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Oxygen Blenders In Neonatal Transport


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#1 nicuRN

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Posted 20 April 2012 - 05:54 AM

Please bear with me as this is my first post! I am a NICU transport RN (also CCEMT-P) with a newer NICU and transport program, in which I'm heavily involved. We do both ground and rotor wing transport, with varying team composition. RT is new to neo transports. Discussions taking place:
1. What are the current trends in regards to Air/O2 blenders during neo transport?
a. Are blenders being used or are programs manually blending air/O2?
b. Any equipment or blender problems occurring?
2. What are your liter flows with vented neonatal patients using MVP-10 and how accurately can air/O2 be manually blended?
3. Any discrepancies found with end tidal CO2 readings in neonatal population?
RT feels we've had too many blender "issues/alarms" and thus wants to take the blender off completely and manually blend during transports. The blender we use is in our delivery rooms as well, but no issues with these; only during transports have we had alarms. As instructed by RT, we used 8-10 lpm to run the MVP-10, (causing multiple issues)but also had leaks, empty E cylinders prior to transport etc. Per RT, this is from a "tank fairy" and daily equipment checks. Just wondering if I can get some feedback? I have concerns with taking the blender off (thus, the only audible alarm on our isolette) and not doing daily equipment checks...but with good rationale, I am open to change. Also, as a huge fan of EtCO2, I am pushing for this with every vented patient, but I'm being told the readings are inaccurate in the neonatal population-is this true?
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#2 SerendepitySaki

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Posted 20 April 2012 - 01:55 PM

i may have missed it, but i did not see this discussion in either the AARC Transport section or the Neo-Pedes section... wealth of experience there, well worth tapping into....and no, with respect to etCO2, it is not entirely true and there are other ways to measure CO2...all depends on what you're after... again, we DO have some experts here who forgotten far more than i will ever know, but i think you might get a more rapid and broad range of responses by posting on AARC....
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#3 Macgyver

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Posted 20 April 2012 - 10:43 PM

Biggest hassle is poor tolerance on various compressed gas sources (main tanks, portable s and pumps) causing a pressure imbalance in the blender (it has a very tight pressure band to remain calibrated) Is this clinically significant? Usually not - we are titrating after all. Just annoying and hard on neo ears.

LP base tank pressures can be from 48-60PSI in my experience, seen some as high as 65 with a good fill and old reg. "E" tanks usually run 45-53 psi, and air pumps output pressure varies tremendously as the CFM changes. Each pump is different so you wil have to get the pressure/volume curves for each and check the 50 psi curve. Usually blenders will tolerate 2 or 3 psi differential from air to oxygen (or vice versa) with no issues.

LP bases with dual air pumps or high volume pumps, or some Air Methods instalations with an accumulator and 2 pumps, can hold much more consistent air pressures (for a while - until depleted and the pumps have to do it all) as long as you are not at low fiO2 and high lpm (HFOV / bronchotron especially and even the MVP-10 at some settings)

As to accuracy - it will vary with altitude as all the orofices and flow balance systems are calibrated at (usually) close to sea level. As air density decreases this balancing of the air and the (fixed) O2 pressure causes increasing imbalance. If you need a specific Fio2 then an oxygen analyser is your friend. Ignore the blender dial (kind of like you do with a bronchotron) and adjust to get the FiO2 you want. Do some trials at common tank pressures and air flow rates at altitude and adjust both regulator output pressures to eliminate the blender alarm most if not all of the time.

Caution with the MVP 10 or if using high flow nasal cannula - they can SUCK gas. I've seen total gas volumes of in excess of 40lpm...
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#4 Macgyver

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Posted 20 April 2012 - 10:56 PM

re CO2 - the transcutaneous system can be used (must be with HF vents) but it needs frequent recalibration and sensor relocation to prevent skin damage. If you are using ETT sensors, go with sampling (sidestream) not optical, less deadspace issues (usually) and can be used via sampling cannula as well. ALWAYS get an ABG to correlate the monitor to the actual values. It's not so much that monitors are inaccurate in the technical sense as that they are best used clinically as a trending indicator. Once you know the offset, you can mentally keep the target range happening instead of relying on some unknown bias differential (usually 8-12 different than the ABG). Don't forget a low volume HME or filter to prevent moisture from getting drawn into the sampling line - especially in high humidity situations, cold enviroments or long transports...
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#5 medicRT

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Posted 21 April 2012 - 05:57 PM

1. What are the current trends in regards to Air/O2 blenders during neo transport?

Absolutely need to be able to offer blended gasses and FiO2

a. Are blenders being used or are programs manually blending air/O2?

We use a two flowmeter system (like an Anaesthesia Gas Machine) Air/O2 - Bird (dial) type blenders where changed out before my time (break down in cold Canadian weather and hard to insure proper input psi.

b. Any equipment or blender problems occurring?

as above

2. What are your liter flows with vented neonatal patients using MVP-10 and how accurately can air/O2 be manually blended?

less flows with prems 6lpm combined upto 10lpm in term baby. Can blend to whatever FiO2 you need - just put an oxygen analyzer in line in the inspiratory limb of the circuit and you can see the exact FiO2 you have.

3. Any discrepancies found with end tidal CO2 readings in neonatal population?

From experience, end-tidal not very reliable in the prems, lots of motion artifact from road vibration, poor correlation in obstructive diseases -mec asp, bornchiolitis.

Take a serious look at transcutaneous monitoring - very reliable, very accurate - many plusses that outweigh the minuses in my opinion/experience - I didnt understand Macgyver's note about "must be used with HF vents" - perhaps clarify with them

Hope this helps.
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#6 Macgyver

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Posted 22 April 2012 - 02:02 AM

Take a serious look at transcutaneous monitoring - very reliable, very accurate - many plusses that outweigh the minuses in my opinion/experience - I didnt understand Macgyver's note about "must be used with HF vents" - perhaps clarify with them


My experience with exhaled co2 monitoring of pts on the bronchotron (high frequency oscillator) is that there isn't enough tidal volume and it cycles so fast (400-800Hz) that the sampling technology wouldn't reliably obtain a good reading whereas the TC monitors worked well. On pedes with asthma and larger volumes, mostly using the VDR (high frequency but with an underlying volume cycle as well) it sometimes worked but again not reliably. TC worked fine.
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#7 nicuRN

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Posted 22 April 2012 - 02:56 AM

i may have missed it, but i did not see this discussion in either the AARC Transport section or the Neo-Pedes section... wealth of experience there, well worth tapping into....and no, with respect to etCO2, it is not entirely true and there are other ways to measure CO2...all depends on what you're after... again, we DO have some experts here who forgotten far more than i will ever know, but i think you might get a more rapid and broad range of responses by posting on AARC....

Thank you-I wasn't aware of this site despite having RT friends. I think you're right-may have more specifics, and 'I'll tap into that!' :-)Thank you!
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#8 nicuRN

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Posted 22 April 2012 - 03:28 AM

1. What are the current trends in regards to Air/O2 blenders during neo transport?

Absolutely need to be able to offer blended gasses and FiO2

a. Are blenders being used or are programs manually blending air/O2?

We use a two flowmeter system (like an Anaesthesia Gas Machine) Air/O2 - Bird (dial) type blenders where changed out before my time (break down in cold Canadian weather and hard to insure proper input psi.

b. Any equipment or blender problems occurring?

as above

2. What are your liter flows with vented neonatal patients using MVP-10 and how accurately can air/O2 be manually blended?

less flows with prems 6lpm combined upto 10lpm in term baby. Can blend to whatever FiO2 you need - just put an oxygen analyzer in line in the inspiratory limb of the circuit and you can see the exact FiO2 you have.

3. Any discrepancies found with end tidal CO2 readings in neonatal population?

From experience, end-tidal not very reliable in the prems, lots of motion artifact from road vibration, poor correlation in obstructive diseases -mec asp, bornchiolitis.

Take a serious look at transcutaneous monitoring - very reliable, very accurate - many plusses that outweigh the minuses in my opinion/experience - I didnt understand Macgyver's note about "must be used with HF vents" - perhaps clarify with them

Hope this helps.


Thank you-this does help! We will look at transcutaneous again, it would be nice to trend it with the end-tidal AND ABGs. I'm just so excited that I've got a neo listening! And now he wants it even more via nasal cannula after cpap or extubation-yay! The other neo still needs a little convincing. Send those convincing stories my way:)
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#9 medicRT

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Posted 22 April 2012 - 01:11 PM

My experience with exhaled co2 monitoring of pts on the bronchotron (high frequency oscillator) is that there isn't enough tidal volume and it cycles so fast (400-800Hz) that the sampling technology wouldn't reliably obtain a good reading whereas the TC monitors worked well. On pedes with asthma and larger volumes, mostly using the VDR (high frequency but with an underlying volume cycle as well) it sometimes worked but again not reliably. TC worked fine.

I understand now and completely agree - ETCO2 not helpful for oscillation, TC best for these patients.
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#10 medicRT

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Posted 22 April 2012 - 01:20 PM

Thank you-this does help! We will look at transcutaneous again, it would be nice to trend it with the end-tidal AND ABGs. I'm just so excited that I've got a neo listening! And now he wants it even more via nasal cannula after cpap or extubation-yay! The other neo still needs a little convincing. Send those convincing stories my way:)


one other way to bring ETCO2 in is for use on patients (intubated or even more so those that aren't) who are receiving procedural sedation.

we use it in our non-ETT patients receiving chloral hydrate or fentanyl or benzo sedation for PICC line insertion in the interventional radiology suite or even more so in the MRI where direct monitoring and access are limited.

key words to have in any plan to the higher ups: Patient Safety, Early Warning of instability, Improved Monitoring, Non-Invasive, Continuous, possibly allows less sedation needed and less recovery and length of stay .....

and no I don't work for ETCO2.inc
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#11 kidsrrtnps

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Posted 28 April 2012 - 08:45 AM

12 years of peds/neo transport and ICU care... these are my 2 cents


1. What are the current trends in regards to Air/O2 blenders during neo transport?
I have always had a blender on our transport isolettes. I would say it is a must, especially for your micros.


a. Are blenders being used or are programs manually blending air/O2?
Blender!

b. Any equipment or blender problems occurring?
I've only ever had a pressure variation issue once in flight in an EC 135. The issue was the PSI on the medical air on the aircraft, not the blender. In this instance, we just turned the blender to 100% and utilized our O2 until the issue was resolved.


2. What are your liter flows with vented neonatal patients using MVP-10 and how accurately can air/O2 be manually blended?

The MVP-10 can typically run with 6-10LPM. Analyzer can be placed inline on the inspiratory side to adequately give fio2. If you are running the vent through the blender, only ONE flowmeter on the MVP10 need to be utilized, saving also on tank drainage.

3. Any discrepancies found with end tidal CO2 readings in neonatal population?
EtCo2 typically is not useful in neonates. In addition, adding that extra deadspace could be detrimental. My suggestion would be to always have pedicap available in case there is question of ett dislodgement, or TCM if you really are concerned. that being said, TCM tend to be fussy, even in a still and controlled environment, let alone on transport.

As far as tanks running dry, we had transport isolettes that held 4 tanks. I can't remember a time where I ran out. We also carried pigtail adaptors for all the different types (puritan bennett, ohio, chemtron) of quick connects so that we could adapt our hoses easily and quickly to the OSH wall O2/Air.
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