Sats are 85%, controlling surgeon...

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jetproppilot

jetproppilot

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Had an incident a while back during a thoracoscopic MAZE procedure.

Nice, young dude we put to sleep.

38 years young.

Chronic A fib. History of HTN and asthma.

Working dude.

Big dude, about 240, shorter than me.

And not a bodybuilder physique. Rather, an

I EAT FRIED FOOD physique.

So operation is on.

A line is in, TLC is in, double lumen tube is in,

Dude is flipped on his left side, right side up,

right lung isolated, ventilating the left lung only,

surgeon starts and we're on our way.

I look down the DLT with the fiberoptic and I can see the carina with the little blue cuff almost-but-not-really popping outta the left mainstem.

Perfect.

Check with the CRNA, everythings cool.

I run to Day Surgery to see a cuppla people, go to room 9 to start a TAH, room 5 has a problem with urine output so I go there, beeper goes off so I meander to PACU, back to Day Surg for a cuppla pre ops, colleague tied up in a room so I go start his room, finally a break so wander into Room Six where my orthopedist buddy is operating to shoot the breeze for a while....

BEEEEEP BEEEEEP BEEEEEEEP

Maze procedure room looking for me.

I walk into the Maze room.

Look at the monitors.....sats are 85-86%.

Dudes in Afib witha rate of about 120-130 (yeah, well, uhhhh, Dude, thats why you're here).

BP OK.

Surgeons worried about barotrauma to the isolated lung so only wants 500mL tidal volumes.

Keep in mind this is about a 240 pound dude.

With his ventilated lung on the down side of his big body.

Top of the end tidal CO2 tracing shows a noticeable upstroke.

Surgeon doesnt want albuterol because of patient's already-present tachycardia, he wants Atroventtm instead...

SO LETS SAY

just to make it interesting, this is your FIRST DAY on the job with your new private practice job with C-NOTE ANESTHESIA, LLC.

Your DREAM GIG.

Here you are.

Theres not an attending to turn to since now, resident colleagues,

YOU ARE THE F UKKING ATTENDING.😆

Walk me through how you're gonna handle this situation with a solution that will save the patient from his current hypoxemic state, and also save face with a controlling surgeon that brings alotta benjamins to your practice.

I want you guys to realize that there are ways to KILL TWO BIRDS WITH ONE STONE.

Think of some.

Remember, you've got ONE STONE.

And 2 birds to kill.

One-haffa-the-stone will kill the hypoxemia.

The other-half will quell the surgeon's ego without hurting the surgeons ego......this ain't academia, Dudes....ya can't just say "F YOU" to the surgeon, in an act of anger, anymore.

Gotta STEP UP TO THE MIKE and make everyone happy.....the patient (life), the surgeon (ego,case), and you (job satisfaction, c-notes).

"LAUNCH READY FIVE." (thatsa quote from Top Gun BTW, meaning ENGAGE!!!!!!! )
 
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OH.....

wanna add that theres no stupid answers here....I'm effectively BANNING flames so ALL can contribute....

I wanna engage everyone, even med students who have at least studied bronchospastic disease....

WTF?

Whaddya do now????:scared:

"SATS ARE EIGHTY-FIVE PERCENT, DOCTOR! WHAT DO WE DO NOW????
 
Not sure what you magic stone is but here are some things i would do:

Crank up the O2, Cpap to the non dependant lung, atrovent if he wants it (or just give albuterol and say it's atrovent). Change to pressure control if it gets you better TV. Deepen anesthetic with volatiles if Bp permits.
 
I'd do everything DHB said. In addition to CPAP, you can give a little ventilation briefly to the non-dependant lung, too. This is a relatively common scenario. Provided your peak pressures aren't above 40 cm H2O and the sats are stable, you just proceed. Probably not an issue with the asthma here then. And, albuterol (predominately beta-2) isn't contraindicated, but not necessary unless you have high peak pressures. And, I'd crank up the tidal volume a little bit and give a little more expiratory time (not that that's going to necessarily help with oxygenation and will increase your peak pressures). Once they finish the maze, you shouldn't have anymore ectopy foci for the tachycardia... if your surgeon is a stud.

What are you thinking, Jet? Not a beta-blocker, right? The tachycardia, though, will contribute to increased O2 demand as well as more CO2 generation.

-copro
 
in addition to above, i'd first check with FOB to make sure DLT not down too far, then i might increase resp rate, increase I:E to 1:2.5, control HR to rate under 100.
 
Side question Jet: ask your surgeon if he trained to do the procedure under James Edgerton. Wondering how much of Edgerton's equipment and techniques are propagating around.
 
I have a more basic question about this case.

What's the problem?

Big fatty is having a VATS and is on one lung ventilation with a sat in the mid 80s. What's the big deal? This happens all the time. He's got AFib (as usual for the patient) and is hemodynamically stable. I'd say the surgeon isn't unreasonable for requesting limited TV. During a VATS procedure, the image on the screen will be bouncing all over the place if you give larger tidal volumes.

What would I do in this scenario?

-Crank up the FiO2
-Keep tidal volumes around 2-3 ml/kg of IBW
-Snake a suction catheter into the nonventilating lung and hook it up to oxygen flow so you can passively oxygenate that lung.
-turn the pulse ox alarm down a few notches (say 84%)

Albuterol, Atrovent, etc might make a little difference but probably not much.
 
jetproppilot said:
Look at the monitors.....sats are 85-86%.

Dudes in Afib[/]b witha rate of about 120-130...

BP OK.

Surgeons worried about barotrauma to the isolated lung so only wants 500mL tidal volumes.

Keep in mind this is about a 240 pound dude.

With his ventilated lung on the down side of his big body.

Top of the end tidal CO2 tracing shows a noticeable upstroke.

Surgeon doesnt want albuterol because of patient's already-present tachycardia, he wants Atrovent tm instead...
Walk me through how you're gonna handle this situation with a solution that will save the patient from his current hypoxemic state, and also save face with a controlling surgeon that brings alotta benjamins to your practice.

I want you guys to realize that there are ways to KILL TWO BIRDS WITH ONE STONE.

Think of some.

Remember, you've got ONE STONE.

And 2 birds to kill.

One-haffa-the-stone will kill the hypoxemia.
Click to expand...


Med student thrown stone.

Increase PEEP.
 
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dhb said:
crank up the o2, cpap to the non dependant lung, atrovent if he wants it (or just give albuterol and say it's atrovent). Change to pressure control if it gets you better tv. deepen anesthetic with volatiles if bp permits.
Click to expand...

+1
 
When surgeon is not looking...take O2 monitor off patient and put in on my own finger. Sat now reads 98% and everybody's happy
 
Schooner said:
When surgeon is not looking...take O2 monitor off patient and put in on my own finger. Sat now reads 98% and everybody's happy
Click to expand...

HAHAHAHAHAHAHA.........thats good!!!😆
 
run a couple of liters of O2 to the up lung will help oxygenation without inflating lung, if PIP increased then atrovent, might try sone diltiazem to decrese HR and myocardial demand. Swithc to prressure contol if it increase TV.
 
what the hell is atrovent gonna do? he has asthma, not COPD. and i don't think i'd expect a hell of a lot of action from atrovent, which doesnt exactly work real quickly. somebody feel free to correct me.

when i see sats of 85% and i want 90%+, atrovent doesn't really come to mind.
 
if i had to hazard a guess, i'd say options are as dhb said. pump up the o2 to max, give a little peep, to increase oxygenation. also xopenex and changing to pressure control.
 
So, you started one lung ventilation and all was well. Good sats.

Then you went to day surgery, saw a couple people, started a TAH, checked on some urine, stopped by the PACU, did some preops, started another case, then chatted with an orthopod for a while. Then you got called.

That seems like a long time, even for a supremely efficient PP master. Sounds like her sats on OLV all this time were fine, but now they're down? If anything I'd expect oxygenation to be a little better after a period of OLV as HPV starts to improve your V/Q and work for you.

In addition to all the stuff listed above, I think we need to at least consider other events. Not all hypoxia during OLV is caused by OLV ... can't forget the rest of the differential and get tunnel vision on the "sats are low because of OLV" theory.


But assuming nothing else is going on - of course you're on 100% O2 and have been since the start. PEEP and CPAP with some apneic oxygenation to the nondependent lung. Confirm tube placement with the scope. You don't need a bronchodilator unless you're having trouble achieving your desired tidal volumes so I wouldn't give albuterol. More volatile is probably going to worsen your V/Q. The fix for the tachycardia and its O2 demand is surgical, and it's being done by the guy qualified to do it.

Give the atrovent if it makes the surgeon feel better, but I'd live with the 85% if I was sure that nothing else was going on. 85% isn't going to kill any brain cells. If it got lower you might have to revert to 2LV for a while.

Turn off the alarm on the pulse ox and discreetly shift the monitor away from the surgeon.
 
radslooking said:
what the hell is atrovent gonna do? he has asthma, not COPD. and i don't think i'd expect a hell of a lot of action from atrovent, which doesnt exactly work real quickly. somebody feel free to correct me.

when i see sats of 85% and i want 90%+, atrovent doesn't really come to mind.
Click to expand...

You are right, Ipratropium will do nothing.
 
Check vitals, ensure proper fxn pulse ox, may recheck positioning
1. CPAP to non-dep lung
2. PEEP to dep lung
3. Pt should already be on 100% (someone earlier said increase FIO2)
4. See no problem w/ giving ipratropium, it actually works in some pts
5. I would see no issue keeping TV around 500, increase RR and consider increasing I:E to 1:2.5
6. Now focus on rate control
😱
 
Planktonmd said:
You are right, Ipratropium will do nothing.
Click to expand...

Mag sulfate? My Stone is thrown. Zebra in the house!!!!😱

I don't know what the risk of arrhythmia is with it, but it would dilate and might slow down the rate.
 
Thanks for all the responses.

Here's what we did and the reasoning behind it:

From a political standpoint, even with a surgeon that tends to micromanage, I don't ever remember one not responding positively to well thought out plans of action when there is a problem that concerns you.

Of course little problems don't need to be discussed most times.....but if the problem is big enough to concern you, I'd bring it up, express your concern, and what you're doing about it.

Simple.

Communication works.

From a clinical standpoint, after making an assessment, I did many of the things you suggested needed to be done.

Confirmed good placement with the scope.

Ran an ABG which confirmed the SpO2 was accurate. Rest of the ABG was normal.

I was convinced there was an atelectatic component to the oxygenation problem....this was a big dude, high 400's tidal volume wasnt gonna cut it......thats usually enough during OLV, but wasnt for this guy. Additionally, looking at the capnograph combined with his history, I was convinced there was an asthmatic component as well. Of course not all wheezing is asthma, but in this patient/scenerio it seemed most likely....so I'll treat it like airway hypersensitivity and see what happens....

As you know, treatment of asthma intraoperatively, or any other medical event for that matter, does not differ from treatment in the ER. SO, the triad of asthmatic sequalae were all addressed:

1)Bronchospasm: Used albuterol. Xopinex is a great suggestion but I don't think we have it in our carts...and if the heart rate bumped up a bit I wasnt too concerned. I don't like using ipatroprium in asthma because of it's drying qualities which could exacerbate the tenacious mucous plugging seen in asthmatics.

2) Inflammation: Solumedrol. Of course it doesnt work immediately but ameliorates air trapping over several hours.

3)Mucous plugging.....we did suck some goo out....upped the crystalloid a bit.

As far as the atelectasis, we changed to pressure support, tolerated peak pressures of around forty for a while. Within an hour they were back near 30 with a concominant tidal volume near 700 on one lung, I assume because our treatment of bronchospasm worked.

Dude was already on FiO2=1.0

Added peep to dependent lung.

Deferred the (good) idea of CPAP to nondependent lung since surgeon wanted the lung as flat as possible and I thought we could improve the situation without it.

I disagree, Mman, that one should tolerate a sat of 85% because your safety net is gone. Situations sometimes get worse, not better, so I start trying to improve any sat below 90%.

Anyway, the interventioned worked.

Sats were approaching 90 within minutes of increasing the TV and albuterol administration, and were back at 99% within an hour.

UT, I'll ask him!

Think I covered everything we did.
 
you would not want to change I:E to 1:2.5...this would shorten inspiratory phase and increase peaks. changing I:E to 1:1.5 or 1:1 would be a more reasonable approach.

passive oxygenation, peep to dep, cpap to non-dep.
if lactate stays low i would take high 80s. if lactate is rising...would discuss proceeding with surgeon.
 
Jeff05 said:
you would not want to change I:E to 1:2.5...this would shorten inspiratory phase and increase peaks. changing I:E to 1:1.5 or 1:1 would be a more reasonable approach.

passive oxygenation, peep to dep, cpap to non-dep.
if lactate stays low i would take high 80s. if lactate is rising...would discuss proceeding with surgeon.
Click to expand...

I think I would increase exp time (1:2.5) by increasing expiration since asthma is an obstructive disease - i'd worry a bit about auto peeping if he's still bronchospasming with 1:1. If peaks get too high, can decrease resp rate (increasing insp time) or if you dont have an 500 year old volume vent can try pressure control which will likely get more volume in a ever so slightly more controlled fashion (since your popping off a lotta volume with volume control due to peak pressures).
 
jetproppilot said:
1)Bronchospasm: Used albuterol. Xopinex is a great suggestion but I don't think we have it in our carts...and if the heart rate bumped up a bit I wasnt too concerned. I don't like using ipatroprium in asthma because of it's drying qualities which could exacerbate the tenacious mucous plugging seen in asthmatics.
Click to expand...

Xopenex, I believe, actually expires rather quickly if not kept cold/dark... so that could be a reason that it is not on your cart. The other issue is, in my rather limited experience, the idea of the isomeric form (did I just make up a word? I have had several beers, so that is possible! 🙂) has not held up to clinical practice as well as laboratory testing. I don't know if this is due to actual efficacy or patients minds (COPDers love their Q4 schedule).

The bit about Atrovent as an anticholenergic is a good point. I have addressed this with many residents when they put EVERYBODY on "duonebs"... but then want Mucomyst added in for secretion clearance... pt has no hx of reactive airway dx... how about we do away with that ipatropium?

Interesting case, it is very interesting how things change in the OR from the ICU (which is what I am used to). Can't wait until I can get in that environment. Just got my MCAT scores back... Just hafta decide between MD/DO and AA...
 
RT2MD said:
Xopenex, I believe, actually expires rather quickly if not kept cold/dark... so that could be a reason that it is not on your cart. The other issue is, in my rather limited experience, the idea of the isomeric form (did I just make up a word? I have had several beers, so that is possible! 🙂) has not held up to clinical practice as well as laboratory testing. I don't know if this is due to actual efficacy or patients minds (COPDers love their Q4 schedule).

The bit about Atrovent as an anticholenergic is a good point. I have addressed this with many residents when they put EVERYBODY on "duonebs"... but then want Mucomyst added in for secretion clearance... pt has no hx of reactive airway dx... how about we do away with that ipatropium?

Interesting case, it is very interesting how things change in the OR from the ICU (which is what I am used to). Can't wait until I can get in that environment. Just got my MCAT scores back... Just hafta decide between MD/DO and AA...
Click to expand...

Dude...umm assuming dude or just use dude as meaning anyone.

I'm assumin your MCAT is mediocre by the way you say deciding b/w MD/DO and AA...

Stick it out and do it right. MD/DO. You took the MCAT, that's what you want. Plus, you want to make decisions, not have them handed to you. If all you want is a pay grade increase...?

You are Non-trad, by way of RT school right.? Allopathic schools like to make N.Trads wait an extra year, just to see if you are serious. Esp., if you are mediocre in your MCAT and the rest looks good. This is from personal experience. I got accepted in my 2nd attempt. If you are going MD, try 2x, if it doesn't look good, go DO. If you are a decent candidate, you got C-Notes, you can get accepted DO. No offense to the DO's out there, but I interviewed to both in year two and was accepted to 3 out of 3 DO schools. And a double no offense to those who believe in the "A.T. Still" philosophy of disease processes and say, "that is how I want to be trained". Whatever. Jst know DOs have a few more hurdles to jump to get where the want to go.

As JPP would say, it is time to "Step up to the MIC"
 
McSnappy said:
Dude...umm assuming dude or just use dude as meaning anyone.

I'm assumin your MCAT is mediocre by the way you say deciding b/w MD/DO and AA...

Stick it out and do it right. MD/DO. You took the MCAT, that's what you want. Plus, you want to make decisions, not have them handed to you. If all you want is a pay grade increase...?

You are Non-trad, by way of RT school right.? Allopathic schools like to make N.Trads wait an extra year, just to see if you are serious. Esp., if you are mediocre in your MCAT and the rest looks good. This is from personal experience. I got accepted in my 2nd attempt. If you are going MD, try 2x, if it doesn't look good, go DO. If you are a decent candidate, you got C-Notes, you can get accepted DO. No offense to the DO's out there, but I interviewed to both in year two and was accepted to 3 out of 3 DO schools. And a double no offense to those who believe in the "A.T. Still" philosophy of disease processes and say, "that is how I want to be trained". Whatever. Jst know DOs have a few more hurdles to jump to get where the want to go.

As JPP would say, it is time to "Step up to the MIC"
Click to expand...

MCAT is a 30... which makes me pretty competitive with my instate Allopathic school... especially with my LORs, work experience, etc..

My main pull toward AA is this:
9-14-08024.jpg


8 years is a long time to be away from my daughter, although I think that Med School would make me the happiest professionally... there is more to life than professional! I have been, and continue to wrestle with this on a daily basis. Who knows which one will finally win out. The nice thing is that the pre-reqs are the same for either... I just keep swimming!

Thanks for you input, it is appreciated. Good luck in your endeavors.
 
RT2MD said:
MCAT is a 30... which makes me pretty competitive with my instate Allopathic school... especially with my LORs, work experience, etc..

My main pull toward AA is this:
9-14-08024.jpg


8 years is a long time to be away from my daughter, although I think that Med School would make me the happiest professionally... there is more to life than professional! I have been, and continue to wrestle with this on a daily basis. Who knows which one will finally win out. The nice thing is that the pre-reqs are the same for either... I just keep swimming!

Thanks for you input, it is appreciated. Good luck in your endeavors.
Click to expand...

Beautiful child!!

I'm sure your decision will be the best for you and your family.👍
 
jetproppilot said:
I want you guys to realize that there are ways to KILL TWO BIRDS WITH ONE STONE.

The other-half will quell the surgeon's ego without hurting the surgeons ego......this ain't academia, Dudes....ya can't just say "F YOU" to the surgeon, in an act of anger, anymore.

Gotta STEP UP TO THE MIKE and make everyone happy.....the patient (life), the surgeon (ego,case), and you (job satisfaction, c-notes).
Click to expand...

Jet,
How did you tactfully implement your plan without offending your customer?

e
 
Jeff05 said:
you would not want to change I:E to 1:2.5...this would shorten inspiratory phase and increase peaks. changing I:E to 1:1.5 or 1:1 would be a more reasonable approach.

passive oxygenation, peep to dep, cpap to non-dep.
if lactate stays low i would take high 80s. if lactate is rising...would discuss proceeding with surgeon.
Click to expand...

forgive a stupid question, but i'll never learn if i don't ask, but can you explain the rationale behind peep to dep lung and cpap to non-dep in OLV.
 
ear-ache said:
Jet,
How did you tactfully implement your plan without offending your customer?

e
Click to expand...

In a non threatening, non demanding fashion, explain the problem, and why you're doing what you're doing:

"Yeah, Joe? Dude's sat is hanging at eighty five.....isn't budging.....I confirmed good tube placement....I know you're worried about barotrauma but the five hundred cc's aint gonna do it this time so we need to go up. The benefit outweighs the risk. Additionally, we've got evidence of bronchospasm which needs to be addressed. Albuterol will help us, Joe, as will some solumedrol and bumping up the fluids a bit. Atrovent I feel won't help and actually may hurt us. We're gonna address these issues and I'll keep you informed. Cool with that?"

Went something like that and surgeon dude responded positively.

There are certain times, maybe a cuppla times a year, where you've gotta, uhhh, be a dick, get in the dudes face, show him you are not intimidated by his egotistical BS. I've yet to have this happen when an urgent clinical situation is happening. Its always happened over something stupid......

I've posted a cuppla those.

This certainly wasnt one of those times.

99.8% of the time you knowledgeably communicate, and the problem is addressed by the two of you.
 
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a lot of good suggestions - but here are my thoughts

1) i am assuming the non-dependent lung is open to atmosphere? i would give a LITTLE puff of O2 into that lung every 10 minutes or so (little puff = 100 ml)... surgeons barely notice that... and if they do (rare) then just say the tube migrated and reposition.

2) run a LOW-dose EPINEPHRINE infusion... perfect for the lungs without too much of a BP/HR change... i usually start at 0.5mcg/min and titrate up

but the reality is - 85% sat for a young healthy dude ain't the end of the world - it won't affect his brain --- of course, it depends on how much longer the surgeon has to tinker around... 85% is what your sats would be if you went skiing in Vail...

BUT, i truly believe communication is key in establishing relationships... if you show up into the room without showing confidence and thorough understanding of physiology and the supporting literature, you will never gain respect... I have worked with SOME very controlling surgeons during my training, and when the good anesthesia attendings came in they didn't even bother to pay attention to anything else but cutting/sewing.. so it is doable.

the idea of trying to trick people by doing one thing (giving albuterol) and implying that you gave (atrovent) something else, not only creates a situation for COMPLETE distrust, but also opens a bag of worms if there is an adverse reaction?

by the way, a surgeon recommending atrovent for this situation shows that he is a 100% dumb-ass... in which case, you have two choices

1) academia: play smack-down and point out what an idiot he is for even mentioning atrovent for this situation and the clear lack of knowledge re: pulm. physiology and pharmacology - snicker, fix the situation, walk out of the room and mutter under your breath "i can't believe i have to work with *****s like you"

2) private practice: "Atrovent is a great suggestion, but I have some tricks up my sleeve that will fix this, and our patient's numbers will be lookin' great in jiffy"
 
RT2MD said:
MCAT is a 30... which makes me pretty competitive with my instate Allopathic school... especially with my LORs, work experience, etc..

My main pull toward AA is this:
9-14-08024.jpg


8 years is a long time to be away from my daughter, although I think that Med School would make me the happiest professionally... there is more to life than professional! I have been, and continue to wrestle with this on a daily basis. Who knows which one will finally win out. The nice thing is that the pre-reqs are the same for either... I just keep swimming!

Thanks for you input, it is appreciated. Good luck in your endeavors.
Click to expand...



Been in your exact shoes a few years ago ... had the acceptance letter and other interview invitations in hand. I wound up not matriculating and it was the best decision for the family. I would have missed my youngest's four years of high school. I still do occasionally get wistful about my decision, from a purely personal-desire perspective, but I had to decide what was best for the family overall in the long run and I think I made the right choice.

I can't tell you what to do, but I know it's a difficult decision. Best of luck evaluating all the circumstances and factors and may you make the right decision.



.
 
amyl said:
forgive a stupid question, but i'll never learn if i don't ask, but can you explain the rationale behind peep to dep lung and cpap to non-dep in OLV.
Click to expand...

You're ventilating the dep lung, in applying peep you want to avoid atelectasis, auto-peep and put yourself on the favorable slope of you P/V curve.

You're non-dep lung isn't ventilated but if you apply cpap with pure O2 you are going to get a minimal O2 flow that will improve oxygenation.
Plus you can give an intermittent squeeze to your cpap set to get a little more O2 to that non-dep lung.
 
RT2MD said:
MCAT is a 30... which makes me pretty competitive with my instate Allopathic school... especially with my LORs, work experience, etc..

8 years is a long time to be away from my daughter, although I think that Med School would make me the happiest professionally... there is more to life than professional! I have been, and continue to wrestle with this on a daily basis. Who knows which one will finally win out. The nice thing is that the pre-reqs are the same for either... I just keep swimming!
Click to expand...

Most people (to not say everyone) provided they study enough are capable of making it through Med school.
OTH not everyone is capable of making the right decision when deciding on entering Med school.

Only you can decide, but I think you already have. (AA is a great path 😉 )
 
amyl said:
forgive a stupid question, but i'll never learn if i don't ask, but can you explain the rationale behind peep to dep lung and cpap to non-dep in OLV.
Click to expand...

It's mostly semantics. PEEP and CPAP are related terms that mean almost the same thing. In both cases the machine is delivering some minimum level of positive pressure to the circuit.

PEEP = positive end expiratory pressure. If there's an "end expiratory" period ventilation is occurring. You can't use the term PEEP for a nonventilated lung.

CPAP = continuous positive airway pressure. This can be applied to a ventilated or a nonventilated lung.

PEEP may improve oxygenation by reducing atelectasis and by keeping smaller airways open, both of which are likely to improve V/Q matching. Since we're ventilating with 100% O2, absorption atelectasis could be an issue (most would argue that it's not clinically significant) and PEEP helps prevent this.

Even if sats improve, PEEP can reduce cardiac output by reducing venous return, so oxygen delivery (CO x CaO2) may not actually improve. (This is not an issue with OLV if the chest is open, but it could be during a VATS.)

Another caveat is that hypoxic pulmonary vasoconstriction works to your advantage during OLV because the nondependent nonventilated lung gets less O2, and the local hypoxia results in some fraction of its blood flow getting diverted to the dependent ventilated lung. In theory, CPAP'ing or periodically ventilating the nondependent lung could sacrifice some of that HPV, resulting in a quick return to worsened V/Q as soon as you quit ventilating that lung again.

I'm pretty sure I know what phrase militarymd would apply to all of the above physiologic theorizing about issues that are probably clinically insignificant, but there it is. 🙂
 
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McSnappy said:
Dude...umm assuming dude or just use dude as meaning anyone.

I'm assumin your MCAT is mediocre by the way you say deciding b/w MD/DO and AA...

Stick it out and do it right. MD/DO. You took the MCAT, that's what you want. Plus, you want to make decisions, not have them handed to you. If all you want is a pay grade increase...?

You are Non-trad, by way of RT school right.? Allopathic schools like to make N.Trads wait an extra year, just to see if you are serious. Esp., if you are mediocre in your MCAT and the rest looks good. This is from personal experience. I got accepted in my 2nd attempt. If you are going MD, try 2x, if it doesn't look good, go DO. If you are a decent candidate, you got C-Notes, you can get accepted DO. No offense to the DO's out there, but I interviewed to both in year two and was accepted to 3 out of 3 DO schools. And a double no offense to those who believe in the "A.T. Still" philosophy of disease processes and say, "that is how I want to be trained". Whatever. Jst know DOs have a few more hurdles to jump to get where the want to go.

As JPP would say, it is time to "Step up to the MIC"
Click to expand...

What an absolutely assinine post to put in the middle of a clinical thread.
 
jetproppilot said:
I disagree, Mman, that one should tolerate a sat of 85% because your safety net is gone. Situations sometimes get worse, not better, so I start trying to improve any sat below 90%.
Click to expand...

I agree that you should try to improve sats that are below 90%. However, I don't really think it is a terribly big deal in this clinical scenario. Your safety net is the fact that you can quickly give a couple two lung breaths of 100% oxygen and get the pulse ox up to 100 in this relatively young and otherwise mostly healthy patient.

Understanding why the pulse ox is low is the important thing. Then you can decide if and what you should do to fix it. In a situation where giving larger tidal volumes adversely impacts the surgeon, I'm willing to tolerate sats a little lower than I otherwise would.

I'm never going to fault somebody for trying their darndest to get the pulse ox to 100 in this patient, but I'm not going to lose sleep over it being around 85-90 either.

just my 2 cents
 
for the best mental masturbation on this subject read Yao and Artusio. Makes me believe that you can theorize as much as you want regarding OLV and methods to improve PaO2 but essentially its all experimentation and seeing what works. For example you could use PEEP to possibly shunt in the ventilated lung, OR that same peep could increase airway pressures in that same lung and cause more blood to be sent to your deflated lung therefore worsening shunt. And of course it also depends what percentage of blood is going to each lung in the first place, and if the pulmonary vasculature is fixed from Pulm HTN, and etc..blah blah blah. Basically FiO2 at 100. then try all the other stuff and just see if it works. If all else fails, gotta go to 2 lung or clamp the PA on the deflated lung.


btw, excellent clinical thread Jet, Im glad more of these are starting to pop up again
 
Great case Jet! Thanks. Any suggestions for a case based book similar to the one in this thread?
 
these are great cases because they are so clinically relevant and have so many possible fixes that help refresh almost the entire sphere of respiratory physiology, from positioning to v/q to atalectasis to obstruction/restriction...

i think its the best resident learning case there is
 
Forget stepping on toes, this isn't a political show, you took an oath to help patients, do the right thing buddy, follow your instincts, if you can't do that, then don't practice. This ain't about egos. If you think it is watch Patch Adams and get a friggin grip on the reality of life. Doctor and mother of dead son due to an idiots EGO.





jetproppilot said:
Had an incident a while back during a thoracoscopic MAZE procedure.

Nice, young dude we put to sleep.

38 years young.

Chronic A fib. History of HTN and asthma.

Working dude.

Big dude, about 240, shorter than me.

And not a bodybuilder physique. Rather, an

I EAT FRIED FOOD physique.

So operation is on.

A line is in, TLC is in, double lumen tube is in,

Dude is flipped on his left side, right side up,

right lung isolated, ventilating the left lung only,

surgeon starts and we're on our way.

I look down the DLT with the fiberoptic and I can see the carina with the little blue cuff almost-but-not-really popping outta the left mainstem.

Perfect.

Check with the CRNA, everythings cool.

I run to Day Surgery to see a cuppla people, go to room 9 to start a TAH, room 5 has a problem with urine output so I go there, beeper goes off so I meander to PACU, back to Day Surg for a cuppla pre ops, colleague tied up in a room so I go start his room, finally a break so wander into Room Six where my orthopedist buddy is operating to shoot the breeze for a while....

BEEEEEP BEEEEEP BEEEEEEEP

Maze procedure room looking for me.

I walk into the Maze room.

Look at the monitors.....sats are 85-86%.

Dudes in Afib witha rate of about 120-130 (yeah, well, uhhhh, Dude, thats why you're here).

BP OK.

Surgeons worried about barotrauma to the isolated lung so only wants 500mL tidal volumes.

Keep in mind this is about a 240 pound dude.

With his ventilated lung on the down side of his big body.

Top of the end tidal CO2 tracing shows a noticeable upstroke.

Surgeon doesnt want albuterol because of patient's already-present tachycardia, he wants Atroventtm instead...

SO LETS SAY

just to make it interesting, this is your FIRST DAY on the job with your new private practice job with C-NOTE ANESTHESIA, LLC.

Your DREAM GIG.

Here you are.

Theres not an attending to turn to since now, resident colleagues,

YOU ARE THE F UKKING ATTENDING.😆

Walk me through how you're gonna handle this situation with a solution that will save the patient from his current hypoxemic state, and also save face with a controlling surgeon that brings alotta benjamins to your practice.

I want you guys to realize that there are ways to KILL TWO BIRDS WITH ONE STONE.

Think of some.

Remember, you've got ONE STONE.

And 2 birds to kill.

One-haffa-the-stone will kill the hypoxemia.

The other-half will quell the surgeon's ego without hurting the surgeons ego......this ain't academia, Dudes....ya can't just say "F YOU" to the surgeon, in an act of anger, anymore.

Gotta STEP UP TO THE MIKE and make everyone happy.....the patient (life), the surgeon (ego,case), and you (job satisfaction, c-notes).

"LAUNCH READY FIVE." (thatsa quote from Top Gun BTW, meaning ENGAGE!!!!!!! )
Click to expand...
 
So which was the ONE stone, Jet?
I was expecting something dramatic like "we had the surgeon clamp the PA to the nondependent lung". ie. if the surgeon won't let you fix the ventilation, assuage his ego by enlisting him to fix the perfusion. Not that this would be my first, second, or third choice...

jetproppilot said:
Thanks for all the responses.

Here's what we did and the reasoning behind it:

From a political standpoint, even with a surgeon that tends to micromanage, I don't ever remember one not responding positively to well thought out plans of action when there is a problem that concerns you.

Of course little problems don't need to be discussed most times.....but if the problem is big enough to concern you, I'd bring it up, express your concern, and what you're doing about it.

Simple.

Communication works.

From a clinical standpoint, after making an assessment, I did many of the things you suggested needed to be done.

Confirmed good placement with the scope.

Ran an ABG which confirmed the SpO2 was accurate. Rest of the ABG was normal.

I was convinced there was an atelectatic component to the oxygenation problem....this was a big dude, high 400's tidal volume wasnt gonna cut it......thats usually enough during OLV, but wasnt for this guy. Additionally, looking at the capnograph combined with his history, I was convinced there was an asthmatic component as well. Of course not all wheezing is asthma, but in this patient/scenerio it seemed most likely....so I'll treat it like airway hypersensitivity and see what happens....

As you know, treatment of asthma intraoperatively, or any other medical event for that matter, does not differ from treatment in the ER. SO, the triad of asthmatic sequalae were all addressed:

1)Bronchospasm: Used albuterol. Xopinex is a great suggestion but I don't think we have it in our carts...and if the heart rate bumped up a bit I wasnt too concerned. I don't like using ipatroprium in asthma because of it's drying qualities which could exacerbate the tenacious mucous plugging seen in asthmatics.

2) Inflammation: Solumedrol. Of course it doesnt work immediately but ameliorates air trapping over several hours.

3)Mucous plugging.....we did suck some goo out....upped the crystalloid a bit.

As far as the atelectasis, we changed to pressure support, tolerated peak pressures of around forty for a while. Within an hour they were back near 30 with a concominant tidal volume near 700 on one lung, I assume because our treatment of bronchospasm worked.

Dude was already on FiO2=1.0

Added peep to dependent lung.

Deferred the (good) idea of CPAP to nondependent lung since surgeon wanted the lung as flat as possible and I thought we could improve the situation without it.

I disagree, Mman, that one should tolerate a sat of 85% because your safety net is gone. Situations sometimes get worse, not better, so I start trying to improve any sat below 90%.

Anyway, the interventioned worked.

Sats were approaching 90 within minutes of increasing the TV and albuterol administration, and were back at 99% within an hour.

UT, I'll ask him!

Think I covered everything we did.
Click to expand...
 
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