Scott et al.,
I am a former medic, flight nurse, and ACNP student (who knows just enough to get me in trouble) stuck in a situation where I am 6 weeks back in the hospital as a bedside ICU RN and the decisions/care being provided goes completely against my training, experience, and what's I've learned from EMCrit over the years.... Thank you in advance for any constructive critique, suggestions, or thoughts.
Yesterday I landed a morbidly obese, post abdominal surgical patient who had small bowel hernias on top of her small bowel hernias. The surgeon resected several sections of her necrotic small bowel, and left her belly open for another go, in a day or two. She was 5'1 and had a generous ideal body weight of no more than 60kg (but weighed more like 160kg). An extensive history included DM, HTN, CKD, and likely undiagnosed COPD after smoking for 45 years.
She was clearly septic based on symptoms before surgery, and came out with a lactate of 11.6, metabolically acidotic (bicarb of 11 and pH of 7.1), profoundly hypotensive (art line showing systolic pressures in the mid 60s when she arrived), and tachycardic in the 150s. HGB was 11.6 after 1 unit of PRBCs during the surgery. And then one of our pulmonologist-“intensivists” got involved...
These pulmonologists have never heard of lung protective ventilation and EVERY patient in the ICU is on AC with 10-12 mL/kg of volume with Pplats often above 30. When the patients are ready to be weaned they go straight from AC to CPAP. Even patients who are conscious, alert, and able to answer questions are on AC and left in misery, sometimes with sedation but never with analgesia.
But I digress. My patient was conscious and responsive within 30mins of arrival to the ICU, was being ventilated at 600, AC at 20, 80%, and 10 of peep, and was over-breathing the vent at a rate of 30 and had an SaO2 of 100%. She had gotten only 2L of fluid in the OR (just maintenance drips prior to surgery), and came out on 15 of Levo and 5 of Dopamine. 1 more liter of fluid was ordered (which hypothetically might have stretched it to 2L) and I was instructed to titrate the Levo up to improve the pt's BP. With the 2 additional liters in, and Levo now at 20, her pressure was only up to the upper 70s. Oh yeah, and her lung sounds were dramatically diminished on the L (assessing chest rise was impossible with her body habitus), but they wouldn’t pull back the tube until a CXR was shot. No air on the right and the tube came back 3cm and voilà, she has bilateral lung sounds, slightly coarse (she probably spent the entire surgery in the right main-stem). Over the 4 hours I had her in the ICU she also got an additional unit of PRBCs, 4 amps of Bicarb, and was put on a bicarb drip. Urine output was in the toilet (pun intended).
RNs are not allowed to touch the vents, but hypothetically I may have adjusted it to 400mL and 4 of peep to see what would happen. Her Pplat dropped from 37 to 26, SaO2 to 98%, and her systolic pressure increased to 99, and she nodded yes when asked if she was more comfortable. When I turned it back to the ordered settings, her pressure tanked back to the upper 70s and she went back to grimacing and banging on the bedrails.
With no other options ordered, I started the Vasopressin just so I could give the patient something in an attempt to make her comfortable (Precedex). I tried to assess IVC collapse (as she was getting 10mL/kg of volume) with a Sonosite machine (again, without orders to do so—I’ve never seen it used but to place central lines) but was unable to visualize the IVC. I don’t have a ton of experience doing so and am not sure if the foam dressing they had left under the top part of the incision that was partially closed (she was cut from just below her xiphoid process to below her umbilicus) got in my way, or if the IVC was just so collapsed I couldn’t see it. All I could see was the bottom of the heart moving.
At 1900 I handed the very uncomfortable, conscious, and miserable patient off to the oncoming RN. She increased the Levo to 30, called to get orders, and was instructed by an on-call doc who had never seen the patient to add an epi drip. Without doing anything to assess fluid volume.
My suspicion was the patient was without likely short on fluid volume, was being inappropriately ventilated, and likely didn’t need so many vasopressors had she be ventilated properly. But I feel hamstrung to do anything (like change vent settings or order more labs, maybe to assess serum osmolality) to prove my suspicions. My questions:
1. Are there some treatment guidelines of which I am unaware that don’t match my prior experience/training?
2. Did she need that much peep considering the likely reduction in preload? That much ventilator volume?
3. Can anyone offer any other suggestions or how they would have managed her differently from my local docs?