Under Pressure

[mobey]

This patient is severly acidotic, and for my transport that will be my focus.

I have no problem with levaing the PEEP at 8, although a lung protective ventilatory strategy may be appropriate here. Lets go 6ml/kg of IDEAL bodyweight and keep an eye on that EtC02 and Sp02, not to mention skin colour and diaphoresis (oh ya! we have a patient to assess too lol).

I would like to get that BP up though. Do we have a MAP calculation? Just want to correct the V/Q mismatch from the poor perfusion. With a high lactate like that, and a CXR looking like ARDS, it is pretty clear we are dealing with SIRS/SEPSIS..... something inflammitory and bad. He can have a crystalloid bolus of 20ml/kg to get us warmed up

What do those lungs sound like anyway?

Urine output in last 24hrs?

Thx for the scenario

Edited April 11, 2012 by mobey

[chbare]

What is the patient's ideal body weight? Why is the patient acidotic? Why crystalloids over blood, is blood indicated at this point?

The X-ray shows bilateral ground glass infiltrates. The PV ventilator loop shows something called a duck bill pattern. What is the significance of that? Lung sounds indicate crackles in all lobes.

So, it seems most are putting ARDS at the top of their differentials? I want to see if we can get some type of concensus of vent settings and an overall management plan for this patient. Thanks for participating and keep em coming!

Edit: Urine output has been about 30 ml over the past 12 hours.

[DartmouthDave]

Hello,

I looked at the flow sheet for the RT's and PBW Tidal Volume for a 5'9" patient is 424 (6cc/kg), 495 (7cc/kg) and 566 (8cc/kg).

The IBW calulation: IBW= 50+.91(hight in cm - 152.4)

So, 70kg?? A vt 420, 490 and 560.

Now, I asked an RT and a Duck Bill pattern indicates ARDS.

So, based on my expereince with ARDS net I would set the vent at :AC 30/550/.80/+14 and work down on the Vt until I get a airway pressure that I can live with.

We have a low PEEP and a high PEEP parameters for ARDS. I would go with the high PEEP due to the uniformed ground glass look of the CXR. I am assuming that all the lung units have poor compliance.

We like to keep the ARDS patients dry if possible. So, I want to see what the IVC u/s, CVP et al show. Plus see how our vent setting work out. Can I have a current set of VS?

From my reading and expereince I know that ARDS has stages. Typically, the first stage is the exudative or wet stage from the immune/inflamtory response. Suction the patient PRN.

His acidosis is mixed. The medabolic side is due to an ischemic gut (compartment syndrome), ARF (induced by the compartment syndrome) and poor perfusion. This will be hard to fix quick. But, i would like to see the lactate drop some.

Good scenario...

Too bad I am at work.....I have to run!

Cheers

Edited April 11, 2012 by DartmouthDave

[mobey]

Dave, you are probably right, but I disagree with you about keeping this patient dry.

Lactate clearance and VQ correction is going to be accomplished with fluids. Although this is an ARDS case, there is an underlying SEPSIS that needs to be treated aggressively in my opinion. This patient is acidotic to a critical level, and I think for transport purposes we need to bring that PH up to avoid a cardiac arrest.

I like your vent settings, except that PEEP is a little out of my comfort zone for transport, I think I would dial down to 10.

Whether blood is indicated for this patient or not is way above my pay grid.

[DartmouthDave]

Hello,

I am waffling on the fluid issue. I think you are right on the fluid issue.

His Hgb is 10 g/dL (100g/L) so I am happy with this. Also, blood can worsen outcomes in sepsis. I think there is a big Australian study on this. But, I can't recall right now. It is cold, typically old and can worsen the immune/inflammatory response. I would only give blood for two reasons.

One, if he was bleeding and his Hgb fell below 60 or if ST changes are seen on the EKG.

Two, if his SvO2 is below 70% and his Hgb is below 100 as well.

I agree that transport (unless it is a very short run) is dangerious unless his Ph starts correcting and the lactate is clearing. I would do an other ABG. If the pH and CO2 isn't correcting I would increase the rate to 32 with a max of 35.

I would also have some Levophed ready as well. He will need deep sedation and Levophed may be needed to offset the hypotension.

Cheers!!

[chbare]

Good: we have one ideal body weight calculation. An imperial based on we use in the United States for a male is: 106 + (6 times number of inches above 60). Then divide that number by 2.2.

The duck bill pattern is not necessarily ARDS, but it does represent over distention. Also the PV loop is good at identifying increased WOB. Remember looking at quasi static PV diagrammes in chemistry under adiabatic conditions? The area within the loop was the work that the system did. This is also true of a human being. The PV loop indicates that significant work is being applied as well.

Blood administration is a murky decision here. The patient is anaemic, so it would be good to look at what happened during surgery. What do you guys think about the patient's temperature?

Let's say we do a lung protective strategy and administer a bolus of warmed fluids?

We have the following:

Vt 420 ml

f- 18 with f total at 30 in VCV

PEEP 13 cmH2O

I:E is 1:3.1

PIP 40

Pplateau: 38

PV loop is unchanged

Patient is saturating 84%

What are we going to do?

[DartmouthDave]

Hello,

Isn't 97.7F = 36.5C So, more or less normal. All I would do is ensure that the patient dosen't become hypothermic now or during the transfer.

What dose the OR report say? EBL? A decompressive lap shouldn't have to much blood loss.

With a SpO2 of 84% I would turn the FiO2 up to 100% and may creep up on the PEEP.

I have been thinking about AC-PC (PCV). I have readed mixed stuff but the last study I read by the Spanish Lung Group said that PCV has no major clinical difference. Also, I am weak in this area. So, I think I will stay the course with AC-VC.

A couple of questions:

1. I would turn the set rate up to 30 and sedated to the level to limit patient assisted breaths. Wouldn't this reduce the medabolic demand imposed by breathing?

2. I:E 1:3 Would a 1:1 ratio be better? Considering he is breathing 30 time a minute. One second in and one second out?

3. What is the PaCo2 right now? If it is still too hight I would increase the rate to 32 (max of 35). Again, would the I:E would need to be 1:1??

Here is my thinking at the moment. We are reaching the end of what we can do for lung protective ventilation. Even more so considering the limits of transport vent. It is time to pack up and roll to a centre that has HFO, ECHMO, Nova Lung, Folan and other complex stuff. Also, if posible, I would like to snag an RT for the transfer.

DD

Edited April 13, 2012 by DartmouthDave

[chbare]

Decreasing the I:E can be a consideration; however, this does decrease the time for exhalation, so you need to consider the pitfalls. In addition, continuing to increase the rate will eventually take us past the point of diminishing return. A small volume and high rate doesn't to always equal improved minute ventilation in spite of what we learn. (Ve= f*Vt). Ultimately, we must consider the alveolar ventilation.

So, we are at the end of the line for lung protective ventilation? Being aware of the literature and mortality, can we still consider other modalities?

[chbare]

Dave, you are probably right, but I disagree with you about keeping this patient dry.

Lactate clearance and VQ correction is going to be accomplished with fluids. Although this is an ARDS case, there is an underlying SEPSIS that needs to be treated aggressively in my opinion. This patient is acidotic to a critical level, and I think for transport purposes we need to bring that PH up to avoid a cardiac arrest.

I like your vent settings, except that PEEP is a little out of my comfort zone for transport, I think I would dial down to 10.

Whether blood is indicated for this patient or not is way above my pay grid.

Why would you decrease the PEEP? What is your PEEP threshold? Can we actually do testing to determine optimal PEEP?

[DartmouthDave]

Hello,

A trial of PCV may be worth a go. In theory, PCV has a longer inspritory phase which increases the mean airway pressure and gas exchange. But, the evidence is mixed here and ARDS net supports VCV.

A bronchoscopy could be worth a go. Take a look and clean things out. This is high risk in this situation.

As for the other unique modes of ventilation (bi-level, APRV, et al.) I have no idea if they have been studied or have any role here.

There is also HFO as well. But, I have only seen this done a few times and these patients are 1:1 for the RT's and few centers have this ability.

Statins (Lipitor) has shown to improve long-term outcomes. Steroids may be helpful in the inflammatory stage. Keeping the patient's dry if possible may be useful in the immune/inflammatory stage. I even recall reading something about nebulized Heparin. There are also various drugs that can be used to drop the pulmonary arterial pressure. I think one is called Flolan and is side streamed in with the inspritory circuit. But, most of these will not help us now.

You could also put the patient on ECHMO if the option is there.

If this hospital can stabalize the patient he should stay there (i.e. HFO,ect..). If not, he should be transfer ASAP. This case reminds me of a young patient with ARDS that had a bad outcome due a very delayed transfer.

Cheers

Edited April 16, 2012 by DartmouthDave