  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 SZEGEDI INTENZÍVES TALÁLKOZÓ 2010 november 13. A Hamilton Medical engedélyével Jövő a jelenben lélegeztetés à la Hamilton Medical Fischer Gábor, Anamed Kft.

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Három téma: Biztonságról, mert a biztonsági határok között menedzselt lélegeztetés-vezetés terhet vesz le személyzet válláról Biztonságról, mert a célorientáltan átlátható lélegztetés- monitorozás segíti a gyorsabb helyzetértékelést Biztonságról, mert a teljes zárthurkú lélegeztetés segít finomabb határok között tartani a beteg paramétereit, a gyógyító által meghatározott célok alapján

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Az USA egészségügyi biztonsági nyilvántartása: – haláleset évente orvosi hibából (American Hospital Association, Hospital Stat. 1999)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Az USA polgári repülés biztonsági nyilvántartása: 11 baleseti haláleset a polgári repülésben (2004). (NTSB database,

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Hiba  a nővérek túlterheltsége miatt Scott LD. J Nurs Adm Hiba  rezidensek túldolgoztatása Baldwin DC. Acad Med Kiégés  az intenzíves nővérek 33%-a Poncet MC. Am. J. Respir. Crit. Care Med Kiégés  Az intenzíves orvosok 47%-a Embriaco N. Am. J. Respir. Crit. Care Med Az erőforrások hiánya okozta klinikai problémák:

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Needham CCM 2005 Increase number of ventilated patients

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Resources are limited

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 The demand will not be satisfied Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2008 Revision. Committee on Quality of Healthcare in America. To Err is Human. Institute of Medicine, 1999 Angus D. JAMA 2000 Martin GS. CCM 2006 Poncet MC. AJRCCM 2007 Embriaco N. AJRCCM2007 Need of Intensivists Intensivists available DANGER!!! Megfelelő tervezéssel bizonyos tevékenység alól tehermentesíthető a személyzet, és figyelmét, energiáját a betegre összpontosíthatja.

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Why comparing aviation and critical care?

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Aviation and critical care are high-risk industries „Over the years, healthcare services have developed a ‚cover-up‘ culture where mistakes have been hidden … However, this traditional attitude is beginning to change as we learn from other industries where great harm is possible, e.g. aviation and nuclear power, which approach the concept of safety with a no-fault or limited fault approach.“ Jean-Louis Vincent Head of Intensive Care, Erasme Hospital Free Unversity of Brussels, Belgium (Editorial to ICU Management 6:1:2006)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 A múlt pilótafülkéje… (C141B)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 És a jelen (új Boeing 787):

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 The cockpit of today (new Boeing 787) Simplifies procedures and reduces … training … predicts vertical path relative to terrain … providing excellent situational awareness

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 The past machine data action  Integrate  Interprete  Evaluate

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Today machine visualization action  Evaluate  Integrate  Interprete

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Make the unexpected obvious

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Milyen gépet szeretnénk a beteg mellett látni?  CMV, PCV, APRV, BiPAP, DuoPAP, SIMV, IPPV, CPPV, PCV, PS, IRV, PAV, ASB, MMV, A/C, IMV, CPAP, CPPB, PPS, APV, ASV, PRVC, VS, CMV+, AutoMode, VAPS, PC, ITG, HFV, HFJV, HFO, AutoFlow,

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Too many modes

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Too many settings

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00  Esetleg ilyet szeretnénk…

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Hogyan használjuk… Mit tudunk? A beteg testmagasságát, esetleg a betegségeit Mit lenne jó tudni? A lélegeztetési módot és a paramétereket (Szabályok, protokolok, stb.) És mindezt folyamatosan monitorozva, újtaértékelve…

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Kiút a dzsungelből  FiO 2  PEE P VAVA TpTp  Rat e  P sup  P ins p TiTi TeTe  FiO 2  PEEP VtVt  SIM V  PCV  PSV  Alveolar Ventilation Hagyományos: Ez lenne a cél: O2O2

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  Optimális paraméterek: Hogyan választunk frekvenciát és térfogatot?  Elasztikus munka  Rezisztiv munka

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  Minimális légzési munka: Frekvencia WOB in Joule/sec 1+2a*RCe*(MV-V‘ D )/V D -1 f-target = a*RCe Testtömeg Perctérfogat

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  V T kiszámítása 00  500  1'000  1'500  2'000 00  10  20  30  40  Frekvencia  Vt in ml  f cél  Vt cél

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  Tüdőbarát stratégia  Megelőzendő:  a:apnea  b:volu/barotrauma  c:AutoPEEP  d:excessive V’ D /tachypnea 00  500  1'000  1'500  2'000 00  10  20  30  40  Légzésszám  Vt in ml aa bb cc dd

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Optimális légzés: Beteg újravizsgálata légzésenként (RC e’ V T’ f)  Optimális légzésminta újraszámítása (V Target’ f Target )  P insp & mand.rate beállítása (P insp’ f mand’ I:E arány)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Összefoglalva: Mind aktív mind passzív betegeken működik, a spontán aktivitást automaikusan érzékeli Magába foglalja a PRVC-SIMV-Spont/PS módokat, automatikus paraméter-állítással Magába foglalja az MMV módot Megelőzi a felületes légzést (RSB) Megelőzi a nagy volumeneket és alacsony frekvenciát Megelőzi az apnoét Kevesebb riasztás és rutin manipuláció

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Elhelyezve a többiek közt: INTUBATION FULL SUPPORTWEANING EXTUBATION ASV ® PAV NAVA ® Time SmartCare ®

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Az első teljes zárthurkú lélegeztetési megoldás mind a ventilláció mind az oxigenizácó céljából, az intubációtól az extubációig, a HAILTON MEDICAL-tól megszokott átláthatósággal, invazív eszközök nélkül INTELLiVENT ® -ASV

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent®: Comparison

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Ventilator delivers user defined breaths Patient Assessment of physiological status Clinician Standard ventilators Adjustment of individual settings Conventional mechanical ventilation

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Automatic adjustment of RR and VT to changing lung conditions Patient Assessment of physiological status Clinician State-of-the-art HAMILTON ventilators Adjustment of oxygenation and MV ASV – a first step into automation (1998)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Patient Monitoring of patient conditions Clinician HAMILTON-S1 Decision about therapy goals Automatic adjustment of ventilation and oxygenation to changing patient needs Continuous monitoring of lung mechanic and patients physiological status INTELLiVENT-ASV – full automation (2010)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Adaptive support ventilation (ASV) Still 3 regulators

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent®

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Oxygenation Ventilation What is INTELLiVENT-ASV automating?

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent®: Automatic controllers

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Reliable NONINVASIVE sensor technology for physiological input

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Mainstream CO2 sensor (Capnostat5) Intellivent: Physiological input for ventilation

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Pulse oxymetry with artefact rejection Intellivent: Physiological input for oxygenation

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Overview  MinVol ASV automatic on EtCO 2 /RR  PEEP/FiO 2 automatic on SpO 2  PEEP versus FiO 2 on: - ARDSnet tables (FiO 2 /PEEP table and Open lung concept) - PEEP limitation by the user + hemodynamic (HLI)  Dedicated Interface

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Depends on patient type and conditions IntelliVent ® Targets: EtCO 2 /RRspont and SpO 2 - Knowledge-based - Permissiveness vs level of support - Anti-Oscillation & Auto-Stabilization - Gradient [Pa-et]CO 2 “in” & adjustable - Flexible

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Minute Volume (MV) Tidal Volume (VT) Respiratory Rate (RR) Pressure Support (PS) Inspiratory Time (TI) …are automatically adjusted and constantly optimized to keep etCO2 and RRspont in the target range. Automation of ventilation

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Detailed ventilation map

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : EtCO 2 targets (ventilation map) Increase MVDecrease MV

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Target E T CO mmHg (Ppeak ≤ 25) for passive COPD

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Target E T CO mmHg for passive brain injury

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Fine %MV adjustment to target the middle of range E T CO 2 acceptable Treatment kept constant Ventilation controller and normal PETCO 2 (passive patient)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Breath by breath %MV increase proportional to current E T CO 2 – target E T CO 2 (max stepsize= 5%MV) E T CO 2 above range. Increasing %MV + Ventilation controller and high PETCO 2 (passive patient)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Breath by breath %MV decrease proportional to current E T CO 2 – target E T CO 2 (max stepsize= 5%MV) E T CO 2 below range. Decreasing %MV + Ventilation controller and low PETCO 2 (passive patient)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Ventillation controller in active patients: Target RR for all conditions except brain injury Keep RRspont within RRtarget + %MV/10

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Ventilation controller: Target RRspont within range RRspont acceptable Treatment is kept constant

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 RR above accepted range. Increasing %MV Breath by breath %MV increase proportional to RRspont – %MV/10 -RRtarget (max stepsize= 5%MV) Ventilation controller: Target RRspont above range

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Ventilation controller: PETCO 2 offset - PETCO 2 limits are flexible; -PETCO 2 offset may be regulated by user; -PETCO 2 limits are changed ± 5 mmHg (30-36 or 40-46)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 FiO 2 PEEP Oxygenation parameters

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Detailed oxygenation map

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Oxygenation controller

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : SpO 2 targets (oxygenation map) Decrease FiO 2 /PEEP Increase FiO 2 /PEEP

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Fine FiO 2 adjustment to target the middle of range SpO 2 acceptable Treatment kept constant Target SpO 2 in Intellivent (SpO 2 within range) +

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Decrease of FiO 2 and/or PEEP every 60 s SpO 2 above expected Consider decreasing treatment Target SpO 2 in Intellivent (SpO 2 above range) +

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Increase of FiO 2 and/or PEEP every 30 (360) s SpO 2 too low Increasing treatment Target SpO 2 in Intellivent (SpO 2 below range)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Emergency increase to 100% FiO 2 SpO 2 critically low Increasing treatment rapidly Target SpO 2 in Intellivent (SpO 2 extremely low) +

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Target SpO % for most patients (with offset)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 FiO 2 PEEP PEEP- FiO 2 curve

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Relation between oxygen and PEEP (increasing therapy)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : ARDSnet Oxygen / PEEP table

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Relation between oxygen and PEEP (decreasing therapy)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Oxygenation controller Fine FiO 2 controller Fast FiO 2 controller (100% O 2 ) PEEP and FiO 2 controller

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 PEEP PEEP decrease by 1 cmH 2 O every 360 s (slow: on the loop) or 30 s (fast: outside the loop) PEEP controller (decreasing)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 PEEP PEEP increase by 1 cmH 2 O every 360 s PEEP controller (increasing)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 APRV as a recruitment tool Short release time 40 cmH 2 O for 20 sec

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 PEEP Ventilation and Oxygenation controller

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® Ventilation controller: PUSH TO WEAN If FiO 2 < 40% and PEEP < 8 cmH 2 O and EtCO 2 within acceptable ranges for 25 minutes: 5 minutes PUSH TO WEAN trial

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® Oxygenation controller: PUSH TO WEAN If SpO 2 within acceptable ranges AND Patient above the line AND FiO 2 automatic for > 60 minutes AND No PEEP changes in the last 30 minutes Reduce FiO 2 stepwise

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Unique graphical user interface

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Ventilation/Oxygenation horizons

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Ventilation/Oxygenation maps

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : practically speaking… Based on “simple” technology (SpO 2 /EtCO 2 ) Based on Knowledge/Clinical practices Based on well-known guidelines (ARDSnet) Flexible (Manual/Auto – Acceptable ranges)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® flexibility: Full auto or partial manually Depends on set patient’s condition or doctor’s choice

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Visual trends

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Reduce complexity

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® reduces complexity by … … giving guidance on complex decision making … visualizing complex information in an intuitive way … implementing and supporting protocolized care

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Supporting protocolized care Using standardized therapy concepts without compliance issues: ARDSnet, OpenLung concept, permissive hypercapnia Providing transparency of what the device is doing. (Clinicians remain in the driver seat) (Explaining the WHY)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 More time for the patient

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 IntelliVent ® : Reducing the burden of routine tasks and adjustments Continuous adaptation of ventilation and oxygenation 11 22 … 80% off all adjustments are routine modifications …

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 INTELLiVENT-ASV: PEEP/FiO 2 adjustment Who would wean manually a patient so fast from oxygen? (38% O 2 reduction in 5 min) 5 min Who would wean manually a patient so fast from oxygen? (38% O 2 reduction in 5 min)

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Intellivent: Reducing stress for the entire staff Nuisance alarms are reduced by continuous adaption of ventilation to patient needs. Less alarms and ventilator adjustments during transient states of the patient Automatic adjustments of ventilator settings (like FiO 2 ) before patient conditions deteriorates.

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 INTELLIVENT-ASV increases safety by … … reducing the potential for mistakes and errors … reducing the risk of escalations … applying lung protective rules

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Reducing the risk of escalations When do clinicians normally check and adjust oxygen? After ABG, during periodic round and when an alarm occurs … … but than patient is already desaturating. With INTELLiVENT-ASV the patient will get optimal oxygenation!

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 Gives more time Reduces Complexity Increases safety The benefits of INTELLiVENT-ASV

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 There is no application like INTELLiVENT ® There is no other device like HAMILTON-S1

  7.15  8.30  5.50  8.00   6.40  5.70  0.45  0.30  5.90  6.40   9.00  7.00 SZEGEDI INTENZÍVES TALÁLKOZÓ 2010 november 13. Köszönöm megtisztelő figyelmüket