What is the pathophysiology? SPO2 34%

[Guest219794]

Walkie talkie, good waveform.  Real deal 34%.

Anybody understand the pathophysiology here?

[JKL33]

Aside from wanting to verify...

There are hypotheses

[Wuzzie]

Methemoglobinemia is a thought. . 

[Susie2310]

I assumed it was confirmed that the equipment was working correctly and that there was no human error in reading the result.  Was an ABG drawn?  What labs were drawn?  What were the results?

[Kitiger, RN]

Is this a "Happy Hypoxic", as could happen with COVID pneumonia?

[Guest219794]

7 hours ago, Susie2310 said:

I assumed it was confirmed that the equipment was working correctly and that there was no human error in reading the result.  Was an ABG drawn?  What labs were drawn?  What were the results?

Yes- the monitoring equipment was in order.  Good looking wave form lining up with QRSs, expected changes in response to interventions.

Never saw the ABG- Was fully task oriented for 3.5 hours.  I recall hearing the lactate was 7.9. Managed the PT with one AC and  2 anterior chest IVs untill he got a central line.  High flow NRB brought it just up to 80%, so he got tubed.  Chased an SBP ranging from 75-210 for quite some time, took a total of 16 mg versed to get him to stop bucking the vent.  3.5 hours of 2 nurses working full on, full PPE, and probably an hour of hands on for the doc, and obviously RT, as well as folks outside the room running for supplies.  Oh yeah- 275lbs.  Not huge by local Walmart standards, but not to easy to move around.

Pressors started shortly after he got to the unit.  Once they restarted the propofol, pressure went to hell.

Off the top of my head-

• 3 IVs on a hard stick
• etomidate
• rocc
• fentanyl
• propofol
• versed
• Labs
• BC x2
• Lactate
• Covid swab
• Foley
• UA
• ABX x 2
• Central line
• Propofol drip
• Fentanyl drip

Luckily I work with a good team- I was actually helping the primary nurse, but still had 3 admits and an emergency PT.  I had mentioned my concern to charge about a DKA that had been mismanaged overnight, and she had somebody catch the BG at 56 and intervene.  Otherwise, there easily could have been a death caused by Covid on a PT without Covid.

[Susie2310]

48 minutes ago, hherrn said:

Yes- the monitoring equipment was in order.  Good looking wave form lining up with QRSs, expected changes in response to interventions.

Never saw the ABG- Was fully task oriented for 3.5 hours.  I recall hearing the lactate was 7.9. Managed the PT with one AC and  2 anterior chest IVs untill he got a central line.  High flow NRB brought it just up to 80%, so he got tubed.  Chased an SBP ranging from 75-210 for quite some time, took a total of 16 mg versed to get him to stop bucking the vent.  3.5 hours of 2 nurses working full on, full PPE, and probably an hour of hands on for the doc, and obviously RT, as well as folks outside the room running for supplies.  Oh yeah- 275lbs.  Not huge by local Walmart standards, but not to easy to move around.

Pressors started shortly after he got to the unit.  Once they restarted the propofol, pressure went to hell.

Off the top of my head-

• 3 IVs on a hard stick
• etomidate
• rocc
• fentanyl
• propofol
• versed
• Labs
• BC x2
• Lactate
• Covid swab
• Foley
• UA
• ABX x 2
• Central line
• Propofol drip
• Fentanyl drip

Luckily I work with a good team- I was actually helping the primary nurse, but still had 3 admits and an emergency PT.  I had mentioned my concern to charge about a DKA that had been mismanaged overnight, and she had somebody catch the BG at 56 and intervene.  Otherwise, there easily could have been a death caused by Covid on a PT without Covid.

I'm thinking along the lines of severe sepsis/septic shock/ARDS/MODS.

[JKL33]

9 hours ago, Kitiger said:

Is this a "Happy Hypoxic", as could happen with COVID pneumonia?

The above link from ATS discusses that phenomenon

[Guest219794]

On 11/4/2021 at 9:30 PM, JKL33 said:

Aside from wanting to verify...

There are hypotheses

I can follow some of the proposed reasons for the hypoxia, and even the lack of dyspnea. 

But- having trouble understanding how other organs are perfused with so little O2 being delivered.  The brain, for example.  How is enough O2 getting into brain cells to allow higher levels of functioning?

Not expecting definitive answers here- Our medical director also is a bit mystified.

 

[CommunityRNBSN, BSN, RN]

Have no idea but I’m SOB just reading about it. 

[Susie2310]

I'm also thinking that the ABG results would give much more information and most accurately measure the patient's oxygenation/ventilation status, but I know you weren't able to see them -  I wondered what your medical director thought about the ABG's.  My understanding is that in conditions such as severe sepsis/septic shock/ARDS where there is altered perfusion and severe hypoxemia, the SpO2 would be less accurate. 

[Guest219794]

5 hours ago, Susie2310 said:

I'm also thinking that the ABG results would give much more information and most accurately measure the patient's oxygenation/ventilation status, but I know you weren't able to see them -  I wondered what your medical director thought about the ABG's.  My understanding is that in conditions such as severe sepsis/septic shock/ARDS where there is altered perfusion and severe hypoxemia, the SpO2 would be less accurate. 

I'll see what I can find out- but, ABG would be a while after intubation.