7Immediate complications of endotracheal intubation Severe hypotension Severe hypoxia Esophageal intubation Intubation of RMB Dental injury Aspiration Pneumothorax Cardiac arrest Death
8Injuries to Face, Lips and Oropharynx Trauma to the lip and cheeks from the tube tiePerioral herpesInjuries to the tongue particularly when entrapped between the endotracheal tube and the lower teethPressure ulcers to the palate and oropharynx are very uncommon
14Upper gastrointestinal hemorrhage: StressDecreased gastric mucosal protection secondary to a fall in splanchnic blood flowDecreased motility of stomach and small intestine
15Upper gastrointestinal hemorrhage: StressDecreased gastric mucosa protectionsecondary to a fall in splanchnic blood flowDecreased motility of stomach and small intestine
16Liver and GallbladderReduction in portal venous flow secondary to the fall in cardiac outputHepatic engorgementElevation of serum transaminasesand hyperbilirubinemiaReduction in drug clearance secondary to reduction of hepatic blood flow
19Renal Effects of MVThe usual renal response to reduction of cardiac output and mean arterial pressureReduction in urine output secondary to a fall in the trans mural pressure of the right atrium that results in reduction of the secretion of atrial naturitic peptide and the activation of renin-angiotensin-aldosterone system and pituitary vasopressin secretion
20Neurological Functions during Mechanical Ventilation Decreased intracerebral blood volumePEEP reduces cerebral perfusion pressure by decreasing venous return and increasing intracranial pressureDisrupt Sleep
21Mechanisms by which mechanical Ventilation Disrupt Sleep
22Asynchrony with the ventilator Fighting the ventilatorsInconsistent tidal volumeIncrease work of breathingBarotraumas and thoracic air leakInsufficient gas exchangeDisturbances in the cerebral blood flow
25Ventilator-associated Pneumonia Definition of VAPThe development of a new pneumonia at least 48 hrs after initiation of mechanical ventilation
26Independent risk factors for the development of VAP in children ImmunodeficiencyImmunosuppressionNeuromuscular blockade
27Additional risk factors genetic syndromes with neuromuscular weaknessburnssteroid administrationuse of total parenteral nutritionantibiotic uselonger ICU lengths of stayuse of indwelling cathetersuse of H2-receptor-blocker therapyreintubationtransport out of the ICU while intubatednasoenteric tubein-line nebulizersmanipulation of ventilator circuits
28Cumulative risk of developing VAP with the duration of mechanical ventilation.
29Although length of time with an endotracheal tube in place increases the risk of nosocomial pneumonia, the greatest risk is during the first 2 weeks of intubation.Nearly all intubated children will have colonization of their endotracheal tube with hospital-acquired organisms by a mean of 5 days.
30The most common organisms isolated in the developing countries Enterobacteriaceae spp. (26%)Pseudomonas aeruginosa (26%), with 60% resistant to fluoroquinolonesS. aureus (22%), with 84% methicillin resistantAcinetobacter spp. (20%)
31The bacterial organisms identified most often are gram-negative bacilli, with P. aeruginosa being the most common species identified in PICUs.The second most common bacterial etiology of pediatric nosocomial pneumonia is the gram-positive organisms. The frequently isolated bacteria are S. aureus and coagulase-negative staphylococci.
32S. epidermidis nosocomial pneumonia is a common cause in the NICU population and is typically the result of hematogenous spread.Anaerobic nosocomial pneumonia is rare in the pediatric population but accounts for 23% of nosocomial pneumonias in adults.
33Viruses, predominantly RSV common cause of nosocomial respiratory infections.Fungal infections are exceedingly rare but may occur in children who are immunosuppressed, especially if they frequently receive broad-spectrum antibiotics.
34Diagnosis of VAP in children clinical & without the use of bronchoscopy
36The CDC criteria for diagnosis of VAP in infants and children are evidence of new or progressive infiltrate, fever or leukopenia with new onset of purulent sputum, and increased sputum production.
37Recognized methods to determine the causative organism positive blood cultures that cannot be attributed to another source,positive cultures from pleural fluid,a positive bronchoalveolar lavage specimen despite its limitations,>5% of cells from bronchoalveolar lavage containing intracellular bacteria,a positive culture of lung parenchyma,histopathologic evidence of fungal hyphae
39Once nosocomial pneumonia is suspected, empiric treatment should be started, covering the most likely organisms with consideration of the hospital's resistance patterns.When a specific causative is identified, antibiotic coverage should be adjusted.If the diagnostic workup is negative and a viral etiology is suspected, the discontinuation of antibiotics may be considered.
40Proposed bundle for prevention of ventilator- associated pneumonia in infants and children Items to prevent iatrogenic spread of infectionAdherence to good hand hygiene practices Use of universal precautions Use of appropriate isolation techniques based on infectious organism (proven or suspected)Items to prevent aspiration of gastric contents Elevate the head of the bed between 30 and 45 degrees Monitor/drain gastric contentsItems to improve oral hygiene Oral rinsing/cleaning with chlorhexidine (0.12%) Use of toothbrush and oral swabs in daily oral care
42Endotracheal Suctioning? Endotracheal suctioning should not be a routine intervention, but it should be performed when obstructive secretions are indicated by clinical assessment of a patient’s respiratory status.The instillation of physiological saline should not be a routine part of endotracheal suctioning.
43Ventilator-associated Lung Injury (VALI) Definition: lung damage caused by application of positive or negative pressure to the lung by mechanical ventilation.oxygen toxicity
44Mechanisms of VALIVolutrauma: damage caused by over-distension. High volume or high-end inspiratory volume injuryBarotrauma: high pressure induced lung damageSimilar histological appearance, high-permeability pulmonary edema in uninjured lung & exacerbated damage in injured lungAlveolar over-distention rather than pressure itself causes lung injury
45Mechanisms of VALIAtelectotrauma: lung injury associated with repeated recruitment and collapse, low end-expiratory volume injuryTheoretically prevented by using a level of positive end-expiratory pressure (PEEP) greater than the lower inflection point of the pressure volume curveThe pressure needed to reopen an occluded airway is inversely proportional to its diameter → damage occurs distally
46Mechanisms of VALIBiotrauma: pulmonary and systemic inflammation caused by the release of mediators from lungs subjected to injurious mechanical ventilationProtective ventilation can lower concentration of cytokines in lung and plasma
47Oxygen toxicityFiO2 > 60% for more than 72 hoursElevated intrathoracic pressures with decreased venous return, intravascular volume repletion