Friday, March 27, 2020

One Ventilator and Multiple Patients?

Economy does not equal quality.

An anticipated shortage of hospital ventilators has led some organizations to look at potential innovative ways to maximum the use of available hospital equipment.  Undoubtedly, these are trying times for critical care docs.

However, numerous organizations have highlighted major potential risks associated with these measures, including this list provided by the Society for Critical Care Medicine:

  • Volumes would go to the most compliant lung segments.
  • Positive end-expiratory pressure, which is of critical importance in these patients, would be impossible to manage.
  • Monitoring patients and measuring pulmonary mechanics would be challenging, if not impossible.
  • Alarm monitoring and management would not be feasible.
  • Individualized management for clinical improvement or deterioration would be impossible.
  • In the case of a cardiac arrest, ventilation to all patients would need to be stopped to allow the change to bag ventilation without aerosolizing the virus and exposing healthcare workers. This circumstance also would alter breath delivery dynamics to the other patients.
  • The added circuit volume defeats the operational self-test (the test fails). The clinician would be required to operate the ventilator without a successful test, adding to errors in the measurement.
  • Additional external monitoring would be required. The ventilator monitors the average pressures and volumes.
  • Even if all patients connected to a single ventilator have the same clinical features at initiation, they could deteriorate and recover at different rates, and distribution of gas to each patient would be unequal and unmonitored. The sickest patient would get the smallest tidal volume and the improving patient would get the largest tidal volume.
  • The greatest risks occur with sudden deterioration of a single patient (e.g., pneumothorax, kinked endotracheal tube), with the balance of ventilation distributed to the other patients.
  • Finally, there are ethical issues. If the ventilator can be lifesaving for a single individual, using it on more than one patient at a time risks life-threatening treatment failure for all of them.

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