to trach or not to trach?

[deleted87051]

---

Members do not see this ad.

How much is it?

It was cheap...about $60/month.

 

[deleted171991]

Surgeon books a 147 KG EF 20% OHS/OSA pt w septic shock 103 fever on 20 ucg levo and primacor with bp 100/60 who is on peep 10 and FIO2 100% with RR 24 TV 600 on the vent for a trach. Surgeon won’t do it bedside (he isn't comfortable). He has been intubated for 20 days and his pulm wants me to do it. My concern is his PO2 will drop like a rock with the transport and eventually the switch leading me to have to recruit him back up w PPV and he will code at that point. Should have been done weeks ago but the wife was refusing.

One question that still has no answer is why is this guy on milrinone, too? That's very unusual, unless the patient has PHTN, which is probably caused by hypoxia/hypercarbia (on top of the pre-existing one from OSA), which is probably the reason for those humongous tidal volumes at a relatively low PEEP. PEEP of 10, when the belly is pressing upwards with much more than 10 cm of H2O, is a joke.

Btw, the EF of 20% could be just from sepsis.

What the patient needs is not a trach (tracheal stenosis is his least important future problem). It's a better intensivist. And a proning bed adequate for his size.

 

[Guillemot]

I cant believe anyone thought my comment was serious... Hahaha...

 

[chocomorsel]

Well, if the echo estimated the pa pressure of 60, what would you do?

I would die happy. And avoid acidosis, hypoxia and hypercarbia. You know.
Just want to know if this is Biventricular failure or just left heart is all.
Anything else?

 

[drmwvr]

Just want to know if this is Biventricular failure or just left heart is all.
Anything else?

Then why not just look at the ventricular function on the echo and not mess with PAP estimates? You made the statement. Don't know what the hostility is all about...

 

[drmwvr]

We had a 16yo dog with very symptomatic CHF. The vet put her on pimobendan which made her like a pup again. Bought her almost a year of excellent quality of life.

Same here, actually. Goes by Vetmedin, if I remember correctly.

 

[dchz]

We had a 16yo dog with very symptomatic CHF. The vet put her on pimobendan which made her like a pup again. Bought her almost a year of excellent quality of life.

The latest published data states that there is no mortality benefit. But this one guy at the SCA didn't care about that publication and they're still regularly using levosemiden in Europe.

I also echo (see what I did there) the need for a better intensivist, but a good intensivist doesn't justify their cost over a midlevel that will be pushed over by anyone....

 

[chocomorsel]

Then why not just look at the ventricular function on the echo and not mess with PAP estimates? You made the statement. Don't know what the hostility is all about...

The OP didn’t mention anything about the right heart on his/her presentation.
I wanted to get an idea of the whole picture.
RV function and PAP all go together. I read the whole report.
The Milrinone threw me off as I said in my first Post. Why in a septic patient?

 

[Twiggidy]

The OP didn’t mention anything about the right heart on his/her presentation.
I wanted to get an idea of the whole picture.
RV function and PAP all go together. I read the whole report.
The Milrinone threw me off as I said in my first Post. Why in a septic patient?

I think what people are getting at is that this gentleman is already obesity hypoventilation syndrome with an EF of 20%. PA numbers won't be the make or break in this situation because by definition he's already pulmonary hypertensive and right heart failed. The milrinone is an effort to lower the PAs and improve heart function despite the sepsis, therefore they added the levophed for vasoconstriction. The problem is levo increases PAP, so Vasopressin would've been a better choice.

This combined with the vent settings is why some say the best answer to situation is "find a better ICU doctor"

 

[deleted171991]

I think what people are getting at is that this gentleman is already obesity hypoventilation syndrome with an EF of 20%. PA numbers won't be the make or break in this situation because by definition he's already pulmonary hypertensive and right heart failed. The milrinone is an effort to lower the PAs and improve heart function despite the sepsis, therefore they added the levophed for vasoconstriction. The problem is levo increases PAP, so Vasopressin would've been a better choice.

This combined with the vent settings is why some say the best answer to situation is "find a better ICU doctor"

Let's assume for a moment that the RV is failing (because of the PHTN). We also know that the LVEF is 20%. I don't know which is primary. Hence one would want appropriate preload, maintained/increased contractility without increased oxygen consumption, and maintained/decreased afterload with good coronary perfusion pressures for both. It's not easy.

Milrinone plus vaso MAY have been the better combo. Or maybe epi plus vaso, or epi plus levo, or epi alone, or levo plus vaso, I have no idea how this patient responds. EVERY PATIENT IS DIFFERENT, regardless what the textbooks/studies say. But that's not what I didn't like in the management.

What I didn't like were the vent settings, and the fact that, even at FiO2 of 100%, the PEEP was a joke, the patient was not being proned, and the intensivist was concerned about getting a trach (which means he didn't even consider proning, among other things).

 

[anbuitachi]

Let's assume for a moment that the RV is failing (because of the PHTN). We also know that the LVEF is 20%. I don't know which is primary. Hence one would want appropriate preload, maintained/increased contractility without increased oxygen consumption, and maintained/decreased afterload with good coronary perfusion pressures for both. It's not easy.

Milrinone plus vaso MAY have been the better combo. Or maybe epi plus vaso, or epi plus levo, or epi alone, or levo plus vaso, I have no idea how this patient responds. EVERY PATIENT IS DIFFERENT, regardless what the textbooks/studies say. But that's not what I didn't like in the management.

What I didn't like were the vent settings, and the fact that, even at FiO2 of 100%, the PEEP was a joke, the patient was not being proned, and the intensivist was concerned about getting a trach (which means he didn't even consider proning, among other things).

Is it even common to do proning in the icu. none of the major hospitals ive rotated at did this.

 

[dpmd]

Is it even common to do proning in the icu. none of the major hospitals ive rotated at did this.

We did it at our hospital and we weren't that big a place. Not commonly though.

 

[MoMoGesiologist]

Is it even common to do proning in the icu. none of the major hospitals ive rotated at did this.

Did your hospitals do VV ECMO? If they are doing ECMO, they probably should be proning

 

[deleted87051]

NEJM - Error

Impressive but proning a critically ill 147kg patient is not without risk. Rotoprone limit is 160kg.

 

[deleted171991]

Is it even common to do proning in the icu. none of the major hospitals ive rotated at did this.

It is a common (and proven) treatment of severe ARDS. Another proof that anesthesiology-CCM fellows should rotate through MICUs, because that's where the truly sick patients are.

I would also try to use it as a last resort in any severe hypoxia due to V/Q mismatch.

 

[Psai]

I don't understand the point of proning if youre on vv ecmo

 

[deleted171991]

NEJM - Error

Impressive but proning a critically ill 147kg patient is not without risk. Rotoprone limit is 160kg.

While in fellowship, we had an almost 400 lb-patient with severe ARDS and sepsis. He was on 2-3 pressors, a pain to ventilate. We proned him as a last resort (in a regular ICU bed). Almost immediately we were able to drop his FiO2 to 50% and his pressors. A few days later, while supine (and still on pressors), he self-extubated... successfully. We probably would not have had the guts yet. After a few more days he walked out of the hospital.

It's amazing how much atelectatic lung the morbidly obese can have.

 

[coffeebythelake]

NEJM - Error

Impressive but proning a critically ill 147kg patient is not without risk. Rotoprone limit is 160kg.

rotoprone-assisted morbidity or mortality have occurred. Think inadvertent extubation while prone.

 

[MoMoGesiologist]

I don't understand the point of proning if youre on vv ecmo

I think you prone to avoid going on VV ECMO. Try all the things of last resort to avoid ECMO.

 

[Psai]

I think you prone to avoid going on VV ECMO. Try all the things of last resort to avoid ECMO.

Oh I see what youre saying, I totally agree with you

 

[Radetzky]

I don't understand the point of proning if youre on vv ecmo

Well you still have to get off ECMO at some stage and proning can be part of the strategy to achieve this. Also being on ECMO doesn't guarantee oxygenation will be easy and there are a few reasons you might want to increase the contribution of the pts lungs towards oxygenation relative to that of the circuit.

 

[MoMoGesiologist]

Well you still have to get off ECMO at some stage and proning can be part of the strategy to achieve this. Also being on ECMO doesn't guarantee oxygenation will be easy and there are a few reasons you might want to increase the contribution of the pts lungs towards oxygenation relative to that of the circuit.

Can you explain this further? When would you come off ECMO and prone someone? Wouldn't you continue ECMO until the lungs are good enough to function without proning? Why stop the ECMO and go onto max vent settings and proning?

Also, in what situations would VV ECMO not be able to oxygenate? I would think misplaced cannula, recirculation, inability to pull enough blood flow into ECMO circuit. In what situation would the lungs be working well enough where you would preferentially divert flow through the native heart and lungs and not the ECMO circuit? Why place them on VV ECMO in the first place? Do you mean a failing heart needing VA ECMO? Asking for my education!

 

[Radetzky]

You can prone while on ECMO, which will aid with lung recovery.

You can only oxygenate the blood flowing through the ecmo circuit, which is max 7L/min. However the cardiac output which this mixes with may be much higher, and also peoples oxygen consumption varies. Running high flows through the circuit to achieve oxygenation may not be desirable as it increases the risk of suction events, which can result in total loss of flow through the circuit. Increasing the contribution from the lungs and running slightly lower circuit flows may be preferable (but it depends on what stage of the illness the patient is at).

I'm not an expert by any means, but hopefully that answers your question.

 

[leviathan]

Presumably the milrinone was for a component of cardiogenic shock in this patient. But given the rest of the management, perhaps the doc just picked drugs randomly out of a hat to start on his/her patient.

 

[leviathan]

No evidence that proning would aid with lung recovery. It may help with oxygenation but the underlying disease process doesn't get improved by proning, though you could make a stretch and say proning may help with clearing secretions. I can't understand a situation where you would remove someone from ECMO when they're still at a point where they need proning to maintain oxygenation.

 

[deleted87051]

No evidence that proning would aid with lung recovery. It may help with oxygenation but the underlying disease process doesn't get improved by proning, though you could make a stretch and say proning may help with clearing secretions. I can't understand a situation where you would remove someone from ECMO when they're still at a point where they need proning to maintain oxygenation.

Recruitment is probably a better term than recovery.

 

[Radetzky]

I can't understand a situation where you would remove someone from ECMO when they're still at a point where they need proning to maintain oxygenation.

I never said you would.

My comments were about the fact that even on ECMO you sometimes need to recruit lung and proning is part of the commonly used strategy used to achieve this.

 

[deleted171991]

No evidence that proning would aid with lung recovery. It may help with oxygenation but the underlying disease process doesn't get improved by proning, though you could make a stretch and say proning may help with clearing secretions. I can't understand a situation where you would remove someone from ECMO when they're still at a point where they need proning to maintain oxygenation.

You are right, we don't have good trials to show improved mortality in ARDS from proning, except maaaaybe in some highly-selected populations (and those trials are debatable).

For those interested in the evidence, there is an interesting discussion of the PROSEVA trial on UpToDate (and the entire article about prone ventilation in ARDS is excellent).

 

[leviathan]

I wasn't disagreeing with the mortality benefit from proning (though im sure as with every study there are people who do). I was only referring to the idea that proning would help with lung recovery, though that person rephrased it as recruitment.

 

[leviathan]

I never said you would.

My comments were about the fact that even on ECMO you sometimes need to recruit lung and proning is part of the commonly used strategy used to achieve this.

That's interesting, we don't prone people on ECMO where I trained, not to say what you're proposing is necessarily wrong. I just allow lung rest but maintain enough PEEP that the lung still remains somewhat open. I'd be worried about decannulation during proning.

 

[Radetzky]

That's interesting, we don't prone people on ECMO where I trained, not to say what you're proposing is necessarily wrong. I just allow lung rest but maintain enough PEEP that the lung still remains somewhat open. I'd be worried about decannulation during proning.

I've seen it done when they've been on for weeks with minimal improvement and CT shows some "recruitable lung".

And yeah the whole process of proning with cannulas in always made me nervous.

 

[Psai]

I've seen it done when they've been on for weeks with minimal improvement and CT shows some "recruitable lung".

And yeah the whole process of proning with cannulas in always made me nervous.

I've heard of people doing it successfully. At shock trauma they even have people on ecmo ambulating down the halls.

 

[abolt18]

Did your hospitals do VV ECMO? If they are doing ECMO, they probably should be proning

We have lots of ecmo. I have not seen a patient proned yet (it certainly may still happen when I'm not in the unit). Though, it certainly has been discussed on some of those patients.

 

[vector2]

That's interesting, we don't prone people on ECMO where I trained, not to say what you're proposing is necessarily wrong. I just allow lung rest but maintain enough PEEP that the lung still remains somewhat open. I'd be worried about decannulation during proning.

I think we're splitting hairs when talking about whether proning helps the underlying disease process vs helping the symptomatology. ARDS is an inflammatory condition that results in alveolar leak / excess extravascular lung water and uneven ventilation distribution. Proning would seem to help both the intrinsic disease process (favorable distribution of lung water) and iatrogenic ventilator injury (reduced atelectrauma). It's kind of like lasix in heart failure- no one argues that lasix definitely improves mortality in a CHF exacerbation but that doesn't stop anyone from pushing 80mg IV when the pt is obviously volume overloaded.

 

[leviathan]

I don't think it's splitting hairs in the context of someone on ECMO. Diuresing a CHF patient just like proning an ARDS patient are both measures to improve physiology as a bridge while you're presumably addressing the underlying pathology, or waiting for it to improve on its own. If someone is already on ECMO and waiting for lung recovery, adding proning doesn't seem to give much further benefit against the possible harm. As someone else said, we have ambulated people on ECMO with Avalon cannulas, and that has obvious benefits for mobilization / preserving muscle strength.