Levo and pH

TakeBack · Mar 24, 2011

If she was that sick she needed a swan... and from the sounds of it tons and tons and tons of volume. How much volume is tons? Give it on pressure bags or with a Level one rapid infuser/warmer until you get to the downward trend of the starling curve. I'm guessing her hgb was ok? Remember....always optimize volume status before using vasopressors and inotropic agents. A pH of 7.19, while very low, isn't ridiculously low and the levo should've done SOMETHING. She probably should've had about 4 amps of bicarb and a gtt or if that didn't work, (as someone already suggested) tham. What's a PMA and why would they tell you to run levo wide open without trying something else like epinephrine or neosynephrine?

We don't know alot about the pt but I don't think a swan is going to help in this situation based on the info provided. 7.19 isn't "ridiculously low" but is more than low enough to cause refractory depression of vascular tone and myocardial function.

Fix her acid-base first then look for other problems.

Norepi is actually a great drug in this case as it gives you more potent combined beta and alpha effects. The pt's LV function is probably at least moderate to severely impaired at that pH. Pure phenylephrine is only adding afterload. Epi is similar to norepi but nowhere near as strong for a situation like this.

richard1980 · Mar 24, 2011

We don't know alot about the pt but I don't think a swan is going to help in this situation based on the info provided. 7.19 isn't "ridiculously low" but is more than low enough to cause refractory depression of vascular tone and myocardial function.
Fix her acid-base first then look for other problems.
Norepi is actually a great drug in this case as it gives you more potent combined beta and alpha effects. The pt's LV function is probably at least moderate to severely impaired at that pH. Pure phenylephrine is only adding afterload. Epi is similar to norepi but nowhere near as strong for a situation like this.

I disagree, I think a swan would be indicated as she appears to be in severely decomponsated shock of some sort and doesn't appear to be responding to the treatment they were giving her, a continuous SvO2 monitor would be nice to see as well. (SvO2 monitoring is, IMO, one of the most important numbers in situations like this) While they did not do enough to correct her acidosis, a PA cath definitely would help guide her treatment plan, studies have shown that even the most seasoned health care professional accurately guesses the correct filling pressures as little as 30% of the time. While, I agree with you that we do not have enough information to accurately guide care I disagree on your take that Epi wouldn't help. If it's a pump failure due to acidosis, I highly doubt that thats the only problem, Epi would improve contractility. If she's giving birth she's young enough to tolerate a pH of 7.19 without having complete circulatory collapse. Something else is going on here, sounds like a possible embolism and dying tissue. As I said earlier, I don't think her volume status was optimized and if you're to the point where you're running wide open norepi, there are other options to consider, such a swan and other vasopressive/inotropic agents.... I'd also maybe try an amp of Calcium Chloride as well.

tahoe77 · Mar 24, 2011

The swan could tell us if she is in cardiogenic vs. septic shock.

TakeBack · Mar 24, 2011

I disagree, I think a swan would be indicated as she appears to be in severely decomponsated shock of some sort and doesn't appear to be responding to the treatment they were giving her, a continuous SvO2 monitor would be nice to see as well. (SvO2 monitoring is, IMO, one of the most important numbers in situations like this) While they did not do enough to correct her acidosis, a PA cath definitely would help guide her treatment plan, studies have shown that even the most seasoned health care professional accurately guesses the correct filling pressures as little as 30% of the time. While, I agree with you that we do not have enough information to accurately guide care I disagree on your take that Epi wouldn't help. If it's a pump failure due to acidosis, I highly doubt that thats the only problem, Epi would improve contractility. If she's giving birth she's young enough to tolerate a pH of 7.19 without having complete circulatory collapse. Something else is going on here, sounds like a possible embolism and dying tissue. As I said earlier, I don't think her volume status was optimized and if you're to the point where you're running wide open norepi, there are other options to consider, such a swan and other vasopressive/inotropic agents.... I'd also maybe try an amp of Calcium Chloride as well.

You need to correct the acidosis first. If we're talking about real world approach to this problem (not textbook), you normalize the ABG, aggressively administer volume (using CVP to guide your resuscitation) and use pressors for interim support. While your coding her shock state you're getting full labs. Positive trops, CXR, echo findings etc would guide you towards a swan if you suspect a cardiogenic cause but you would not use a SGC as a measure of filling. CVP and TTE are less invasive, and echo is more useful. There's a reason swans have had a moratorium in many centers- they're notoriuously misused.

Second, I don't disagree that epi would NOT help, but norepi is the first line drug here. Vasopressin and dopamine are useful as well. You're simply not going to get the alpha effects you need in decompensated acidosis with epi alone. Assuming this is only due to acidosis. If she has a major PE then you're in a different ballgame, different stadium.

richard1980 · Mar 24, 2011

You need to correct the acidosis first. If we're talking about real world approach to this problem (not textbook), you normalize the ABG, aggressively administer volume (using CVP to guide your resuscitation) and use pressors for interim support. While your coding her shock state you're getting full labs. Positive trops, CXR, echo findings etc would guide you towards a swan if you suspect a cardiogenic cause but you would not use a SGC as a measure of filling. CVP and TTE are less invasive, and echo is more useful. There's a reason swans have had a moratorium in many centers- they're notoriuously misused.
Second, I don't disagree that epi would NOT help, but norepi is the first line drug here. Vasopressin and dopamine are useful as well. You're simply not going to get the alpha effects you need in decompensated acidosis with epi alone. Assuming this is only due to acidosis. If she has a major PE then you're in a different ballgame, different stadium.

Absolutely levophed is the first drug of choice but if she's further decompensating perhaps its cardiogenic and epi and perhaps a swan would be indicated. We uses swans every day in my unit. Vigileos are, imo, garbage. The pt can't be tachy or afib and according to Edwards all their test subjects were intubated, sedated and paralyzed in NSR. Of course you have to look at everything, and no, i don't automatically jump to, lets swan them. But a swan is indicated in severe shock which she clearly is in. The criteria for a swan, which I'm sure you're familiar with are as follows:

Diagnosis of shock states - check

Differentiation of high- versus low-pressure pulmonary edema

Diagnosis of idiopathic pulmonary hypertension

Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE) possible check

Monitoring and management of complicated AMI

Assessing hemodynamic response to therapies - check

Management of multiorgan system failure and/or severe burns - possible check

Management of hemodynamic instability after cardiac surgery

Assessment of response to treatment in patients with idiopathic pulmonary hypertension

In my facility, depending on the intensivist working, she would probably get a swan.

I really think the whole idea of not using swans has gone too far. We used to swan everyone. Now it's fallen out of favor, wouldn't surprise me to see it fall back in favor, kinda like how levophed was out of favor for quite a while...now its very popular

Maevish, ASN, RN · May 3, 2011

I haven't been on here for awhile and seeing all these replies is great! I think I had failed to mention that after she'd gotten 8L NS and a couple units of blood (before the "stat" echo) that her EF was 10%! Unbelievable....now it's so far removed that I don't remember more of the details, but you guys have helped so much! :-)

Maevish, ASN, RN · May 3, 2011

Okay, I'm remembering a little more now: She had an art line that was put in in as they were sewing her up from the C-Section right in the OR, but that was it until they were able to get a PICC in an hour or so later. Pre-echo, we'd been giving all these fluids (I think 4L in OR and 4-5 here in ICU) and the blood, but weren't seeing any results.

It got to where the vent couldn't even get the volumes in that were necessary so we got to thinking that she was leaking or 3rd spacing the fluid, but the only way to do that was to go to the OR and explore. By this time, they were thinking that they'd do a balloon pump before the OR. So the balloon pump was finally inserted, but then when they opened her up in the OR, it was projectile fluid/blood ALL over the place so it had been leaking for sure.

After she left our unit though, all I heard was reports as things were happening so all I left with that morning was that she'd passed by 0830 and the baby was perfect.

allnurses Guide · May 8, 2011

Sounds like she needed emergent VAD or ECMO.

Epi would not be a good idea in this situation if the patient is already acidotic, it's just going to worsen that. At 10% EF and frank cardiogenic shock, she needed LV pump assistance. Even IABP is not going to do much in that situation, she needs more than 1-2 l of CO.