Guest JMPA Posted July 23, 2014 Share Posted July 23, 2014 the abg shows compensated respiratory acidosis. is the patient over sedated? is his pain adequately controled? does he have diaphramatic paralysis? heart us? cardiac tamponade? Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 23, 2014 Moderator Share Posted July 23, 2014 the abg shows compensated respiratory acidosis. is the patient over sedated? is his pain adequately controled? does he have diaphramatic paralysis? heart us? cardiac tamponade? Read above and it says his pain is adequately controlled (at least I read moderate pain responsive to opioid as controlled), I doubt we have a paralyzed diaphragm as I figure we would be told of elevated diaphragm on CXR, still waiting for the echo, hearts sounds are normal and various other reasons make me think tamponade is unlikely. Link to comment Share on other sites More sharing options...
FfIghter23 Posted July 23, 2014 Share Posted July 23, 2014 Still intrigued by this case...The only thing that keeps coming to mind is ARDS due to alveolar collapse and the amount of physiological shunting. This would also explain it being managed by 100% FiO2 over the weekend as his body has compensated. Link to comment Share on other sites More sharing options...
andersenpa Posted July 23, 2014 Author Share Posted July 23, 2014 So there are problems with diffusion (either lack of inspired or actually exchange problem at the membrane), extraction (like cyanide), delivery (like shock, HF), and carrying capacity (anemia) I was initially thinking problems with exchange, but more recently thinking a a delivery problem. He didn't seem dry according to his CVP, so I was think more of a ineffective pump problem. We could try a 500cc bolus just to see if it's volume depletion and see if it decreases vasopressor need or a TTE I think would give me an answer. Or I'm way off base Good. At this point he is off all pressors for several hours with a stable blood pressure. Or maybe he's hemoconcentrated hiding anemia? Nvm. that wouldn't really affect the sat as it measures oxygen bound to henoglobin Think about a study to eval for intravascular volume status. CVP is a proven POOR tool for this. the abg shows compensated respiratory acidosis. is the patient over sedated? is his pain adequately controled? does he have diaphramatic paralysis? heart us? cardiac tamponade? Diaphragms are nl height on CXR. He is responsive and brisk. Pain is well controlled now. Read above and it says his pain is adequately controlled (at least I read moderate pain responsive to opioid as controlled), I doubt we have a paralyzed diaphragm as I figure we would be told of elevated diaphragm on CXR, still waiting for the echo, hearts sounds are normal and various other reasons make me think tamponade is unlikely. Echo is a good first choice after your routine resp failure workup: H&P, CXR, ABG, +/- D dimer, BNP. What are the diagnostic criteria for tamponade? What else will echo tell us? Still intrigued by this case... The only thing that keeps coming to mind is ARDS due to alveolar collapse and the amount of physiological shunting. This would also explain it being managed by 100% FiO2 over the weekend as his body has compensated. What are the diagnostic criteria for ARDS? (I mentioned at least one already) Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 23, 2014 Moderator Share Posted July 23, 2014 Good. At this point he is off all pressors for several hours with a stable blood pressure. Think about a study to eval for intravascular volume status. CVP is a proven POOR tool for this. Diaphragms are nl height on CXR. He is responsive and brisk. Pain is well controlled now. Echo is a good first choice after your routine resp failure workup: H&P, CXR, ABG, +/- D dimer, BNP. What are the diagnostic criteria for tamponade? What else will echo tell us? What are the diagnostic criteria for ARDS? (I mentioned at least one already) Did not know CVP was a poor indicator. Thanks. I'll try an answer the questions without looking them up. Off the top of my head, I can't think of a good "study" for intravascular status. We could look at at his electrolytes, UOP, UA, tachycardia with hypotension, poor skin elasticity (tenting) which would give us indicators. Some of these obviously masked by our current treatments. Not sure about "diagnostic criteria," unless you mean signs/symptoms. We could see elevated JVP, tachycardia, drops in SBP with inspiration (pulsus paradoxus I believe)? Always seem to mix the second part up with alternans), ECG swings, large heart on CXR, a rub/muffled heart sounds, equalization of pressures on PA cath, and obviously changes on echo with diastolic dysfunction. That's about all I can name. I'm sure there's more. Echo will tell us about ventricular filling, EF, atrial chamber sizes, regurgitation and stenosis of valves, ventricular aneurysms and function...feel like I'm missing stuff but having a brain fart Ards: the only criteria I can remember for sure is a Pao2/fio2 less than 200 or 300mmhg? on vent or cpap and ruled out other causes. Other things that I know happen clinical are that it's within a few days of insult and is bilateral. Keep having to use increasing peep for oxygenation? This concludes almost all my knowledge of ARDS. Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 23, 2014 Moderator Share Posted July 23, 2014 Forgot to mention BUN/Cr greater that 15 can indicate intravascular status and is the most common cause of prerenal kidney injury. Link to comment Share on other sites More sharing options...
andersenpa Posted July 24, 2014 Author Share Posted July 24, 2014 Echo will tell us about ventricular filling, EF, atrial chamber sizes, regurgitation and stenosis of valves, ventricular aneurysms and function Echo is a great test because is noninvasive, carries essentially no risk (as a transthoracic) unless you are allergic to ultrasound gel, and is dynamic. In this patient it rules out several things quickly which can contribute to cardiorespiratory insufficiency: tamponade, left sided valvular regurgitation, ventricular dysfunction, volume overload to name a few. I would use the other things you mentioned (OUP, HR, skin turgor, chemistries) in forming the ddx and then use echo to rule in/out. Since echo is becoming more standard as a point-of-care study in the ICU it's used more readily than in the days when you had to call in the echo tech to perform it and get a read from a cardiologist. The ARDS criteria are easy to find but yes severe hypoxia, bilateral patchy infiltrates in the absence of cardiogenic cause (low/nl PCWP/PAD) So what would the ddx be for his hypoxia based on the difference classes you gave. Echo shows only modestly impaired LV function EF 40s, no tamponade, no valve leak, no intracardiac shunt. Link to comment Share on other sites More sharing options...
andersenpa Posted July 24, 2014 Author Share Posted July 24, 2014 With CVP the real question is: Will the patient's stroke volume (and thus CO) respond to a fluid bolus? Marik's paper: http://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=2172965&PDFSource=13 Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 24, 2014 Moderator Share Posted July 24, 2014 Echo is a great test because is noninvasive, carries essentially no risk (as a transthoracic) unless you are allergic to ultrasound gel, and is dynamic. In this patient it rules out several things quickly which can contribute to cardiorespiratory insufficiency: tamponade, left sided valvular regurgitation, ventricular dysfunction, volume overload to name a few. I would use the other things you mentioned (OUP, HR, skin turgor, chemistries) in forming the ddx and then use echo to rule in/out. Since echo is becoming more standard as a point-of-care study in the ICU it's used more readily than in the days when you had to call in the echo tech to perform it and get a read from a cardiologist. The ARDS criteria are easy to find but yes severe hypoxia, bilateral patchy infiltrates in the absence of cardiogenic cause (low/nl PCWP/PAD) So what would the ddx be for his hypoxia based on the difference classes you gave. Echo shows only modestly impaired LV function EF 40s, no tamponade, no valve leak, no intracardiac shunt. If that's all the echo showed (normal EDV) then I'm guessing he has an exchange problem. ARDS/atelectasis would be high on the list. Didn't see the b/l opacities on CXR, though we could be in early stages I suppose. I would assume he would be getting worse before he got better, especially in ARDS. Any change in respiratory status/ABG? Any change on CXR? Link to comment Share on other sites More sharing options...
JCrownover Posted December 17, 2014 Share Posted December 17, 2014 What happened to this thread? Pt hx of COPD, Asthma, Tobacco, other hx? Segmental atelectasis, compensated respiratory acidosis, diminished sounds left base, mild tachypnea. Bronchoscopy? Link to comment Share on other sites More sharing options...
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