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Weaning dr yair

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Y
Yair Alvarez

charla de destete ò libercion del ventilador.

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Dr. Yair Álvarez Mejía M.D. Clínica Misericordia The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
CONCEPTO El destete ventilatorio es un proceso donde se realiza una reducción gradual del soporte ventilatorio, haciendo que el paciente asuma una ventilación espontánea efectiva The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
CAUSAS DE VENTILACION IRA EN POP NEUMONIA ICC SDRA TRAUMA SEPSIS The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
FISIOPATOLOGIA DE LA DEPENDENCIA DEL VENTILADOR Desequilibrio entre la carga y la capacidad del sistema respiratorio para afrontar una ventilación espontanea The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
ESTRATEGIAS PARA PREVENIR LA VM Y REDUCIR SU RIESGO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
CONDICIONESPARAINICIAR DESTETEVENTILATORIO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved DESTETE VENTILATORIO HEMODINAMICAMEN TE ESTABLE GLASGOW > 7 ESTABILIDAD CARDIOVASCULAR SEPSIS CONTROLAD A EQUILIBRIO METABOLICO NUTRICION ACEPTABLE INTEGRIDAD NEUROLOGICA CONDICIONES PSICOLOGICAS
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved HEMODINAMICAMENTE PAM ≥ 65 MMHG FR < 100 LPM GU 0.5 cc/Kg/Hr GC adecuado Hb > 10 Gr/Dl
AUSENCIA DE DROGAS VASOACTIVAS DOPAMINA < 5 µg/Kg ESTABILIDAD CARDIOVASCULAR The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
CRITERIOS PARA DESTETE VENTILATORIO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved RECAMBIO GASESOSO CARGA VENTILATORIA MECANICA RESPIRATORIA IMPULSO RESPIRATORIO
RECAMBIO GASEOSO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved Ventilación minuto (Ve) > 5 lpm y < 10 lpm CARGA VENTILATORIA MECANICA RESPIRATORIA IMPULSO RESPIRATORIO
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • PO2 ≥ 60 torr en FiO2 ≤ 50% • PaCo2 en el nivel normal o 10 torr sobre el valor inicial • Ph: 7.30 – 7.45 • FR ≤ 35 rpm • FC ≤ 130 lpm • PAS > 90 mmHg OBJETIVOS DEL DESTETE VENTILATORIO
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved MODO DE DESTETE VENTILATORIO
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • Paciente consiente • Reposo semisentado • Conectar el circuito de tubo en T (TT): - Corrugado – fuente de O2 – Humidificador intercalado – TT - FiO2 10% mas del que se usa en VM • Duración suficiente de la prueba: 30 min PRUEBA DE TUBO EN T
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • Permite la sincronización de respiraciones espontaneas y las asistidas por el respirador, limitada por el flujo y presión • SIMV: reducir la frecuencia mandatorio de 1 a 3 respiraciones cada vez • Monitorear pH en cada cambio • Permite una fácil transición entre el soporte respiratorio total y el destete SIMV Y SIMV + PS
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • El nivel de presión de la vía aérea es preseleccionado mientras el paciente mantiene control y el tiempo inspiratorio, Vt, Vm y FR. • La inspiración comienza cuando el ventilador reconoce el esfuerzo inspiratorio del paciente por medio de un sistema de disparo y la rápida respuesta a pequeños cambios de presión • Con este método el paciente puede controlar su propia frecuencia, la duración de la inspiración y espiración • Mejora la eficacia de la respuesta espontanea y reduce el trabajo respiratorio y el consumo de O2 por los músculos respiratorios durante el destete previene la aparición de la fatiga diafragmática VENTILACION CON PRESION DE SOPORTE (PSV)
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • No es un verdadero Modo Ventilatorio en VM ya que no asiste en forma activa la inspiración • Es efectiva solo si el paciente respira espontáneamente • Se aplica cierta presión positiva en forma continua a través del ciclo respiratorio • CPAP, es una modalidad de respiración espontanea en la cual se mantiene una presión subatmosferica continua en la vía aérea MODO CPAP
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved GASOMETRICOS • SaO2 < 90% con FiO2 < 0.5 • PaCO2 > 10 mmHg por encima del basal • pH < 7.30 HEMODINAMICOS • de la ]PAS > 30% o > 20 mmHg sobre basal • de la FC > 110 Lpm o > 25% sobre la basal • Hipoperfusion periférica - Shock RESPIRATORIOS • FR > 35 rpm • VT < 250 ml • Asincronia o respiración paradójica • Trabajo respiratorio incrementado NEUROLOGICOS • Disminución del nivel de conciencia • Agitación no controlable • Ansiedad excesiva CRITERIOS PARA INTERRUMPIR EL DESTETE
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved SIGNOS DE SUFRIMIENTO RESPIRATORIO FR > 35 rpm SatO2 < 90% FC > 140 lpm PAS > 180 o < 90 mmHg Ansiedad, Agitación o Diaforesis
The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved

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  • 1. Dr. Yair Álvarez Mejía M.D. Clínica Misericordia The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 2. CONCEPTO El destete ventilatorio es un proceso donde se realiza una reducción gradual del soporte ventilatorio, haciendo que el paciente asuma una ventilación espontánea efectiva The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 3. CAUSAS DE VENTILACION IRA EN POP NEUMONIA ICC SDRA TRAUMA SEPSIS The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 4. FISIOPATOLOGIA DE LA DEPENDENCIA DEL VENTILADOR Desequilibrio entre la carga y la capacidad del sistema respiratorio para afrontar una ventilación espontanea The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 5. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 6. ESTRATEGIAS PARA PREVENIR LA VM Y REDUCIR SU RIESGO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 7. CONDICIONESPARAINICIAR DESTETEVENTILATORIO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved DESTETE VENTILATORIO HEMODINAMICAMEN TE ESTABLE GLASGOW > 7 ESTABILIDAD CARDIOVASCULAR SEPSIS CONTROLAD A EQUILIBRIO METABOLICO NUTRICION ACEPTABLE INTEGRIDAD NEUROLOGICA CONDICIONES PSICOLOGICAS
  • 8. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved HEMODINAMICAMENTE PAM ≥ 65 MMHG FR < 100 LPM GU 0.5 cc/Kg/Hr GC adecuado Hb > 10 Gr/Dl
  • 9. AUSENCIA DE DROGAS VASOACTIVAS DOPAMINA < 5 µg/Kg ESTABILIDAD CARDIOVASCULAR The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 10. CRITERIOS PARA DESTETE VENTILATORIO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved RECAMBIO GASESOSO CARGA VENTILATORIA MECANICA RESPIRATORIA IMPULSO RESPIRATORIO
  • 11. RECAMBIO GASEOSO The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved
  • 12. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved Ventilación minuto (Ve) > 5 lpm y < 10 lpm CARGA VENTILATORIA MECANICA RESPIRATORIA IMPULSO RESPIRATORIO
  • 13. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • PO2 ≥ 60 torr en FiO2 ≤ 50% • PaCo2 en el nivel normal o 10 torr sobre el valor inicial • Ph: 7.30 – 7.45 • FR ≤ 35 rpm • FC ≤ 130 lpm • PAS > 90 mmHg OBJETIVOS DEL DESTETE VENTILATORIO
  • 14. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved MODO DE DESTETE VENTILATORIO
  • 15. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • Paciente consiente • Reposo semisentado • Conectar el circuito de tubo en T (TT): - Corrugado – fuente de O2 – Humidificador intercalado – TT - FiO2 10% mas del que se usa en VM • Duración suficiente de la prueba: 30 min PRUEBA DE TUBO EN T
  • 16. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • Permite la sincronización de respiraciones espontaneas y las asistidas por el respirador, limitada por el flujo y presión • SIMV: reducir la frecuencia mandatorio de 1 a 3 respiraciones cada vez • Monitorear pH en cada cambio • Permite una fácil transición entre el soporte respiratorio total y el destete SIMV Y SIMV + PS
  • 17. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • El nivel de presión de la vía aérea es preseleccionado mientras el paciente mantiene control y el tiempo inspiratorio, Vt, Vm y FR. • La inspiración comienza cuando el ventilador reconoce el esfuerzo inspiratorio del paciente por medio de un sistema de disparo y la rápida respuesta a pequeños cambios de presión • Con este método el paciente puede controlar su propia frecuencia, la duración de la inspiración y espiración • Mejora la eficacia de la respuesta espontanea y reduce el trabajo respiratorio y el consumo de O2 por los músculos respiratorios durante el destete previene la aparición de la fatiga diafragmática VENTILACION CON PRESION DE SOPORTE (PSV)
  • 18. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved • No es un verdadero Modo Ventilatorio en VM ya que no asiste en forma activa la inspiración • Es efectiva solo si el paciente respira espontáneamente • Se aplica cierta presión positiva en forma continua a través del ciclo respiratorio • CPAP, es una modalidad de respiración espontanea en la cual se mantiene una presión subatmosferica continua en la vía aérea MODO CPAP
  • 19. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved GASOMETRICOS • SaO2 < 90% con FiO2 < 0.5 • PaCO2 > 10 mmHg por encima del basal • pH < 7.30 HEMODINAMICOS • de la ]PAS > 30% o > 20 mmHg sobre basal • de la FC > 110 Lpm o > 25% sobre la basal • Hipoperfusion periférica - Shock RESPIRATORIOS • FR > 35 rpm • VT < 250 ml • Asincronia o respiración paradójica • Trabajo respiratorio incrementado NEUROLOGICOS • Disminución del nivel de conciencia • Agitación no controlable • Ansiedad excesiva CRITERIOS PARA INTERRUMPIR EL DESTETE
  • 20. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved SIGNOS DE SUFRIMIENTO RESPIRATORIO FR > 35 rpm SatO2 < 90% FC > 140 lpm PAS > 180 o < 90 mmHg Ansiedad, Agitación o Diaforesis
  • 21. The New England Journal of Medicine,. Downloaded from nejm.org on February 4, 2015. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved