Case discussion: why acidosis?

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waterbottle10

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i did a robot nephrectomy and i kept my patient intubated at the end due to respiratory acidosis. she is elderly with the usual hypertension, DM on insulin, but also with bad pulmonary disease, a component of COPD and severe reduced dlco. on home o2 2L. room air saturation 79-84%

surgery uneventful. 400 ebl. 6 hour case in lateral position. 2.5L fluid.

On emergence, following instructions, having minute ventilation of ~5L, (RR 16, TV ~350-400), with no vent support, thru a 7.0 tube. However, i was unable to wean him off. On ABG pH of 7.15 and PaCO2 75. (PaO2 on 100% was 370!) Waited 20 minutes, repeat ABG same thing. Patient awake and following instructions well, able to hold hand up.. not weak (also reversed with sugamadex). I kept patient intubated and brought to PACU.

1) would you have extubated
2) would you try anything else to optimize extubation
3) why do you think shes at a PaCO2 of 75 despite decent RR and TV? PaO2 was surprisingly good.

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1. Absolutely extubate. Staying intubated was due to numbers not the patient status.
2. No. She wouldnt die with a PCO2 of 75 and she wasn't unstable.
3. She had dramatic dead space so your ETCO2 was probably reasonable but her actual PCO2 the whole case was high. And her normal PCO2 is probably 50 or more.
 
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She probably has acute on chronic hypercapnic respiratory failure from her COPD. Can consider transitioning to BIPAP and trend blood gas.
 
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i did a robot nephrectomy and i kept my patient intubated at the end due to respiratory acidosis. she is elderly with the usual hypertension, DM on insulin, but also with bad pulmonary disease, a component of COPD and severe reduced dlco.

surgery uneventful. 400 ebl. 6 hour case in lateral position. 2.5L fluid.

On emergence, following instructions, having minute ventilation of ~5L, (RR 16, TV ~350-400), with no vent support, thru a 7.0 tube. However, i was unable to wean him off. On ABG pH of 7.15 and PaCO2 75. (PaO2 on 100% was 370!) Waited 20 minutes, repeat ABG same thing. Patient awake and following instructions well, able to hold hand up.. not weak (also reversed with sugamadex). I kept patient intubated and brought to PACU.

1) would you have extubated
2) would you try anything else to optimize extubation
3) why do you think shes at a PaCO2 of 75 despite decent RR and TV? PaO2 was surprisingly good.

What was the base deficit/excess?
What fluid did you use?
 
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What was the base deficit/excess?
What fluid did you use?

I dont usually look at BE/BD so i dont remmeber. I can check later
It was a mix of LR and NS (one on each IV). about half of each
 
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1. Absolutely extubate. Staying intubated was due to numbers not the patient status.
2. No. She wouldnt die with a PCO2 of 75 and she wasn't unstable.
3. She had dramatic dead space so your ETCO2 was probably reasonable but her actual PCO2 the whole case was high. And her normal PCO2 is probably 50 or more.

Her etco2 was around 55-60, so her Paco2 was about 15-20 higher than etco2.
 
i did a robot nephrectomy and i kept my patient intubated at the end due to respiratory acidosis. she is elderly with the usual hypertension, DM on insulin, but also with bad pulmonary disease, a component of COPD and severe reduced dlco. on home o2 2L. room air saturation 79-84%

surgery uneventful. 400 ebl. 6 hour case in lateral position. 2.5L fluid.

On emergence, following instructions, having minute ventilation of ~5L, (RR 16, TV ~350-400), with no vent support, thru a 7.0 tube. However, i was unable to wean him off. On ABG pH of 7.15 and PaCO2 75. (PaO2 on 100% was 370!) Waited 20 minutes, repeat ABG same thing. Patient awake and following instructions well, able to hold hand up.. not weak (also reversed with sugamadex). I kept patient intubated and brought to PACU.

1) would you have extubated
2) would you try anything else to optimize extubation
3) why do you think shes at a PaCO2 of 75 despite decent RR and TV? PaO2 was surprisingly good.

Vq mismatching from the high fio2?
 
What was the base deficit/excess?
What fluid did you use?

pH 7.15 with pCO2 75 is pure respiratory acidosis with slight compensatory metabolic alkalosis. BE/BD likely close to 0.

Respiratory acidosis is likely due to exogenous CO2 insufflation during 6 hrs of laparoscopy. Did the patient have any subcutaneous emphysema? Will probably take hours for the patient to blow off all that CO2. If all else looked well, I would have extubated.
 
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Absorption atelectasis

That's incorrect.

Background

Dead Space - Areas of ventilation without perfusion. At the extreme a V/Q of infinity. This can be thought of as a CO2 issue

Shunt - Areas of perfusion without ventilation. At the extreme a V/Q of zero. This can be thought of as a O2 issue.

The spectrum is everything in between.

So in units with a higher V/Q(excessive ventilation in relation to perfusion, or low perfusion in relation to ventilation) you are more towards the dead space spectrum (infinity), and have worse dead space/difficulties removing carbon dioxide compared to lung units with a normalized ratio.

Units with a lower V/Q(excessive perfusion in relation to ventilation, or low ventilation in relation to perfusion) you are more towards the shunt spectrum ( zero) and have difficulties with oxygenation compared to a lung unit with a normalized ratio.

The cause of increased arterial carbon dioxide when giving COPD patients supplemental oxygen is not due to decreased respiratory drive. The respiratory drive has been shown not to change in multiple studies of COPD patients with supplemental oxygen.

The increase in arterial carbon dioxide is due to two effects, HPV and the Haldane effect in relation V/Q.


HPV:

The goal of HPV is to distribute blood flow to lung units with high V/Q, lowering this ratio and improving the match between ventilation and perfusion. It also diverts blood flow away from lung units with low V/Q and improve the ventilation and perfusion match between these units as well.

In the patient with COPD, lung units with poor ventilation have the blood(by HPV) forced to lung units with high ventilation. The lung units with high V/Q now by HPV have more blood being distributed to them and a lower V/Q ratio. Hence it transitions the lung unit away from the spectrum of dead space(improving ability to remove carbon dioxide). In addition, the poorly ventilated unit(low V/Q) now has blood flow diverted from it, increasing the V/Q, and reducing physiological shunt to improve oxygenation.

In addition, by driving blood to areas where oxygenation is more efficient it also utilizes the Haldane effect to help remove carbon dioxide.

Haldane Effect:

Deoxygenated hemoglobin binds H+ more efficiently than oxygenated blood, therefore blood will carry more carbon dioxide when deoxygenated. As the blood reaches an area of high oxygen concentration(lungs) the blood becomes oxygenated and binds H+ less efficiently leading to release carbon dioxide where it can be exchanged to the atmosphere.

Therefore, the greater oxygen gradient between the mixed venous and arterial blood(a-mV), the greater amount of CO2 will be displaced due to the Haldane effect and be able to be ventilated to the atmosphere. In situations where the oxygen difference between the mixed venous and arterial blood is smaller due to poor oxygenation, less CO2 will be displaced and unable to be removed by the lungs. This can be referred to as 'Haldane deadspace.'

In the COPD patient a poorly ventilated lung unit with normal perfusion is an example of this. Even though by V/Q ratio it appears low, hence would be on the shunt spectrum, because of the minimum change in the oxygen a-mV gradient, this also causes Haldane deadspace.

However, this effect is minimized by HPV which maximizes the displacement of CO2 by the Haldane effect by driving blood to lung units with adequate oxygen(large gradient, increased CO2 displacement).

Supplemental Oxygen:

When you give a patient with COPD supplemental oxygen it inhibits the above processes leading to an increase in arterial carbon dioxide, but not due to decreased ventilatory drive.

By giving supplemental oxygenation you are inhibiting the HPV as described above.

Now the blood that was diverted towards units with elevated V/Q helping to normalize them and improve dead space is now lost. Therefore, these lung units once again have excess ventilation in relation to perfusion and experience a relative worsening of dead space(the V/Q is increasing again and efficiency of CO2 removal is less for a given minute ventilation)

In addition, by having this supplemental oxygen the blood is now once again flowing to poorly ventilated lung units due to the inhibition of HPV. This leads to a decreased oxygen gradient(a-mV) and less carbon dioxide being displaced by the Haldane effect and worsening of the Haldane deadspace.

Finally at higher levels of supplemental oxygenation your mixed venous saturation which is on the steeper portion of the oxyhemoglobin dissociation curve increases more than the arterial saturation on the flat portion of the curve. This also narrows your oxygen gradient(Arterial-mV) and further worsens Haldane deadspace.

This might have errors ( all the crazy V/Q talk), if it does I'll be glad to correct them.
 
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pH 7.15 with pCO2 75 is pure respiratory acidosis with slight compensatory metabolic alkalosis. BE/BD likely close to 0.

Respiratory acidosis is likely due to exogenous CO2 insufflation during 6 hrs of laparoscopy. Did the patient have any subcutaneous emphysema? Will probably take hours for the patient to blow off all that CO2. If all else looked well, I would have extubated.
We don't know anything about the severity of the COPD in terms of the baseline carbon dioxide levels? So at the current level of 75 we have no clue what respiratory component is acute ( 0.08 pH change for every 10 CO2) vs chronic (0.03 change for every 10 CO2). We have limited information and shouldn't make assumptions of what component is acute/chronic from a respiratory standpoint, and we have literally zero information from a metabolic standpoint both baseline and current. In a chronic COPD of significant severity I wouldn't expect a baseline base excess to be close to zero, I'd expected it to show a higher base excess to compensate for the hypercarbia and maintain eucapnia.

All that being said, it totally could be the exogenous CO2 matched with insufficient minute ventilation during the case causing an acute on chronic respiratory acidosis. And agree, I would have extubated, I wouldn't have even gotten the initial ABG.
 
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That's incorrect.

Background

Dead Space - Areas of ventilation without perfusion. At the extreme a V/Q of infinity. This can be thought of as a CO2 issue

Shunt - Areas of perfusion without ventilation. At the extreme a V/Q of zero. This can be thought of as a O2 issue.

The spectrum is everything in between.

So in units with a higher V/Q(excessive ventilation in relation to perfusion, or low perfusion in relation to ventilation) you are more towards the dead space spectrum (infinity), and have worse dead space/difficulties removing carbon dioxide compared to lung units with a normalized ratio.

Units with a lower V/Q(excessive perfusion in relation to ventilation, or low ventilation in relation to perfusion) you are more towards the shunt spectrum ( zero) and have difficulties with oxygenation compared to a lung unit with a normalized ratio.

The cause of increased arterial carbon dioxide when giving COPD patients supplemental oxygen is not due to decreased respiratory drive. The respiratory drive has been shown not to change in multiple studies of COPD patients with supplemental oxygen.

The increase in arterial carbon dioxide is due to two effects, HPV and the Haldane effect in relation V/Q.


HPV:

The goal of HPV is to distribute blood flow to lung units with high V/Q, lowering this ratio and improving the match between ventilation and perfusion. It also diverts blood flow away from lung units with low V/Q and improve the ventilation and perfusion match between these units as well.

In the patient with COPD, lung units with poor ventilation have the blood(by HPV) forced to lung units with high ventilation. The lung units with high V/Q now by HPV have more blood being distributed to them and a lower V/Q ratio. Hence it transitions the lung unit away from the spectrum of dead space(improving ability to remove carbon dioxide). In addition, the poorly ventilated unit(low V/Q) now has blood flow diverted from it, increasing the V/Q, and reducing physiological shunt to improve oxygenation.

In addition, by driving blood to areas where oxygenation is more efficient it also utilizes the Haldane effect to help remove carbon dioxide.

Haldane Effect:

Deoxygenated hemoglobin binds H+ more efficiently than oxygenated blood, therefore blood will carry more carbon dioxide when deoxygenated. As the blood reaches an area of high oxygen concentration(lungs) the blood becomes oxygenated and binds H+ less efficiently leading to release carbon dioxide where it can be exchanged to the atmosphere.

Therefore, the greater oxygen gradient between the mixed venous and arterial blood(a-mV), the greater amount of CO2 will be displaced due to the Haldane effect and be able to be ventilated to the atmosphere. In situations where the oxygen difference between the mixed venous and arterial blood is smaller due to poor oxygenation, less CO2 will be displaced and unable to be removed by the lungs. This can be referred to as 'Haldane deadspace.'

In the COPD patient a poorly ventilated lung unit with normal perfusion is an example of this. Even though by V/Q ratio it appears low, hence would be on the shunt spectrum, because of the minimum change in the oxygen a-mV gradient, this also causes Haldane deadspace.

However, this effect is minimized by HPV which maximizes the displacement of CO2 by the Haldane effect by driving blood to lung units with adequate oxygen(large gradient, increased CO2 displacement).

Supplemental Oxygen:

When you give a patient with COPD supplemental oxygen it inhibits the above processes leading to an increase in arterial carbon dioxide, but not due to decreased ventilatory drive.

By giving supplemental oxygenation you are inhibiting the HPV as described above.

Now the blood that was diverted towards units with elevated V/Q helping to normalize them and improve dead space is now lost. Therefore, these lung units once again have excess ventilation in relation to perfusion and experience a relative worsening of dead space(the V/Q is increasing again and efficiency of CO2 removal is less for a given minute ventilation)

In addition, by having this supplemental oxygen the blood is now once again flowing to poorly ventilated lung units due to the inhibition of HPV. This leads to a decreased oxygen gradient(a-mV) and less carbon dioxide being displaced by the Haldane effect and worsening of the Haldane deadspace.

Finally at higher levels of supplemental oxygenation your mixed venous saturation which is on the steeper portion of the oxyhemoglobin dissociation curve increases more than the arterial saturation on the flat portion of the curve. This also narrows your oxygen gradient(Arterial-mV) and further worsens Haldane deadspace.

This might have errors ( all the crazy V/Q talk), if it does I'll be glad to correct them.


It’s always a mixed picture with different phenomena being dominant in different West lung zones. But I think @coffeebythelake was referring to absorption atelectasis. @coffeebythelake is welcome to correct me if I’m mistaken.
 
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It’s always a mixed picture with different phenomena being dominant in different West lung zones. But I think @coffeebythelake was referring to absorption atelectasis. @coffeebythelake is welcome to correct me if I’m mistaken.
I really can’t stand people who are like “that is wrong”. Or “that’s incorrect” all self assuredly. It comes off as so douchey and gunnery. As if they are a know it all who never makes mistakes.

Just say “I think what’s happening is this”.
People like that are perfect for academics.
 
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i did a robot nephrectomy and i kept my patient intubated at the end due to respiratory acidosis. she is elderly with the usual hypertension, DM on insulin, but also with bad pulmonary disease, a component of COPD and severe reduced dlco. on home o2 2L. room air saturation 79-84%

surgery uneventful. 400 ebl. 6 hour case in lateral position. 2.5L fluid.

On emergence, following instructions, having minute ventilation of ~5L, (RR 16, TV ~350-400), with no vent support, thru a 7.0 tube. However, i was unable to wean him off. On ABG pH of 7.15 and PaCO2 75. (PaO2 on 100% was 370!) Waited 20 minutes, repeat ABG same thing. Patient awake and following instructions well, able to hold hand up.. not weak (also reversed with sugamadex). I kept patient intubated and brought to PACU.

1) would you have extubated
2) would you try anything else to optimize extubation
3) why do you think shes at a PaCO2 of 75 despite decent RR and TV? PaO2 was surprisingly good.

Yes would have extubated to face ask nebulizer.

Given the severe respiratory disease ideally you could have a discussion with the surgeon about doing this open under epidural and sedation - but I’m sure that’s not going to go over well with the ***** surgeon using a robot on this person for 6 hrs
 
Yes would have extubated to face ask nebulizer.

Given the severe respiratory disease ideally you could have a discussion with the surgeon about doing this open under epidural and sedation - but I’m sure that’s not going to go over well with the ***** surgeon using a robot on this person for 6 hrs
Doing a nephrectomy under neuraxial and sedation would be mental masturbation man. And open surgery is significantly more morbid and higher risk for her in my opinion. That would be a very poor choice. Keep it simple. General anesthesia wins.
 
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It’s always a mixed picture with different phenomena being dominant in different West lung zones. But I think @coffeebythelake was referring to absorption atelectasis. @coffeebythelake is welcome to correct me if I’m mistaken.

I wasn't talking absorption atelectasis. I was talking about hypoventilation and the newer physiologic explanations for why high fio2 is not recommended for bad copd'ers
 
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Doing a nephrectomy under neuraxial and sedation would be mental masturbation man. And open surgery is significantly more morbid and higher risk for her in my opinion. That would be a very poor choice. Keep it simple. General anesthesia wins.

Have done it and disagree

6hr robot for this lady is the poor choice.

Can do this open in 90 mins breathing spontaneously, but I admit it’s not a mainstream approach especially nowadays when we all bow down to the surgeon and the robot
 
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Have done it and disagree

6hr robot for this lady is the poor choice.

Can do this open in 90 mins breathing spontaneously, but I admit it’s not a mainstream approach especially nowadays when we all bow down to the surgeon and the robot

What are usual times for robo nephrectomy? Perhaps laparoscopic would have been better? Or maybe a faster surgeon?
 
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Ok, I have to ask, why did you check a blood gas in a patient with good respiratory mechanics, who was awake and oxygenating well? They are awake... and showing that they can mechanically breath well enough through a tube. Take the damn tube.

I may have missed it skimming through all the responses, but what was the rest of the gas? While the pH and PCO2 would suggest a respiratory process, the bicarb may suggest otherwise. I get calls all the time from hospitalists for similar gases, with the Hospitalist or ED doc panicking over the respiratory acidosis, trying to sedate the patient for BiPAP compliance, and saying how the patient NEEDS admission to the ICU, when they actually just need correction of the underlying metabolic process driving the bulk of the acidosis, in a patient with a chronic respiratory acidosis. Given the hx and the baseline room air sat, I expect your patient has a chronic respiratory acidosis. Combine this with reasons for an acute metabolic acidosis, and you can have a confusing picture and difficulty interpreting the gas. I this situation, go with what the patient is showing you. If they're awake and mechanically breathing well, take the damn tube, and continue to work on the suspected metabolic process. If you're really worried, place them on BiPAP in PACU, and follow clinically and tend ABGs as you continue resuscitation.
 
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I really can’t stand people who are like “that is wrong”.

People make statements that are wrong.
Or “that’s incorrect”

People state things that are incorrect.
all self assuredly.

I felt I wrote a organized detailed reply supporting the pathophysiology. How else should one do it?
It comes off as so douchey and gunnery.

My wife agrees with you. I could have been more diplomatic.

As if they are a know it all who never makes mistakes.

See the last sentence of my first reply. Definitely make mistakes.

Just say “I think what’s happening is this”.

See diplomacy statement above. I'm not stating what I think though? This isn't my opinion. It's a well studied pathophysiology.

People like that are perfect for academics.

70+ percent (most recent job) career in private practice. :)
 
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People make statements that are wrong.


People state things that are incorrect.


I felt I wrote a organized detailed reply supporting the pathophysiology. How else should one do it?


My wife agrees with you. I could have been more diplomatic.



See the last sentence of my first reply. Definitely make mistakes.



See diplomacy statement above. I'm not stating what I think though? This isn't my opinion. It's a well studied pathophysiology.



70+ percent (most recent job) career in private practice. :)
How do you break this all up to answe point per point?
 
How do you break this all up to answe point per point?
Click the quote button so it turns from +Quote to -Quote. It should say something like "message added to multi quote ." Then click reply. Then in the quoted reply click enter at the end of the sentence you want to quote and it should break it off and allow you to type a response.
 
1) would you have extubated
2) would you try anything else to optimize extubation
3) why do you think shes at a PaCO2 of 75 despite decent RR and TV? PaO2 was surprisingly good.
Yes

No

75 is probably not far from where she lives


Hypercarbia is pretty well tolerated, physiologically, even with a pH of 7.15 - much more so than a metabolic acidosis of comparable severity. Even if her actual pCO2 baseline was only 60, 75 isn't that alarming. She was awake and mentating well enough to follow commands.

I'd have extubated her and probably watched her in the OR for a few minutes. What's the worst thing that can happen? She doesn't fly, and you ... reintubate her and take her to PACU or ICU.


An intensivist who I respected once told me that if you never have to reintubate someone, you're not extubating enough people.
 
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Click the quote button so it turns from +Quote to -Quote. It should say something like "message added to multi quote ." Then click reply. Then in the quoted reply click enter at the end of the sentence you want to quote and it should break it off and allow you to type a response.
Ahah. Thank you.

Sorry, haven’t figured this one out and keep seeing it done.

And I too have been told I need to work on Diplomacy more. So touché.
 
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I really can’t stand people who are like “that is wrong”. Or “that’s incorrect” all self assuredly. It comes off as so douchey and gunnery. As if they are a know it all who never makes mistakes.

Just say “I think what’s happening is this”.
People like that are perfect for academics.
Wrong is wrong. I sit in the ivory tower, not the tower of ignorance, and the lion doesn’t concern himself with the opinions of the sheep.
 
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Ok, I have to ask, why did you check a blood gas in a patient with good respiratory mechanics, who was awake and oxygenating well? They are awake... and showing that they can mechanically breath well enough through a tube. Take the damn tube.

I may have missed it skimming through all the responses, but what was the rest of the gas? While the pH and PCO2 would suggest a respiratory process, the bicarb may suggest otherwise. I get calls all the time from hospitalists for similar gases, with the Hospitalist or ED doc panicking over the respiratory acidosis, trying to sedate the patient for BiPAP compliance, and saying how the patient NEEDS admission to the ICU, when they actually just need correction of the underlying metabolic process driving the bulk of the acidosis, in a patient with a chronic respiratory acidosis. Given the hx and the baseline room air sat, I expect your patient has a chronic respiratory acidosis. Combine this with reasons for an acute metabolic acidosis, and you can have a confusing picture and difficulty interpreting the gas. I this situation, go with what the patient is showing you. If they're awake and mechanically breathing well, take the damn tube, and continue to work on the suspected metabolic process. If you're really worried, place them on BiPAP in PACU, and follow clinically and tend ABGs as you continue resuscitation.

mainly to see if we missed anything. the case was controlled ventilation. and during preoxygenation prior to intubation, we did not have etco2 anywhere close to this level. i usually do not extubate if their etco2 is 65 unless they can prove to me they can reduce it. i also know she has a severely reduced dlco, so i was wondering what her paco2 is, in addition to seeing if there are any lab abnormalities/significant acidosis since she is a high risk patient, with high chance of decompensation post op.
 
Yes

No

75 is probably not far from where she lives


Hypercarbia is pretty well tolerated, physiologically, even with a pH of 7.15 - much more so than a metabolic acidosis of comparable severity. Even if her actual pCO2 baseline was only 60, 75 isn't that alarming. She was awake and mentating well enough to follow commands.

I'd have extubated her and probably watched her in the OR for a few minutes. What's the worst thing that can happen? She doesn't fly, and you ... reintubate her and take her to PACU or ICU.


An intensivist who I respected once told me that if you never have to reintubate someone, you're not extubating enough people.
if she lives at paco2 of 60, wouldnt i see that during preoxygenation or immediately after intubation. etco2 was like high 40s after intubation. (i did not mask ventilate).

Also if she lives at 60,why would her pH be 7.15 with a co2 of 75. unless there is metabolic component. she should be better compensated already
 
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if she lives at paco2 of 60, wouldnt i see that during preoxygenation or immediately after intubation. etco2 was like high 40s after intubation. (i did not mask ventilate).
What you see with end tidal isn't necessarily what level is in her arterial blood, in fact it never is even in healthy young people. The only way to know is to get an ABG. It's also important to get an ABG because the PaCO2 by itself is a useless number. One always needs it in the context of the pH. Normocarbia (a CO2 level that is within the normal limits of a laboratory test, usually 35-45 mmHg) is useless. What we care about is the pH in relation to the CO2.

Also if she lives at 60,why would her pH be 7.15 with a co2 of 75. unless there is metabolic component. she should be better compensated already

Agree. If she chronically is at 60 her body would have adjusted to maintain a normal pH for this arterial carbon dioxide level. So what happened? You either have a
1. Acute on Chronic Respiratory Acidosis
Why?
Increased CO2 production and/or
Decreased removal (see the long post above why this happens in COPD patients when higher oxygen concentrations are given even if the minute ventilation remains the same)

2. A pure Metabolic Acidosis on top of her chronic respiratory acidosis where she normally lived at a CO2 of 75

3. A combination acute respiratory acidosis(on top of chronic) and metabolic acidosis.

Seeing the rest of the ABG including base deficit and lactate would be helpful. More data the better. :)
 
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just for fun, for all those people saying they would extubate, agree with most likely she'll do fine. question is what if for, whatever reason (imagine she complains of pain in pacu, nurse gives her opioid which cause her resp status to worsen, etc or some other reasons) she doesnt, and needs to be reintubated. the case gets reviewed, worse malpractice happens, how do you defend against extubating with paco2 of 75 and ph of 7.15

many extubation 'criterias' depending on source, have paco2 and or pH as part of the criterias, such as if patient should not be significantly acidotic prior to extubation, etc.

what is your lawyer going to say? just curious
 
I agree pt probably would have been fine. But I also would not have immediately extubated. Presumably you got the gas because her ETCO2 was in the 50s despite the typical spontaneous minute ventilation.

Agree this is likely from exogenous CO2 either from duration + inadequate minute ventilation or from their insufflation going where it shouldn’t. I once made a surgeon come out and desufflate while I set the minute ventilation to 15-20 L/min for 5-10 min after we noted a bunch of subQ air. We resumed and the patient was extubated at the end.

Catching up with minute ventilation on the vent before getting spontaneous and extubating might have been the cleanest approach for you assuming it was from the exogenous Co2 and nothing paranchymal (which is my guess based on your description of how the pt was doing at the end of the case). Again pt probably could have managed on their own with just extubating but I don’t think anyone should fault you for keeping her intubated.
 
@anbuitachi
Lawyer isn't going to say anything because I wouldn't have gotten an ABG in the first place.

OP described a patient who is AWAKE, breathing spontaneously, unassisted, through a 7.0ETT, maintaining their SpO2, following commands, minute ventilation of 5+L/min. This patient would have already been extubated because nothing here is concerning to me. It's still unclear to me why the blood gas was drawn in the first place.
 
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A bit of an aside but to add to this, managing mod-severe metabolic acidosis on someone with “inadequate ventilation” is challenging too. When I was a fellow I’d see colleagues intubate patients with pH 7.1 (all metabolic) and have a repeat gas with pH 6.8 because they forgot to keep up with someone who was pulling 15-20+ L/min before induction.

Ok, I have to ask, why did you check a blood gas in a patient with good respiratory mechanics, who was awake and oxygenating well? They are awake... and showing that they can mechanically breath well enough through a tube. Take the damn tube.

I may have missed it skimming through all the responses, but what was the rest of the gas? While the pH and PCO2 would suggest a respiratory process, the bicarb may suggest otherwise. I get calls all the time from hospitalists for similar gases, with the Hospitalist or ED doc panicking over the respiratory acidosis, trying to sedate the patient for BiPAP compliance, and saying how the patient NEEDS admission to the ICU, when they actually just need correction of the underlying metabolic process driving the bulk of the acidosis, in a patient with a chronic respiratory acidosis. Given the hx and the baseline room air sat, I expect your patient has a chronic respiratory acidosis. Combine this with reasons for an acute metabolic acidosis, and you can have a confusing picture and difficulty interpreting the gas. I this situation, go with what the patient is showing you. If they're awake and mechanically breathing well, take the damn tube, and continue to work on the suspected metabolic process. If you're really worried, place them on BiPAP in PACU, and follow clinically and tend ABGs as you continue resuscitation.
 
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if she lives at paco2 of 60, wouldnt i see that during preoxygenation or immediately after intubation. etco2 was like high 40s after intubation. (i did not mask ventilate).

Also if she lives at 60,why would her pH be 7.15 with a co2 of 75. unless there is metabolic component. she should be better compensated already
You see where she lives by getting a baseline room air ABG before you go to sleep. Her baseline pH is probably around 7.32-7.35 with a paCO2 around 50-55.

The folks on here acting like a pH of 7.15 is no biggie kinda blow my mind.

DLCO has nothing to do with ventilation impairment.

Your very high fio2 may have worsened her ventilation by blunting the HPV she lives on and pulling pulmonary blood flow to poorly ventilated lung units.

6 hour GETA with CO2 insufflation for this patient is not acceptable (that's the surgeons fault). Taking this patient to ICU intubated after a 6 hour GETA is fine. They will extubate to BiPAP. You could have done the same, but (and I'm not trying to be pejorative here) that does not appear to be in your skill set.

One could argue that this patient should go to ICU post-op either way, given her severe COPD and ARISCAT score of 65. A post-op COPD exacerbation and/or respiratory failure is almost expected.
 
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A bit of an aside but to add to this, managing mod-severe metabolic acidosis on someone with “inadequate ventilation” is challenging too. When I was a fellow I’d see colleagues intubate patients with pH 7.1 (all metabolic) and have a repeat gas with pH 6.8 because they forgot to keep up with someone who was pulling 15-20+ L/min before induction.
And the reason for intubation? Couldn’t be just the 7.1 alone
 
just for fun, for all those people saying they would extubate, agree with most likely she'll do fine. question is what if for, whatever reason (imagine she complains of pain in pacu, nurse gives her opioid which cause her resp status to worsen, etc or some other reasons) she doesnt, and needs to be reintubated. the case gets reviewed, worse malpractice happens, how do you defend against extubating with paco2 of 75 and ph of 7.15

many extubation 'criterias' depending on source, have paco2 and or pH as part of the criterias, such as if patient should not be significantly acidotic prior to extubation, etc.

what is your lawyer going to say? just curious

Honestly you either keep patient intubated or you attempt to extubate her with low threshold to initiate BiPap postop. Either way she might end up in ICU, but i'd do the latter especially if patient was wide awake and responsive and following commands. There are options. You aren't just dumping the patient in Pacu and pretending everything is fine and dandy

I did this with one of my patients last week. Extubated, called RT to have BiPap ready, pH 7.2 with PaCO2 82. Did fine.
 
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Where I am, the ICU would much rather have the patient come intubated to tune them up than roll the dice and have to reintubate in a couple of hours when they fail even for easy airways. Cultures may be the opposite elsewhere.
 
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No preop arterial . There is a VBG from 1 year ago, with pCO2 of 46, pH of 7.36, BE of 1, Hco2 of 26

Preop BMP before procedure showed a CO2 of 25, Chloride of 107,
 
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I stand corrected. Looks more like an acute respiratory process, then. BMP doesn't jive with chronic CO2 retention. Odd that she would be as described, awake and breathing comfortably on the vent. Adjust PSV, treat possible COPD (albuterol, methylpred vs dexamethasone) trend gases. To ICU tubed for wean, or could go to BiPAP and trend ABGs, if she really is briskly awake and you feel aggressive.
 
Have done it and disagree

6hr robot for this lady is the poor choice.

Can do this open in 90 mins breathing spontaneously, but I admit it’s not a mainstream approach especially nowadays when we all bow down to the surgeon and the robot
IMG_2334.jpeg
 
@anbuitachi
Lawyer isn't going to say anything because I wouldn't have gotten an ABG in the first place.

OP described a patient who is AWAKE, breathing spontaneously, unassisted, through a 7.0ETT, maintaining their SpO2, following commands, minute ventilation of 5+L/min. This patient would have already been extubated because nothing here is concerning to me. It's still unclear to me why the blood gas was drawn in the first place.

I guess pt has an a- line and it is convenient to do, lol
 
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