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PUL in the PACU

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pd4emergence

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50 something yo lady with h/o large renal pelvis stone, relatively healthy lady, active, normal size (amazing since most of the PUL's I do can't be under 325lbs). Pt does have NIDDM, on oral meds and under control. Pt is now s/p PUL (percutaneous urolithotomy), in the PACU with chest pain/shortness of breath. Sat's hanging around in the low 90's even with supplemental O2 and alot of it. The usual stuff was done. CXR, EKG, enzymes drawn, ABG, BMP. EKG with no acute changes, CXR read by radiology as "CHF" but pt with totally clear breath sounds and good air movement and it looks like an exhalation film. ABG pretty much normal PO2 200. BMP normal. What next?
 

Planktonmd

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50 something yo lady with h/o large renal pelvis stone, relatively healthy lady, active, normal size (amazing since most of the PUL's I do can't be under 325lbs). Pt does have NIDDM, on oral meds and under control. Pt is now s/p PUL (percutaneous urolithotomy), in the PACU with chest pain/shortness of breath. Sat's hanging around in the low 90's even with supplemental O2 and alot of it. The usual stuff was done. CXR, EKG, enzymes drawn, ABG, BMP. EKG with no acute changes, CXR read by radiology as "CHF" but pt with totally clear breath sounds and good air movement and it looks like an exhalation film. ABG pretty much normal PO2 200. BMP normal. What next?
So, she is dyspneic with Low SPO2 on pulsox but normal PO2 on ABG! Strange!
Was she given Methylin blue?
Any reason for her to have methemoglobinemia?
 

jwk

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Has her pain been treated?
 

VentdependenT

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50 something yo lady with h/o large renal pelvis stone, relatively healthy lady, active, normal size (amazing since most of the PUL's I do can't be under 325lbs). Pt does have NIDDM, on oral meds and under control. Pt is now s/p PUL (percutaneous urolithotomy), in the PACU with chest pain/shortness of breath. Sat's hanging around in the low 90's even with supplemental O2 and alot of it. The usual stuff was done. CXR, EKG, enzymes drawn, ABG, BMP. EKG with no acute changes, CXR read by radiology as "CHF" but pt with totally clear breath sounds and good air movement and it looks like an exhalation film. ABG pretty much normal PO2 200. BMP normal. What next?

ECHO, Lasix 40, toprol 5, NTG ggt, fentanyl, troponin, heparin 5K, cards consult in the PAR (they come fast). SOrry dude you gotta rule that crap out. She's gonna buy a cath. Once stabilized get her to a scanner to rule out PE.

Hypoxia + wet CXR + SOB + CHest pain in a fattie diabetic = MI or PE to me. Tube her if you gotta.

If her hypoxia magically disappears with fentanyl then great! She's still bought a cards consult. No GOLD STAR for NOT working her up.
 

swpm

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Sat's hanging around in the low 90's even with supplemental O2 and alot of it.

ABG pretty much normal PO2 200.

You're not going to have a sat in the low 90s with a PaO2 of 200 unless either the hemoglobin is abnormal or some piece of equipment is broken. Our ABGs all come with co-oximetry. I take it yours do not?

(Or is her 10% methemoglobinemia the part of her ABG that isn't "pretty much normal" :)?)

She may well be having an MI or PE, and that deserves to be considered as Vent posted, but something else is also wrong/broken.
 

2ndyear

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Our ABG's do not come with co-oximetry. Very interesting to have that though. I haven't sent one to the real hospital lab (we have an OR stat lab) in so long that I forgot if they do, but I don't think so.
 

Jeff05

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must r/o PE and MI. EKG, CXR, ckmb, trops, abg, CBC (hct wnl?) cards consult.
while you wait - high Fi02, beta blocker, fent/morphine, and sL NTG.
 

Planktonmd

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ECHO, Lasix 40, toprol 5, NTG ggt, fentanyl, troponin, heparin 5K, cards consult in the PAR (they come fast). SOrry dude you gotta rule that crap out. She's gonna buy a cath. Once stabilized get her to a scanner to rule out PE.

Hypoxia + wet CXR + SOB + CHest pain in a fattie diabetic = MI or PE to me. Tube her if you gotta.

If her hypoxia magically disappears with fentanyl then great! She's still bought a cards consult. No GOLD STAR for NOT working her up.
What hypoxia?
He said PO2 on ABG was above 200!
 

Planktonmd

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The absence of hypoxia on ABG makes PE and CHF unlikely, the abnormal SPO2 and chest pain could be explained by Methemoglobinemia.
The CXR appearance is most likely due to weak exposure.
 

Jeff05

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if patient is on a NRB mask (fi02 higher than 0.8) with a po2 of 200, she is, indeed, hypoxic.
 

pd4emergence

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You're not going to have a sat in the low 90s with a PaO2 of 200 unless either the hemoglobin is abnormal or some piece of equipment is broken. Our ABGs all come with co-oximetry. I take it yours do not?

(Or is her 10% methemoglobinemia the part of her ABG that isn't "pretty much normal" :)?)

She may well be having an MI or PE, and that deserves to be considered as Vent posted, but something else is also wrong/broken.

She is on a closed facemask at about 8L per minute. At times the PACU nurse has been cranking her O2 up to keep her in the low 90's. I figure her Fio2 is probably about 80%. I should have put this in the initial post. Do the math PAo2 .80(760-47)-45/.8=514, even correcting for age and Fio2 she still has a pretty large gradient >than 200.
 

epidural man

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You're not going to have a sat in the low 90s with a PaO2 of 200 unless either the hemoglobin is abnormal or some piece of equipment is broken. Our ABGs all come with co-oximetry. I take it yours do not?

(Or is her 10% methemoglobinemia the part of her ABG that isn't "pretty much normal" :)?)

She may well be having an MI or PE, and that deserves to be considered as Vent posted, but something else is also wrong/broken.

Absolutely agree. If her sat's are 90ish and her PaO2 is 200, something is up with that.

However, if the numbers you give are correct, she has PaO2/FiO2 ratio of 250 which puts her in the Acute lung injury category. (remember, <200 = ARDS, <300 = ALI). She has the bilateral infiltrates, so you have that criteria. Now you got to figure out if it is cardiogenic. Criteria for ARDS is CVP <18. I don't think you would do a central line just to find out, but you certainly can easily check a peripheral venous pressure. I know the trend has been shown to correlate well and absolute numbers are not that usefull - however, if the CVP is over 18, you will not get a peripheral venous pressure of 6 or 8, so check that.

I think distinguishing between ALI and cardiogenic is more than just an academic issue - it will also help your management.

Was there any ultrasound used to break up the stones? Lung contusion maybe if they did?
 

epidural man

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What hypoxia?
He said PO2 on ABG was above 200!

Agree.

Hypoxia = decrease or inadequate O2 at the tissue level
Hypoxemia = decrease or inadequate O2 level in the blood.

Although this patient has a large A-a gradient, she seems to have plenty of O2 in the blood. The question is wether she has adequate oxygen at the tissue level. We do not have enough information to decide or answer this question.
 

swpm

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She is on a closed facemask at about 8L per minute. At times the PACU nurse has been cranking her O2 up to keep her in the low 90's. I figure her Fio2 is probably about 80%. I should have put this in the initial post. Do the math PAo2 .80(760-47)-45/.8=514, even correcting for age and Fio2 she still has a pretty large gradient >than 200.

I'm not saying she doesn't have a PE or something else causing V/Q mismatch. You're right, that is an abnormal A-a gradient, and it deserves an explanation.

But a PO2 of 200 doesn't produce a sat in the low 90s, regardless of what's going on in the lungs ... unless the hemoglobin is abnormal or the machine is broken.
 

urge

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pd4emergence,

Could you describe how they do the PUL? What kind of anesthetic she had? Was she ok for wake-up assuming GA? Was her sat ok in the OR? How much fluid she had? What were the Vital Signs like? What was the sat on the ABG?

Agree with Pao2 of 200 should not give a sat of 90. Something is wrong there.
Agree with something else is going on to produce so a large A-a gradient.

Could she have aspirated?

I would elucidate the possible methemoglobinemia before doing anything else.
 

Planktonmd

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Even if we assume that you are able to produce an FIO2 of 80% by simple face mask (not a non re breather), if the PO2 is 200 I don't see how this is going to produce an SPO2 of "low 90" unless there is something tricking the puls-ox like methemoglobin or your SPO2 equipment is faulty.
What was the saturation on the ABG?
 

pd4emergence

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pd4emergence,

Could you describe how they do the PUL? What kind of anesthetic she had? Was she ok for wake-up assuming GA? Was her sat ok in the OR? How much fluid she had? What were the Vital Signs like? What was the sat on the ABG?

Agree with Pao2 of 200 should not give a sat of 90. Something is wrong there.
Agree with something else is going on to produce so a large A-a gradient.

Could she have aspirated?

I would elucidate the possible methemoglobinemia before doing anything else.

Basically a PUL bypasses the ureter or renal pelvis for urine drainage. This patient went to IR and had a wire placed so that the surgeon could then place the otomy tube. I talked to the radiologist later and he said that she was very difficult to access and his access point was somewhere between the 11th and 12th rib. She came to the OR and looking at the record she did OK, no sat issues, no bp issues. She was prone, GA, 1 hr long procedure, about 700ccs of fluid was given by us. Uro guy does use cystoscopy/ureteroscopy to help place this thing. It was not my case, I inherited this as I was coming on call from one of my partners who left as pt hit the PACU. I asked the CRNA about aspiration and she said that all was clear when she suctioned and the tube was clean. Still a possibility at that point though.
 

pd4emergence

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This lady really had no problems until about 20 min after she hit the pacu. She told the nurse she was hurting and was given some pain meds. About the same time the recovery room nurse notes that she is needing more and more O2 to maintain her sat. About 10 minutes later the RN's call me and says that something ain't right and this lady is starting to complain of chest pain and dyspnea. I go and order the above. She is on about 8L and was able to keep a sat of 93-94 on her pulse ox. She was also febrile (101) at the time but was febrile before the OR d/t UTI/pyelonephritis which is why they wanted to do this. She tells me she is having substernal chest pain and is having trouble catching her breath. I get all of the above and looking at her chest xray, i give her some lasix even though she sounded pretty clear. I also gave her some morphine/nitro which did not seem to help much. I ordered the abg at that time which was a little acidemic 7.35 or so, normal co2, pao2 was about 180 or so, sat correlated with the pulseox 93 or 94%. I thought it was kinda strange that her sat was low with that high of a po2 but was more worried about the fact that it should have been higher and that she continued to c/o of chest pain and dyspnea. Enzymes had been drawn, EKG was pretty normal. Morphine/nitro was not much help. During this time she peed out about 1L from a 20mg dose of lasix in about 30 minutes (which helped her some but not completely)

So my list of possibles at the time was
1 ischemia with heart failure
2 PE
3 Volume overload from the irrigation fluid (they used three big bags of normal saline for irrigation during the procedure)
4 PTX not on CXR
5 Aspiration
6 pneumonia she had some infiltrates on the right on her cxr which I sort of wrote off as being a bad film but possible

At this point, she was stable, BP's ok, HR's ok, RR about 25, sats staying 93-94%. I talked to cards and told them she was stable and that I was going to send her to CT. Cards guy says he will see her there. CT showed an obvious large pleural effusion on the same side as the PUL. I look at the cards guy and say that it probably ain't cardiac and he says he will rule her out anyway. Pt was sent to the ICU where one of our pulmonologists saw her. They d/c'ed the PUL tube and drained a bunch of yellow fluid from her plural space and her symptoms resolved. Apparently the PUL access site communicated with her pleural space and either during or after her operation she developed this effusion. I think it was probably after b/c she did ok for that first while in the pacu. I have never seen urothorax and it for sure wasn't on my differential. As far as the methemoglobinemia thing, I just didn't think of it at the time. I might have gotten there if the CT was negative(maybe). As far as the discussion as to why her Pao2 was so high and her sat wasn't 100%, She was hyperthermic and a little acidemic shifting the o2 dissociation to the right, maybe with some mild sepsis from her pyelo/uti, O2 uptake was probably increased and maybe that Pa02 just wasn't high enough to get her to 100%. That's my best guess. To top it all off this lady is one of the top administrators at our hospital. Luckily she did fine, they were able to litho out what was left of the her stone about a week later.
 

proman

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Are you going to submit this to a journal? I did a pubmed search on "urothorax" and there are 9 hits (including animals), mostly in the trauma literature. This is the only one in the anesthesia literature. Nice case.

Leroy G, Dupuis F, Guy JP, Le Blanc C, Trovero C, Bricard H, Quesnel J.
No Abstract
[Urothorax following total cystectomy]
Cah Anesthesiol. 1984 Mar;32(3):235. French. No abstract available.
PMID: 6529660 [PubMed - indexed for MEDLINE]
 

epidural man

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wow. cool case. I agree you should submit it.

Are you going to submit this to a journal? I did a pubmed search on "urothorax" and there are 9 hits (including animals), mostly in the trauma literature. This is the only one in the anesthesia literature. Nice case.

Leroy G, Dupuis F, Guy JP, Le Blanc C, Trovero C, Bricard H, Quesnel J.
No Abstract
[Urothorax following total cystectomy]
Cah Anesthesiol. 1984 Mar;32(3):235. French. No abstract available.
PMID: 6529660 [PubMed - indexed for MEDLINE]
 
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