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DartmouthDave

Bad Lungs Bad Transfer

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Hello,

You are dispatched for an urgent transfer from a regional hospital ICU to a larger university hospital.

You arrive to a very hectic and busy room in the ICU.

An 18 year-old female was admitted  three days ago for worsening SOB that has progressed to respiratory failure that required intubation by day 2.  

Things have worsened dramatically over the past 24 hours.

She is sedated (Fentanly+Versed) and ventilated.  Alarms are endlessly ringing. 

VS as follows:

HR 150

BP 70/40

SpO2 72%

Lastly, bilateral chest tubes have been inserted.

 

Thank you,

David

 

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ABC's

Has the tube buggered up? Are the chest tubes bubbling away like they should or have they gone awry and she's tensioning out? What are the vent settings?

Short term a fluid challenge and a push pressor while we start getting things sorted would seem reasonable. The only infusing medications you've mentioned are the Fentanyl/Versed. What are they set at?

Allergies? Meds? PMHx.? History of the precipitating event? Any recent lab values available?

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Hello,

The ET and CT x 2 are in good position.

The patient decompensated from the pneumos and the insertion of the chest tubes.

The Fentanly is at 100mcg/hr and Versed at 5mg/hr.  She moves her arms wealy from time to time.

The patient is on AC-VC with a volume of 650cc with a rate of 20. However, the high pressure alarm is ringing madly (PIP 40).  ETCO2 is 55. They are considering stopping the ventilator and bagging the patient.

You start some IV fluids.  You push IV pressor of choice and the BP improves some.

NKDA

The patient had an admission 18 months ago for an autoimmune vasulitis of her lungs.  Despite an extensive workup no soild dx was made.  However, she resonded to Methotrexate and was switched to oral steroids.  The patient secretly stopped taking the steroids due to excessive weight gains.

Also, the patient had flu-like symptoms and has developed a red lesions on her feet.

Thank you,

David

 

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Let's bump up the FiO2 to 1.0 if it isn't already. Paralyze. Nebulize Ventolin/Atrovent into the vent circuit. Dial her rate back to 12. Looks like she's probably hyper-inflated. Continue with some fluids at this point. Titrate in norepinephrine to a MAP of 70 if necessary. Methylprednisolone 125mg IV.

What does her EtCO2 waveform look like? Surely they've done some labs on this girl. The chest tubes are in position but are they kinked or otherwise blocked off preventing relief of a pneumo?

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Agree with wanting to know the above.  Also:

How tall is this 18 year old female?  That tidal volume seems a little high.  Is she coughing against the tube or otherwise bucking it?  Has the tube been suctioned recently to ensure there's nothing blocking it?

I think I'd like to increase the versed/fent combination.  Let's start with a bolus of 5mg and 200mcg.

Labs would be good if available, please.  But I think they can wait until we get her situated a little more comfortably with the ET and chest tubes along with the vent.

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Why did they put chest tubes in?  From what you wrote sounds like she got worse after the chest tubes and the ET tube.  What happened after they tubes were placed?

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There is a lot missing here.  We need to know more about the hospital course.

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 Do we have labs, an arterial blood gas and an x-ray? What is her plateau pressure and how has it been trending? How much PEEP is she on? Does the ventilator have a graphics package?

Let's find her ideal body weight and look at a lung protective ventilator strategy. If need be, we can transition to pressure controlled ventilation or possibly a hybrid that allows us a degree of control over pressures and the inspiratory flow waveform. Is the patient comfortable?

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Seems everyone is in agreement. We want more information so that we can proceed.

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Hello Everybody,

My apologies for the delay.

Here is some much needed information.

The chest tubes:

The patient was difficult to ventilate.  The airway pressures (PIP and plateau) were very high and the patient blew a (L) and (R) pneumothorax.  The patient was unstable and this bad turn of events has worsened the situation.  A CXR shows complete whiteout of both lungs and two well placed chest tubes.

The patient height and weight:

As noted by all the volumes are a bit excessive.  Lets say according to IBW calculations  is 60kg (6cc/kg = 360 7cc/kg = 420 8cc/kg = 480)  Do we drop the Vt slowly or quickly? 

The labs:

ABG: 6.9 / 80 / 70 / -11 / 11.2 (ph/co2/o2/be/lac)

WBC 25

HgB 60

K 7.0 Na 135 Mg .60

Cr 1200

Ur 50

The vent:

AC 20/650/.8/+5 PIP:44

I am not an expert on scalars and loops (I suggest watching chbare YouTube videos) .  What I can say is the patient was too awake.  Things settle down with proper sedation (RASS-3) and a good suction (copious amounts of secretions) but work still needs to be done.

After suctioning and sedation only Vt of 100-125 is being delivered.

Thank you,

David

 

 

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