Charlie Transfer Guide 2023 July : simplebooklet.com

CHARLIE – Approach to Interfacility Transfers                                                 •  •  •       •  •  •                         

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      Circulation

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                            Disability- Neuroprotection Exposure

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 •  •  •  •  •  • 

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ARDS The 8 Ps of ARDS PEEP/Lung Protective Ventilation (LPV) • High PEEP - ↓TV ventilator strategy avoids VILI by limiting volumes. & pressure. • Keeps alveoli open with PEEP. ↓Mortality Approach • Set RR to maintain MV: adjusting rate up to 35 to maintain goal pH>7.3. • Start-TV = 6ml/kg. Keep Plateau Pressure (Pplat) <30cmH2O. • ↓ TV to maintain Pplat<30cmH2O. • if pH is <7.2, might have to ↑ both TV and Pplat >30cmH2O. • Adjust PEEP and FIO2 to maintain SpO2 >94% or Pa O2 >55mmhg. •Use ↓↑PEEP to protocolize PEEP/FIO titration. Paralysis (e.g., Neuromuscular Blockade) • Improves ventilator compliance, ↓O2 consumption. • Sedate deeply (e.g., RASS-4) • Use infusion of Cisatracurium or Vecuronium to achieve and maintain NMB. • Wean dose as tolerated. Prone Positioning • ↓dependent Edema, ↑Lung volumes (from reduced atelectasis), improves secretion clearance. • Apply soft pads, secure all tubes/lines, place pillows on chest and wrap with sheet (e.g., burrito technique) • 6 or more people required to rotate the patient as a unit: (Supine once per day for 4-6hrs) Inhaled Prostacyclin • Dilates blood vessels in areas of the lung that are well ventilated. • Improves V/Q Mismatch • Start ↑dose- generally have >20% ↑ in PaO2 within 10min. Pleural Evacuation Thoracentesis) • Improves Oxygenation by ↓collapsed lung from effusion. • Look for large pleural effusions using POCUS, -drain if present. Peeing (e.g., Diuresis) • ↓Extravascular H20 in lungs • Conservative fluid • Use PO of electrolyte repletion, avoid blood product transfusion unless necessary, Concentrate V meds. Peripheral Oxygenation (ECMO) • Direct Oxygenate blood- eliminate CO2- provide mechanical circulatory support. • Consider only in selected patients with most benefit. Prednisone (e.g., Corticosteroids) • Mitigation of early exudative phase by anti-inflammatory & immunomodulatory effects from glucocorticoids • Start within 14 days. • Methylprednisone 1mg/kg for 21 days then taper or •Dexamethasone 20mg daily for 10 days then 10mg for 5 days •There is evidence for lower doses in Covid 19 (6mg IV or PO daily)

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RASS RICHMOND AGITATION–SEDATION SCALE Description Term Score Overtly combative or violent; immediate danger to staff Combative +4 Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff Very Agitated +3 Frequent non-purposeful movement or patient–ventilator desynchrony Agitated +2 Anxious or apprehensive but movements not aggressive or vigorous Restless +1 Alert and Calm Alert and Calm 0 Not fully alert but has sustained (more than 10 seconds) awakening, with eye. contact, to voice Drowsy -1 Briefly (less than 10 seconds) awakens with eye contact to voice. Light Sedation -2 Any movement (but no eye contact) to voice Moderate Sedation -3 No response to voice, but any movement to physical stimulation Deep Sedation -4 No response to voice or physical stimulation Unrousable -5 Procedure • Observe the patient. Is patient alert and calm (score 0)? • Does a patient have behavior that is consistent with restlessness or agitation score 1 to 4 using the criteria listed above, under DESCRIPTION)? • If the patient is not alert, in a loud speaking voice state patient’s name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker. • Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score 1). • Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score 2). • Patient has any movement in response to voice, excluding eye contact (score 3). • If a patient does not respond to voice, physically stimulate the patient by shaking shoulder and then rubbing sternum if there is no response to shaking shoulder. • Patient has any movement to physical stimulation (score 4). • Patient has no response to voice or physical stimulation (score 5). Click →

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Hypoxia and Hypoxemia Rate of O2 deliver (ml/min Hb concentration (g/L) DO2 = CO X (1.39 x [Hb] x SaO2 = (0.003 X PaO2)) Amount of dissolved O2 in blood (ml). For every 1mmHg of 02 tension, 0.03ml of O2 gas is dissolved in 100ml blood. Cardiac Output (L/min) Oxygen binding capacity of Hb: 1.39ml per gram Haemoglobin oxygen saturation expressed as a fraction (i.e., 97% is 0.97) Hypoxemic Hypoxia Insufficient O2 in the blood (most common type of hypoxia Low Pa02 Ischemic Hypoxia Insufficient blood flow to tissues (stagnant hypoxia) E.g., Low CO Low SvO2→Low PaO2 Anaemic Hypoxia Insufficient 02 carrying capacity (e.g., sever blood loss) or abnormal haemoglobin (e.g. COHb, MetHb) Low CaO2→Low SvO2→Low Pa02 Cytopathic Hypoxia Cells cannot use O2. (e.g., cyanide toxicity, Sepsis) High PaO2, High SvO2 Low Inspired O2 (PiO2) Fewer O2 molecules enter the lungs with respiration (low PAO2) Normal Aa difference PaO2 with supplemental O2 Causes: Low atmospheric pressure (high altitude), or low partial pressure of 02 (FiO2, confined space, low O2 gas mixture) Alveolar Hypoventilation Fewer O2 molecules reach the alveoli due to deceased ventilation (low PA02) Normal AA difference 2 with supplemental O2  PaCo2 Causes: ↓ Respiratory drive (opioids, CVA-Brainstem, OHVS), Neuromuscular weakness (GBS, ALS), chest wall problems (kyphoscoliosis, flail chest), or airflow obstruction (COPD, Asthma) V/Q Mismatch Imbalance between regional lung ventilation and perfusion (low V/Q) PaO2 with supplemental O2 Increased Aa difference Causes: Obstructive lung disease, pulmonary vascular disease (pe), Alveolar filling processes (pneumonia, pulmonary oedema), interstitial disease & atelectasis. Shunt Blood passes from R to left without being oxygenated. PaO2 does NOT with supplemental O2  Aa difference Causes: Anatomical (ASD,VSD, P& physiological shunts (atelectasis, pneumonia, ARDS) where blood bypasses alveoli without effective gas exchange Diffusion Limitation Impaired O2 diffusion from alveoli to RBC, causing hypoxemia particularly in with ↑ CO. PaO2 with supplemental O2  Aa difference Causes: Pulmonary fibrosis, oedema & inflammation that impair gas exchange in the alveoli Low Mixed Venous O2 (SvO2) Venous blood returning to the lungs (SvO2) has incredibly low O2 due to ↑ extraction. • Normal Aa difference • PaO2 normalized with supplemental O2. Causes: Severe anaemia (↓ CaO2 rarely a problem unless Hb <5), ↓ CO & ↑ O2 consumption Hypoxia: Insufficient O2 delivered to tissue to meet demand Hypoxemia: Low O2 in the blood (most common type of hypoxia) PiO2: Atmospheric O2 (how much 02 is inspired) PAO2: Alveolar O2 (how much O2 reaches the alveoli) PaO2: O2 dissolved in arterial blood (measured on ABG) SaO2: Percent saturation of hemoglobin in arterial blood CaO2: O2 content of arterial blood (dissolved & Hb bound)

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Non-Invasive Respiratory Support (HFNO & NIV) NIV- Support Oxygenation and Ventilation- Can be used in acute respiratory failure to avoid Endotracheal Intubation Contra-Indications: Inability to trigger breath, protect airway/recent head/neck surgery/copious secretions. ABG Pulse Ox pH/PCO2 PaO2 HCO3 SpO2 Ventilation ↑ the pH→ Driving pressure (IPAP-EPAP= PSupp) Oxygenation ↑PaO2/SpO2 Adjust Oxygenation parameters (Fio2/EPAP - PEEP HFNO 2-0.21-1  flow: 40-60lpm  31-37°C  inspiratory flow  set FIO2  Comfort  positive airway pressure (up to 4 cmH2O) Washout of nasopharyngeal dead space Reduce inspiratory effort Helmet 2: 0.21-1 : 10-12 cmH2O :10-12 cmH2O No humidification needed Fastest pressurization time No risk of pressure ulcers Better tolerated Full Face Partial Face Nasal ●↑ Risk for pressure ulcers Oral meds an option More comfortable for CPAP or ↓ pressure Hight air-leak Tolerate higher pressures using mask than nasal interface. Full face mask ↓risk of pressure ulcers + ↓ air-leak Variable comfort Air leaks may occur. Mode Description/Pro/Con Ventilator setting/example CPAP (Continuous positive airway pressure) • Continuous pressure through the resp cycle • Keep open collapsible airways and improving oxygenation. • Triggered by pt. breath. • Can add Pressure Support • Improves Oxygenation • APO/CHF • Can Augment TV and assist with Ventilation. • Does not assist ventilation, unless Pressure Support added • PEEP (EPAP) +5 • FIO2 60-100% • PSupp: +3 • Monitor Ventilation BIPAP (Spontaneous Timed) • Inspiratory/Expiratory pressure • Every breath is supported with positive pressure. • Pt triggers breaths, but also has backup rate. (Similar to Pressure support) • Improves Ventilation & Oxygenation • Can cause Volutrauma. • T-time/pressure/flow, C-flow, L-Pressure • Backup RR: (set low) 8bpm. • IPAP: 16cmH2O • T: 1 sec • Risetime: 0.15sec • EPAP: +5 • FIO2: 60-100% • Monitor Ventilation volumes AVAPS (Adaptive volume assures pressure support • Hybrid mode that dynamically adjusts inspiratory pressure (IPAP) to deliver a desired TV (Analogous to PRVC/VC + Modes) • Ensures minimum Ventilation within desired pressure range. • Can cause Volutrauma- with ↑ patient effort. • T-time/pressure/flow, C-Volume, L-volume • Backup RR: 8bpm • Goal TV: 450ml • Pmin: 10 • Pmax: 20 • Risetime: 0.15sec • PEEP: +5 and FIO2: 60-100% • Monitor ventilation and pressure volumes.

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Ventilator Modes  Oxygenation: support PaO2/SpO2 Ventilation: maintain pH Patient comfort: vent synchrony- decrease sedation - Facilitate weaning  minimize muscle loss, promote readiness to wean from support. Ventilator Modes: Pressure/Volume mode (each mode has 3 features) Trigger (T)- What initiates a breath. Cycle (C) - What ends a breath. Limit (L)  What stops a breath early. Oxygenation If you want to change the PaO2 or SpO2 Classification of mechanical ventilators Control (How the ventilator knows how much flow to deliver) Cycling How the ventilator switches from inspiration to expiration Triggering (What causes the ventilator to cycle to inspiration?) Volume Controlled (Volume limited, volume targeted) and Pressure Variable Time cycled - such in pressure controlled. ventilation Time: the ventilator cycles at a set frequency as determined by the controlled rate Pressure Controlled (Pressure limited, pressure targeted) and Volume Variable Flow cycled - such as in pressure support Pressure: the ventilator senses the patient's inspiratory effort by way of a decrease in the baseline pressure. Dual Controlled (volume targeted (guaranteed) pressure limited). Volume cycled  the ventilator cycles to expiration once a set tidal volume has been delivered: this occurs in volume-controlled ventilation. If an inspiratory pause is added, then the breath is both volume and time cycled. Flow: modern ventilators deliver a constant flow around the circuit throughout the respiratory cycle (flow-by). A deflection in this flow by patient inspiration is monitored by. the ventilator and it delivers a breath. This mechanism requires less work by the patient than pressure triggering. ABG Pulse Ox pH/PCO2 PaO2 HCO3 SpO2 Ventilation If you want to ↑pH → Ventilation parameters Measurement and optimization Measure ABG/SpO2 Adjust settings.

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Ventilation Modes Mode Description/Pro/Con Ventilator setting/example VC – Volume Control • Every breath delivered is the same set volume (TV) • Good for lung protective ventilation • Monitor pressure to avoid barotrauma. • T-time/pressure/flow, C-Volume, L-Volume • RR: 12-15 (According to what is required) • TV (4-8ml/kg- depending on what is required) • PEEP: +5 • FIO2 60-100% Monitor Pressures (Ppeak, Pplat) PC – Pressure Control • Every breath delivered is a set pressure for a set time. • Good for limiting pressures. • Monitoring Volumes to avoid Volutrauma or hypoventilation. • T-time/pressure/flow, C-time, L-Pressure • RR: 12-15 (According to what is required) • IP: 25cmH2O • Ti: 0.9 sec • Risetime: 0.15sec • PEEP: +5 • FIO2: 60-100% Monitor Ventilation volumes (TV, MV) PRVC – Pressure regulated Volume Control • Hybrid PC mode that dynamically adjusts inspiratory pressure (IPAP) to deliver a desired TV. • Guarantees TV but delivers pressure-controlled breaths (e.g., ↓ risk of causing VILI), which potentially may be more comfortable for patients. • In patients with ↑ WOB this mode will provide less support • T-time/pressure/flow, C-Volume, L-volume • RR: 12-15 (According to what is required) • TV: (4-8ml/kg- depending on what is required) • Ti: 0.9 sec • Risetime: 0.15sec • Pmax: 30cmH2O • PEEP: +5 • FIO2: 60-100% Monitor Pressures and Volumes SIMV- Synchronous Intermittent Mandatory Ventilation • Delivers mandatory breaths with a fixed volume but pt. cannot trigger. • Can use PS. • T-time, C-Volume, L-Volume • RR: 12-15 (According to what is required) • TV: (4-8ml/kg- depending on what is required) • PEEP +5 • FIO2: 60-100% Monitor Pressure (Ppeak/Pplat) PS – Pressure Support • All breaths are patient initiated; ventilation determined solely by patient. • Ideal weaning mode, most comfortable as it allows patient to control ventilation. • Need to monitor to ensure adequate ventilation. • T-Pressure/flow, C-flow, L-Pressure • PS: • PEEP: +5 • FIO2: 60-100% Monitor Volumes (TV/MV) APRV – Airway Pressure Release Ventilation • Inverse ration ventilation (e.g., I time> E time) that allows patient to breath spontaneously –can combine with P/S • Good for ARDS patients with spontaneous breathing • Risk of VILI because of complicated settings • T-time, C-time, L-pressure •THigh: 5.5sec •Tlow: 0.5sec •Phigh: 25cmH2O •Plow: 0cmH2O • FIO2 Monitor volumes and gas exchange PCO2/EtCO2

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Oxylog 3000 Plus VC-CMV/VC-AC: Volume controlled: Controlled mandatory ventilation with or without PEEP. Volume controlled: Assist control with or without PEEP VC-SIMV: Volume controlled – Synchronized Intermittent mandatory ventilation. PC-BIPAP: Pressure Controlled – Biphasic Positive Airway Pressure VC-SIMV+: Pressure Controlled – Synchronized Intermittent Mandatory Ventilation Spn-CPAP: Spontaneous breathing – Continuous Positive Airway Pressure Additional settings for ventilation: • Pressure support can be supplied in the ventilation modes: VC-SIMV, PC-BIPAP and Spn-CPAP • Apnoea ventilation for spontaneously breathing patients: in the ventilation mode BIPAP. • AutoFlow (optional): in the ventilation modes VC-CMV, VC-AC and VC-SIMV • NIV: in the ventilation modes: Spn-CPAP (/PS), PC-BIPAP (/PS), VC-CMV/AF, VCAC/ AF and VC-SIMV/AF. Using the NIV mode, non-intubated patients can be ventilated with a mask. Autoflow is an adjunct to volume control ventilation mode, it automatically regulates inspiratory flow and inspiratory pressure. If the Autoflow function is activated the ventilation stroke is delivered with the minimal flow required to deliver the set volume within the set inspiratory time. The resulting end expiratory pressure is used as the inspiratory pressure for the next breath. Subsequently a decelerating inspiratory flow profile is used (flow pattern changes from the constant flow to a decelerating flow pattern). Once expiration begins, delivered (inspiratory) volume is compared to the set tidal volume. The inspiratory pressure of the next mandatory stroke is adjusted, up or down, according to the measured inspiratory volume of the previous breath. The inspiratory pressure is adjusted by a maximum of ±3mbar per breath. The inspiratory pressure will not increase to more than 5mbar below the upper airway pressure alarm limit. If the set tidal volume can no longer be achieved, an alarm “VT low, pressure limit” is generated. Spontaneous breathing may cause fluctuations in the tidal volume however autoflow ensures a constant tidal volume is applied, on average and over time. Ventilator Troubleshooting: ↑PEAK Oxylog 3000 Plus Capabilities Ventilator Troubleshooting V

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Consider: • Oxygen to stoma and/or face • Assess patency of Trachy using suction catheter Complete Obstruction (Unable to pass suction catheter) Deflate the cuff  access for signs of breathing and improvement (use EtC02 waveform) If patient and breathing improve- continue ABC assessment and oxygenate If no improvement  ventilate using BVM and mask via face. If unable to ventilate and oxygenate  remove tracheostomy tube and ventilate using BVM and mask over stoma. Partial Obstruction (Able to pass suction catheter) Suction of tracheostomy Ventilate through tracheostomy if possible. Should complete obstruction develop manage accordingly. Assess if oxygenation and ventilation via face is possible.  Tracheostomy Bleeding (Considerations) Early (<7-14 days) • Early bleeding may be at the surgical site, from suction trauma, or due to tracheitis- Consider lower airway bleeding/hemoptysis. • Tx: inflate cuff, apply direct pressure. Late (>7-14 days) •Late bleeding may be due to the above or due to development of a Tracheo-innominate artery trachea. Look for ETT Pulsations  (this can cause life-threatening hemorrhage • Tx: Overinflate cuff to tamponade, ventilate from above and remove tracheostomy, intubate from above, insert finger into stoma a pull anteriorly to occlude innominate artery. • Surgical management of hemorrhage will be required (high mortality w/0 surgery) Components of Tracheostomy Tube The outer cannula fits into the stoma to keep it open. The outer cannula has a neck plate that rests on the skin. The obturator is a device that guides the outer cannula into the stoma during placement of the cannula. The obturator is removed after the cannula is in place. The inner cannula fits inside the outer cannula. The inner cannula can be removed for cleaning. Different Tracheostomy Tubes

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A-lines are connected to a pressure monitoring transducer by using rigid pressure-monitoring tubing. The tubing is filled with an isotonic solution, usually normal saline. The transducer will convert the physical or pressure waveform signal into an electrical signal which is transferred and displayed as a waveform and numerical value on the monitor. The A-line needs to be connected to a free-flowing fluid source (Which needs to be under pressure) to maintain catheter patency and prevent backflow of arterial blood into the system. Pulse pressure variation (PPV) • Pulse pressure is proportional to SV. • PPV is a representation of the interaction between lungs and heart. • Ventilations effects intrathoracic pressure and causes SV to vary. • ↑ Variability in SV (↑PPV) may suggest fluid responsiveness. • A PPV >12% suggest that there will be an ↑ SV with fluid challenge. Interpretation of PPV involves 3 conditions to be present. • Sinus Rhythm indicating a consistent filling time. • Mechanically ventilated (no spontaneous breaths), TV 8ml/kg- indicating a consistent ventilator effect. • Must not have an open chest (heart/lung interacting) In contrast to an ↑ in BP with respiration causing ↑PPV, Pulses paradoxus is the ↓ in SBP >10mmHg with respiration, associated with tamponade and other conditions. Closed blood sampling systems Enable blood draws with minimal waste. ↓ Risk of Bacterial contamination ↓Blood transfusions- because smaller size sample tubes and ↓lab frequency Common A-Line Terminology Leveling: Correct level is 4th intercostal space along the mid axillary line (phlebostatic axis). If a transducer is . Re-level the transducer after any patient movement. Zeroing: eliminates the effects of atmospheric pressure on measured hemodynamic values. Because intrathoracic pressures influence Arterial pressure and Cardiac output by its effect on venous return, readings should be recorded at the end of expiration phase. Both CO and Arterial pressure would be increased. Damping: Influence on a system during oscillation by dissipation of energy Square Test (Dynamic response test): The frequency at what the pressure monitoring system vibrates at when a pulse wave hit. How fast the system vibrates in response to a pressure signal. Open Flush valve (squeeze flush system device) quickly exposing the transducer to the pressure of the fluid (300mg/hg). Waveform should rise sharply, plateau and drop off sharply when released. >2 oscillations before returning to baseline (underdamped), 1-2 oscillations before returning to baseline (correct), 0-1 oscillations before returning to baseline (Overdamped) Overdamping: (↑loss of energy) waveform lose its normal characteristics, appear smooth with a diminished or absent dicrotic notch. (SBP underestimation/DBP overestimation. ARTERIAL LINES A-Line Uses • Continuous Invasive blood pressure measurement • Arterial blood sampling • Analysis of waveform- (CO, Predict Volume responsiveness, identify specific pathologies Square Wave Test • Line needs to be calibrated for accuracy. • Rapidly flushing the line (by pulling the release on the flush device) generates a square wave. • Oscillations after square indicate the functionality of the line.

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Tube Positioning • CXR: Correct placement to drain air/fluid. • All 6 of side holes within chest cavity- any movement since last CXR • If a chest tube is mal positioned it may need to be removed/replaced Chest Tube Output • Output in last 24hrs Tidaling (Respiratory variation) • Indicate drain is in pleura and transducing the pleural pressures. • Look for movement of the indicator ball in the chest drain. • Look for cyclic movement of fluid in dependent loops of tubing. • (Suction tubing can temporarily be occluded to make it easier to evaluate Tidaling Air leak • Presence of bubbles in the Water seal chamber- air within chest or leak in drainage system • Intermittent air leak during respiratory cycle- indicates injury to lung or airways (Have the patient cough to see if air leak occurs with higher pressures • Continuous air leak  throughout the respiratory cycle suggests either a large injury to lung or airways or a leak in tubing. Weaning a Chest tube • Usually, chest tubes are placed on suction to facilitate air/fluid removal. • On Resolution of the Pneumothorax or drainage of an effusion- suction can be discontinued (called ‘being on water seal’) • Clamping a chest tube simulates removal. Suction • Is the drain connected to the suction? • How much suction is applied? • Take caution when applying suction to large effusions as rapid drainage can precipitate re-expansion pulmonary Edema. Points to remember when transferring the patient with a Chest drain. • Ensure site of tube insertion is stable and secured properly. • All connections are secured to prevent separation. • Mark or record the depth of the tube for reference. • Keep drainage bottle below level of the patient and upright. • If attached to a suction device, find out if the suction can be discontinued. If not, attach it to the portable suction device. • Assess patency of line by Tidaling/Swinging and record any output (blood) • Do not clamp the drain unless the drainage bottle requires replacement. • Large amounts of frank blood drainage may require a transfusion, and continuous bubbling may be a sign of a tracheobronchial tear. CHEST DRAINS Underwater chest drain system combines Drainage, a one-way valve (Water seal), and allows a precise amount of negative pressure to be applied (Pressure regulator)

Charlie Transfer Guide 2023 July

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