Bagging ETT

amoLucia · Apr 18, 2020

Can't help you, but a terrific person to ask I think would be a Resp Therapist'

They know EVERYTHING! Seriously, they are a terrific resource if you can connect with one.

surenot442 · Apr 22, 2020

Besides turning up fi02 there are other interventions you can initiate. Suctioning and providing oral care, adjusting sedation, assessing if your patient requires a bite block, re-positioning, and percussion and vibration are all good places to start. Try to figure out why your patients 02 if dropping first and foremost. If you do have to bag the patient recruitment can be obtained with the use of a PEEP valve on the BVM. Ask your charge or RT if your unit stocks them. Hope this helps... ?

Wuzzie · Apr 22, 2020

Unless the kid has certain cardiac anomalies by the time their sats are in the 40’s you are beyond mouth care and nearing code status. Anytime a peds patient sats drop the very first thing you need to do, after increasing the FiO2 and calling for help is assess them for breath sounds to rule out tube dislodgement, mucus plug or pneumothorax. This can be done in a very short period of time. If you have equal breath sounds and they aren’t coming up grab your Ambu and start bagging as near to the rate their vent was set as your adrenaline allows. By this time you should have other people at the bedside to help you figure out what’s going on and to decide if other measures need to be put in place. Alveolar recruitment means nothing if the kid loses his heart rate and dies.
I agree with the other poster. You need to talk to your unit’s RT. They will help you understand the physiology behind vent modes and settings and what recruitment means among other things. You will be able to ask them questions until you have a solid grasp on the concept.

Below are two articles describing the various shunts in pediatric cardiac anomalies. It’s much easier to understand if you have pictures. Hopefully this will help you understand when supplemental O2 is and is not appropriate.
https://www.merckmanuals.com/professional/pediatrics/congenital-cardiovascular-anomalies/overview-of-congenital-cardiovascular-anomalies

https://www.rtmagazine.com/disorders-diseases/cardiopulmonary-thoracic/oxygen-and-the-cardiac-compromised-pediatric-patient/

adventure_rn, MSN, NP · Apr 25, 2020

On 4/17/2020 at 10:07 PM, stacylethani said:
but if your kids sats are sitting in the 40s and they aren’t coming up with going up on their fio2, how long do you wait/how do you know to bag? Also with cardiac kiddos, you don’t want to automatically increase their oxygen first, right? Cause then their lungs steal blood flow? I’m confused ?

I mean this in the gentlest way possible, but I think you're asking the wrong questions in the wrong forum. I responded to your RVOT post on the general nursing forum, and recall you saying that you're a peds cardiac ICU nurse.

The way we approach oxygenation and ventilation in kids with cardiac defects is vastly different from the way you'd treat somebody with a normal heart (especially an adult). The critical care forum is generally frequented by adult nurses, and they're going to give you information that's pertinent to adult patients.

If you were to treat mixed sat cardiac kids in the peds cardiac ICU the same way you'd treat an adult in the CTICU, it would probably kill them. You may get more pertinent responses about your patient population in the PICU forum than the adult critical care forum; that said, peds cardiac ICU a tiny niche, so there may or may not be responses.

Back to your question about the lungs "stealing" oxygen: yes, in peds cardiac, that is very true (again, this concept literally doesn't exist in adults, so we treat these kids differently). That's why, even if they're satting in the 40s, we might only turn them up to 30-40% FiO2 instead of going straight to 100%. And, unlike in adult care, there are certain kids (a.k.a. "the anaerobes") who just live their lives satting 60% for months or years on end until they can get repaired.

I wrote a very detailed post about cardiac kids and how oxygen affects the direction of blood flow on the NICU forums a few months ago. I highly recommend you read through it. It might help answer some of your questions, or clarify any further questions you have about FiO2 during decompensation/resuscitation.

stacylethani, BSN · Apr 25, 2020

Adventure_rn, thank you so much!! That is so helpful!
I’ve been lost on which forums to post questions to because peds cardiac ICU doesn’t have its own category - I guess lumping it with PICU makes sense. Thanks for your help guys!

adventure_rn, MSN, NP · Apr 25, 2020

1 hour ago, stacylethani said:
Adventure_rn, thank you so much!! That is so helpful!
I’ve been lost on which forums to post questions to because peds cardiac ICU doesn’t have its own category - I guess lumping it with PICU makes sense. Thanks for your help guys!

That's totally OK! I know the site navigation can be a little tricky at first (once you figure it out, it's intuitive).

It's still OK to ask your questions in the critical care forums; it can be interesting to hear their feedback, and the forum can be a bit more active than the peds forum. It would just be more helpful for us if you preface the questions with the fact that you work in peds cards, since your specific population may determine the answers. In this post, I only realized that you were asking about cardiac kid from context clues, and because I'd read your other post.

Like I mentioned, when you ask questions on this forum ("critical care"), people will assume that you're an adult nurse. They'll give you advice that would be very helpful for adults, but could be fatal for cardiac kids (I.e. leaving them on 100% FiO2).

Unfortunately, there aren't a ton of peds cardiac people on AN. I've done peds cards, and I know the learning curve can be pretty steep; I'm always happy to answer questions if I know the answers. Honestly, the very best teachers will be the staff on your unit (your preceptor, charge nurse, unit educators, RTs, NPs and physicians). Not only do they know the population very well, but they're also familiar with your unit policies.

amoLucia · Apr 25, 2020

Regardless of where you post, there's almost always something to learn, even if a teeny-tiny bit. Esp for those of us retired, or as a refresher for some, and for many, just new interesting info in a new specialty. TY all.

Stay safe & strong.

adventure_rn, MSN, NP · May 4, 2020

@stacylethani, I don't know if you've had a chance to look over the link I posted regarding the basics of blood mixing in cardiac defects. If you understand that core peds cardiac concept, I may be better able to answer your question.

In that post, I explained the basics of how the blood in cardiac kids' hearts can preferentially choose flow towards the body or the lungs (the Qp:Qs ratio), and I explained why the direction of flow is affected by your FiO2. The main take-away is that more FiO2 will cause blood to preferentially flow towards your lungs (since O2 is a pulmonary vasodilator), and less FiO2 will cause blood to preferentially flow towards your body. That's why you rarely leave a cardiac kid on 100% FiO2 (unless they're on < 1 L of flow, or they're a "chronic anaerobe," and they still consistently sat in the 60s even when they're on 100%).

So, here's an answer to your question about resuscitating cardiac kids who are sitting in the 40s (via bagging, turning up FiO2, etc.) It's long, so I'm including subtitles for clarity, like I did in my other post.

Assessment

First and foremost, you need to assess why the kid is desatting, because that will be the biggest consideration in the treatment.

In cardiac kids, they may well be having a meltdown and need more sedation. In my peds cardiac experience, 9 times out of 10, pain/agitation played some role in big desats. As I'll touch on below, agitation in cardiac kids can cause a pulmonary hypertensive crisis and shunt all of their blood away from their lungs. Even paralyzed kids can decompensate because they're agitated under their paralytic (the only signs and symptoms are VS changes and pupil size).

My cardiac unit was very sedation-friendly, and our first-line treatment was usually giving a PRN, which often completely resolved the desat. If a kid is clamping down (even if paralyzed), or trashing around and fighting the vent, they aren't going to sat well.

Also, you need to assess what's going on with the patient respiratory-wise. Have their tidal volumes suddenly dropped off? Are they riding the vent? Is their end-tidal CO2 going up? Do they have a ton of secretions shooting up into their tube? If you can pinpoint what's causing the desat, that will inform how to treat it.

For instance, if all of the sudden your tidal volumes drop from 10/kg to 3/kg, the baby either needs to be bagged or have the vent settings adjusted, because the current vent settings aren't providing enough flow. Sedation may also help to improve their tidal volumes if they're clamping down.

If they don't usually ride the vent, but suddenly they've started and it's causing them to desat, they need more rate (either from increasing the vent settings or bagging them at a faster rate). If they're spewing a ton of secretions into the tube, they probably need to be suctioned; this should also help them to calm down if they're agitated, since people tend to panic when they can't breathe...

Oxygen and Blood Flow

So, as you probably realize, oxygen in cardiac kids is a very tricky business. Too much can kill them, and too little can also kill them. Again, this discussion assumes that you've read and understand that other post I wrote, so I'm jumping right in.

So, we know that in cardiac kids, too much oxygen can cause pulmonary vasodilation (much like nitric oxide), which leads to overcirculation. If you crank up a cardiac kid to 100% FiO2 and allow them to overcirculate for too long, it will lead to distribute hypotensive shock and cardiac arrest.

However, that last post was specifically about kids who are not in distress. Once a cardiac kid is in distress, the hemodynamics in their heart/lungs change dramatically.

When a cardiac kid is in distress and desating, they are very likely to have sudden, profound pulmonary hypertension (aka a pulmonary hypertensive crisis). This is usually what it means when people say kids are 'clamping down,' because the blood vessels in their lungs become very narrow and 'tight,' with super high pulmonary vascular resistance and minimal blood flow.

Here's the same picture of a Truncus that I used in my last post. Recall how we said that the flow of blood to the body and the flow of blood to the pulmonary arteries should be equal (a Qp:Qs ratio of 1:1).

If this baby were to have a severe pulmonary hypertensive crisis, 90% of their blood would flow to their body and only 10% of blood would flow to their lungs. That would mean that only 10% of their blood would be getting ventilated and oxygenated with 100% O2 sats. The other 90% would be shunting deoxygenated blood out into the body, meaning that the child's systemic O2 sats would drop off (I.e. a desat to the 40s).

So, here's a very crucial point about oxygen for these kids:

Remember how we said in my last post that oxygen is a vasodilator; the opposite is also true, and desaturation can cause severe vasoconstriction. Desaturation is one of the greatest causes of pulmonary hypertension in these kids. Let's say they get agitated and desat a little bit; once they're desatured, you can end up in a downward spiral toward a pulmonary hypertensive crisis (where the desat makes the pulmonary hypertension worse, which makes the desat worse, which makes the pulmonary hypertension worse, etc...)

So, you may need to treat them with some oxygen, even if it's just a little bit. If this baby appears to be having a pulmonary hypertensive spell (I.e. tiny tidal volumes, a huge drop in O2 sats), oxygen will help loosen up their clamped down, vasoconstricted pulmonary blood vessels because oxygen is a pulmonary vasodilator.

Going back to my original post, we usually avoid giving cardiac kids oxygen, since it's a vasodilator and we don't want them to overcirculate. However, in a case where they don't have any blood going to their lungs, we do want to give them a vasodilator. If they're profoundly desaturated (I.e. 40s), that's just about the only time you should be giving them extra FiO2.

However, because oxygen can be harmful to cardiac kids, we only give them a tiny bit of extra FiO2. In most of peds, if a kid had a bad desat, you might go directly to 50% FiO2. However, in cardiac kids, you'll usually only want to increase their FiO2 in 5-10% increments. So, if you baby was desatting in the 50s, you might go up from 25% to 35%.

You really don't want to overshoot it and give them too much oxygen, because they can quickly go from having pulmonary hypertension (too little pulmonary blood flow) to overcirculation (too much pulmonary blood flow). You should give the minimal amount possible to resolve the desat.

Sidebar, agitation and acidosis also contribute to pulmonary vasoconstriction and can cause a pulmonary hypertensive crisis, so while you're increasing your O2, you should probably be giving a sedation PRN (right away), and preparing to draw up some bicarb (if the desat is prolonged).

Action

The very best thing you can do is to know the kid. If the off-going nurse says that they had a lot of desat spells, you should ask the nurse what worked best to resolve them (sedation, FiO2, suctioning, bagging, etc.) Whatever worked for the last nurse, you should plan to try that first.

The next thing you should do is to touch base with your RT at the beginning of the shift to find out what they think you should do. If I was told that a baby needed to be bagged whenever they'd desat, I'll usually check in with the RT to let them know that's what I was told, and to make sure they're on the same page.

Honestly, as a new grad, I wouldn't recommend that you go straight to bagging. Not only will this risk some derecruitment in the lungs, but it takes a while to get the hang of. You need to bag with the correct rate, pressure (PIP), and I-time, of the kid will do even worse than they were on the vent. This is especially true because kids of different ages need different rates and pressures. When you're first starting out, it may be safest to let the RTs bag while you watch (or have the RTs or your preceptor watch you and give feedback while you bag).

In the moment, if you see your patient desating, here's what I'd do:

First, do a quick, 10-second assessment: Do they need sedation (are they thrashing, is their HR/BP up 50 points, etc.)? Is anything funky with the vent (low tidal volumes, vent alarms, new-onset riding the vent)? Do they need suction (are they coughing, does their chest feel rattly, are there secretions in the tube)?

Next, my initial steps (over the course of about 30 seconds) were to start a sedation bolus on my pump, increase the FiO2 by 5-10%, call the RT, and suction if I needed to. If I was at the point where I had to pop the baby off to bag, I'd usually yell for help or hit the code bell (not because the patient was necessarily coding, but because I needed more hands).

Prevention is also key for these kids. It is absolutely essential that you keep them calm and happy, since they can quickly have a hypertensive crisis and code when they become agitated.

Does that help? I know it's confusing, but it should make more sense over time.

Dreamofjeann · Jul 1, 2020

Hi! I work in peds in a CTICU.

If theyre minimally desatting, I will try suctioning and giving a breath (100% fio2 except for shunt kids). 40% is a little too low for my liking to start hesitating whether to bag or not.

if my kid has normal sat parameters and are heading towards the 60s I'm already bagging and calling my RT. Then when they can take over I either call my fellow or if they're desating because they're pissed then thats when I grab my sedation if it isn't already a drip I can bolus from.

If it's a SV kid with sat goals of >75, I'll starting bagging for the low 50s.

Also depends how my kid's color and waveform looks like.

If a kid desating consistently despite being on full vent support and calm, that's when I'll utilize my paralytic.

I just wanna say when I was newer I remember always thinking "how do I know when to bag?" but my first time doing it was when I got from report that the nightshift RN had to do it multiple times. So when I heard that I was less hesitant on initiating it myself.

allnurses Guide · Aug 9, 2020

On 5/4/2020 at 3:21 AM, adventure_rn said:

Thanks for this comprehensive answer - as an adult CTICU nurse with minimal peds experience, this is super interesting!!

murseman24, MSN, CRNA · Nov 6, 2020

Looks like ya'll pretty much got the physiology covered, quality post guys! Only thing I can add towards bagging "technique" is when squeezing hold the bag for a quick half second at end inspiration to allow the alveoli to remain open and turn up the PEEP. If the desat is due to junky lungs from pna or something that could cause some atelectasis it is really helpful to do some "recruitment breaths" at first. This means giving a couple big breaths while holding your squeeze on the bag at end inspiration for a few seconds to pop open the alveoli, it really helps to increase their oxygenation if they have collapsed alveoli. I don't do cardiac peds in my job but I've got some experience ventilating kiddos and adults. Take care!