.

Tip: follow along at home with the examples given in the talk and work through them yourself on paper and by the end you should be comfortable attacking any gas!

 

Part 1 – basics and the anion gap (23min)

 

Part 2 – anion gap and the delta ratio (15min)

 

Part 3 – respiratory calculations (42min)

 

Part 4 – metabolic alkalosis (29min)

ASV (Adaptive Support Ventilation) with the Hamilton Ventilator

Here is a video I produced for Adult Retrieval Victoria on Hamilton’s proprietary intelligent ventilation mode, ASV, using the Hamilton T1 Ventilator, but it’s applicable to our Hamilton C1.

Please do not distribute, as these videos are AV property.

 

ASV takes into account the patient’s respiratory mechanics, which are measured breath-by-breath by the proximal flow sensor. ASV ensures optimal ventilation for each patient during passive ventilation but also has automatic adjustment in spontaneously breathing and weaning patients.

In passive patients, ASV is a volume-targeted pressure controlled mode with automatic adjustment of inspiratory pressure, respiratory rate, and inspiratory/expiratory time ratio. Maximum tidal volume is controlled by setting a maximum inspiratory pressure. Expiratory time is determined according to the expiratory time constant in order to prevent dynamic hyperinflation.

 

Watch the following video, together with the Initial Setup (Page 2) & Troubleshooting Guides below:

Initial ventilator settings, Western, Draft, Feb 2020
 Ventilator problems algorithm, Hamilton, Version 5, May 2018

 

 

Hamilton Ventilator Education

Here are some videos I produced for Adult Retrieval Victoria, using the Hamilton T1 Ventilator, but all are applicable to our Hamilton C1.

Please do not distribute, as these videos are AV property.

 

To begin please watch the videos linked below produced by Hamilton to familiarize yourself with the Hamilton T1:

Device Overview

Setup and Preop Checks

User Interface

Basic ventilator settings

Alarm Management

 

Then watch the following videos, together with the Initial Setup & Troubleshooting Guides below:

Initial ventilator settings, Western, Draft, Feb 2020
 Ventilator problems algorithm, Hamilton, Version 5, May 2018

 

 

 

Initial Setup:

Troubleshooting:

Idiosyncracies of the Hamilton:

 

Organ donation – GIVE

Thanks to ICU consultant Forbes McGain for his annual presentation on organ donation.

 

Organ and Tissue Donation-ED Reg. Presentation-2015

 

Key points:

  1. remember the trigger – GIVE – GCS <5; Intubated, Ventilated, End of life care
  2. Acute intracerebral catastrophe (eg bleed) is the most likely ED scenario wherein donation may be considered
  3. patient’s wishes regarding donation can be unknown to their family and must be broached sensitively
  4. discussions regarding donation may be appropriately deferred to the ICU team or the on-call Donation co-ordinator (phone number found via ICU or switchboard) to maintain separation between ED care-givers and the Donation team
  5. Brain death testing is usually deferred to ICU
  6. Donation after circulatory death is an extremely unlikely ED outcome
  7. observe the fewer absolute contraindications to donation eg. active malignancy, HIV, age > 80

Central venous catheterisation (CVC)

Here are some resources that I’ve found useful.

  1. How to scrub. This is often done badly in ED – there’s no excuse for this. Please make sure that the insertion site, the patient and the bed are all covered by drapes.
  2. Blind insertion. This is not recommended. There is a ton of evidence supporting the use of ultrasound.
  3. Ultrasound-guided insertion:
  4. How to confirm line placement and avoid complications.
  5. Using an angiocath instead of the needle to avoid inadvertent displacement outside of the lumen of the vein.
  6. Where should the tip sit?
  7. Setting up the transducer.
  8. Which ports to use?:
    • distal port (usu ~ 16-gauge lumen): the largest lumen; used for CVP monitoring, emergency access, blood products
    • medial and distal port (smaller lumens, more chance of extravasation): used for everything else
    • don’t run anything else with inotropes/pressor
    • radiocontrast media (RCM) – CAN go through the CVC – any port ≥ 18-gauge – check CVC type and max flow rate; discuss with radiology

After all of this, you should be a line guru!

download

Thanks,

Stacy

Hyponatraemia

An in-depth look at the management of hyponatraemia, with special attention to a new concept called the “dDAVP clamp.”

Summary:

– only treat hyponatraemia if symptoms are severe – coma, seizures or severe delirium
– use 3% saline 100ml, up to three doses
– consider giving dDAVP to prevent a rapid climb in the serum sodium
– aim to correct the serum sodium by only 3-6mmol/L in the first 24 hours

For more information, have a look at Scott Weingart’s EMCrit Wee, and Josh Farkas’s blog post.

Thanks,
Stacy

Ventilation

An overview of the mechanics of ventilation, using the initial ventilator protocol with the Hamilton ventilator and using the troubleshooting algorithm when encountering difficulties.

Summary:

– Use low pressures, low volumes (lung protective ventilation strategy)

– Optimise expiratory time if obstructive

– Titrate FiO2, then titrate PEEP to FiO2

If problems:

– Look at Compliance & Resistance and follow the Deteriorating Ventilated Patient algorithm

– If in doubt, disconnect from the vent, allow to expire, then bag

Acid-base and Fluids

Acid-base and its practical application, according to the quantitative (Stewart) approach + the effects of fluids on acid-base.

Summary:

  • pH is determined by the need for electrical neutrality
  • Strong ions and weak acids determine acid-base, not H+ and HCO3-
  • The Stewart approach allows you to quantify the contribution of different abnormalities (e.g. lactate) on metabolic acidosis
  • Fluids have an effect on acid-base – saline is strongly acidotic and therefore may not be the most sensible choice!

If you want to learn more on the ‘ideal’ generic fluid, have a read of this post by Josh Farkas on the Emcrit website.