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The ambulance bring a patient in on a rebreather. She is elderly and has been unwell for the last few days. Her respiratory rate is 32, heart rate is 125 and sats are 90%. She is afebrile and examination is normal apart for a few creeps in both bases. A set of gases reveals the following: pH 7.3 PaO2 63 PaCO2 37 HCO3 20 SaO2 90% Does she meet Criteria for Non-Invasive Ventilation(NIV)? Yes she does? What type of NIV would you use; CPAP or BiPAP? What type of NIV would you use for: (A) Acute Pulmonary Oedema? (b) COPD? (c) Asthma? .... and why ... all answers in the 9 minute video below: You place the patient on BiPAP (settings EPAP 6 / IPAP 11) and wean down to 50% and the patients gases improve markedly: paO2 137 paCO2 39 The patients respiratory rate is still high at 28 breaths per minute. What setting would you change on the machine to assist the patient?
4 Comments
I think it’s relative lack of uptake is related to the fact that we do it intuitively. If your patient has a heart rate that equals their systolic blood pressure, you’d worry wouldn’t you? Most physicians would look at a sagging blood pressure and decide to treat that patient.
Rady(1) found it a useful measure of cardiovascular performance and a marker for predicting the onset of hypotension; an index of >0.8, being associated with a 95% sensitivity for predicting shock. It has been shown to predict which emergency patients need vasopressors within 72 hours (2), as well as who may suffer organ failure. Montoya et al (3) found that in trauma patients a SI >0.9 resulted in increased mortality at 24 hours. It has also been used to identify severely injured children (4). However in children, a complicating factor, is that it requires age adjustment, due to the fact that children’s heart rates and blood pressures vary with age. Perhaps the one area where I know of it being used most, is in predicting post intubation hypotension (5,6). It certainly does this well when the SI is greater than 0.8-0.9. A high shock index is used to treat the patient’s blood pressure before any induction is given. The aim in some centres is a SI = 1. You know that when you’re about to intubate, if your patients blood pressure is low you’ll probably have hypotension post intubation. Certainly start by filling the tank. Give a fluid bolus of 250-500mL of Normal Saline and as I do, leave the line open(unless there are contraindications) whilst intubation is undertaken. In Australia we would give Metaraminol, to raise the BP. It comes either in 10mg vials or is premixed to 0.5mg/mL. The dose is 0.25-1mg IV and titrate. Induction drugs need to be rethought and instead of using Propofol, would prefer Ketamine and Rocuronium. So there it is; the SHOCK INDEX. A lot of studies on it, but not sure how much it is used. It may very well have a place in allowing us to identify that patient that is progressively worsening, with smaller changes in their vitals and it certainly has a role in intubation. References:
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AuthorDr Peter Kas Archives
November 2016
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