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斯科特韦林特，MD FCCM。beplay sportsEmcrit 3 - 喉镜作为谋杀武器（LAMW）系列 - 通风杀灭 - 具有严重代谢酸中毒的患者。beplay sportsEmcrit博客. Published on May 22, 2009. Accessed on November 21st 2021. Available at [//www.jddyrj.com/emcrit/tube-severe-acidosis/ ].
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感谢您的有用信息。这太有意思了
It would be interesting to have this great approach modified if ED has no quantitative ETCO2. Thanks.
您可以在没有定量的情况下肯定会管理，在这种情况下，您只需通过240毫升/ kg / min来进行，如果您将潮气量设置为8 ml / kg，则每分钟转换为30呼吸。只需务必以罕见的方式获取后管ABG。
Great podcast, and I really like the idea of using a regular ventilator in a non-invasive way. Occasionally, I have two or more people requiring BiPap at the same time with only one BiPap machine available. What would the disadvantage of setting the initial respiratory rate to 12 breaths per minute using the NIV mask and using this to pre-oxygenate the patient? Certainly the SIMV mode would allow spontaneous breaths, and you wouldn’t have to remember to change the rate once you’ve paralyzed the patient. Also, do you generally leave the vent mode on SIMV once the patient is intubated,…Read more »
Mike
only disadvantage is the patient may not tolerate the machine breaths, otherwise no problem. i don’t generally use simv once the pt is intubated, my take on vent management is in two of the later podcasts. just search the site for “dominating the vent.”
斯科特
斯科特-
We discussed this recently and the question of why SIMV came up? Could you explain your take on SIMV vs. PRVC or even BVM in this situation?
谢谢！
BVM几乎总是连枷。高速公路的BVM只是简单的危险。PRVC会很好，但它比直的SIMV更复杂，我试图尽可能简单地保持排气。PRVC将没有固有的优势。
Hey Scott,
Very cool concept! One question ….any attempts in the past taking the rate beyond 12 during the “pseudo NIV” phase???
谢谢！！
You absolutely can, but you are balancing additional breath-induced gastric insufflation with the need to keep down CO2. You can make a determination on a per-patient basis.
I listened to this podcast months ago and actually got to apply it in an aeromedical transport. Severe metabolic acidosis with RR 40’s, awake nasal intubation done by CCU as we arrived. Problem was patient was fighting the vent and grabbing for the tube. I didn’t want to use paralytics but after exhausting our options it was decided that was the safest option. Prior to paralyzing I placed the patient on our monitors including capnography. ETCO2 19 with RR 24. ABG at same time with pCO2 23. pH 7.1 I set the vent with TV 500 AC, RR 23 and…Read more »
fantastic stuff, Charles!!!
谢谢您的详细播客威先博士。我在几周内给出了类似患者的案例会议。在呼吸补偿中，在严重代谢酸中毒的气道管理方面，我没有在文献中找到很多。Manthous从2010年急救医学文章杂志提供了一些建议，但没有像你的播客那么详细。您对该主题有其他建议的读数吗？
谢谢丹。
Lewis Nelson wrote something up on the intubation of ASA overdoses, that one and the one you mention are all I have seen.
是这一个吗?“机械通气是协会iated with acidemia in a case series of salicylate-poisoned patients”Acad Emerg Med. 2008 Sep;15(9):866-9.
我也看到了这一点;
Patient moribund and hypotensive but still maintaining airway and spont venting. ICU started inotropes and placed the vascath in, dialysed to a more comfortable pH and then intubated a few hours later.
绝对，如果您可以避免插管这些人，并且可以优化它而不是转移。
嘿斯科特，伟大的播客，谢谢2个问题：1。你怎么看待在你的播客中使用RSA作为介入或而不是NIV命题？即，刚刚弹出镇静/麻痹，并放置LMA和袋子以维持合适的二氧化碳，然后通过LMA插管。我知道RSA已被建议作为需要插管的缺氧PT的策略，但我认为没有理由为什么它不是酸性彻底的酸性的策略，这是必须通过插管过程维持的重症的重要补偿过度融合。2.在您建议的协议中，假设您…Read more »
我使用RSA的唯一时间是您描述的PT。我找不到LMA是一个伟大的预贡献设备，但它是一个梦幻般的通风设备。我提到了RSA作为这种情况在插管清单播客中的关键。
45 sec for Sux, Roc is 60 sec.
1.有趣。你为什么不找到LMA一个伟大的预贡献设备？当然，您可以获得BVM +/-窥视阀的益处，但有一个更直接的气道？
2. what I mean re the timing is that after you push your paralytics there may be 45/60 seconds before you can intubate but for most of this time the patient is still breathing cause your sedatives haven’t taken full effect yet.
Therefore is there great benefit in turning the rate up to 12?
It’s not that it is not a good preox device just an unnecessary one. Patients don’t need to be ventilated to maintain oxygenation.
至于时机，不确定您使用的药物，但异丙酚，依托咪酯和硫喷妥牙均在几秒钟内导致呼吸暂停。我们使用的麻痹性会导致呼吸暂停，10-15秒。
ok I see your point but what if the cause of their hypoxaemia is inadequate ventilation? eg the obtunded/resp fatigued patient who is failing to ventilate and who is not acidotic so you don’t care about a rise in C02 but you need to ventilate to pre-ox before intubation? RSA makes sense then surely. Anyway in this particular acidotic patient in your podcast, instead of pushing your drugs and turning the RR=12 for the apnoeic period, would it not be better to just RSA and flick the ventilator right up to RR = 30 (and increase your flow rate). Then…Read more »
Is the point of that first period where you have them on pseudo-NIV and a RR =0 before pushing RSI drugs just so you get an idea of what their end tidal CO2 is pre intubation so that you know where you want to keep it during/post intubation?
Is there any other purpose of this first period other than getting you prepared for the next period (where you can click them up to a RR 12 during apnoea)?
Anand, You are giving them PSV during that period sharply augmenting their own resp efforts in an attempt to blow off CO2 prior to the intubation.
我明白了，谢谢
实际上，那然后让我到另一个问题。如果rr = 0，它们就是他们的自发呼吸的psv。那正确吗？如果是这样，将潮气量设置为550ml的目的是什么？这只是让你在呼吸暂停期间将RR旋转到12时，您已经设置了第二个时期的机器吗？在推送RSI药物之前，在第一期电视= 550ml有任何其他好处吗？
Yep, it is so you only need to twirl one dial as you push the meds
您认为使用氯胺酮是否优选在这些酸性患者中如Prin / Thio等其他药物，因为它会在瘫痪发生之前最小化呼吸症时期，从而减少在此期间CO 2的升高？
有趣的。我认为我们会谈论秒内的秒数，因为呼吸暂停在推动松弛剂时发生的暂停发生，而在咽部咽部全部小肌肉松弛的时间相比。
我知道了。我认为早期的呼吸暂停发生主要是由于镇静剂如异丙酚/硫硫醚的影响。你是否建议即使在他们没有缺席的情况下，只有瘫痪会导致呼吸暂停，在咽炎瘫痪前仍然是一个公平的姿势？
如果是这样，那么是的，氯胺酮可能无济于事。
正确的。观看PT在下一个RSI上停止呼吸的点。对我来说，它通常在10秒标记。
Yep, but that probably wouldn’t prove if it was the sedative or the paralytic causing the apnoea at the 10 second mark.
当他们在氯胺酮+麻痹RSI后停止呼吸时，我抓住了知道的唯一方法。
Have you noticed apnoea starting much later than the 10 second mark in such situations?
just read a section of Miller’s Anaesthesia suggesting that the diaphragm is the most resistant to paralytic agents and the pharyngeal muscles are more sensitive suggesting the latter would paralyses first.
The onset and intensity of blockade vary among muscle groups. This may be due to differences in blood flow, distance from the central circulation, or different fiber types. Furthermore, the relative sensitivity of a muscle group may depend on the choice of muscle relaxant. In general, the diaphragm, jaw, larynx, and facial muscles (orbicularis oculi) respond to and recover from muscle relaxation sooner than the thumb. Although they are a fortuitous safety feature, persistent diaphragmatic contractions can be disconcerting in the face of complete adductor pollicis paralysis. Glottic musculature is also quite resistant to blockade, as is often confirmed during…Read more »
ok thanks, although I think your response was cut off by the website
It is the ketamine RSIs I was thinking of, they still go apneic v. soon after push. May be even sooner as ketamine distributes muscle relaxants quicker than propofol. In ED, we rarely give enough induction agent to cause apnea.
Anand,
我打算说，所有这一切都需要采取事实的背景，即我使用至少两倍的汉语昆虫学生的南姆斯。
我明白了，谢谢
Great. Loved it ! I was wondering why you choose flow @ 30 LPM first and then switched to 60 LPM later.Do we really need to set a flow rate for spontaneously breathing patient on PSV ? Why not just leave it at 60 LPM from beginning (normal setting of ventilators) ?
斯科特, Can you recommend a plan B strategy for intubating such highly acidotic patients in a rural hospital setting, without access to ventilators…
伟大的播客。
Do you have any thougts about using THAM instead of bicarb preintubation in these patients?
比bicarb更具意义，但大多数单位都没有它库存。不确定是否时间从药房获取是现实的
Hi Scott excellent podcast as always. Just a point however, don’t you think sux is not an option at all here as patient is likely high risk for hyperK. Therefore the only option is roc?
无论如何，保持这种生活保存网站
由于Hyper-K的风险不是SUX的矛盾。如果PT实际上有Hyper-k，请当然可以选择ROC。但是在具有正常受体（无神经系统疾病等）的PTS中，您正在谈论SUX的钾的0.5 Meq。如果这可以在合理的水平下保持PT，请参加它。
Randa Ibrahim，Em Residence
Hi Scott
excellent podcast as usual ,do you think awake intubation has a place in intubating such acidotic pt?
提前。
兰达。我也有这个想法的玩具，它有一些优点。在过去的日子里，清醒的设置花了太久了。现在，快速测序清醒。这绝对是一个选择。
亲爱的斯科特博士,谢谢你的回复
您是否会向我提供关于我查询的参考，因为我们即将开始研究唤醒插管技术在PT的低pH值。
Great podcast and appreciate the tips for intubating these patients. I have had a couple of these severe metabolic acidosis patients (renal failure and DKA etiology) that come in altered or working fairly hard, At what point do you pull the trigger to intubate these patients, I am never sure how long to take to try and reverse the acidosis before intubating them? I have tried to start fixing the acidosis in the ED and not intubated with concern to not being able to match their RR but when they go up to the ICU that is the first thing…Read more »
getting worse instead of better
DKA + some other badness rather than dka alone
at risk for losing airway