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The Bedside Physiologist by Yogesh Apte

Date post: 14-Jul-2015
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THE BEDSIDE PHYSIOLOGIST Yogesh Apte Intensivist, Robina Hospital
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THE BEDSIDE PHYSIOLOGISTYogesh Apte

Intensivist, Robina Hospital

CASE• 47 y male

• morbidly obese, non-smoker, 2 beers a day

• H/O 5/7 worsening cough, SOB walking bed

• GP visit 2/7 ago

• ED examination

• alert, febrile T = 38’C

• HR 100/min sinus, BP 120/50 (MAP 75), warm

• RR ~ 20, few crackles bilaterally, no wheeze

• SPO2 94% HM 6 lpm O2

• Laboratory results

• WCC 25000, neutrophilia

• mild LFT derangement

• Normal Coagulation profile and albumin

• Urea 11 Creatinine 150

MET CALL

MET CALL• respiratory distress

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

• HCO3 18, Lactate 2, Na 136 K 4.6 Cl 98

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

• HCO3 18, Lactate 2, Na 136 K 4.6 Cl 98

A-a gradient = 320.3

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

• HCO3 18, Lactate 2, Na 136 K 4.6 Cl 98

AG = 20 (HAGMA)A-a gradient = 320.3

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

• HCO3 18, Lactate 2, Na 136 K 4.6 Cl 98

AG = 20 (HAGMA)

High A-a gradient hypoxia

• Dead Space

High A-a gradient hypoxia

• Dead Space

• Shunt

High A-a gradient hypoxia

• Dead Space

• Shunt

• Diffusion defects

High A-a gradient hypoxia

• Dead Space

• Shunt

• Diffusion defects

High A-a gradient hypoxia

• Dead Space

• Shunt

• Diffusion defects

High A-a gradient hypoxia

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

• HCO3 18, Lactate 2, Na 136 K 4.6 Cl 98

AG = 20 (HAGMA)A-a gradient = 320.3

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

• HCO3 18, Lactate 2, Na 136 K 4.6 Cl 98

A-a gradient = 320.3

HAGMA

M - methanol U - uremia (AKI)

HAGMA

M - methanol U - uremia (AKI)

D - DKA P - paraglutamic acid

HAGMA

M - methanol U - uremia (AKI)

D - DKA P - paraglutamic acid

I - INH, Iron L - lactic acidosis

HAGMA

M - methanol U - uremia (AKI)

D - DKA P - paraglutamic acid

I - INH, Iron L - lactic acidosis

E - ethylene glycol R - rhabdomyolysis

HAGMA

M - methanol U - uremia (AKI)

D - DKA P - paraglutamic acid

I - INH, Iron L - lactic acidosis

E - ethylene glycol R - rhabdomyolysis

S - salicylates, sepsis

HAGMA

MET CALL• respiratory distress

• RR ~ 30/min, SPO2 ~ 92% on 10 lpm HM O2

• HR 120/min sinus, BP 90/50 (MAP ~ 65)

• ABG -

• pH 7.29 PCO2 30 PO2 70 SaO2 92%

• HCO3 18, Lactate 2, Na 136 K 4.6 Cl 98

AG = 20 (HAGMA)A-a gradient = 320.3

• Hypoxic respiratory failure due to severe CAP and morbid obesity

• Septic shock with MODS

What we know

• Cardiac function

• Bug

• Respiratory mechanics-dynamics

Unknowns

• BiPAP 100% pre-oxygenation

• IAL inserted - MAP 50

• RIJ CVC inserted - CVP 12 cm H2O

• ScvO2 80%

• BiPAP 100% pre-oxygenation

• IAL inserted - MAP 50

• RIJ CVC inserted - CVP 12 cm H2O

• ScvO2 80%

CVP

• BiPAP 100% pre-oxygenation

• IAL inserted - MAP 50

• RIJ CVC inserted - CVP 12 cm H2O

• ScvO2 80%

FACTORS INFLUENCING CVPFactors Increasing CVP Primary change:

Compliance (C) or Volume (V)

Decreased cardiac output VIncreased blood volume V

Pericardial pressure CChange from standing to supine V

Arterial dilation VThoracic pressure changes C

Abdominal Pressure changes V, CRV Compliance C

The only reason to give fluid challenge in critically ill patients should be to improve their

cardiac output.

“Filling up the tank” shows no understanding of human physiology.

SCVO2

• O2 consumption = O2 delivery x O2ER

SCVO2

• O2 consumption = O2 delivery x O2ER

• VO2 = DO2 x O2ER

SCVO2

• O2 consumption = O2 delivery x O2ER

• VO2 = DO2 x O2ER

• O2ER =VO2 / DO2

SCVO2

• O2 consumption = O2 delivery x O2ER

• VO2 = DO2 x O2ER

• O2ER =VO2 / DO2

• SVO2 = 1 - O2ER

SCVO2

• O2 consumption = O2 delivery x O2ER

• VO2 = DO2 x O2ER

• O2ER =VO2 / DO2

• SVO2 = 1 - O2ER

• Normal SVO2 = 75%

SCVO2

SCVO2

SCVO2Decrease in ScvO2

Increased O2 consumptionStressPain

HyperthermiaShivering

Reduced O2 deliveryAnemiaHypoxia

Reduced CO

SCVO2Decrease in ScvO2

Increased O2 consumptionStressPain

HyperthermiaShivering

Reduced O2 deliveryAnemiaHypoxia

Reduced CO

Increase in ScvO2

Reduced O2 consumptionAnalgesiaSedation

AnesthesiaHypothermia

Increased O2 deliveryIncreased CO

SepsisIncreased CaO2

• No more fluids given

• Noradrenaline started

• RSI, intubated using C-Mac Grade II larynx

SIMV

VT 450 ml RR 15 PEEP 12 I:E 1:2

PPeak 34 PPlat 28

Volume

Pressure (PPlat - PEEP) • Compliance =

Volume

Pressure (PPlat - PEEP) • Compliance =

Compliance = 28 ml/cm H2O

Volume

Pressure (PPlat - PEEP) • Compliance =

Compliance = 28 ml/cm H2O

LUNG COMPLIANCE

Technically difficult studyRV mildly dilatedLV mild global hypokinesisValves normalNo pericardial effusion

Technically difficult studyRV mildly dilatedLV mild global hypokinesisValves normalNo pericardial effusion

Technically difficult studyRV mildly dilatedLV mild global hypokinesisValves normalNo pericardial effusion

ECG normalTroponin 1.8

BNP 680

Further strategies

• Diuretics

• Recruitment

• Nitric Oxide

• Prostacyclin

• Proning

• ECMO

Further strategies

Progress

• Vasopressin added to NorAd

Progress

• Vasopressin added to NorAd

• Dialysed (SLEDD x 5 treatments)

Progress

• Vasopressin added to NorAd

• Dialysed (SLEDD x 5 treatments)

• Tracheostomy D6 ICU

Progress

• Vasopressin added to NorAd

• Dialysed (SLEDD x 5 treatments)

• Tracheostomy D6 ICU

• Sputum: Klebsiella Pneumoniae - sensitive toTazocin

Progress

• Vasopressin added to NorAd

• Dialysed (SLEDD x 5 treatments)

• Tracheostomy D6 ICU

• Sputum: Klebsiella Pneumoniae - sensitive toTazocin

• Discharged from ICU on D19 and to home D56

Progress

Eyes see what your brain knows.

Eyes see what your brain knows.

What our eyes can't see, the brain fills in.


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