O2 Sat 88%-90%, MD no action, opinions.

[NocturneNrse]

A pt of mine had an 02 sat of 88-90% during my shift while on 5l oxymizer. The previous shift nurse stated she'd called the MD and alerted him to this but he decided to take no action... nurse state pt was CO2 retainer and this

was where "he lived". Would you over ride MD and put pt on more 02?

[GreyGull]

Respectfully,

They additionally placed the patient on a non-rebreather @ 100% due to the sats being in the low 80's (the patient lived at 87,88%).

If the patient is hypoxic, you can not use the hypoxic drive theory as a reason for "knocking out his respiratory drive".

I believe Dr. Kamen had his glory days in the 60s. For the past 25 years we have learned much more about the hypoxic drive theory. More physicians and textbooks now teach about the release of hypoxic pulmonary vasocontriction and V/Q mismatching. The release of the hypoxic pulmonary vasoconstriction when the nebulizer was given may have been what caused your patient to experience a sudden rise in PaCO2 and not the fact that someone was trying to get the patient's SpO2 from the low 80s.

Any Respiratory Therapist who with holds O2 from a patient as you described:

did complain of SOB and was, as usual, extremely dyspnic at rest

******************

due to the sats being in the low 80's

should have their license removed immediately or be demoted to tank jockey in the basement.

If this patient this had a significant PaCO2 rise, he probably had a significant hypoxemia episode with pulmonary vasoconstriction. Some people do need ventilatory assistance but the alternative would be to see how long the cardiac, neuro and renal system can last while one theorizes about the "hypoxic drive". By your description, if nebulizers and O2 had been with held, this patient probably would have been a cardiac arrest and not just respiratory. Do not fear O2 when a patient is symptomatically in respiratory distress. If the patient goes apneic, it was probably inevitable.

And yes, it is possible to bag a patient who has an elevated PaCO2 level down but recognition of the respiratory distress, recovery time, adverse effects of hypoxemia and pulmonary vasculature constriction.

[April, RN, BSN, RN]

Respectfully,

If the patient is hypoxic, you can not use the hypoxic drive theory as a reason for "knocking out his respiratory drive".

I believe Dr. Kamen had his glory days in the 60s. For the past 25 years we have learned much more about the hypoxic drive theory. More physicians and textbooks now teach about the release of hypoxic pulmonary vasocontriction and V/Q mismatching. The release of the hypoxic pulmonary vasoconstriction when the nebulizer was given may have been what caused your patient to experience a sudden rise in PaCO2 and not the fact that someone was trying to get the patient's SpO2 from the low 80s.

Any Respiratory Therapist who with holds O2 from a patient as you described:

should have their license removed immediately or be demoted to tank jockey in the basement.

If this patient this had a significant PaCO2 rise, he probably had a significant hypoxemia episode with pulmonary vasoconstriction. Some people do need ventilatory assistance but the alternative would be to see how long the cardiac, neuro and renal system can last while one theorizes about the "hypoxic drive". By your description, if nebulizers and O2 had been with held, this patient probably would have been a cardiac arrest and not just respiratory. Do not fear O2 when a patient is symptomatically in respiratory distress. If the patient goes apneic, it was probably inevitable.

And yes, it is possible to bag a patient who has an elevated PaCO2 level down but recognition of the respiratory distress, recovery time, adverse effects of hypoxemia and pulmonary vasculature constriction.

I think most of us understand oxygenation and the many different variables taken into consideration when determining an appropriate SpO2 level. The OP said the previous nurse already notified the physician and he/she said no action was needed. The OPs question was whether or not they should over-ride the MD. One would think the patient's MD knows the patient's history, so the nurse should not be over-riding the MDs decision not to increase the O2. If anything, the OP should have contacted the MD again if she was concerned and the MD to clarify why no action is needed.

[GreyGull]

I think most of us understand oxygenation and the many different variables taken into consideration when determining an appropriate SpO2 level. The OP said the previous nurse already notified the physician and he/she said no action was needed. The OPs question was whether or not they should over-ride the MD. One would think the patient's MD knows the patient's history, so the nurse should not be over-riding the MDs decision not to increase the O2. If anything, the OP should have contacted the MD again if she was concerned and the MD to clarify why no action is needed.

I addressed that in my first post.

I also expanded when some may not have seen a 5 L oxymizer as significant amount of O2 regardless of SpO2. The RN was correct in calling the physician and documentation should also be noted that the physician was aware of the amount of O2 required to maintain an SpO2 of 88%. We also don't know the physician's intentions for being aggressive or if he was putting off officially writing a "do not esculate care".

I am just basing my posts on the amount of FiO2 the patient was on and the assumptions made that "this" is normal.

Edit:

I also never assume the physician knows all the details. Many patients are admitted under a surgeon, hospitalist or PCP they haven't seen in years and this doctor is making a text book assumption as well. A history of "COPD" also does not mean the patient is a CO2 retainer and 88% is normal. For most COPD patients it is not normal. The change in FiO2 may also have been ommitted. A patient can have a great SpO2 on a non-rebreather mask and may even be resting comfortably. However, if it takes that much O2 to achieve that, there is a problem. SpO2 does not equal PaO2 or say very much about how well the patient is actuallly oxygenating.

Inform, question for specifics and document.

[PureLifeRN]

Did the pt already have an ABG done recently? What does the respiratory therapist say? I had the same situation a couple weeks ago, I had a patient come up from the ER with 6L oximizer at 83% (yeah, the report I got was 99% on 6L, but whatever, another topic). I called respiratory and they came up and asked which pulmonary dr was on the case. Resp Therapists KNOW the pulmonary dr's and are able to anticipate what the dr would order. This particular dr likes ABG's done before being called, so thats what we did, plus put the pt on a non-rebreather (pt had pulm htn, not copd). Not the "textbook" answer, but I would have had my butt handed to me if I didnt have those ABG results when I called that dr!

[azhiker96, BSN, RN]

I admitted a late 20s female from the OR. She'd had something minor done, hernia repair or skin lesion removed. She came to me with a non-rebreather mask at 15L, initial sats were 88%. In report the anesthesiologist said she was to go home with the mask because it was hers. She came in with it and with a pre-op sat of 90%. She had some kind of progressive lung disease and lived on O2 at home. Rales were present in all lung fields. I was pretty proud when she woke up and reached 92% on 10L non-rebreather. I must say though, my coworkers thought I'd lost my mind when I transferred her to phase 2 on a non-rebreather mask.

My point is to treat the patient. Certainly if I had not gotten a good report I would have been calling the MD.

[MissBrn, ADN, RN]

I agree with the Md on this. A quick Hx check should've revieled COPD related d/o. That could've clued you in regarding their sats. Maybe I would have bumped him down to 3 L to see if his sats. went up. Usually we have an order set that includes an order stating, "MD to nurse obtain blood gases for sats

[ayla2004, ASN, RN]

agreed 88=92 is our target range for retainers as a rule, 5 litre though would be considered too high we prefer 2-4 for copd pt

[GreyGull]

Here is a good link for those who are not familiar with the Oxymizer.

http://ccn.aacnjournals.org/cgi/content/full/22/4/41

Remember COPD may not be the only disease process you are treating.

[heron, ASN, RN]

Great clinical discussion. Seems like the take-home message is assess and treat the patient, not the monitor.

[NurseLoveJoy88, ASN, RN]

No need to override the MD. For COPD patients pulse 0x in the 80's is sometimes theurapuetic for them and any increase in oxygen can lead to 02 toxicity.

[April, RN, BSN, RN]

agreed 88=92 is our target range for retainers as a rule, 5 litre though would be considered too high we prefer 2-4 for copd pt

What would you do if your patient had an O2 sat of 82% on 4L? You would have to increase the FiO2.

And for the sake of the thread, of course the nurse would notify the physician of the increased O2 requirement.

[RNperdiem, RN]

What kind of unit are you in?

I would be OK with a patient like this in ICU or stepdown where I can monitor them closely.

If this patient deteriorates, I would like to have some warning and have equipment at hand.

I would call the MD if the patient shows symptoms or requires more oxygen to maintain an 88-90% saturation.