Clinical Case 059: Tricks from twitter mates
This case is all about the application of tricks and tips I have learned in the last few years from social media, blogs and the wonderful clinicians out there in the ether who form a community of docs with a common goal – doing better for our patients.
A few years ago I would have managed this case very differently. I would have done “standard care”, it would have been a struggle and I would not have been confident. Looking back, I would have given the same care I learned 10 + years ago from teachers, who themselves were also 10 years out of training. I would have been practising the “standard care of 1992!”. Thanks to my mates from the twitter-sphere I was able to apply the type of care that leaders of the critical care world are using today, and be confident that it was a better plan for my patient. OK, onto the case…
84 yo. man with a few chronic problems:-
- chronic AF – on verapamil for rate control, warfarinised – INR currently 4.2. Big left atrium, and hypertrophic LV.
- Severe aortic stenosis: last ECHO was 6 months ago showed an aortic valve area of 0.6cm2! Despite this he had no history of angina, syncope or failure.
- Chronic interstitial lung disease (?asbestos related) – no home oxygen etc, but a lot of fibrosis on the CXR
- Oh, and the CXR showed a significantly displaced trachea! Possibly due to mediastinal fibrosis or the dilated pulmonary vessels?
He presented to ED with a fever, cough and increasing dyspnoea – his AF was faster than we would like. Likely due to a viral LRTI, but he was treated for severe pneumonia with IV abs. After admission he got sicker, tachypnoeic and had a paO2 of 57 on a non rebreather mask.
When I first met this man he was put on NIV for his respiratory ( type 1) failure and he did pretty well. But over the next 12 hours he slowly got tired and intolerant of the mask. His gases started to drift and we were struggling to maintain a good MAP on the settings required to keep him oxygenated.
This is one of the problems with remote critical care: he probably would have done OK with ongoing NIV, but it is along way (2000 km) to ICU if he doesn’t – so we made the call to transfer him before he got any sicker. In an ideal world we would transfer on NIV as it was working ok when he was able to keep it on. But if you are the flight doc you really want a definitive airway in place for transfer – and that mandates intubation and all the risks, morbidity and long slow wean at the other end. From my perspective this is tough, by tubing we are converting a relatively stable situation into a potential disaster scenario. Keeping him is an option, but this might result in a midnight crash call and that is not ideal either. Have you had cases like this?
So how do you plan to incubate and ventilate a hypoxic, CPaP dependent man, with severe AS and a potentially difficult airway? Tricky situations require tricky solutions – so I leaned heavily on the lessons learned from my network of colleagues in the online crit-care world to get it right, keep my anxiety under control and turn a stressful scenario into a controlled and methodical plan. There are many ways to skin a cat – but here are the basic moves we used:
You also have a good idea of the tidal volumes, rates and presures that the patient is likely to require. So you can set up your vent with a pretty good guess as to what rate etc you need. In this case we went with ~ 6ml/kg at a rate of 25 /min, PEEP of 10cm. And it was good – his CO2 and Spo2 didn’t really move.
The article that described apneic oxygenation by Weingart and Levitan was legendary before it even hit the press thanks to social media in crit care circles!
So – how did it all go?
Very well. The tube went in first pass. The arterial line trace did not budge. The sats dropped to 96% for about 20 seconds before climbing back up to 99%.
Thanks to all the folks out there who offer all this free advice, knowledge and support for those of us on the frontline. My job just keeps getting easier and easier!
Casey
Great post Casey- and a great advertisement for social media in medical education and clinical practice.
Chris
nice one, Casey!
I currently have an article under review on the safety profile of NIPPV during aeromedical retrieval, a 3 year audit and patient fatigue was THE major contributing factor to serious complications of NIPPV attempted during aeromedical transport. So very wise to proceed to intubation despite its many challenges in this case!