Elevated Ammonia level

Matthew89 said:

Hello everyone! New nurse here. I had a question and wanted to know your opinions. Working in ICU. Had a patient that was a rapid. Ammonia level was 293, lethargic, PCO2 101. Came in to our unit lethargic of course A&O x1, GCS 12 at the time. Placed on bipap gave lactulose. But in 4 hours patient GCS declined to 8 or 9. Obtunded. Called the doctor about possible intubation to protect airway. He said leave him on Bipap for now because pCO2 went down from 101 to 92. But patient mental status was declining. Question can high ammonia make the patient obtunded where they are unable to protect their airway? I know he wasn't already doing well with the elevated PCO2. But was wondering aside from the elevated PcO2 could elevated ammonia level also cause them to be obtunded where they are unable to protect their airway? I was told to metabolic encephalopathy had nothing to do with respirations. And should just monitor CO2. Im confused now. 

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Yes, hyperammonemia causes neurological changes up to and including seizures or coma. https://pubmed.ncbi.nlm.nih.gov/19104924/#:~:text=Elevated concentrations of ammonia in,seizures%2C ataxia and coma).

https://www.ncbi.nlm.nih.gov/books/NBK557504/

In my view, and experience, you are well served to be considering a possibility that this patient may further deteriorate.  I wonder why someone would tell you that metabolic encephalopathy wouldn't have the potential to affect respiratory status.  

Thank you for the reply! ? It confused me if I was wrong. The patients PCO2 was trending down from 110 to 90s. But the patients mental status was not improving but further deteriorating. I asked the doc if the ammonia level could affect it. Rather than focusing on PCO2 thats trending down. He told me ammonia level would only affect the mental status and not respiration. I understand but would being obtunded on bipap shouldn't airway protection be considered? And he had had already aspirated three times. Hence the rapid. He was desaturating on the floor. When is intubation considered? RT kept on saying he was sating 100. I felt like a criminal who just wanted to intubate someone. ? That's why I wonder if I was wrong. And if elevated ammonia levels does play a part for the patient being obtunded aside from PCO2. And when is airway protection considered. 

I would probably trust the RT more than the doctor. I would not trust any doctor who gave me a be all and end all statement like that.. etc.., and if they are invalidating your concerns, and the patient has deteriorated & needed a BiPAP, obviously their breathing as been affected. Were any other vitals affected? Hemoglobin, pH, blood sugar?

Nope, you're absolutely right. I stayed quiet more than I should have in my first couple of years because I doubted myself and I've seen more than one bad outcome because others tried convincing me I was wrong.

First, any decline in mental status by itself makes me nervous. Couple that with a CO2 in the 90's (that's an acceptable improvement, doc?) and an ammonia in the 200's. PLUS a history of aspiration? Patient is rapidly heading in the wrong direction. I would absolutely get ahead of this and intubate.

I'm happy as a new nurse your gut was already telling you this wasn't right. 

My favorite part about being a nurse lmao (being told no). You voice your concerns but the buck stops with the doc. There's only so much you can advocate for but at the end of the day, if they say no, it's a no.

Your gut instinct for intubation for airway protection was valid. If the patient vomits, welp, they're going to aspirate because they're obtunded. At this point, I'd just have the RSI kit pulled and ready to go.

Lipoma said:

You voice your concerns but the buck stops with the doc. There's only so much you can advocate for but at the end of the day, if they say no, it's a no.

I don't agree with this. If I believe we're not doing the right thing I'll get others involved. I've been lucky to work with fantastic strong charge nurses that have worked with some of these doctors longer than I've been a nurse. I'll talk with them first thing. The doctors respect and trust them and they can have incredible pull in these situations. When it comes to airway issues of course RTs can be a great resource as well (but in my experience can be hit or miss - especially with staffing after covid).

We're here for our patients and doctors are only human. If I've exhausted my options or I've spoken with additional trusted people that believe we're OK with how things are, then a no is a no. Not before.

MaxAttack said:

I don't agree with this. If I believe we're not doing the right thing I'll get others involved. I've been lucky to work with fantastic strong charge nurses that have worked with some of these doctors longer than I've been a nurse. I'll talk with them first thing. The doctors respect and trust them and they can have incredible pull in these situations. When it comes to airway issues of course RTs can be a great resource as well (but in my experience can be hit or miss - especially with staffing after covid).

We're here for our patients and doctors are only human. If I've exhausted my options or I've spoken with additional trusted people that believe we're OK with how things are, then a no is a no. Not before.

I'm not sure if you realize you're agreeing with me. 

But agree or not, if you go to the attending to have the patient intubated for airway protection and the say no, how is the patient going to get intubated?? RT isn't going to do it. The medical director? They for sure will talk to the attending on service first.

Btw it's easier to have patients intubated outside of critical care areas because you can easily call a rapid response but in the ED and ICU, if you approach the doc and say hey, can we intubate this patient and they say no, then what? I've had this same experience in the ED when I had an obtunded patient brought in by EMS and I requested the patient be intubated and the doc said no. I explained to them if this patient gets admitted and they go to a tele floor they for sure will be a rapid response and intubated and upgraded to the ICU. It took the intensivist saying "intubate before they get admitted to us" before the ED attending did otherwise. Like I said, the buck stops with the doc. 

Lipoma said:

Btw it's easier to have patients intubated outside of critical care areas because you can easily call a rapid response but in the ED and ICU, if you approach the doc and say hey, can we intubate this patient and they say no, then what? I've had this same experience in the ED when I had an obtunded patient brought in by EMS and I requested the patient be intubated and the doc said no. I explained to them if this patient gets admitted and they go to a tele floor they for sure will be a rapid response and intubated and upgraded to the ICU. It took the intensivist saying "intubate before they get admitted to us" before the ED attending did otherwise. Like I said, the buck stops with the doc. 

Your hospital sounds terrifying. I just didn't want OP (or anyone identifying as a new nurse) coming away from this thread thinking this is normal everywhere.

MaxAttack said:

Your hospital sounds terrifying. I just didn't want OP (or anyone identifying as a new nurse) coming away from this thread thinking this is normal everywhere.

...that wasn't the point I was trying to make. The point is...the buck stops with the doc as proven above. That's normal...scary yes...but that's hierarchical health care for ya (hence the sugar coated term go up the chain of command). If the attending physician says NO, the answer is NO.