COVID-19 Management:

Critical Care – OR Ventilators

All patients on ventilators must get either a machine check or an HME/HEPA filter change.
MACHINE CHECKS (DAYS ONLY – night time should just do all filter changes)
Look at the admission board to see when last machine checks were done.
Plan to perform 6 machine checks. Any machine checks done 3 days ago must be completed. After that prioritize the older ones OR if any patients will be away for travel (e.g., do the machine check while someone is at CT).
On your to do list, circle the room numbers that will will be machine checks and cross out room numbers that are unoccupied.
- Ensure machines in all unoccupied rooms are OFF.
HME/HEPA FILTERS CHANGES (days [when no machine check] and nights [all])
Any room not planned for a machine check should get an HME/HEPA filter change (see section below).
SUPPLY CART FOR VENTILATOR ROUNDS
Make sure the supply cart (stored in White Anesthesia Workroom) for ventilator rounds is stocked. (see picture)
- Top: HME/HEPA filters, isoflurane, open glove boxes, to do list
- Middle: viral filters (for expiratory limb), full circuits
- Bottom: CO2 absorbers, water traps

Please use the linked guide for machine checks. If you have any questions, contact Dan Saddawi-Konefka (his cell phone number is in the paging directory).

Replace blue HME/HEPA filter with new filter using linked guide. See video (1 minute), also embedded below.

All Days and Nights
Refill isoflurane to top line if isoflurane in use (or potentially in use)
- If being used, make sure that alarm limit for iso is just under the set value
Ensure appropriate equipment present in room (see linked photo)
- On top: AMBU bag with PEEP valve and viral filter; clamp with gauze, mask, manometer
- Top Drawer: Viral filter, CO2 sample line, PEEP valve, Water trap
- Bottom Drawer: Extra circuit
Record ETT depth and cuff pressure
- Goal cuff pressure 20-30; if <20, fill to 20
- If there is cuff leak at 30, increase cuff pressure until it is gone and inform the ICU team
Replace CO2 absorber if significant condensation
Replace circuit and expiratory limb viral filter if significant condensation
Check scavenger
- Make sure it is turned on and float is in correct position.
Ensure that Tip:Tinsp is set to 0%.
- Because of resistance that builds across filters over time, the default 10% may be misleading. This is unique to closed circuit ventilation. See video (8 minutes), also embedded below.

Use this linked sheet.
When completely filled out, tape to the right of the Admission board, and tell Responding Clinicians to record updates (ETT depth / cuff pressure, most recent filter change / machine check) in their progress notes.

After ventilator rounds are done, please wipe down all rails and surfaces with hospital-approved wipes.
Return it to White 3 anesthesia workroom.
Restock it for the next shift.

(from door, to minimize unnecessary exposure)

Once an hour, look at the ventilators from the door.
Take note of:
- Ventilator setting (mode, parameters)
- Pressures (Peak, PEEP)
- Volumes
- Respiratory rate
- Gases (FiO2, EtCO2, FiCO2, isoflurane)
Document the ventilator mode, and data validate all of the measurements and settings in Flowsheets in Epic.
NOTE: Plateau pressures are NOT reliable with short inspiratory pauses (because of resistance that builds across filters over time). This is unique to closed circuit ventilation. So, do not document plateau pressures unless you are doing an actual check with 40% inspiratory pause. See this video that explains the deceptive plateau pressures, also embedded below.

Once vent team finishes ventilator rounds, update ETT depth, cuff pressures, and most recent dates/times for machine check and viral filters in your progress note. A respiratory progress note template is available at .covidresp.

Consider changing the HME/HEPA filter.
- If peak pressures are increasing significantly over time, consider a resistance to flow issue (e.g., kinked tube, secretions, etc). Keep a low threshold to change the anesthesia circuit, as this may imply a clogged filter (Video). If you need help changing the filter, call the ICU Swing resident.
  - A slow expiratory limb could imply HEPA filter clogging – see PDF

ALL STAFF entering the room needs an N95 as subtle leaks may be occurring proximal to the viral filter

Check cuff pressure and ETT depth
Ensure that in-line suction device is not entraining air
- Collaborate with nursing staff about being vigilant in pulling back the in-line suction catheter to the solid blue line
- There should be two caps on the in-line suction
- Check that all caps are tight on in-line suction: proximally where the saline bullet irrigation attaches as well as the distal end where wall suction line attaches
Tighten all circuit connections from the patient to the anesthesia machine, and consider replacing circuit.