![Nutrition Protocol
The daily energy expenditure is expressed as basal energy expenditure[BEE]
For men- BEE[ KCAL/24HRS] = 66+[13.7× Wt]+[5 × ht]-[6.8 × age]
For women- BEE[KCAL/24HRS] = 65.5+[9.6 × Wt]+[1.8 × ht]-[4.7 × age]
More simplified equation is BEE=25 × Wt [kg]
For fever BEE × 1.1
For mild stress BEE × 1.2
For moderate stress BEE × 1.4
For severe stress BEE × 1.6
• requirement of energy / day 30 kcal / kg / Day (± 5kcal)](https://image.slidesharecdn.com/protocolandguidelineincriticalcareppt-210308081614/85/Protocol-and-guideline-in-critical-care-ppt-3-320.jpg)
![Low tidal volume Ventilation
• Calculate the ideal body weight of the patient
o Male=50 + 0.91[height(cm)-152.4]kg
o Female=45.5 + 0.91 [height(cm)-152.4]kg
• Mode: Pressure controlled ventilation (PCV) or volume controlled ventilation
(VCV)
• Aim for tidal volume of 6 mL/kg IBW while not exceeding Pplat of 30 cmH2O
• If Pplat > 30 cmH2O, decrease tidal volume by 1 mL/kg up to 4 mL/kg. If Pplat <
25 cmH2O tidal volume may be increased by 1mL/kg up to 8 mL/Kg if Pplat
remains ≤ 25 cmH2O
Adjust FIO2 and PEEP (cm H2O) to maintain PaO2 55–80 mm Hg.
• Use PEEP 8-12 cmH2O if PaO2/FIO2 ≥ 250
• Use PEEP > 12 cmH2O if PaO2/FIO2 < 250
Keep the arterial PH > 7.1
• pH <7.30, increase rate to maximum 35 breaths/min
• pH <7.30 and rate = 35, consider bicarbonate administration
• pH <7.15, consider increase in tidal volume by 1mL/kg even if Pplat > 30 cmH2O](https://image.slidesharecdn.com/protocolandguidelineincriticalcareppt-210308081614/85/Protocol-and-guideline-in-critical-care-ppt-15-320.jpg)
![Apnea test
Absence of a breathing drive tested with a CO2 challenge
Procedure
• Adjust vasopressors to a systolic blood pressure ≥100 mm Hg.
• Preoxygenate for at least 10 minutes with 100% oxygen to a PaO2
>200 mm Hg.
• Reduce ventilation frequency to 10 breaths per minute to eucapnia.
• Reduce PEEP to 5 cm H2O
• If pulse oximetry oxygen saturation remains >95%, obtain a baseline
blood gas (partial pressure of oxygen [PaO2 ], PaCO2, pH,
bicarbonate, base excess).
• Disconnect the patient from the ventilator.
• Preserve oxygenation (e.g., place an insufflation catheter through
the endotracheal tube and close to the level of the carina and deliver
100% O2 at 6 L/min).
• Look closely for respiratory movements for 8–10 minutes.
Respiration is defined as abdominal or chest excursions and may
include a brief gasp.](https://image.slidesharecdn.com/protocolandguidelineincriticalcareppt-210308081614/85/Protocol-and-guideline-in-critical-care-ppt-46-320.jpg)
Protocol and guideline in critical care ppt
- 1. PROTOCOL AND GUIDELINE IN CRITICAL CARE: NONPHARMACOLOGICAL DR. VINOD SINGH JATAV SR NEUROLOGY GMC KOTA
- 2. Outline 1. Nutrition Protocol 2. Mechanical Ventilation Protocol 3. Heating, ventilation and air conditioning (HVAC) in intensive care unit 4. Sepsis Management Protocol 5. Aspiration pneumonia 6. Prophylaxis of Deep Venous Thrombosis 7. Brain Death 8. Organ donation guideline 9. Biomedical waste management
- 3. Nutrition Protocol The daily energy expenditure is expressed as basal energy expenditure[BEE] For men- BEE[ KCAL/24HRS] = 66+[13.7× Wt]+[5 × ht]-[6.8 × age] For women- BEE[KCAL/24HRS] = 65.5+[9.6 × Wt]+[1.8 × ht]-[4.7 × age] More simplified equation is BEE=25 × Wt [kg] For fever BEE × 1.1 For mild stress BEE × 1.2 For moderate stress BEE × 1.4 For severe stress BEE × 1.6 • requirement of energy / day 30 kcal / kg / Day (± 5kcal)
- 4. Modifications in the requirement of the calorie 30 kcal/kg/day • Undernourished +10% • Each degree Cel rise in temp +10% • Post operative major surgery +15% • Severe sepsis/ trauma +25% • Extensive burns +35% (Major Catabolic States)
- 5. • Enteral nutrition- If gut is functioning, use the gut advantages Noninvasive, No I.V. Line required – no line related complications. Requires less nursing care. Maintains the structural and physiological integrity of entire GI System and its mucosa. Maintains the physiological integrity of liver, gall bladder, pancreas Prevents translocation of microoganism in gut. • Maintains / improves immunological status. • Cost effective. • Less complications as compare to parenteral nutrition.
- 6. Contraindications • Bowel obstruction • Peritonitis • Ileus • Intestinal ischaemia / necrosis • Anastomosis of gut - initially • Short bowel syndrome • Ulcerative colitis
- 7. Parenteral Nutrition • Indication If there is evidence of protein calorie malnutrition (recent weight loss > 10-15% or actual body weight < 90% of IBW) EN is not feasible If a patient is malnourished and is expected to undergo major upper GI surgery • Administration a. High osmolarity PN through central line b. Low osmolarity (<850 mOsmol/L) peripheral venous line
- 8. Single nutrient solution Dextrose – 10%, 25%, 50%. Lipid -10%, 20%, 30%. Amino Acid solution5%, 10%. Two-in-one Solution Amino Acid Solution + (Electrolytes) Dextrose solution Volume – 1.5 – 2L Cal – 1500 - 2000 kcal Three-in-one solution (AIO) •All three components – Dextrose, Fat, Amino Acids and electrolytes are supplied in a single three chambered pack. •Mixed together just before I.V. infusion with many advantages. •Volume – 2L •Calorie – 2000kcal
- 9. Single nutrient solution Two-in-one Solution Three-in-one solution (AIO)
- 10. Components a. Non-protein calorie should be provided at 20-25 kcal/kg/day b. Protein should be supplied at least 1-1.5 g/kg/day c. Lipids are provided at 0.7-1.5 g/kg/day d. Glucose : fat calorie ratio are around 60:40 or 70:30 of non- protein calories in order to avoid hyperlipidemia e. Daily dose of multivitamins and trace element should be included f. Electrolyte is added according to serum levels Obese patients a. For all classes of obesity where BMI is >30, the goal of the energy goal should not exceed 60% to 70% of target energy requirements b. Proteins are provided at ≥ 2 g/kg IBW/day for BMI 30-40 and at ≥ 2.5 g/kg IBW/day for BMI ≥ 40 Severe Hepatic Encephalopathy: protein restrict to 0.6 g/kg /d
- 11. Complications 1. Related to I.V. line - A) Due to insertion - Injury to Nerves, blood vessels, pneumothorax, infusion of PN solution into plueral cavity. B) Infection C) Thrombophlebitis D) Air Embolism. 2. Electrolytes imbalance 3. Dehydration or overhydration (hyperosmotic diuresis) . 4. Glucose related – hyper & hypoglycaemia, ↑ CO2 prod. 5. Gall bladder - Cholelithiasis and chlecystitis 6. Liver - hepatomegaly, fatty changes, elevated enzymes. 7. Lipid Related – hyperlipidaemia - LCT 8. Immunosuppression – accumulation of unmetabolized free fatty acids (LCT) in blood PGE2 - immunosuppressant. 9. Deterioration of gut - functional and structural integrity of gut is lost
- 12. Nutrition Protocol Estimation of Nutritional Requirement
- 13. Mechanical Ventilation Protocol Indication • Acute lung injury or ARDS • Vital capacity < 15ml/kg • Minute ventilation < 10L/m • Failure of secretion clearance • Respiratory muscle fatigue • GCS <8 • RR >35 • Hypoxia pCo2>55mmHg, pO2<60mmHg • Severe acidosis (pH<7.25) Contraindication • Pneumothorax, untreated • Medical futility
- 14. Mode • Controlled mandatory ventilation Suitable when pt has no breathing effort or under heavy sedation or muscle relaxant • Assist control (AC)- mechanical breath time triggered (control) or pt triggered( assist) Use for pts have stable respiratory drive • SIMV- used for weaning and provide backup when pt tired • PCV- augment TV of spontaneous breathing pt used with SIMV in difficult to wean pt. • CPAP- provide positive pressure during both inspiration and expiration
- 15. Low tidal volume Ventilation • Calculate the ideal body weight of the patient o Male=50 + 0.91[height(cm)-152.4]kg o Female=45.5 + 0.91 [height(cm)-152.4]kg • Mode: Pressure controlled ventilation (PCV) or volume controlled ventilation (VCV) • Aim for tidal volume of 6 mL/kg IBW while not exceeding Pplat of 30 cmH2O • If Pplat > 30 cmH2O, decrease tidal volume by 1 mL/kg up to 4 mL/kg. If Pplat < 25 cmH2O tidal volume may be increased by 1mL/kg up to 8 mL/Kg if Pplat remains ≤ 25 cmH2O Adjust FIO2 and PEEP (cm H2O) to maintain PaO2 55–80 mm Hg. • Use PEEP 8-12 cmH2O if PaO2/FIO2 ≥ 250 • Use PEEP > 12 cmH2O if PaO2/FIO2 < 250 Keep the arterial PH > 7.1 • pH <7.30, increase rate to maximum 35 breaths/min • pH <7.30 and rate = 35, consider bicarbonate administration • pH <7.15, consider increase in tidal volume by 1mL/kg even if Pplat > 30 cmH2O
- 16. • Weaning of Mechanical ventilation weaning process should begin very soon after intubation The cause of the patients' initial respiratory failure must be significantly improved repeated at least on a daily basis. The patient must be awake, cooperative hemodyamically stable and able to cough and protect airway before extubation. • Risk factors of extubation failure Impaired neurological status Poor cough Increased secretion High APACHE score at the time of weaning Positive fluid balance Age > 65 ys Chronic respiratory disease Chronic cardiac disease
- 17. Assessment of readiness to wean Clinical assessment • Resolution of acute phase of disease for which patient was intubated. • Adequate cough • Absence of excessive tracheobronchial secretion Objective criteria • Adequate oxygenation: PaO2>60 mmHg with PEEP ≤ 8 cmH2O, SaO2≥90%, FIO2≤0.5, PaO2/FIO2 > 200 • Respiratory rate < 30 /min • PH and PaCO2 appropriate for patients’ baseline respiratory status. • Hemodynamically stable: minimal or no vasopressor /inotropes, no evidence of myocardial ischemia • HR< 140 beats/min • Patient is arousable or Glasgow Coma Scale (GCS) ≥ 13
- 18. • Spontaneous breathing trial o Ventilator o T-Piece • Protocol for SBT o Allow 30 to 120 minutes of initial trial of spontaneous breathing o Increase the FIO2 by 10% for the period of spontaneous breathing o SBT is considered failure when patients develop respiratory, cardiovascular, or neurological disability. • Criteria of successful SBT o Gas exchange acceptable (SPO2≥90%; PaO2≥60 mmHg; PH ≥ 7.32; increase in PaCO2 ≤ 10 mmHg from the start of the trial o Stable respiratory rate (RR ≤ 30-35 breaths /min, change in RR < 50%) o Hemodynamically stable (HR < 120-140, HR increase by less than 20%, SBP > 90 mmHg and < 180 mmHg, change in SBP < 20% o No significant change in mental status, anxiety, or agitation o No diaphoresis or sign of increased work of breathing (use of accessory muscle, dyspnea, paradoxical breathing) • Tracheostomy after long term ventilation support (7-10 days)
- 19. Non-invasive ventilation protocol Indications of NIV • Bedside observation Increase dyspnea moderate to severe Tachypnoea (>24 bpm in obstructive, >30/ min in restrictive) • Signs of increased work of breathing, accessory muscle use, and abdominal paradox • Gas exchange Acute or acute on chronic ventilatory failure (best indication), PaCO2 > 50 mmHg, PH < 7.35 Hypoxaemia (use with caution), PaO2/FIO2 < 200
- 20. Contraindication of NIV • Agitation • Glasgow<12 (the exception being suitable "do not intubate" unconscious patients with hypercapnic COPD) • Ineffective cough • Airway obstruction • Distended abdomen • Vomiting • Upper GI bleeding • Hemodynamic instability • Complex arrhythmia • Facial trauma • Esophageal surgery • Undrained barotrauma • Pneumonia • Neuromuscular disorder
- 21. • Initial settings for Bilevel Positive Airway Pressure (BPAP) : Inspiratory Positive Airway Pressure (IPAP) of 10cmH2O and Expiratory Positive Airway Pressure (EPAP) of 4-5cmH2O= Pressure Support (PS) level of 5-6cm H2O • Increases to IPAP of 2-5cmH2O can be undertaken every 10 minutes or as clinically indicated, until therapeutic response is achieved. • The maximum IPAP should not exceed 20 – 23 cmH2O • If the patient does not clinically improve within four hours of starting NIV, the decision to intubate and ventilate is to be made
- 22. Heating, ventilation and air conditioning (HVAC) in intensive care unit • maintain good ‘indoor air quality’ as an important non- pharmacological strategy in preventing hospital-acquired infections • Essential functions of HVAC system includes heating (adding heat to raise or maintain temperature), cooling (removing heat to lower or maintain temperature), humidifying (in order to maintain the moisture content of the air) filtering (removing dust particles, biological contaminants like bacteria, viruses and fungi), ventilating (air change rates between outdoor) and air distribution (velocity, flow pattern, direction of movement and distribution patterns)
- 23. • Components of HVAC system • three basic components (1)outdoor air intake and air exhaust ducts and controls, (2) air handling units (AHU), and (3) air distribution systems • Recommended standards for HVAC system in the ICU Temperature- 16 °C to 25 °C Relative humidity- relative humidity (RH) of 30% to 60%
- 24. • Filtration Indian guidelines mention filtration up to 99% efficiency till 5 μm • Air change (outside air/total) per hour Most of the recommendations suggest a total of 6 ACH, whereas operating rooms require a minimum of 20 ACH • Pressurization: Positive pressure- create a protective environment to the patient to avoid acquiring any airborne infection Burns, post-transplant, febrile neutropenia Negative pressure- protective environment to the healthcare providers as well as other patients in the ICU Tuberculosis, swine flu, COVID-19 and other airborne viral diseases
- 25. Long-term complications of critical care
- 27. • ICU-acquired weakness (ICUAW) evoked by CIP, CIM, or CIPNM • ICUAW- clinically MRC score is less than 48 points • NCS or EMG is necessary to diagnose CIP and CIM • the incidence 25%–45% • often causes prolonged intensive care unit stays and mechanical ventilator dependence and long-term disability • Early pulmonary and physical rehabilitation prevents ICUAW
- 28. Early Rehabilitation • improved muscle strength, physical function and quality of life • Reduced Duration of Mechanical Ventilation, Length of Stay (LOS) and Costs • Neuromuscular Electrical Stimulation • Cycle Ergometer • Deep breathing exercises and spirometry • Percussion and vibrations • Positioning 2- to 4-hour intervals, Passive ROM and stretching • transitioning from passive exercise to active exercise Goal of pulmonary rehabilitation Reducing secretion retention, atelectasis, and pneumonia Maintaining or recruiting lung volume Optimizing ventilation and oxygenation Improving compliance and ventilation/perfusion mismatch, reducing work of breathing Decreasing ventilator dependence and improving residual function Improving respiratory muscle strength Reducing postoperative complications
- 30. • Early determination of serum procalcitonin (PCT) levels is recommended to rule out severe sepsis • serum procalcitonin concentrations of <0.5 ng/ml unlikely and above 2.0 ng/ml highly likely • Biomarker of invasive fungal infection Galactomannan, 1-3 beta-Dglucan, Anti Mannan • Severe sepsis includes SIRS and at least one of the following and not explained by other known etiology of organ dysfunction o Hypotension (<90/60 or MAP <65) o Lactate > 2 mMol/L o Creatinine > 2 mg/dl o Disseminated intravascular coagulation (DIC) o Acute renal failure or urine output<0.5 ml/kg/hr o Cardiac dysfunction o Platelet count <100,000 o Hepatic dysfunction Bilirubin >2 or INR >1.5 o Acute lung injury or ARDS
- 31. • (gram-positive and gram-negative) 90% of cases • gram-positive sepsis (Staphylococcus aureus, coagulase negative staphylococci, enterococci, and streptococci) • gram-negative sepsis (Enterobacteriaceae, especially Escherichia coli and Klebsiella pneumoniae, Pseudomonas aeruginosa). • E coli remains the most prevalent pathogen causing sepsis • The leading fungal pathogen causing sepsis Candida. Site of infection • The respiratory tract accounted for 44.4 - 60%. • the bloodstream 20% • abdomen 26% • skin 14% • urinary system 12 - 20.8 %. • In 20% to 30% of patients, a definite source of infection is not found. • Ventilator-associated pneumonias- combination of CPIS (cut- off ≥6) and procalcitonin (cut-off ≥2.99 ng/ml) increase PPV.
- 32. Hospital acquired and Ventilator Associated Pneumonia • incidence of VAP was reported to range 9–27% • Modified Clinical pulmonary infection score
- 33. Prevention • Hygienic hand disinfection before and after each patient • use aseptic techniques during the placement of central venous catheters • remove the intravascular and urinary catheters without delay as soon as they are no longer indicated • subglottic suction • head of bed elevated 45° • Nutrition • Oral antiseptics for mouth care (mainly 0.12%–0.2% chlorhexidine) • use antiseptic-coated catheters
- 34. Aspiration pneumonia Prevalence of aspiration pneumonitis varies among studies from 5% to 15% Risk factor • Stroke, Drug overdose, Alcohol use disorder, Seizures, General anesthesia, Head trauma, Intracranial masses, Dementia, Parkinson disease • Esophageal strictures • Gastroesophageal reflux disease • Pseudobulbar palsy • Tracheostomy • NG tube • Bronchoscopy • Protracted vomiting gram-negative bacilli contributed to 49%, followed by anaerobes (16%)
- 35. • right lower lobe is most frequently involved Prevention • Elevate patient’s head of bed between 30 and 45 degree • Reduce the use of sedatives when possible • Check feeding tube placement every 4 hours • Assess for signs of feeding intolerance every 4 hours in tube-fed patients(Regularly checking gastric residuals) • Avoid bolus feedings • Consider swallow studies for recently extubated patients • Keep endotracheal cuff pressures at proper levels and suction secretions from the hypopharynx (between 20 and 30 cm H2O to prevent secretions from leaking into the lower airway) • Oral hygiene with chlorhexidine (0.12–0.2%) • Screen for dysphagia
- 36. Dysphagia • Stroke is the leading neurological cause of dysphagia • 42% to 67% of patients presenting with dysphagia within 3 days of stroke • Fifty percent of these patients aspirate, and one third of patients who aspirate develop pneumonia. Bedside screening test for dysphagia • GUSS test reached 100% sensitivity and 50% specificity when compared with FEES
- 39. Prophylaxis of Deep Venous Thrombosis risk factors for thromboembolism in critically ill patients • Recent surgery • Trauma • Burn • Malignancy • Sepsis • Stroke, spinal cord injury • Age > 40 years • Obesity • Mechanical ventilation Prevalence of DVT 30 % in ICU patients General Principles • Mechanical methods of prophylaxis should be used routinely in whom pharmacological prophylaxis is contraindicated
- 40. Contraindications for pharmacological DVT prophylaxis include: • Active bleeding or recent bleeding or high risk for bleeding. • Patients with coagulopathy (INR greater than 1.5) • Planned surgical procedure in the next 6 to 12 hours • Thrombocytopenia (Less than 50,000). • Bleeding disorders Elastic stockings are considered the least effective methods of DVT prophylaxis and should never be used alone Intermittent pneumatic compression is more effective than elastic stockings and can be used alone • Contraindications to the use of graded compression Arterial insufficiency Absent peripheral pulse Deep vein thrombosis Lower extremity ischemia/gangrene
- 41. Pressure ulcer
- 42. Delirium
- 45. Determining Brain Death in Adults The clinical evaluation (neurologic assessment). Coma. • Patients must lack all evidence of responsiveness. Eye opening or eye movement to noxious stimuli is absent Absence of brainstem reflexes. • Absence of pupillary response to a bright light is documented in both eyes • Absence of ocular movements using oculocephalic testing and oculovestibular reflex testing • Absence of corneal reflex. • Absence of facial muscle movement to a noxious stimulus • Absence of the pharyngeal and tracheal reflexes
- 46. Apnea test Absence of a breathing drive tested with a CO2 challenge Procedure • Adjust vasopressors to a systolic blood pressure ≥100 mm Hg. • Preoxygenate for at least 10 minutes with 100% oxygen to a PaO2 >200 mm Hg. • Reduce ventilation frequency to 10 breaths per minute to eucapnia. • Reduce PEEP to 5 cm H2O • If pulse oximetry oxygen saturation remains >95%, obtain a baseline blood gas (partial pressure of oxygen [PaO2 ], PaCO2, pH, bicarbonate, base excess). • Disconnect the patient from the ventilator. • Preserve oxygenation (e.g., place an insufflation catheter through the endotracheal tube and close to the level of the carina and deliver 100% O2 at 6 L/min). • Look closely for respiratory movements for 8–10 minutes. Respiration is defined as abdominal or chest excursions and may include a brief gasp.
- 47. • Abort if systolic blood pressure decreases to <90 mm Hg. • Abort if oxygen saturation measured by pulse oximetry is <85% for >30 seconds. • Retry procedure with T-piece, CPAP 10 cm H2O, and 100% O2 12 L/minute. • If no respiratory drive is observed, repeat blood gas (PaO2, PaCO2, pH, bicarbonate, base excess) after approximately 8 minutes. • If respiratory movements are absent and arterial PCO2 is ≥60 mm Hg (or 20 mm Hg increase in arterial PCO2 over a baseline normal arterial PCO2), the apnea test result is positive (i.e., supports the clinical diagnosis of brain death). • If the test is inconclusive but the patient is hemodynamically stable during the procedure, it may be repeated for a longer period of time (10–15 minutes) after the patient is again adequately pre-oxygenated
- 48. Organ donation guideline • Deceased donation is a legal option. (THOA 1994) • Diagnosis of brain death is established and recorded by two doctors not belonging to the retrieval and transplantation teams • Out of the two doctors, one must be a specialist in neurology For certification of brainstem death requires a panel four doctors. 1. Doctor in charge of the patient, 2. The doctor in charge of the hospital where the patient was treated, 3. An independent specialist of unspecified specialty(physicians, surgeons or intensivists) nominated from the panel of names approved by the appropriate authority, 4. Neurologist or neurosurgeon. • Form 10 should be filled and signed by the medical experts certifying brain stem death.
- 49. • Amendments in the THOA(2011) and THAO rules 2014 have allowed selection of a surgeon/physician and an anesthetist /intensivist, in the event of the non-availability of neurosurgeon/ neurologist. • Clinical examination and apnea test need to be done two times after an interval of six hrs • The NOTTO Organ Donor Register is a computerized database which records the wishes of people who have pledged for organ and tissue donation Medical record Documentation • etiology and irreversibility of coma / unresponsiveness • absence of motor response to pain • absence of brainstem reflexes during two separate examinations separated by at least 6 hours • absence of respiration with pCO2 ≥ 60 mm hg • justification for, and result of, confirmatory tests if used necessary to inform police about organ donation consent (superintendent of Police or Deputy Inspector general), if it is a documented medico legal case
- 50. Exclusion criteria for organ donation Infection with human immunodeficiency virus, Human T cell leukemia-lymphoma virus Systemic viral infections (measles, rabies, adenovirus, parvovirus) and herpetic meningoencephalitis Active malignant disease or a history of malignancy Goals for maintenance of potential organ donor
- 51. Age limit for deceased organ donor
- 52. Biomedical waste management Steps of waste management • Segregation • Collection and Storage • Transportation • Treatment and Disposal
- 54. • Segregation
- 55. References • Martindale RG, McClave SA, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; American College of Critical Care Medicine; A.S.P.E.N. Board of Directors. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: Executive Summary. Crit Care Med. 2009;37:1757-61 • 1. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, Pearl R, Silverman H, Stanchina M, Vieillard-Baron A, Welte T. Weaning from mechanical ventilation. Eur Respir J. 2007;29:1033-56. • GBS McNeill, AJ Glossop. Clinical applications of non-invasive ventilation in critical care Contin Educ Anaesth. Crit Care Pain. 2012; 12: 33-37. • Saran, S., Gurjar, M., Baronia, A. et al. Heating, ventilation and air conditioning (HVAC) in intensive care unit. Crit Care 24, 194 (2020). https://doi.org/10.1186/s13054-020- 02907-5 • Practice parameters for determining brain death in adults (summary statement). The Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1995;45:10121014 • .
- 56. THANK YOU