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Respiratory Support

Continue to monitor clinical goals following resolution of shock

  • Wean FiO2 to keep Sp)2 92-97%

  • Continue lung protective strategies

  • Consider diuretics or dialysis if fluid overload > 10-15%

  • PRBCs if Hgb < 7g/dL

  • Wean hydrocortisone when vasoactive infusions no longer required

  • Monitor culture results and reassess antibiotic coverage

  • Consult ID if culture negative sepsis to determine negative sepsis to determine antibiotic duration PT/OT consult, consider PM&R consult

Respiratory support


Begin age-appropriate oxygen therapy regardless of SpO2

Indications for intubation:

  • Hypoxemia or inadequate oxygen delivery

  • Left heart failure or refractory shock

  • To facilitate safety during invasive catheter placement

 

Initial respiratory assessment

 

Respiratory rate

Pulse oximetry

Work of breathing (WOB)

Breath sounds

Goals:

Normal for age

SpO2 92-97%

Minimal, normal

Normal

-->

SpO2 < 92%

Increased WOB

Inadequate gas exchange

-->

Consider:

  • High Flow Nasal Cannula

  • Noninvasive positive pressure ventilation

Gas exchange:

Monitor ABG or noninvasive TcPCO2

 

Respiratory reassessment

Monitor all assessment items in Initial Respiratory Assessment plus:

Venous SCVO2

Lactate

 

 

Goals:                                       

> 70%

< 4 mmol/L

 

SpO2 < 92%

Increased WOB

Arterial pH < 7.25

SCVO< 70%

 

Consider:

  • Intubation

  • Invasive mechanical ventilation

 

Reassess mechanical ventilation goals

 

Pulse oximetry

Arterial pH

SCVO2

Lactate

Goals:

SpO2 92-98%

> 7.25

> 70%

< 4 mmol/L

-->

Meets Goals?

Yes

Lung-Protective Strategy

Tidal volume < 7 mL/kg

PIP < 35 cm H2O

FiO2 < 60%

Wean FiO2 if SpO2 > 98%

Follow:

Oxygenation Index (OI)

PaO2 / FiO2

No

Alternative Ventilator Strategies

Airway Pressure Release Ventilation (APRV)

High Frequency Oscillator Ventilation (HFOV)

 

Oxygenation Index (OI)

Assesses the intensity of ventilator support required to maintain oxygenation (lower is better).

 

Pa02/FiO2 Ratio

Indicates severity of arterial blood hypoxemia given FiO2 only, used in defining ARDS.

Interpretation of OI:

Very good < 5

Medium 10-20

Poor > 25

Interpretation of Pa02/FiO2 Ratio:

Normal 452

Mild ARDS 201-300

Moderate ARDS 101 - 200

Severe ARDS < 100

OI calculator:

http://www.medcalc.com/oxygen.html

 

 

Reconceptualized from: http://www.chop.edu/clinical-pathway/severe-sepsisseptic-shock-icu-clinical-pathway-infants-28-days-and-children-7#lung

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.