rt2crna

Try to keep a COPDer's SaO2 88%-92% (which is a PaO2 of about 60 mmHg, the shoulder of the oxyhemoglobin curve). A baseline ABG might be nice, too. BTW- remember this tidbit "40 50 60, 70 80 90" which means a PaO2 of 40 mmHg roughly corresponds to a SaO2 of 70%, 50 mmHg to 80%, and 60 mmHg to 90%. A PaO2 of 40 mmHg is end-organ damage. Remember that a "true" COPDer is probably on home O2, so start with the home prescription (usually 2-3 L/m via nasal cannula) and titrate upwards carefully. Carbon dioxide retention causing hypoventilation is overblown, but it is out there. Quite often the patient will do it fairly rapidly right in front of you, though. If you don't have an ABG, look at the lytes. If the CO2 is above 30 they are possibly a retainer, so keep a close eye on them. Also stay away from sedatives in COPD. Mouth breathing is a problem when calculating FiO2 using the 4% per L/m formula. Constant flow of oxygen into the reservoir of the nasopharynx is drawn into the lungs with each breath. Increased mouth breathing of room air will dilute the oxygen for a lower FiO2 overall, which is why a venturi mask (constant FiO2 at a constant minute volume) is the most certain way to deliver a particular FiO2. And yes, if a COPDer needs more than 50% FiO2 to maintain a SaO2 of 88% and are getting sleepy, they need a vent.

Right. RE has to be kept cold, but at our institution the anesthetist workroom is right off the R.R. where all the NMBs, etc. are stored in the fridge along with the racemic epi. Quite convenient.

Saw the "balloon rip" too many times. Always asked "Why?" Usual answers: just easier, saves time, what's the diff? Only thought provoking answer: semi-inflated cuff pulls secretions out of the trachea. My response: "Yeah, pulls out secretions, not to mention the vocal cords." How can anyone be sure all that volume in the cuff (especially after nitrous) will be gone by the time you draw the tube up the trachea 2 inches and through the cords? Agreed: truly poor, lazy patient care practice.

Albuterol is one of the safest drugs you will find with as much effectiveness as it has. Also in the top ten of most commonly prescribed. Best choice for bronchospasm. RE is a little riskier and, as previously stated, is best for upper airway pathology. In the post-op arena, it is the drug of choice for post extubation stridor. The diagnosis of stridor can be tricky because the noise of the upper airway will be transmitted to the lungs, making you think wheeze based in the lung, when it's actually coming from the upper airway. Pearl: always listen to the throat before throwing albuterol at the problem. Albuterol will do almost nothing for the stridor, while RE will help stridor and bronchospasm. So if you're wrong about the source of the problem, you won't have wasted precious minutes with an ineffective albuterol neb trying to treat upper airway problems. Of course, you must weigh your options if the patient is tachycardic, as RE will almost always raise the pulse 20 bpm. On the other hand, is the pretreatment tachycardia due to hypoxia or respiratory distress? Then RE is your answer. Tough call, though.

Fresh trachs can be very scary, but once the stoma has developed (granulated skin) if a trach were to slip all the way out, the stoma won't immediately snap shut, but that situation is still something to avoid, by all means. Have one hand on the trach at all times and don't take your eyes off of it. Have your clean tie and cleaning supplies all set before you start. Do the left side removal, cleaning, and re-attatching with your right hand, while gently holding the trach with your left, then switch hands and sides. Great opportunity to practice your digital dexterity! Have a small, curved hemostat ready if you have trouble getting the ties through the slits in the trach flange. Slide the hemostat through the slit and grasp the velcro or twill tape end-on from underneath and pull through. Make sure the skin is dried well when you're done, and definately make sure you can fit a finger easily between the tie and the patient's neck. Nothing causes more trouble than a tight, torqued trach. Take your time and be methodical. The first hundred times you do it, you'll be a little nervous but after that- hey, no sweat! };.)

Reply by Larry77 raises a (maybe silly) question. Can a hospital policy supercede a BON directive? i.e. BON says you can but hospital, or med staff, says you can't or vice versa- hospital says you can, but BON says no. Which would hold up in court? Probably the more restrictive, but what does everyone think?

Hi, I'm new posting to this site. I'm an RRT with 19 years experience at 4 different hospitals, mostly critical care, PACU and some middle management. I have an AAS degree in respiratory therapy. It's time for a change. I would like to advance my career into nursing and, specifically, in nurse anesthesia. I would appreciate any guidance about schools, programs, pathways. Anyone who has gone this route? What are my acedemic options? I live in Alaska, but am willing to move. In fact, I'm willing to go as far as it takes to achieve my goal. I just don't want to waste any steps or miss any opportunities to streamline the educational pathway I must take. If anyone can help, I thank you in advance. rt2crna