PE question

[sozme]

n00b question from idiot med student - this is regarding patient actually admitted with ileofemoral DVT and PE treated with IR/vascular surgery lysis (w/e its called where you use the cordis thing to directly deliver t-PA to the clot). This individual is an otherwise healthy female in her late 20s

So couple days after being admitted, she is constantly having attending paged because she has dyspnea but her vital signs are usually normal during these episodes. Was walking with attending and this patient happened to come out of her room at the same time and started having a coughing spell.

Nurses were all over her, trying to give her supplemental O2. She did have a fast HR in 130s but her SPO2 was 100%.

So my question is why would they insist on giving her supplemental O2 when her hemoglobin is already 100% saturated with oxygen? I asked this very question and nurse said, "Well her HR is elevated."

Thanks for ur time.

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[gro2001]

Nursing is built around protocols. This is not a knock on nursing... it's one of the great innovations of modern medicine to have things like Q4 hour vital signs protocolized. However, one of the side effects is that sometimes what happens is that when nurses act on protocols, they justify them with reasoning that does not make sense. While there are situations where a 100% SpO2 would not reflect true oxyhemoglobin status (carbon monoxide poisoning, CN poisoning, etc), this was not one of those cases. The O2 would not do anything magical for the patient you described. However, sitting the f**** down (if only to have the O2 administered) instead of walking around with a massive/submassive PE, WOULD actually help. So... lesson from this is to not act as a smart ass and do what your nurse tells you.

 

[cozmokramer]

If a medical student walks through the halls slow enough a nurse will put supplemental oxygen on them.

 

[MadMedic704]

Sometimes it provides a placebo effect too. Just make sure they're ambulatory sats are fine on day of discharge

 

[e30ftw]

the patient's dyspnea was most likely caused by a combination of anxiety and pleutific CP from the subsequent alveolar tissue damage and pleural irritation caused by her PE. aka hacking up dead lung tissue. and yes, nurses love protocols..

However pulse oximetry measures SpO2 or percent hemoglobin in blood, increasing FiO2 w/ supplemental oxygen for example does increase PaO2 (dissolved in plasma) even if hbg is already 100% binded. Probably a negligible effect on tissue perfusion in her case however.

This is the physiologic basis why we give pts w/ acute MI supplemental O2 even if their SpO2 is 100%. Of course there's little to no good evidence supporting that practice and it could be associated w/ increased mortality from oxidative damage, etc, but still standard practice.

 

[Janders]

It's not standard of practice where I work to give acute MI's oxygen, unless they are hypoxic. Same with out local EMS crews.

http://www.ncbi.nlm.nih.gov/pubmed/22424003

forgive the thread drift.

 

[RustedFox]

It's not standard of practice where I work to give acute MI's oxygen, unless they are hypoxic. Same with out local EMS crews.

http://www.ncbi.nlm.nih.gov/pubmed/22424003

forgive the thread drift.

Does it aggravate anyone else that the people who create study abbreviations just pick whatever letters they like from whatever words to jam in their message? If you're gonna have an anagram or a mnemoic or whatever... do it right.

For example, I'm going to call this the ANNOY message... see bolded letters above.

 

[TooMuchResearch]

It's not standard of practice where I work to give acute MI's oxygen, unless they are hypoxic. Same with out local EMS crews.

http://www.ncbi.nlm.nih.gov/pubmed/22424003

forgive the thread drift.

Not standard here either.

 

[Groove]

Supplemental O2 remains a Class IIa ACC/AHA guideline for AMIs unless sats <90% or signs of pulmonary congestion, at which point it's a Class I guideline. Honestly, there's little data to support or refute it's use in the context of MI, so I don't think anyone can fault you either way until more studies get out there.

Personally, I slap some O2 on them.

 

[cbrons]

Supplemental O2 remains a Class IIa ACC/AHA guideline for AMIs unless sats <90% or signs of pulmonary congestion, at which point it's a Class I guideline. Honestly, there's little data to support or refute it's use in the context of MI, so I don't think anyone can fault you either way until more studies get out there.

Personally, I slap some O2 on them.

But why would we want to do that if they are normoxic? From my understanding, hyperoxemia promotes coronary vasoconstriction, and the AVOID trial suggests strongly that supp oxygen in patients with greater than 94 spo2 is associated with larger infarct size when measured out 6 months.

The physiology here definitely makes no sense, assuming 100% or close SpO2. Hard to do better than that....

 

[e30ftw]

yeah the acronyms are too much sometimes.

I try to avoid O2 in patients who are not hypoxic but you'd think I had an arm growing out of my forehead when I tell EMS to take the NRB off the trauma patient w/ sats of 99%.. Our county service is pretty good but a lot of the local private EMS services give everyone with any type of chest/dypsnea complaint O2/albuterol/solumedrol and an inch of nitro paste for the hell of it.

But why would we want to do that if they are normoxic?

because your cardiologist will crucify you in the event of a lawsuit from a patient they cathed who had a bad outcome and in whom you specifically instructed RN/EMS/RT to remove oxygen therapy.

They could call any number of RNs/RTs who would say, "I told that doctor to keep the Os on but he said no, now the pt has an EF of 15% instead of 20%."

This is one of those instances where the evidence to support withholding a presumed therapeutic but potentially harmful treatment does not yet outrageously outweigh the evidence telling the MD to just do what is normally done. Statistics can prove anything..

I'm not saying it's "right" but truly, what is? How do you really know? Does anyone know exactly what happened at every enrollment of every patient in every DB-RCT? Are there any true facts in this business beyond, "It is good to suture a gaping laceration." and "Pus needs steel." ?

 

[Old_Mil]

This is the physiologic basis why we give pts w/ acute MI supplemental O2 even if their SpO2 is 100%.

...not here it isn't.

There are temporary facts in medicine, not true ones.

 

[engineeredout]

There are certain hot button topics that I am prepared to argue for against nurses, medics and other support staff with regard to patient care. Putting someone on 2L nasal cannula who doesn't really need it is not one of them.

Choose your battles wisely.

 

[Arcan57]

AVOID seemed like a pretty good reason to lay off supplemental O2. For most things, the best reason to remove the O2 is to figure out what the patient's oxygenation status actually is. 99% on 4 or 8L doesn't tell me anything but there's often some ghost that keeps turning up the O2 as soon as I leave the room.

 

[Vandalia]

There are certain hot button topics that I am prepared to argue for against nurses, medics and other support staff with regard to patient care. Putting someone on 2L nasal cannula who doesn't really need it is not one of them.

Choose your battles wisely.

I have to agree. All the discussion is based on the assumption that people will make the correct decisions before you see the patient.

Given the potential risks, I am much more comfortable with ~100 people getting O2 who don't need it than the 1 who does not getting it. Therefore, I have no problem with nurses/paramedics/EMTs giving oxygen at which point the physician can make the decision to discontinue. Better they give oxygen to the guy with a sprained ankle "just in case", than not give it to the guy with extreme SOB turning blue ("but the pulse ox said 98%!")

When you do this long enough, you realize things that are "never supposed to happen", actually take place with reasonable frequency. (The very fact that the Joint Commission can identify "never events" means they aren't really "never", are they?)