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.

Pulmonary physiology – Alveolar-arterial gradient – depicted

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aagrdntii

Depiction of the alveolar-capillary unit representative of the alveolar-arterial gradient and easily and quickly

defined by the PaO2 / FiO2 ratio (P/F ratio).

As the distance between the alveolus and the capillary increases, it is referred to as an “widening ” of the A-a gradient.

Many things can occupy this potential space :  water, blood, infection (bacteria) as well as thickening membranes.

Tricks of the trade : PaO2 vs. SpO2

Always keep SpO2 < 100% (with rare exception).

An SpO2 between 92% to 99% says something about your patient’s condition.

SpO2                           PaO2                            FiO2                                      P/F ratio

100 %                            600                              100%                                      600

100%                             500                               100%                                     500

100%                             400                                100%                                     400

100%                             300                                100%                                     300

100%                             200                                100%                                     200

100%                              100                                100%                                    100

99%                                   90                                 100%                                       90

98%                                   87                                  100%                                      87

97%                                   85                                  100%                                      85

96%                                   82                                   100%                                     82

95%                                   80                                   100%                                     80

90%                                   60                                    100%                                    60

 

Tricks of the trade : the P/F ratio

 

Normal P/F ratio=600.

As a generalization :

everybody breathing room air (21%) will have an PaO2=100.  P/F ratio=100/0.2 = 500.

everybody breathing 100% oxygen via NRB will have an PaO2=500.  P/F ratio=500/1=500.

so now, you can figure out the max PaO2 on any FiO2.

FiO2                           P/F ratio                        PaO2

100%                          600                                 600

90%                              540                                600

80%                              480                                600

70%                             420                                600

60%                              360                               600

50%                             300                                600

40%                             240                                600

30%                            180                                 600

21%                            120                                 600

 

 

 

Tricks of the trade : P/F ratio without knowing an ABG.

Look at your patient’s SpO2 > this will allow you to approximate both your patient’s  PaO2 and P/F ratio.

If your patient’s spo2 = 90%, your patient’s PaO2=60mmHg.

If your patient’s spo2=99%,  your patient’s PaO2=90mmHg.

So if your patient’s SpO2 = 97% and the FiO2=40%, you can estimate the P/F ratio as ~80/0.4=200.

If your patient’s SpO2=100%, your PaO2 can be anywhere from 90 to 600 > this is no help because you cannot approximate, let alone pinpoint, the pao2.

So, your patient with an SpO2=100% is not very telling of the patient condition.

If your patient’s spo2=100% and the pao2=100, on an fio2=40%, the p/f ratio=100/0.4=250 (=ALI = acute lung injury).

if your patient’s spo2=100% and the pao2=240, on an fio2=40%, the p/f ratio=240/0.4=600 (= normal).

 

Tricks of the trade : the 4-5-6 ; 7-8-9 rule

 

This is a “cute” way to remember SpO2 vs. PaO2.

When the spo2=40%, the pao2=70.

When the spo2=50%, the pao2=80.

When the spo2=60%, the pao2=90.

SpO2                 PaO2

40%                    70

50%                    80

60%                    90

Evaluating the patient – the ventilator

today-icu-bed

VENTILATOR :   10 seconds – give the pulmonary stance of a patient by looking at the ventilator and / or everything around the room that is pulmonary related >> performing an evaluation and having a conclusion within 10 seconds.

Glance at the following quickly :

Type & Mode of Ventilation :   VCV  vs.  PCV  ;  AC  vs.  SIMV  vs. PSV

PEEP :    hi  /  lo  / normal

FiO2 :    hi  /  lo  / normal

P/F ratio :  hi  /  lo  / normal

Lung compliance :   hi  /  lo  / normal

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VCV – likely that the patient is  normal.

PCV – likely that the patient is  sick.

PEEP  > 14 – likely that the patient is  sick.

P/F ratio < 300 – likely that the patient is  sick.

Lung compliance :  round off delivered Vt >> round off dP (change in press).

dV / dP – change in volume / change in pressure = compliance.

compliance < 40  : likely that the patient is  sick.

Ex :  PS=10 yields a spontaneous Vt=500 >> Complinace = 500 / 10 = 50

PCV=30 yields a Vt=1200 >> Compliance = 1200 / 30 = 40

The ICU patient – evaluating the patient in 2 minutes

 

today-icu-bed

Why would you want to evaluate a patient in 2 minutes?

>> To be able to answer anyone who asks : “How’s my patient doing?”

> answer quick and BE READY to defend your stance!

>> Why you think the patient is faring well vs. why you think the patient is decompensating.

>> if they like your answer over the course of 1 to 2 patients (and you were correct),

they will trust you for the rest of your life with anything respiratory related and

patient related as well.

How do you evaluate the patient in 2 minutes?

>> 7 zones to focus on :  2 min = 120 seconds

>> patient.  10 sec

>> patient monitor.  10 sec

>> IV pumps.  30 sec

>> ventilator.  10 sec

>> chest tube.  10 sec

>> urine collection bag.  10 sec

>> any other unusual device in room.  10 sec

>> conclusion and defense thesis.  30 sec

PATIENT :  10 seconds

cyanosis / pale / normal

MONITOR :  10 seconds

HR :  hi  /  lo  / normal
BP :  hi  /  lo  / normal

PA :  hi  /  lo  / normal

CVP :  hi  /  lo  / normal

SpO2 :  hi  /  lo  / normal

IV PUMPS :   30 seconds

Vasoactives :  constrictors  vs.  dilators

Cardiotonics :  inotropes  vs.  chronotropes

Sedation :

Analgesics :

Paralytics :

Epi  /  Levo  /  Neo  /  Vaso  /  Milrinone

Diprivan  /  Ativan  /  Versed  /  Fentanyl

VENTILATOR :   10 seconds

Type & Mode of Ventilation :   VCV  vs.  PCV  ;  AC  vs.  SIMV  vs. PSV

PEEP :    hi  /  lo  / normal

FiO2 :    hi  /  lo  / normal

P/F ratio :  hi  /  lo  / normal

Lung compliance :   hi  /  lo  / normal

CHEST TUBE :   10 seconds

Qualitative analysis :

Quantitative analysis :  hi  /  lo  / normal

URINE COLLECTION BAG :  10 seconds

Qualitative analysis :  clear  /  yellow  /  pink  /  red  / green  /  blue

Quantitaive analysis :    hi  /  lo  / normal

UNUSUAL DEVICES  :  10 seconds

EEG  /  Hypothermia Induction Device  / IAB / VAD / ECMO, CVVH, hemodialysis, wound VAC, compression stockings, external pacing device, cardio-defibrillator, video monitor, patient escape alert device.

CONCLUSION :  immediate

Rationale :  30 seconds

(MORE TO FOLLOW next week)

Respiratory Therapist – Professional Physician Extender

I am strongly looking forward to hearing Garry W. Kaufman’s presentation – the key phrase

that drew my attention is PROFESSIONAL PHYSICIAN EXTENDER.

We all know it … first sign of trouble (desat, cardiac arrest, strange noise, etc.)  and the first words out of anyones mouth is “get respiratory”.

 

resplearn-sbmc-professionalphysicianextender002

I really am looking forward to this and other’s commentary that know the respiratory therapist’s role in the medical field.

(MORE TO FOLLOW … from my soap box).

 

To ALL (RN, RT, MDs).