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Initial Vent Settings?


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#1 mg/kg

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Posted 26 June 2016 - 09:29 PM

I have been told before that SIMV was a "weaning mode" and that all pts transported should be ventilated on A/C over SIMV. Additionally, since the LTV 1200 (vent being used at the time) did not specifically have PRVC, APRV, etc, and that AC was the next best choice. That doesn't seem like the best practice to me. Would it be acceptable to place someone on SIMV with PS for transport if the pt were on PRVC in the hospital? My thought process would be that it would be more comfortable for the pt than AC. Thoughts?


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#2 AMason

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Posted 11 July 2016 - 12:43 AM

I tend to use AC just for convenience in paralyzed or heavily sedated patients because it really doesn't make much of a difference. There's no reason not to use SIMV in any other patient who's overbreathing. I transport all of my peds patients in PC SIMV+PS, both per protocol and because that's how I was trained (PICU background).  It's only slightly more complicated to set up, and not so much that it provides any sort of impediment.

 

PRVC is essentially a volume mode that does not preclude using SIMV (in fact, we ONLY used it as PRVC-SIMV), so VC SIMV+PS is an entirely reasonable choice to transition to, just keep an eye on your peak pressures.

 

What vent are you using now and what modes of ventilation do you have access to?


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#3 ForeverLearning

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Posted 11 July 2016 - 01:40 AM

Initial vent setting for whom? Post Rosc? COPD post RSI? PNA with consolidation and atelecatic lungs? Peds?

A/C offers full support. SIMV with PS and inadequately set PS may not.

It depends
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#4 mg/kg

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Posted 11 July 2016 - 01:14 PM

I tend to use AC just for convenience in paralyzed or heavily sedated patients because it really doesn't make much of a difference. There's no reason not to use SIMV in any other patient who's overbreathing. I transport all of my peds patients in PC SIMV+PS, both per protocol and because that's how I was trained (PICU background).  It's only slightly more complicated to set up, and not so much that it provides any sort of impediment.

 

PRVC is essentially a volume mode that does not preclude using SIMV (in fact, we ONLY used it as PRVC-SIMV), so VC SIMV+PS is an entirely reasonable choice to transition to, just keep an eye on your peak pressures.

 

What vent are you using now and what modes of ventilation do you have access to?

 

Thanks for the input. My last job we utilized the Oxylog 3000+ and the LTV 1200.

 

My motivation for this thread was a discussion I was having with one of my buddies. Sure, it is easy to just put most patients on AC and get them out the door who are acutely intubated. But what about the complicated ICU pt that has been intubated for several days and is sedated on the sedative cocktail of choice of the sending facility? I feel that putting that pt on AC is not an appropriate action if they are on PRVC, APRV, PCV, etc. My reasoning for that is you are going to further stress that pt during transport with an uncomfortable ventilatory mode on top of the typical stressors of air or ground transport. We have to make sure our pt remains stable (relative term) while in our care, but we should also ensure that they are comfortable. And that means utilizing methods on top of analgesia, anxiolysis, and sedation.


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#5 AMason

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Posted 13 July 2016 - 07:46 AM

I think that taking the patient's current vent settings as a starting point is clearly the best bet, and would not generally transition a patient to A/C from SIMV. In fact, when switching over you may run the risk of over-ventilating the spontaneously breathing patient (though probably unlikely). We use the OxyLog 3000+ and the closest you can get to PRVC-SIMV is SIMV+PS (which is VC). Conversely, while I want to optimize comfort, if a patient is on A/C and tolerating it I wouldn't rock the boat. As for APRV... well, good luck. Your guess is as good as mine. I haven't had the luck to run into it in the field yet.

 

Some of the challenge surrounding vent management relates to manufacturer terminology. CMV, AC, AC-VG, PRVC, potato, tomato, etc... Mode selection is less a matter of if the patient is getting "full" or "partial" support, but comfort, adequacy of ventilation and oxygenation and prevention of harm. All of these require a good understanding of the capacities and limitations of your equipment.

 

I completely agree that we should minimize the stressors of transport as much as possible, and good vent management is an important tool in my kit.


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