COVID19/ARDSNet protocol

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COVID19/ARDSNet protocolVentilator ProtocolOverall goal is lung protection. Think of this as a cast or splint for the lung.. Low tidal volume (LTV) for both treatment of ARDS and prevention of ventilation induced lung injury (VILI) Early intubation (>6-8L nasal cannula with hypoxemia <88%) with video laryngoscopy and an expert airway manager. Rapid sequence intubation with adequate neuromuscular blockade (trying to avoid coughing/aerosolization)1-2 mg/kg rocuronium. Adequate and deep post-intubation sedation. RASS -4 – should not trigger/over-breath vent in initial managementBasics:Ventilator Mode: CMV Volume assistVolume assist-control (Can do PRVC, as well)Initial tidal volume: 6 ml/kg predicted body weight. Use patient height/gender/weight11334752747645 SEQ Table \* ARABIC 1 Please use vent tool to calculate. SEQ Table \* ARABIC 1 Please use vent tool to calculate.11334754445Plateau pressure goal ≤30 cm H2OPeak pressure goal <40 cm H2ODriving pressuresee footer (Plateau – PEEP) <15Oxygenation goal PaO2 55-80 mm Hg or SpO2 of 88-95%FiO2/PEEP ratio: Please use ARDSNet protocol card. There is a high or low PEEP titration depending on whether the patient is PEEP responsiveness of the patient’s physiology. Not all ARDS is PEEP responsive, but COVID19 ARDS seems to be more PEEP responsive. CAVEAT: There appears to be an emerging phenotype of ARDS in COVID19 that is less PEEP responsive. Driven by a DIC like hypercoagulable state. This must be derived empirically at the bedside..pH goal: Think pPermissive hypercapnia if needed. pH range 7.20-7.45Given LTV strategy, you must make up your minute ventilation, at least initially, with RR. In ARDSNet trial, RR up to 35 was used. Patient physiology, such as obstructive lung physiology must be taken into account. Although PEEP values with this protocol typically match or exceed patient’s intrinsic PEEP. Sedation: Deep. RASS -2 to -4 (Initially) – Main campus is using fentanyl/midazolam combinations up to 15 mg/hr midazolam and 500 mcg fentanyl/hr. There is a separate protocol that guides sedation/NMB/proning specifically. Goal is zero vent dyssynchrony. Fever control. Both are critical to achieve decreased metabolic demand/decreased oxygen consumption. If there is adequate minute ventilation and blood pressure tolerates this presents no short-term harm to patient. Can also consider sedation wth propofol, being mindful of possible hypotension.Propofol is to be discouraged, but optional. There has been elevated CK in COVID patients that can be worsened with propofol. In addition, volume consideration must be on the mind at all times. Patients should be kept as euvolemic as possible with early and judicious use of diuretics. A word about volume. Keep patient’s dry. If they are hypovolemic and hypotensive give bolus. If they appear dry, give free water via NG. Would strongly discourage routine use of “maintenance” fluids , overall fluid balance of paramount concern in ARDS management. Goal is even/euvolemicTroubleshooting/TitratingFor situations when O2 goals are not met despite adequate FiO2 and PEEP based on ARDSNet card. Please consider neuromuscular blockade using ACURASYS COVID/ARDSNet protocol. Remember patient’s need adequate sedation with neuromuscular blockade on board.For situations when Pplat ≥30 cm H20 for >10 minutes consider the following, sequence:Increase sedationReduce tidal volume to 5mL/kg then to 4 mL/kgDecrease PEEP by 2 cm of H2O and bolus of neuromuscular blockade agentcisatracurium 20 mgFor situations when pH is <7.20 due to hypercapniaIncrease RR up to a maximum of 35 bpm Increase tidal volume to a *max* of 8mL/kg in 1 mL/kg increments with goal Pplat < 30.Weaning:Please use titration guide of ARDSNet protocolStart weaning when FiO2 ≤ 0.40Goal is SpO2 ≥88% and RR 26-35/minDecrease PEEP with goal to 5 in increments of 5 cm H2OUse PS ventilation 20, 15, 10, 5 – whatever value works to achieve adequate minute ventilation with appropriate respiratory rate and work of breathing as deemed by provider. Remember exercise is useful in these patients. Beware of “failed wean”. Make the ventilator fit the patient not vice-versa. Example: If patient’s minutes ventilation on CMV is 9L/min adjust PS to achieve 9L/min with similar RR. If it takes PS 25 wean as long as tolerated, no exceeding 2 hours, and return to CMV.Can Wean/Exercise up to 2 hours daily, after than diminishing returnsOnce at fiO2 ≤0.4 and PS 5 and PEEP 5 with 1-2 hour wean with appropriate RR and work of breathing with good ABG can consider extubationReferences: HYPERLINK "" HYPERLINK "" PBW card: HYPERLINK "" ................
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