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DartmouthDave

Influenza & Bubbling Chest Tubes

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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?

Of course there is concern which is why I asked about it earlier as did someone else. You also asked about the CT angio earlier.

The OP just told us about the leak stopping when pressed.

The post I wrote about ARDSnet ant ventilator settings, that was in response to the OP's question. That also is a very brief explanation.

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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...

Well let's seal that sucker off with some tegaderm or occlusive dressing of choice and see if that solves our problem for the time being. The patient already has two chest tubes in place so a full occlusive should suffice just fine.

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Hello,

Thank you for the answer iStater. I have seen a few occasions in the past that people rush too fast to the minimal 6cc/kg VT or have made the VT so small that nothing much is left after deadspace. Thanks.

I am unsure of all the details. As we all know follow up sometimes isn't the easiest. The patient had developed some sort of fistula from the spinal needle. Hence the massive air leak. Luckly, the leak went away with an occlusive pressure dressing.

This lady was sick. The question is, "How much do you try and fix or change before you leave?" Sure, you know that things are a little off the rails but do you or can you fix it all?

My point of view is effected by the fact that I have spent a long time in the critical care setting. You slowly make changes over a shift or a few days.

Cheers

Edited by DartmouthDave
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Fix the things that you have to fix the facilitate transport and prevent further harm; ie decrease the tidal volume, seal the puncture in the chest, and adjust the sedatives and pressors as needed.

Does this lady need more than what was done? Sure...but at a certain point you need to weigh the cost of staying, potentially getting into a pissing match with the transferring facility (and potentially the receiving facility) and actually getting the patient to the care they need in a timely manner and in as appropriate a condition as possible.

Some things can be done on the road...some must be done before leaving...some things are "nice to do"....some things must be done...knowing the difference and how to pick and choose your battles can be difficult, but can be a big part of doing transfers.

And I'd just like to give a shout out to ventmedic...good to see it back...again... :beer:

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Decreasing the tidal volume prior to transport could lead to problems. The ABG was 7.40. Transport ventilators do not compensate for compressible volume loss. If yoy have a PIP of 36 cmH2O this could mean a loss up to 72 ml. If the patient decompensates mid transport from a significant decrease in tidal volume plus the compressible volume loss you will have a difficult time regaining previous staus and may cause damage with the reopening pressures. Making several changes on the meds just because you can before knowing how and why this hospital got to those settings can lead to a crash. Sometimes attitudes of the transport team towards the sending facility gets their patient into the most problems.

Since it is still not clear about the type of flu, practice strict precautions o prevent airborne contamination. Transport ventilators are difficult to isolate. Make sure you have adequate filter at the ventilator outlet and one to prevent or minimalize exhalation spray. Even with that masks for the caregivers would be advised.

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Hello,

In Critical Care Nurse there is an interesting article by Darcy Day 'Keeping Patients Safe During Intrahospital Transport'. In this article, MV was cited as one of the more frequent transport complications.

http://ccn.aacnjournals.org/content/30/4/18.full.pdf+html?sid=579629ec-4b18-4469-a31f-3757feb3ddb5

I agree with iStater and Triemal04 that caution is the best option with these complex patients. Change things slowly.

I have seen some teams (...and I have been guilty of this myself...) of mucking around too much.

Cheers


Hello iStater,

"Transport ventilators do not compensate for compressible volume loss."

How do you calculate this? Do you double you PIP?

Thank you,

David

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