Here's the question: the patient with Sub-arachnoid bleeding, without ALI/ARDS, in emergency setting, do you set the "usual" peep (peep: around 5 cmH2O)? The protocol here is peep 5 to everybody, except non drained pneumothorax (!) and cranial trauma. For that last part(cranial trauma),we have in hand several studies that indicate that, with a patient at 30 degrees, peep levels up to 10 (and one study suggested 15!), could be tolerated. But we are here in a primary trauma center: intra-cranial pressure is not known, that is why we wait.
But, we have arguments about SAH? Do we consider it to be a traumatic (spontaneous)cranial injury, thus applying the same protocol, or is it considered like thrombotic a stroke, in which peep is installed as usual?
So, before the surgical intervention, do we peep theses patients, or we zeep them and wait?
Thanks you all for your input!This message has been edited. Last edited by: Renton,
I use PEEP of atleast 5 on everyone, period. I have not found any evidence that showed ZPEEP has being benificial, but I have found many that show inadequate PEEP as being Bad.
I used to work at a neurological center and our rule was that for the first 72 hours of a new bleed no PEEP to be utilized.
This is old school, I know, but any increase in interthoracic pressure can possibly lead to increased ICPs and bleeding.
Thanks to both light and Bill C.
Your answers summerise the general feeling in the RT departement. We decided that in the event of a patient without a ICP line and no evidence of ALI/ARDS, we will withold peep till we have the agrement of the neuro/trauma doctors.
Renton I have also experience this. The "old school" dogma was no PEEP on head cases with hyperventilation but now you normalize gases and keep O2 in normal range.
There is a new world traumatic brain text released which has lots of hyperventilation and oxygention data. Admittedly I haven't yet read it all. I don't have it in frontof me to give you the citation but I'll try to get it later.
I still get orders for both PEEP and ZEEP in ER. In ICU with ICP monitor I have never encountered ZEEP. Presuming a normal V/Q I guess you really don't need to worry much however the same argument could be used to support normal PEEP levels provided they aren't impeding venous return. As soon as your parameters negatively impact hemodynamics such as MAP there will be issues with CPP consequently of course ICP. We use to do a tonne of jugular venous bulb extractions ratios as well in order to maximize ventilation and oxygenation which have also fallen to the wayside. It seems that because of being so invasive and tenous in results they tend to reserve them for ditch patients. I guess long in short is they didn't really alter mortality. Well that is based on my limited experience anyway.
It seeems there are so many things happening with the traumatic brain protocol from hypertonic/hyperosmotic, hypothermia, and so that a little PEEP which is not altering VR is not likely altering the outcome either. Having said all that I can't imagine erring on the side of caution isn't a bad thing either.
Just some reflections nothing terribly imperic sorry.