[HSF] Ain't that big !!

[Prasanna Simha M]

The rhythm on weaning was sinus and I routinely pace AAI or DDD all such
patients for a few days so that "atrial training occurs' (sinus rhythm
begets sinus rhythm a" and it suppresses any atrial ectopic that can
initiate the flutter fibrillation cycle.
The open lung ventilation concept has been around for some time and arose
from the work on ARDS. Basically ventilation with low volumes - 6-7 ml /Kg
against the traditional 10-15 ml /Kg with an I : E ratio of 1:1 and higher
ventilator rate or accepting permissive hypercapnea  with a higher PEEP
(10-20 mm Hg) and an FIO2 equal to or < 40 %  has been associated with lower
lung damage due to avoidance of recruitment- de-recruitment cycle with
higher tidal volume ventilation. Any time the ventilator is dsconnected for
eg transport/suction etc PEEP is swwitched to 20 mmHg for 45 -60 seconds to
prevent derecruitment. I have shifted over to this method of ventilation in
all patients and have seen a dramatic improvement in lung function. They
have good looking X Rays and gas exchange and can be weaned rapidly -even
the sicko's who we would expect to get stuck on ventialtors. It also allows
efficient opening of atelectatic segments.
For eg the patient in the example has opened up his lung , was extubated in
4hours and out of the ICU next day morning with no supplemental oxygen. I
have bben impressed woith this strategy. There have been a lot of articles
wrt open lung ventilation and cardiac surgery.I usually give an open lung
arecruitment at induction, before weaning of CPB, after shifting and at the
time of extubation aprt from the low tidal volume high PEEP low FIO2
ventilation .
You just stop seeing those white patches on the X Ray with this method.
Using 6-7 ml /Kg tidal volume  you do not get hypotension when using a PEEP
of 20 . If you do get it the patient is hypovolemic and that has to be
treated first.
Prasanna


On 11/22/06, Nasser F. Abou'Seada <nfaabouseada at gmail.com> wrote:
>
> was the patient in documented AF ????? "...of Course ..!!" ...
> what was the rhythm on weaning from CPB ???? ... before skin closure ?? ..
> in CSICU ?? ...
> incidentally ... why ventilating @ TV 7mls/kg BW ?
> and ... what do you mean by open lung ventilation ? ... apparently your pt
> is on IMV/Assist mode ..?
> Do You keep the PEEP at 20 mmHg for 60 sec continuously ??? ...
>
> NFA
>
> > -----Original Message-----
> > From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> > bounces at lists.hsforum.com] On Behalf Of prasannasimha
> > Sent: Monday, November 20, 2006 1:12 PM
> > To: OpenHeart-L at lists.hsforum.com; ccm
> > Subject: [HSF] Ain't that big !!
> >
> > Patient with 97 % CTR, Giant LA , Mitral stenosis (MVOA 0.8) with MR
> > Grade II with LA body clot.
> > Underwent today MV repair + LA thrombectomy + eMAZE  +Kawazoe type of
> > plication to decompress the compression on the right lung.. Second X Ray
> > in the Panel is the immediate post op X Ray showing the "atelectatic"
> > lung opening up slowly.
> > At present the patient is being given "open lung ventilation"  with
> > ventilation  @ 7ml/Kg tidal volume with PEEP of 14 mm Hg with hourly
> > increase of PEEP @ 20mm Hg  for 45 - 60 seconds hourly to expand the
> > chronically compressed lung and will probably be extubated in a few
> hours.
> > Papery thin LA in certain areas !!
> > I am getting a spate of giant LA's - todays other case also required an
> > atrioplasty + MV repair (though that giant LA has a CTR of 80 % - less
> > dramatic than the 97 % !!)!! When it rains it pours !!
> > Prasanna
>
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-- 
Prasanna Simha M