Improper intubation

[lmc512]

I am interested in your thoughts on this...

Pt. is a G5P5, has stat section for fetal distress under spinal, spinal stops working when they are closing and pt is intubated and put under general. Pt desats soon after intubation and drs think PE, AFE, or air embolus. CT is neg for embolus, chart states something to the effect of "pt has episode of hypoxia/resp failure for 10 minutes" Pt was given epi and some other code drugs i'm not familiar with and is stable enough to move to ICU. Turns out when pt was intubated ET went too far and went down into rt. bronchus so left got no oxygen I am guessing. So...ET was pulled back to correct position and pt improved dramatically.

So she was extubated approx 12 hrs later and brought out to our regular ol' postpartum floor. She is doing decent other than she looks like she has been to hell and back, excellent urine output (turns out only due to the lasix she received prior to transfer), so after about 3-4 hrs with me she starts having a crummy 12cc or so an hour...dr had me fluid bolus her 500cc despite that her lungs are crackling and wheezing (she can barely budge her incentive spiro), and she is so edematous her hands look like sausages, so i gave her the bolus over 2 hrs and it had zero effect on output, i think she had about 15 cc out. So then we do some labs and sent some urine for sodium and creat. According to dr her problem was "prerenal" due to some fena ratio they do which i have never heard of so therefore their conclusion is she is "DRY" So lets give her a LITER bolus now. I mean will they not be happy until she is dead! Luckily I do not have to deal with these issues with postpartum moms often but I am thinking this lady has more than enough fluid on board her body just isn't getting rid of it. Her BP is a tad low, 90's/40's, pulse 70, sats 95 on 2L. So basically in 6 hours she had 112 cc of urine out that was mildly concentrated. No lasix ordered.

So basically I am just wondering your take on all this, especially the fluid boluses.

[WVUturtle514]

Where to start? Well, first of all I can't believe that the anesthesia provider did not recognize that the tube was in too far. That's absolutely insane! One of the first things you do after intubation is listen to bilateral breath sounds.....even if the doc/crna didn't listen to breath sounds, they would have surely noticed that the ETT was in too far because the patient's airway pressures would have been through the roof and the tidal volumes would have been extremely low. I am just amazed that it was let go long enough that the patient coded! *****! Anyways, as far as the urine output goes, feNA means "fraction of excreted sodium (Na)" and it is a measure of the patient's GFR (glomerular filtration rate).....it is a test that helps determine whether the patient is in pre-renal failure (i.e., kidneys are not being perfused properly....can be due to low blood pressure, not enough fluid volume, etc) or renal failure (i.e., there is some sort of pathology going on within the kidneys). Hope this helps!!

[lucky1RN]

:yeahthat:

The first thing I was thinking is how did they jump all the way to PE, etc. without checking placement of the ETT? I don't get how the pt even made it out of the OR with a misplaced ETT.

Regarding the fluid issues...I'll take a stab but I'm by no stretch of the imagination an expert!

So, she had a c-section, and a difficult intubation which involved episodic hypoxia, right? I hear your concern with giving boluses when she has edema and crackles. Sounds like an oncotic pressure or renal issue. What was her BUN/Cr, hgb/hct, albumin, sodium? What did her last CXR look like? You said she looked pretty bad...was her skin cool/clammy? Was she orthostatic? Alert? What were her peripheral pulses like? SBP in the 90s seems low to me for an otherwise healthy adult female (but "I don't know nothin' 'bout birthin' no babies" so maybe that's normal post c-section? or r/t pain control meds?). The 500mL you gave her is like a can and a half of soda...not much fluid IF it is going into the right spaces. But if she's dehydrated/hypovolemic and her kidneys are not perfusing, then you know everything else is going to go to he** too.

So I guess what I'm saying is that if the kidneys aren't being perfused, then her electrolytes could be out of whack, causing the fluid compartment issues. More aggressive, appropriate fluid rescusitation (with close monitoring...is she on tele with frequent VS?) may fix her right up.

Or did I just put her in fluid overload,...CHF. etc.?

What ended up happening with her?

[babyktchr, BSN, RN]

Yeesh. Sounds to me like she is third spacing a bunch of fluid, which could possibly make her intravascularly dry, but interstitially overloaded. Lasix is a good drug is there is a problem with overload, but to use it just to make someone pee is not always the way to go. I find it hard to believe a post partum mom (relatively healthy) would be fluid overloaded. She may, in fact, be on the dry side. I would be interested in a serum protein level. I remember in my old ICU days giving albumin to those who are third spacing, to diurese the patient. It may also be a post "resus" issue with the kidney, being deprived of adequate oxygenation and all. Some post partum moms take a while to do the fluid shift. I think hydrating her would be a good idea, but monitored closely (as the above poster mentioned). Lasix would not be a good idea at this juncture..you are just drying her out and chasing your tail.

Lungs crackly and wheezy??? Post intubation mucus??

Sad that anesthesia could not diagnose a right main intubation. Listening to some breath sounds probably woulda come in handy then.

I know being apart from your baby is a big issue, but I think we move these gals out of ICU too quickly. Too many bad things happen too fast not to take time and let things balance....just my opinion.

[bethem]

A little off topic, if someone is third-spacing, would the administration of an osmotic agent like mannitol or hypertonic saline help? I'm imagining that the osmotic solution in the intravascular space should draw some fluid back out of the tissues/extravascular spaces and then be excreted by the kidneys.

Am I correct? Obviously this is not the first line treatment but I wonder if it would work.

[Jolie, BSN]

Yeesh. It may also be a post "resus" issue with the kidney, being deprived of adequate oxygenation and all.

My thoughts exactly. Sounds like her kidneys, being "non-vital" organs, were deprived of oxygen during the code. I don't know the technical term for this, but it sounds like they need time to recover without being innundated with excessive amounts of fluid.

[babyktchr, BSN, RN]

Yes, an osmotic would help. but I haven't seen mannitol used in that manner. As I said, many moons ago we used to use albumin for severe third spacing, but this was in very sick surgical patients. I have been out of that realm for too long to know what is the "IN" thing to do. In this case, barring any evidence of kidney damage, the fluid would shift on its own, given some time. Sometimes we just have to let the body heal after a traumatic experience.

[MIcrunchyRN]

I only speak from experience of having my children, not from experiance as a nurse because my experience is quite limited still...

But in a C/S they pump you full of fluids normally, then during her episode of resp. distress they will most likely pump her full of more. Then once baby is born your body has some insane fluid shifts that occur. Even mothers who recieve no hydration during labor and had no edema prior to delivery will commonly have pitting edema that can be quite severe (+4).

My thoughts would be is her kidneys may have suffered damage from her being oxygen deprived and therefore are either having a slow start working, or could be permanently damaged. I don't think she's fluid overloaded per say, she could be dry because all of that fluid has shifted after birth. The ucky lung sounds could be from being intubated as well as a CS patient who in the ICU for 12 hours, so this fluid shift was most likely taking place with her laying down in a bed vs being upright and moving around some. Being upright, coughing and deepbreathing post op does loads for the lung sounds...