Failure to maintain sats on ventilator

meanmaryjean, DNP, RN · Aug 13, 2013

NOT a fan of proning- and I think I read somewhere recently that it is not effective.

Biffbradford · Aug 13, 2013

Post surgical? Wasn't tamponade? Could be a P.E. How did it all turn out?

Dodongo, APRN, NP · Aug 14, 2013

NOT a fan of proning- and I think I read somewhere recently that it is not effective.

Wrong. All the most recent studies on proning show a reduction in morbidity and mortality of more than 50 percent when patients are proned for ARDS. You need to look at the P/F ratio. My ICU uses rotaprone beds. HFOV, nitric oxide and Low Vt. If the P/F ratios aren't terrible you can maybe try a triadyne bed.

IvesRN · Aug 14, 2013

I have seen this as well as previous people pointed out usually related to ARD's. Low Vt, watch the peep, watch their blood pressure, try to minimize barotrauma. I wish our ICU would prone patients, we need new beds to do this properly...

Esme12, ASN, BSN, RN · Aug 14, 2013

Has anyone ever had or heard of a patient who was unable to be properly oxygenated/ventilated on a ventilator? I recently had a patient who could not maintain oxygen saturations above 80-85 on a ventilator-- with the RT trying every possible setting and combo. Pt had to be emergently intubated post thoracotomy and BPs were in 70s before pressors and ended up on an extreme amount to keep pressures up.
I just wondered if anybody could share some light on this and what might have made the patient so hard to oxygenate/ventilate. Im guessing it was a result of true cardiogenic shock but I'm not sure.

Why would you think cardiogenic shock after surgical removal of the lung?

emergently intubated post thoracotomy and BPs were in 70s before pressors and ended up on an extreme amount to keep pressures up.

alarms me. Was a CXR done to verify ETT placement? Was another CXR done to check for pneumo/hemothorax?? or a tension pneumo?? Was the a mediastinal shift? Was the patient evaluated for Pulmonary emoli? What was the thorocotomy done for? Was the vent checked for malfunction/proper functin? Was the O2 sat verified by ABG's? what we the ABG's?

[h=3]The Crashing Ventilated Patient [/h]

nurseprnRN, BSN, RN · Aug 14, 2013

Look at your A-a gradient and there's a lot of your answer (assuming no uncorrected cardiac malformation). You can have someone on FIO2 1.0 and a bazillion cm of PEEP and everything else, and if there's no decent functioning alveolar wall, Os aren't getting in. How are this guy's CO2s? (CO2 goes out faster than O2 gets in.)

KenH · Aug 14, 2013

Wrong, wheres the doctor, not every hospital has the same equipment or skills to run them, I have seen more damage done from the unskilled, Transfer to a higher level of care.

A vent just pushes air in lets it out, if the underlying problem isn't fixed, changing the vent wont change anything, With a large V/Q mismatch most are just dead, or better off dead, there are things that are worse than being dead.

Too bad this RT did not suggest another ventilator like even the HFOV and maybe nitric oxide long before now. FAIL. The RT should have been calling his medical director to get advice on getting the best equipment for this patient.

Penelope_Pitstop, BSN, RN · Aug 14, 2013

Wrong. All the most recent studies on proning show a reduction in morbidity and mortality of more than 50 percent when patients are proned for ARDS. You need to look at the P/F ratio. My ICU uses rotaprone beds. HFOV, nitric oxide and Low Vt. If the P/F ratios aren't terrible you can maybe try a triadyne bed.

We actually did, using the rotoprone bed, recently help to bring back a gentleman on the brink of ARDS-related death! I think the reason why proning doesn't seem to work too well for us is that we wait too long to do it.

goodgrief · Aug 15, 2013

you have to consider what was the reason the pt had a thoracotomy? was it a diagnostic VATS? did they do a lobectomy or a pneumonectomy? or a wedge resection? if all/part of a lung was removed that could very well be a reason the pt wasn't doing well oxygenation-wise. how long post-thoracotomy did the pt begin to de-sat? was it b/c the pt didn't have a good pulmonary toilet? incentive spirometry? infection? did the sats come up after the BP was treated and the pt began to perfuse? this doesn't really sound like a picture of cardiogenic shock.....more details needed

TraumaSurfer · Aug 16, 2013

Wrong, wheres the doctor, not every hospital has the same equipment or skills to run them, I have seen more damage done from the unskilled, Transfer to a higher level of care.
A vent just pushes air in lets it out, if the underlying problem isn't fixed, changing the vent wont change anything, With a large V/Q mismatch most are just dead, or better off dead, there are things that are worse than being dead.

The MEDICAL DIRECTOR of respiratory therapy is a DOCTOR. That is why I suggested the RT contact his MEDICAL DIRECTOR (DOCTOR). If the hospital can not come up with a better alternative then transferring is definitely something to be considered. The APPROPRIATE ventilator and mode can also spare the lungs from more damage.

A modern ventilator can also do much more than just push air in and out. It can deliver medications like Flolan or Nitric Oxide which may also need to be considered. A physician who knows ventilators should also be able to manage BP and sedation as well as recommend other modalities like proning. A bed for proning might be more difficult to obtain than a specialized ventilator or nitric oxide.

ICUNurseG · Aug 17, 2013

Yes, that isn't too uncommon. Obviously you wanted heck for a pneumo, pe, etc. If it's ARDS they can sometimes do inhaled nitric oxide, flolan, or a rotoprone bed.

RT_Skyler · Aug 18, 2013

Any pathology that produces shunting will have little to no response to oxygen even at 100%. Usually for a shunt PEEP is increased.