eLibrary – high value pix – alveolus ARDS (injured vs. repaired)

hi-value-pix-ards-injured-vs-repaired-nejm-2000

This picture printed in NEJM 2000 is a great picture to learn from.

I will expand on content at a later date.

Simply GOOGLE search for images with the following “nejm 2000 ards alveolus”.

Pick the image.

And then choose “View image” for a picture of moderate resolution.

 

QoW – 2016 – Q4 – 001 – The Consummate Respiratory Therapist – Thinking Outside the Box

You are called for a patient who is agitated & having a desaturative event  >  you see the following as you enter the room :

monitor-spo2-69pct

pvroute006

uryll

avsv

chtb

The Intensivist meets you at the patient bedside to discuss the patient.  His SBAR report :

S – Situation :  Patient agitated & demonstrating oxymetric desaturation to 69%.

B – Background :  Cardiogenic shock  > Post-op day #3 ; Hospital day #4.

A – Assessment :  Patient agitated but looks comfortable.

P – Plan :  Increase FiO2 from 35% to 50%.

Do you concur?

QoW – 2016 – Q3 – 003

mri02

The patient was on the following ventilator parameters in the CTICU :  SIMV-VCV,  RR(set)=8,  Vt(set)=700,  FiO2=50%,  PEEP=5.

The patient will be in the MRI suite for the next 75 minutes.

a) what will the settings be on this ventilator ?

b) how do you set patient trigger ?

c) how do you set Vt(set) on this ventilator (the “cheat sheet” was ripped off of the side of this ventilator).

d) if you use the vent with the settings that are currently dialed in, what will the ventilators translate to in standard ventilator parameters.

 

20160915-edwards-hemodyn

eLibrary – FREE

 

20160915-edwards-hemodyn

Build up your eLibrary starting with this gem – great hemodynamic tutorial. Hemodynamics is a huge part of our jobs as respiratory therapists and being proficient is key to being a great practitioner.

Anyone and everyone should get this booklet if you are interested in hemodynamics.

It is free to download.

Google search “edwards hemodynamics pdf” and then select the search item I have identified in the inset.

If you go to the Edwards website’s homepage, there are other good booklets for free.

There is a lot of good stuff out there for free from our vendors.

As I have opportunities, I will post them – I will use the key search words eLibrary or FREE so the references can be found.

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

sx01

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

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

sx02

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.