Influenza & Bubbling Chest Tubes

[ERDoc]

I'm a minimalist and a firm believer in the KISS principle. If you have the pt adequately sedated, there is no reason for paralytics. Every medication has side effects, why add more and more meds to increase the number and chance for unwanted side effects and interactions?

[iStater]

There is nothing simple about this patient. Wean too much too fast and you won't get back the lost ground especially with a transport ventilar. Patient dies. A paralytic would be the easiest to re-establish but deep sedation should be maintained if BP permits. You don't want to risk dys or asynchrony.

Still awaiting blood gas verification to see if something creative can be done with the PEEP and other settings. But the transport vent may have vaiations for PEEP and tidal volume if single limb.

How tall is this woman?

[DartmouthDave]

Hello,

I was going by memory, but in essence, the ABG shows ok oxygenation and co2 for such sick lungs. The bad BE and lactate is from poor perfusion and worsening renal function.

Her earlier ABG look awful with low PaO2 (50) and hight PaCo2 (70) ON 100%.

When you listen to her lungs you hear a loud turbulent sound and feel some subcutaneous air. Incidentally, there is a red spot were she was decompressed with a spinal needle. The chest tubes are bubbling vigorously.

The consensus from the post seem to want to reduce sedation to improve hemodynamics. So, you back off on the sedation and for the sake of argument you go with Ketamine or Propfol. You can back off on the Levoped some as well (.3mcg/kg/min).

This improves her pressure some. She is in the 100-120/50 range now. HR is still 100+ and her temperature is 39.5C.

The nurse says she is doing ok now but if you move her too much she SpO2 bottom out.

We are on the fence about the Nimbex it seems.

Cheers

There is nothing simple about this patient. Wean too much too fast and you won't get back the lost ground especially with a transport ventilar. Patient dies. A paralytic would be the easiest to re-establish but deep sedation should be maintained if BP permits. You don't want to risk dys or asynchrony.

Still awaiting blood gas verification to see if something creative can be done with the PEEP and other settings. But the transport vent may have vaiations for PEEP and tidal volume if single limb.

How tall is this woman?

Hello,

She is 80kg and around 5 feet tall.

You do an other gas (please don't look too closely at the numbers) and her PaO2 is 60 and her PaCO2 is 45 with a pH of 7.40 or so. The RT flow sheet and the notes are erratic and it is hard to figure out how she arrived at her current setting.

Thanks

Edited April 16, 2014 by DartmouthDave

[triemal04]

I would have cut back the propofol and versed for fentanyl, but that's me.

As long as the patient stays deeply sedated enough that she doesn't interfere with the vent settings the nimbex can be stopped; if her own respiratory drive starts to cause problems I'd restart her on it before upping the dose of fentanyl (or whatever sedative is being used).

The vent volume needs to be cut way back. 550ml for someone who's only 5 feet or so tall, and has a pneumo, and probably ARDS is far to much. Her ideal bodyweight should be somewhere between 45 and 55 kilo's, depending on exactly how tall she is. Drop it to 440ml and reassess.

Are you able to tell how long her PEEP has been at 22?

No transfusion, it can wait.

What do you mean by a "red dot?" Just a small puncture mark, or something bigger?

Edited April 17, 2014 by triemal04

[rock_shoes]

How about acetaminophen 1g suppository before we cook her brain completely, I know we should still be below critical high for an adult patient but she's already so far up you know what creek dropping her temperature a little probably isn't going to hurt.

Sorry if it has already been posted but what are all the vent settings?

[iStater]

I would rather know what the nurse's flowsheet says. The RT sheet seems to be questionable for the info given about this patient. The settings looks random like they were only chasing numbers. I suppose there is no point in asking about the graphics either but waveforms are a very impotant part to consider and very useful to monitor if your transport vent has this ability.

What is the fluid amount in via IV? Output? Can the fuids be reduced?

Acid base can make or break oxyegenation. I take it the base and HCO3 levels are normal on the abg since the pH is 7.40.

Knowing acid base will guide you wiggle room when transferring to a transport vent. Obviously no ARDS protocol is being done for vent management. However that does not mean you shouldn't prepare for acid base issues which might arise from a transport vent. In a patient like this we would not strive for a 7.40/40/3 digit PaO2 if it means crashing the BP and blowing another pneumo. This is why the ARDS protocol expands extensively in acid base.

I would still be very careful with weaning too much on the sedation or even the paralytic for transport.

Edited April 17, 2014 by iStater

[iStater]

Nurses usually measure ventilator patients for a more accurate height. If not, it only takes a few seconds to do. You still need to know what the PIP is and the pPlat if it is possible to obtain with the air leak. Graphics are again impotant. This will guide you in dropping the tidal volume. But, make to many vent changes and taking off sedatives and/or paralytics is a recipe for something happening which you won't be able to correct. Going into a low tidal volume vent setting is no fun for the patient and their body will respond to this setting in not a good way.

[DartmouthDave]

Hello,

I had a great reply and I lost it. =(

Ok, iStater, she has been on these setting for around a day. I can not comment too much on the waveforms (not my strongest area). However, I can say they look like normal shark-fin like volume waveforms without any auto-peep. You work out her ideal body weight lung volume and lets say it is 450cc.

The red spot is from the needle decompression after she developed a tension pnx from a central line attempt. Now, when you push down on it the air leak stops in the chest tubes. Also, when you push on it the turbulent noise stops. Very odd.

Here is a question for you. I know that ARDSnet like small tidal volumes. Now, for the small peanut sized patients is there a point that you just can not cut the VT? Otherwise, the way I see it, the dead space will eat up most of your VT.

Rock Shoes: Good idea, you push Tyl 1gm down her NG

Thanks...

Edited April 17, 2014 by DartmouthDave

[iStater]

Calculating tidal volume is like calculating medication. You don't just pick random numbers or say "ARDSnet" unless your data backs it up. Some hospitals and transport teams may use a different protocol depending on their research or review of the literaure. Transport teams may need to use a protocol which adusts for the compressible volume loss of their ventilator circuit. This can be anywhere from 0.5 ml/cmH20 - 2 ml/cmH20. Studies have shown a 10% variation from set tidal volumes. Check the compressible volume factor on the circuit you are using.

You also do not just start with 6ml/kg. The recommendation is to start with 8 ml/kg, get your data including ABG waveforms, PIP and pPlat. For this woman here extra 30 kg of obesity must be considered since that may affect numbers. Your waveform is analyzed by the mode, wave delivery pattern selected and variations of that wave for delivery by adjusting flow and/or rise and termination. You have an ICU vent in front of you. There is alot of data to be obtained which can help you set up a transport vent.

The changes in tidal volume from 8 ml/kg to 6 ml/kg are done slowly over 4 hours. You must take into concideration of the MV and may need to adjust the rate up to 35 bpm. This is where waveforms are vital and also where some transport vents fail. Their flow delivery is inadequte to meet demand especially at high FiO2.

But, before making any changes to meds or the vent, you do need to ask questions. The nurses flow sheet is a wealth of info for you and the nurse to review. Experienced transport RNs can scan a flowsheet in 30 seconds and formulate a plan for meds and ventilator.

The questions include

What happens when they triec to wean the sedation?

How they got to the vent setting is important even if it is just to chase numbers.

Did they try to run a high PEEP ARDSnet protocol and had to abandon it?

Did the sending hospital increase everything in anticipation of this transport. This hospital may have had a previous experience from another transport.

[ERDoc]

I think we are missing the forest for the trees. There is more going on than just vent settings. Is anyone concerned with this red hole on the chest? Any chance a CT angio was done before we got there?