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Severe Respiratory Acidosis

Specializes in Trauma/Surgical ICU. Has 2 years experience.

I am an ICU RN and currently my father is in ICU following right upper lobectomy for cancer. A little history on my father is that he is a ex-smoker with a 1 ppd x 35 years, has COPD. Doctors stated that the surgery went well, minimal blood loss. They woke him up in the OR he opened his eyes sat up and looked around a little then went back to sleep (According to the Doctor's). He was extubated in the OR and sent to the recovery room. 15-20 minutes after being in the recovery room they couldn't arouse him. Blood gases were obtained which indicated the following ph 6.9, pco2 143, po2 112. Other labs were obtained and the only abnormal was a K+ that wasn't critically high. He was reintubated at this time. Few minutes later he went into PEA and ACLS was performed. Throughout the day he coded a total of 5 times. He was placed on levophed, epinephrine, vasopressin, all of which were maxed out trying to keep a MAP bp of >65. Throughout the day MI profiles have been obtained mulptiple times with no indicating evidence of an MI but was taken to the cath lab anyways. Heart cath was negative. About 12 hours after all of these events he woke up and now is following commands and writting notes, and he appears to have no neurological deficits all body systems appear to be normal. All pressors are turned off and remains on a vent at this time. My questions is how can a co2 level get so high in such a short period of time and what you guys thought caused the cardiac arrest to begin with? Keep him in your prayers! Thanks.

elizabells, BSN, RN

Specializes in NICU.

I have no answers but... holy crap! So glad he's on the upswing!

That PO2 makes me curious. It seems out of place to me, with the pH and PCO2 being what they were.

BelleKat, BSN, RN

Specializes in CVICU, Burns, Trauma, BMT, Infection control. Has 36 years experience.

I am an ICU RN and currently my father is in ICU following right upper lobectomy for cancer. A little history on my father is that he is a ex-smoker with a 1 ppd x 35 years, has COPD. Doctors stated that the surgery went well, minimal blood loss. They woke him up in the OR he opened his eyes sat up and looked around a little then went back to sleep (According to the Doctor's). He was extubated in the OR and sent to the recovery room. 15-20 minutes after being in the recovery room they couldn't arouse him. Blood gases were obtained which indicated the following ph 6.9, pco2 143, po2 112. Other labs were obtained and the only abnormal was a K+ that wasn't critically high. He was reintubated at this time. Few minutes later he went into PEA and ACLS was performed. Throughout the day he coded a total of 5 times. He was placed on levophed, epinephrine, vasopressin, all of which were maxed out trying to keep a MAP bp of >65. Throughout the day MI profiles have been obtained mulptiple times with no indicating evidence of an MI but was taken to the cath lab anyways. Heart cath was negative. About 12 hours after all of these events he woke up and now is following commands and writting notes, and he appears to have no neurological deficits all body systems appear to be normal. All pressors are turned off and remains on a vent at this time. My questions is how can a co2 level get so high in such a short period of time and what you guys thought caused the cardiac arrest to begin with? Keep him in your prayers! Thanks.[/quote

Did he have a baseline ABG? COPDers retain CO2 normally so some respiratory depression from sedation and his CO2 would shoot up. I'm glad he is neorologically intact. [[HUGS]]

NHSbaseball32

Specializes in Trauma/Surgical ICU. Has 2 years experience.

His baseline ABG's a week prior to surgery were a ph of 7.4 co2 44, po2 was 80. Heck of a lot better than i would have assumed considering his COPD, and his age is 64 if this adds any other useful information.

PiPhi2004

Specializes in Trauma ICU, Surgical ICU, Medical ICU.

I have NEVER seen an abg look THAT bad and someone not suffer neurological deficits. Honestly I have never seen an abg that bad and someone live. I would assume he is in pretty good health otherwise for this to be the case. If it were for a short period of time he may have been able to pull through with no issues. Is it possible this abg was an error? Did they draw others and they were similar? Thats pretty hard to believe but that is great news and it sounds like he is heading in the right direction! Hope all goes well and keep us posted on how things progress!

BelleKat, BSN, RN

Specializes in CVICU, Burns, Trauma, BMT, Infection control. Has 36 years experience.

His baseline ABG's a week prior to surgery were a ph of 7.4 co2 44, po2 was 80. Heck of a lot better than i would have assumed considering his COPD, and his age is 64 if this adds any other useful information.

All I can think is that he was a little over sedated along with the fact that he had lung surgery.Did they rule out PE? Or is he too sick?

Is he is anticoagulated now(lovenox,etc)? I know he's s/p surgery,it might be hard to know what exactly happened to him but it's great that they got him back.

NHSbaseball32

Specializes in Trauma/Surgical ICU. Has 2 years experience.

I didn't really think about a PE because he was oxygenating well the whole time. They never did take him to CT because he was too critical at the time. The only type of prophalatic DVT he is on currenlty is SCD's nothing else that I am aware of. Oh yea something else I forgot to mention earlier is that he had 3 stents placed a few years ago and has been on plavix/aspirin since, he stopped taking these a week prior to the surgery and started him on heparin 5000 units bid. I just went to visit him and he seems in good spirits and they now placed him on a dilaudid pca and he feels like he is on cloud 9 with it :)

BelleKat, BSN, RN

Specializes in CVICU, Burns, Trauma, BMT, Infection control. Has 36 years experience.

It's great that he's feeling better. :)

What was he coded for? Respiratory Depression? BP?

I had a pt with similar BG's who had blood in her lungs...she was very anxious, SOB, cyanotic in her face. she had a trach, and I was suctioning frank blood out. It was specualted that she had been sxmn'd too much or too deeply cusing some kind of tear, i dont know. she was on a heparin gtt. RT was called, she bagged and sxn'd, retook bg, much better. Her blood cleared up a day later, but had black stools, so she was bleeding somewhere, she was transferred to icu, so I never knew what happened with her. Yes, these are the non-icu pts on our 'intermediate' floor.

RN1982

Specializes in ICU/Critical Care.

They probably should have waited for the sedation to wear off before extubating is my guess.

BelleKat, BSN, RN

Specializes in CVICU, Burns, Trauma, BMT, Infection control. Has 36 years experience.

They probably should have waited for the sedation to wear off before extubating is my guess.

Definitely!

NHSbaseball32

Specializes in Trauma/Surgical ICU. Has 2 years experience.

What was he coded for? Respiratory Depression? BP?

I had a pt with similar BG's who had blood in her lungs...she was very anxious, SOB, cyanotic in her face. she had a trach, and I was suctioning frank blood out. It was specualted that she had been sxmn'd too much or too deeply cusing some kind of tear, i dont know. she was on a heparin gtt. RT was called, she bagged and sxn'd, retook bg, much better. Her blood cleared up a day later, but had black stools, so she was bleeding somewhere, she was transferred to icu, so I never knew what happened with her. Yes, these are the non-icu pts on our 'intermediate' floor.

He was coded for bradycardia that soon resulted to PEA. He never had bloody secretions of any sort.

NHSbaseball32

Specializes in Trauma/Surgical ICU. Has 2 years experience.

About the sedation wearing off that was my first thought, but the more I thought about it I started thinking that maybe this was the case: Since he was oxygenating well the entire time with sats 98-100% RR was well from my understanding, but just very shallow breathing. The recovery room nurse didn't attempt to try to arouse him until it was a little too late and I thought that maybe the blood being acidic caused the arrest. I guess it is one of these things that I will never know what happend just speculate on what happend.

RN1982

Specializes in ICU/Critical Care.

His abgs though were not compatible with life. I had a patient with a PH of 6.88 and CO2 over 200 and all because he was a COPDer and placed on a non-rebreather mask which was very bad for him. His respirations sound like little hiccups.

NHSbaseball32

Specializes in Trauma/Surgical ICU. Has 2 years experience.

I know that his pH was that practically of a dead person, its just a miracle that he has no neurological deficits from this and apparently no organ failure at all. Its absolutely amazing.

suanna

Specializes in Post Anesthesia. Has 30 years experience.

If a patient respiratory arrests it takes no time at all for the CO2 to reach astromonical levels. I suspect your father had an obstructed airway- poor muscle tone post anesthesia or less likely by a mucous plug and poor cough. The monitor may have even showed a respiratory rate if he was making an effort to breathe his chest would have been moving causing a waveform on the resp monitor but no air would have been entering the lungs. The problem being if he was somulent before he lost his airway the difference between "resting quietly" and "unarousable" is difficlut to pick up until the patient codes. If he was on supplimental oxygen his pulse ox may not have even dropped completely out before his CO2 was through the roof- If a patients PaO2 is artificially high ie>180 he can be in respiratory failure for a good few minutes before the pulse ox dropps out. SO GLAD HE RECOVERED WITHOUT NEURO DEFICIT!!! As a post-op cardio thoracic nurse I hate it when anesthesia brings us super-drowsy thorocotomy patients. I would rather they left them intubated for an hour or two and let me extubate when they were more fully awake. This isn't a chole. or a hernia repair. These patients have been very deeply under anesthesia PLUS had thier respiratory system compromised both by surgical resection and from pain. I honestly don't feel the recovery room staff can pick up on a patient who develops an obstruction 100% of the time. I happens SO FAST and like I said- "resting comfortably" looks just like "unresponsive" until you try to wake them up.

I am not sure, it sounds like hypoxia, while initially will cause an increase in heart rate (stimulating andrenergic receptors) if prolonged will cause bp/HR to drop?

his baseline abg's a week prior to surgery were a ph of 7.4 co2 44, po2 was 80. heck of a lot better than i would have assumed considering his copd, and his age is 64 if this adds any other useful information.

i am suprised that he is neuro intact with a ph of 6.9 and pco2 that high that is such a deviation from his baseline gas. my question is....have you seen the documentation in the rr that shows what his sao2 was post extubation? i would be suspect....and i might be completly wrong....that post extubation that your dad struggled to maintain his sao2 so it might be interesting to see the minute by minute documentation of those vital signs. my heart goes out to you and i wish you the best.:saint:

NHSbaseball32

Specializes in Trauma/Surgical ICU. Has 2 years experience.

i am suprised that he is neuro intact with a ph of 6.9 and pco2 that high that is such a deviation from his baseline gas. my question is....have you seen the documentation in the rr that shows what his sao2 was post extubation? i would be suspect....and i might be completly wrong....that post extubation that your dad struggled to maintain his sao2 so it might be interesting to see the minute by minute documentation of those vital signs. my heart goes out to you and i wish you the best.:saint:

i have not seen the documentation after extubation, according to the md his sat's were good maintaining 98% with a good pleth, i did ask them about that and his po2 was fine on the abg. he was just not able to blow his co2. does anyone know the full effects of a high co2 and low ph on the cv system? he did go into pea and i know a acidic blood can cause the heart to stop, but what other effects does it have on the cv system? i just got finished visiting him and they had to bronch him today due to a small mucus plug, appears to be doing much better at this time. all pressors remain off, and this am he was just on some pressure support ventilation for about 5 hours then he got a little tired and had to go back on ac. thanks for everyone's thoughts and prayers!!

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