Ventilator Basics in the Adult ICU Ellen Elpern, MSN, RN, APN Types of Ventilation Assist Control (AC):

: set tidal volume (volume control) or a set pressure and time (pressure control) is delivered at a minimum rate. Additional ventilator breaths given if triggered by pt. Ventilator performs work of breathing. Advantages: reduced work of breathing compared to spontaneous breathing. Disadvantages: potential adverse hemodynamic effects, too much or too little ventilation Synchronized Intermittent Mandatory Ventilation (SIMV): breaths given at a set rate and the pt can take spontaneous breaths above set rate as desired. Spontaneous breaths can be pressure supported. Work of breathing may be shared between pt and ventilator. Advantages: may result in less total positive intrathoracic pressure. Disadvantages: increased work of breathing compared with AC Pressure Support Ventilation (PSV): machine provides pre-set pressure boost to the inspiratory phase of spontaneous breaths. Pt controls the respiratory rate and exerts a major influence on the duration of inspiration, inspiratory flow rate, and tidal volume. Advantages: pt comfort and improved pt ventilator interaction. Disadvantages: pt tolerance, requires relaiable drive to breath, no guaranteed level of ventilation Initial settings Should be based on reason for ventilator commitment, resources, and expertise of staff with settings Initial FiO2 set high, then titrate down (FYI room air = FiO2 of 21%). Tidal volume usually starts at 8-10ml/kg (IBW, this is a good way for RD to be useful in rounds by providing this #), consider tidal volumes of 5-8ml/kg if ALI or ARDS (concern over too much stress on lung tissue) Use PEEP in diffuse lung injury and ARDS to achieve/maintain alveolar ventilation and oxygenation Management When facing poor oxygenation, inadequate ventilation, high peak pressures, and pt discomfort suggesting intolerance of ventilator settings consider sedation, analgesia, or neuromuscular blockage Make sure the vent is giving the pt enough time to exhale, pressure may build up in chest and pt may feel air hungry

Neonatal ICU Basics Debra Selip, MD Reviewed respiratory physiology and pathology in NICU

Promoting Growth in Infants Gretchen Witowich, MS, RD, CNSD Premie Growth Charts Fenton (2003): created with large sample size (700,000+) but was a worldwide sample. Used different babies for the 3 parameters. May not represent how US babies should track. Doesnt differentiate between sexes. Allows you to see length, wt, and head circumfrance on one page. This is what they use at RUSH but only because this is what their computerized charting system has. Olson (2010): smaller but still large sample size (200,000+) only using US babies from 33 states. Each baby was used for all 3 parameters. A different chart for both sexes (she gave the example that a female baby may seem to not be growing adequately on Fenton but would grow ok on Olson). The downside is that wt on a different chart than head circumfrance and length. This RD felt that this was the more accurate chart. Growth Velocity Goals: 15-20g/kg/day if < 2kg 25-35g/day if > 2kg Head circumference 0.5-1.0cm/week (per Olsen chart 0.5cm/week females and 0.8cm/week males is average) Length 0.8-1.1cm/week Growth Goals Translated to Nutrients
Body wt Fetal wt Gain Goal Required PN protein/day Required EN protein/day Required PN calories/day Required EN protein/day 500-700g 21g/kg/day 3.5g 4.0g 89kcal 105kcal 700-900g 20g/kg/day 3.5g 4.0g 92kcal 108kcal 900-1200g 19g/kg/day 3.5g 4.0g 101kcal 119kcal 1200-1500g 18g/kg/day 3.4g 3.9g 108kcal 127kcal 1500-1800g 16g/kg/day 3.2g 3.6g 109kcal 128kcal

Parenteral Nutrition Start early (as soon as access established) and start aggressively Intolerance = lack of growth Have a standard initial formula that can be run peripherally to start GIR 4-6 mg/kg/min, manage hyperglycemia by decreasing GIR, not insulin Protein 3 g/kg/day Lipids 1 g/kg/day if feasible (over 24hrs) Ca2+ and phos in appropriate ratio

Cysteine (when available) When transitioning to EN run standard bag of PN as well as IVF if baby is to be on still on IVF. Reduces pressure to add fortifier to EN. Closes protein gap.

Enteral Nutrition Start early, feed if hemodynamically stable Prime the gut with small volume trophic feeds initially while maximizing parenteral nutrition MALT tissue on oropharynx, can swab babys mouth with colostrum If mom not making enough milk can dilute colostrum 1:1 with sterile water Dose feeds at wt of halfway point of week goals Example: Monday wt 1170g. Growth goal 20g/kg/day = 1334g next week. Dose feedings at 1260g Human Milk Varies from 14-35kcal/oz Factors affecting calorie content: type of pump used, time between pumpings (lower kcal when more time between), pumping to empty, portion of expression (fore/hind milk) Can use Creamatocrit machine to measure calorie content of milk. Hind milk can be as high as 35kcal/oz Monitoring If alk phos is > 800 IU and phos < 4.5 mg/dL consider radiographic evidence, birth wt, meds. If plan is to fully fortify feeds for 1 week add 25mg/kg Ca2+ and 12mg/kg/day phos BUN may correspond to adequacy of protein intake when ENTERALLY fed, increased protein incrementally to trend up BUN and growth

Fluid and Electrolyte Management in the ICU Kelly Kinnare, MS, RD, CNSC Congrats ladies! We have covered this stuff over the last couple of years and are definitely up to par with what was taught. Here are a couple of charts and a case example for reference. Hyponatremia
Serum Osmolality High > 285 mOsm Etiology Hyperproteinemia Hyperlipedemia Hyperglycemia Pseudohyponatremia Diuresis Adrenal Insufficiency Psychogenic polydipsia SIADH Renal failure Heart Failure Cirrhosis Treatment Correct underlying condition

Normal 280-285 mOsm Low < 280 mOsm Hypovolemia Isovolemia Hypervolemia

Replace with normal saline Replace with normal saline Restrict free water and mild diuresis Restrict free water and diuresis

Hypernatremia
Volume Status Hypovolemia Etiology Diuresis Vomiting Diarrhea Diabetes Insipidus Extrarenal loss Excessive hypertonic replacement Excessive sodium bicarb administration Primary hyperaldosteronism Cushings syndrome Treatment Replace with normal saline

Isovolemia Hypervolemia

Replace free water or IV D5W Diuresis and replace free water

Hypokalemia
Cause Transcellular shift Etiology Beta-agnosit Bronchodilators Alkalosis Insulin and glucose Diuresis NG drainage Mg2+ depletion Diarrhea Treatment Correct underlying disorder

Depletion

With normal renal function replace with 10mEq for each 0.1 mEq deficit Treat diarrhea

Extrarenal losses

Hyperkalemia
Cause Pseudohyperkalemia Transcellular shift Impaired renal excretion Etiology Hemolysis of blood draw Acidosis Meds Renal insufficiency Adrenal insufficiency Meds Treatment Re-draw labs Correct underlying disorder or change meds Renal replacement therapy or change meds

Hypomagnesemia
Cause Diuretic therapy Antibiotic therapy Etiology Decreased Mg2+ reabsorption Aminoglycosides Amphotericin Pentamidine High concentration of Mg2+ in lower GI secretions Digitalis Adrenergic agents Cispatin Cyclosporine Treatment Change diuretic Change medication

Diarrhea Medication

Treat diarrhea Change medication

Hypermagnesemia
Cause Impaired excretion Release from cells Etiology Renal insufficiency Hemolysis Treatment Renal replacement therapy Treat underlying hemolysis

Hypophosphatemia
Cause Intracellular shift Etiology Glucose loading/refeeding syndrome Respiratory alkalosis Beta-receptor agonist Diabetic ketoacidosis Phosphorus binding agents Treatment Aggressively replace phosphorus

Decreased absorption

Stop medication

Their Guidelines for phos replacement: If GI tract functional or not severe depletion use oral/enteral: -Milk 1cup = 7.3mmol phos 9mEq K+ **If taking PO avoid a phone call to MD -NeutraPhos = 8mmol phos 1.1 mmom K+ -Phos-NaK = 8mmol phos 7.1mEq K+ If GI not functioning or depletetion severe use IV (their replacement seems more aggressive than ours) -Use KPhos if K+ less than 4.0 -Phos 2.5-3.0 give 40mmol Na/KPhos -Phos <2.5 give 60mmol Na/KPhos Hyperphosphatemia
Cause Impaired excretion Release from cells Etiology Renal insufficiency Necrosis Treatment Renal replacement therapy Treat underlying necrosis

Hypocalcemia
Cause Mg2+ decrease Alkalosis Drugs Etiology Inhibiting parathyroid secretion Promote binding of Ca2+ to albumin Aminoglycosides Cimetidine Heparin Theopylline Increase of phos and impaired conversion of vitamin D Treatment Replace Mg2+ Treat alkalosis Change medication

Renal Failure

Lower serum phos

Hypercalcemia
Cause Hyperparathyroiism Malignancy Etiology Increased intestinal Ca2+ absorption Increased osteoclastic activity within the bone Treatment Saline infusion to promote excretion Furosemide, bisphosphonates, glucocorticoids, calcitonin, mithramycin Renal replacement therapy

Parenteral Nutrition Sodium starting dose 1-2mEq/kg or similar to standard IVF (77mEq/L = NS) At RUSH everyone gets 10mEq Ca2+ to start unless levels way off They try to keep K+ around 4.0. So add an additional 10mEq for every 0.1mEq below 4.0. Halve replacement in renal pts. 1gm Mg2+ = 8mEq

Case Example for Electrolytes, Initial PN Solution Serum Level PN Solution 1mEq/kg or 0.45NS concentration Sodium 140 1mEq/kg + 20-40mEq to replace deficiency Potassium 3.6 2/3 chloride: 1/3 acetate with normal labs Chloride 101 2/3 chloride: 1/3 acetate with normal labs CO2 29 10mEq Calcium 8.1 20mmol Phosphorus 4.5 16mEq Magnesium 2.2 Enteral Nutrition Hypernatremia -add free water flushes Hyponatremia -Fluid restricted formula Hyperkalemia -Change to renal formula Hypokalemia -Replace via enteral route Hypophophatemia -Replace Hyperphosphatemia -Start phos binder (recommended before changing to renal formula) Trophic feeds, think of them as MEDICINE for the gut and not nutrition. This is a good way to present idea to physicians.