He is in ATN with minimal UO and his creatinine is 3.7.

You are in a community hospital.

What do you want to know?  What would you do to improve the current situation? 

John E Belcher BS, CCEMT-P, CPTC, CTBS
Donation Coordinator

New England Organ Bank

The patient's IBW indicated that we could increase the TV to 900.  This allowed a drop in the respiratory rate to 27.  An increased i time allowed a 1:1 i:e ratio.  The patient was switch to PCV.  The saturation improved immediately to 99%.  There were also increases in EtCO2, indicating a decreased dead space ventilation.  It's difficult to draw too many conclusions from EtCO2 monitoring in a patient with a low cardiac output and potential underlying respiratory disease.  In this case, it worked nicely to acheive the goal of imrpoving the scenario prior to surgery.

John E Belcher BS, CCEMT-P, CPTC, CTBS
Donation Coordinator

New England Organ Bank

I like low/ inverse I:E ratios for lung recruitment and improved delivered O2. Sad that given the hemodynamics you couldn't inverse it.

What I'd like to know:

Ht, wt, chemistry, CBC, pt/ INR,  AST/ ALT tot bili, GGT, albumin, CO/ CI/ SVR/  & PPV or SVV if available,  U/A

his ideal BW showed you you could increase tidal vuolume... how many cc/ kg of IDBW do you vent at?

Are you willing to tolerate a ph of 7.2-7.4 instead of the physiologic norm?

Had dobutamine already been tried in this donor and with what result?

How did he get into ARF? ( too much vasopressin? mannitol? DI? anoxia?)

What wer hsi gtts when you arreived and after initial interventions?

what is the CXR ?

Were there other imaging studies available CT Chest/ ABD/ pelvis? ( results?)

Adam Bell, CCEMT-P, CPTC
LifeBanc, Cleveland, Ohio, USA

Didn't have to inverse since the previously achieved results.

What I'd like to know:

Ht, wt, chemistry, CBC, pt/ INR,  AST/ ALT tot bili, GGT, albumin, CO/ CI/ SVR/  & PPV or SVV if available,  U/A

6'1" 330 lbs

Na 135

K   3.5

Cl 107

CO2 18

BUN 36

Creat. 3.6

Gluc 296

Pt/ INR 16.9/ 1.4

AST/ ALT 34/17

Albumin 1.7

UA 1+ Protein

The hemodynamic parameters you requested are from the FloTrac.  We use an EDM.  One of its contraindications is an IABP

his ideal BW showed you you could increase tidal vuolume... how many cc/ kg of IDBW do you vent at?

We have a soft cap of 10 cc/ kg of Ideal Body Weight.

Are you willing to tolerate a ph of 7.2-7.4 instead of the physiologic norm?

I'm comforatable with permissive hypercapnea, I was not with the relative hypoxia and the lactic acidosis.

Had dobutamine already been tried in this donor and with what result?

It was not.  Remember he came with a complete occlusion of his LAD.  Huge Troponin leak, not usually to keen on imcreasing his myocardial oxygen demand.

How did he get into ARF? ( too much vasopressin? mannitol? DI? anoxia?)

It's probable that he had underlying kidney dysfunction from undiagnosed hypertension.  Admission Creat. 2.6.  I'm sure there was a component from anoxia.  Also it is conceivable that there was some consideration from the IABP.

What wer hsi gtts when you arreived and after initial interventions?

He was on both Levo @ 6 mcg/ min, and Neo @ 80mcg/ min

We weaned the Levo off in a few hours.

what is the CXR ?

There are low lung volumes. There is no pneumothorax or hemothorax. There is vascular engorgement. There are linear bands of density in the left lung consistent with atelectasis. There is no consolidation or effusion and there is no evidence of interstitial edema.

Were there other imaging studies available CT Chest/ ABD/ pelvis? ( results?)

The only other imaging was an Ultrasound of the liver.

John E Belcher BS, CCEMT-P, CPTC, CTBS
Donation Coordinator

New England Organ Bank

Perhaps some bicarb would be good and then once you correct the base deficit you can lower minute volume and increase mean airway pressure with high I times ( assuming that doens't turn out to knock out your preload)

Good point re the dobutamine. Thanks...Nor have I had much IABP experience.

Sounds like this fellow needs some fluid for KI, also should he be run w/ a higher MAP based on the idea that the KIs are "used to that?"

I think Albumin might be nice in this pt given that is is below 2.3 and he could perhaps use volume { yes I know his Na and CL are not showing hin "dry"...} but given KI issue and given his need for IABP and pressors. So either 100cc 25% and some 1/4 NS boluses say start w/ 500 X2 if no increase in urine after 1st OR 500 cc of 5% albumin.

Vitamil K would be good also...20 mg IVP x 1

then if clotting doesn't improve FFP goes well with his need for volume to be run through him.

Adam Bell, CCEMT-P, CPTC
LifeBanc, Cleveland, Ohio, USA

I had already made the changes.  It's touchy lengthening the i time with such a high respiratory rate.  Cautious to stack breaths.  After all I only needed improve oxygenation at that point. 

Perhaps some bicarb would be good and then once you correct the base deficit you can lower minute volume and increase mean airway pressure with high I times ( assuming that doens't turn out to knock out your preload)

I don't think we would have been able to reduce the MV, he had demonstrated a need for such settings.

Good point re the dobutamine. Thanks...Nor have I had much IABP experience.

Sounds like this fellow needs some fluid for KI, also should he be run w/ a higher MAP based on the idea that the KIs are "used to that?"

Good point, given the history of HTN.  I will normally keep the MAP > 75 mmHg.

I think Albumin might be nice in this pt given that is is below 2.3 and he could perhaps use volume { yes I know his Na and CL are not showing hin "dry"...} but given KI issue and given his need for IABP and pressors. So either 100cc 25% and some 1/4 NS boluses say start w/ 500 X2 if no increase in urine after 1st OR 500 cc of 5% albumin.

I'm not a huge fan of Albumin.  The debate continues....

Vitamil K would be good also...20 mg IVP x 1

Perhaps

then if clotting doesn't improve FFP goes well with his need for volume to be run through him.

At that stage in the game, I normally shy away from blood products/ components unless absolutely necessary.  Too close to the procurement, its seems a waste.

John E Belcher BS, CCEMT-P, CPTC, CTBS
Donation Coordinator

New England Organ Bank