SBAR – quick report format – situation, background, assessment, recommendation

 

sbar-submarine

In a nutshell :

SBAR – quick / rapid report handoff format adopted by hospitals.

why the submarine pic ?  SBAR format was initially designed by submarine personnel.

The long winded version :

(in a submarine : deep, deep underwater with limited oxygen supply and tons of crushing pressure all around, there is not time for lengthy speeches – its more like “you have 2 seconds to tell me what’s wrong and how you would fix it”.

 

I was told a long time ago, by my supervisor back then, “don’t come to me with just a problem … have a suggested solution as well”.  I have always liked that management style and give her credit for introducing me to that notion.

 

The third point, always know the history of anything and everything (in this case : SBAR came from the military).

We should treat a patient in crisis just like we were having a crisis in a submarine :

tell me the problem.

give me relevant background quickly.

tell me why you think the problem happened.

tell me how you would fix it.

Pulmonary Alveolar De-Recruitment – a cautionary tale of frivolous suctioning

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set-up : clock, coke bottle, ETT, ballard suction device, suction source.

BEFORE : coke bottle (=2L of volume) – approximate the size of your lung.

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AFTER : how long to suction 2L of air out of a closed system (totally FLATTENED)?  15 seconds.

In a nutshell :

Benefit : rids the lung of secretions.

Risk : may cause atelectasis to varied extents depending on the patient’s pulmonary status.

The risk : benefit ratio approaches unacceptable level of risk when the lung has a propensity to want to collapse.

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The long winded version :

A long time ago, I read that when suction is initially applied on a closed system that has been connected since the last time the patient was suctioned, the initial insult of the “built-up suction back-pressure” (BUSBP) might be excessively high.

If the pressure had been set at -100cmH2O, the “built-up suction back-pressure” may be in the range of -250-300cmH2O.

Therefore, it was important to break the suction circuit before apply suction to the patient.

That article suggested / demonstrated that excessively negative pressures might collapse a lung.

In this case, the demo shows that a 2L coke bottle can be flattened in approximately 15seconds of normal continuous suctioning.

Most people I see suctioning are quick to suction the trachea but leave continuous suctioning on (~15 seconds) while they clear the line with NSS  (normal saline solution).

THE SCENARIO :

Situation : Patient sounds junky.

Background : Patient has been in the hospital for 2days post-op.  HD=2  POD=2

Assessment : Patient suctioned but “did not get anything.”

Recommendation : Start mucomyst.

THE LESSON :

Be wary of frivolous suctioning.

 

The intrinsic beauty of human physiology >> Beauty of the ICU >> “Art” in the ICU >>(CO = HR x ??)

p1090783

“In a Nutshell” :  the beauty of human physiology

Although this is just a swishing and sloshing of stuff in the ICU, there is intricate beauty in this clip … just activate the “replay” function of the movie player your PC uses.

The urine output flow is demonstrated in the clear urine “moving along” in the urimeter set.

The blood sloshing around represents the collection moving around to the beat of the HR.

Between these 2 fluid volumes sloshing around, is the implied requisite stroke volume per heart beat.

 

The dynamic renal system – the “poor man’s Swan”

p1090771

In a nutshell : urine is formed in proportion to the cardiac output exerted on the nephron.

If the clinician is improving cardiac output, the urine output should improve.

Ex :

give Epinephrine  >> cardiac output increases >> urine output increases !

give 500cc NSS in a dehydrated patient >> cardiac output increases >> urine output increases !

apply Alveolar Recruitment Techniques (ART)  >> cardiac output increases >> urine output increases !

decrease PEEP (in a stellar pulmonary status patient)  >>  cardiac output increases >> urine output increases !

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The “long winded story” :

The renal system in all of its dynamic glory is a beautiful passive organ system.

The dynamic renal system is referred to as the “poor man’s Swan”.

It’s state of flux demonstrates the strength of the cardiodynamic system.

When cardiac output is strong, urine is formed quickly and flows to the urimeter quickly.

When cardiac output is weak, urine is formed slowly and flows to the urimeter slowly.

For doctors / hospitals / states / countries that cannot afford the luxury of a Swan-Ganz catheter, the urine collection system is thus referred to as the “poor mans Swan”.

As long as there is integrity in the system from the nephron (beginning)  to the end (the urimeter), it is a great way to tell of the cardiodynamic status.

This attached movie clip (p1090771 – activate the “replay” feature on your PC’s movie player app) will allow you to envision the urine formation.

The process :   cardiodynamics will bring blood from  :    LV  >> LVOT >> Ao  >> descend Ao >> renal artery >> nephron  >> renal collecting tubules >> bladder >> urimeter.

In this movie clip, the patient had excellent cardiodyanmics and was given Lasix (forced diuresis) so the patient was literally “pouring out” urine.

Traumatic brain injury (TBI) / nueuro-injury may result in sequelae to include SIADH (syndrome of inappropriate anti-diuretic hormone) which allows urine to “pour out” as well.

The beauty of this movie clip is to envision for “x” amount of heart beats, a drop of urine is formed.  When you see urine forming at the rate you see in this movie clip, one has to stand in awe of a passive physiologic process.

 

The ICU vernacular – lots of abbreviations – what do they mean? Here they are (more to follow)

2015 nov 12 - nava sick

ALI = acute lung injury

ARDS = acute / adult respiratory distress syndrome

AHRF = acute hypoxemic respiratory failure

AECC = American – European concensus conference

TRALI = transfusion related acute lung injury

VILI = ventilator induced lung injury

ARF-k = acute renal failure (- kidney)

CRF-k = chronic renal failure (-kidney)

ARF-p = acute respiratory failure – pulmonary

CHF = congestive heart failure

CABG = coronary artery bypass graft

AVR = aortic valve repair / replace

MVR = mitral valve repair / replace

TVR = tricuspid valve repair / regurgitation

AI = aortic insufficiency

AMI = acute myocardial infarction

PTCA = percutaneous transluminal coronary angiography

ECMO = extra-corporeal membrane oxygenation

ECLS = extrac-corporeal life support

RSI = rapid sequence intubation

FOB = fiber optic bronchoscopy

FOI = fiber optic intubation

EBL = endo bronchial lavage

HR = heart rate

BP = blood pressure

SBP = systolic blood pressure

DBP = diastolic blood pressure

PA = pulmonary artery pressure

PA-S = systolic pulmonary artery pressure

PA-D = diastolic pulmonary artery pressure

PA-M = mean pulmonary artery pressure

CVP = central venous pressure

CO = cardiac output

CI = cardiac index

SVR = systemic vascular resistance

PVR = pulmonary vascular resistance

MAP =  mean arterial pressure

MAP = MawP = Pawx = mean airway pressure

 

 

 

2 min Evaluation – Urimeter – darker yellow – 10 seconds to reach a conclusion

uryll

2 min Evaluation – Urimeter = darker yellow – 10 seconds to reach a conclusion

The quick explanation :

Situation :    urine = darker yellow.

Background :    dehydrated / intravascularly depleted.

Action :    cautious intravascular volume repletion.

Recommendation :     Alveolar recruitment technique (ART).

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The “long winded” explanation :

S-B-A-R format reporting – quick reporting format for handoff from one healthcare professional to another.

A lot of this presentation is conjecture … but time and experience has proven correct 99 out of 100 times.

Darker yellow urine is a likely indicator that your patient is intravascularly depleted to some extent.

A “passive leg raise” maneuver (MORE TO FOLLOW AT A LATER DATE) will provide additional information as to the value of  intravascular volume repletion.

If the patient’s systemic blood pressure / cardiac output improve significantly, a 500ml NSS repletion regimen is
likely going to improve outcomes.

Whenever fluid is repleted, alveolar should be protected via ART (alveolar recruitment technique) to avoid unintended
migration of NSS into the pulmonary interstitium and unintended alveolar compression (= compressive atelectasis).

 

2 min Evaluation – Urimeter = translucent red – 10 seconds to reach a conclusion

urmhbur
2 min Evaluation – Urimeter – 10 seconds to reach a conclusion

The quick explanation :

Situation :    urine = (translucent) red.

Background :    hemoglobinuria.  (I had originally identified this erroneously as methemoglobinemia – mea culpa),

Action :    requires alkalinization of urine to avoid acute renal failure.

Recommendation :     increase pH~7.50 (increase minute volume).

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The “long winded” explanation :

S-B-A-R format reporting – quick reporting format for handoff from one healthcare professional to another.

A lot of this presentation is conjecture … but time and experience has proven correct 99 out of 100 times.

Translucent red urine – the hemoglobin have been “beaten up” / ” chewed up” by some unknown process’ (the usual offending agent is heart surgery,
general surgery or rhabdomylosis.

RBCs (=bags of hemoglobin) have lost their membrane integrity and free floating hemoglobin
is now coursing thru the cardiovascular system.

As the hemoglobin pass thru the renal vascular anatomic structures, the hemoglobin molecularly binds with the distal convoluted tubule

(DCT) structures and causes acute renal failure (ARF-k).

The transient solution is to alkalinize the urine.

Alkalinization of urine will create an environment non-conducive to precipitation of free hemoglobin on renal DCT sub-structures. (further reading >> pH and molecular structure / shaping).

The free-floating hemoglobin tends to bind poorly to DCT structures in an alkalemic environment.

Transient solution is to increase the minute volume to target a pH~7.50.

2 min Evaluation – Urimeter – translucent green – 10 seconds to reach a conclusion

urmtlynbl
The quick explanation :

Situation :    urine = (translucent) green.

Background :    hypotension.

Action :    methylene blue intravenous injection.

Recommendation :     Alveolar recruitment technique (ART).

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The “long winded” explanation :

S-B-A-R format reporting – quick reporting format for handoff from one healthcare professional to another.

A lot of this presentation is conjecture … but time and experience has proven correct 99 out of 100 times.

Translucent green urine – refractory systemic vascular hypotension (from excessive nitric oxide in general systemic circulation) >  methylene blue dye irreversibly binds nitric oxide (NO) molecules – systemic blood pressure should increase status post  random scavenging.

The patient’s vascular system is producing excessive amounts of nitric oxide in endovascular epithelial tissue.
Last resort to refractory hypotension is to offer a free floating agent in the cardiovascular system to be reduced by nitric oxide
and thereby decrease the systemic vascular dilation (increased SVR) by “free range” nitric oxide.

Last resort because methylene blue is nephrotoxic.

 

2 min Evaluation – Urimeter = clear – 10 seconds to reach a conclusion

urmtrii

The quick explanation :

Situation :    urine = clear.

Background :    fluid overloaded.

Action :    forced diuresis.

Recommendation :     Alveolar recruitment technique (ART).

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The “long winded” explanation :

S-B-A-R format reporting – quick reporting format for handoff from one healthcare professional to another.

A lot of this presentation is conjecture … but time and experience has proven correct 99 out of 100 times.

Clear – forced diuresis (Lasix) – fluid overloaded – increased CVP .

Fluid overloaded due to a transient hypotensive crisis.

The fluid is coursing its way thru the vasculature and some of that fluid is finding its way into the pulmonary parenchyma.

Use Alveolar Recruitment Technique (ART) to mitigate the effects of rogue intravascular fluid … finding its way to the extravascular space (pulmonary interstitium.