scholarly journals Proning During Pandemic: The Rapid Institution of a Safe, Transferable, and Effective Prone Positioning Program at Nychhc/elmhurst Hospital, A Situationally Resource Limited Facility, During the Peak of the Covid 19 Surge

2020 ◽  
Author(s):  
Alfredo J Astua ◽  
Eli K Michaels ◽  
Andrew J Michaels
Keyword(s):  
Prone Position ◽  
High Reliability ◽  
Blood Gases ◽  
Mass Casualty ◽  
Positional Therapy ◽  
Prone Positioning ◽  
Simple Method ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Cell Counts

Abstract Introduction:The use of prone positional therapy for moderate and severe hypoxicAcute Respiratory Distress Syndrome (ARDS) is known to decrease mortality. There are barriers to the routine use of Intermittent Prone Positioning (IPP), yet medical facilities are being overwhelmed with hypoxic patients due to COVID 19. We present the evolution of a high reliability protocolized program for IPP using minimal materials at the peak of the surge of COVID 19 patients that is applicable in settings of significant limitations and austerity.Methods:In the second week of April 2020 the program evolved through a series of short loop quality-based changes based in the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with moderate to severe ARDS [PaO2:FiO2 ratio (PFr) was < 150 on an FiO2> 0.6 and a PEEP > 5 cm H2O] were eligible to receive IPP.The prone team consists of five to seven persons and patients were placed in the prone position for 16 hours and supine for 8 hours each day. When their PFr was > 200 for > 8 hours supine, positional therapy ceased. Patients were positioned prone using only available materials without additional work from the bedside physicians, registered nurses (RNs) or respiratory therapists (RTs).Arterial blood gases (ABGs) provided the measures of PaO2, PaCO2 and FiO2 and enabled calculation of the PFr and the SaO2:FiO2 ratio (SaFr). Data were collected concurrently by prospective intention for quality assessment. Data are reported as number (n) and percent (%) or mean ± standard error of the mean (SEM) and range. Changes in PaCO2, PF ratios, and SaF ratios are made by paired sample t-tests (2-tailed). Associations of PFr and SaFr at one hour pre-prone are evaluated using Pearson’s correlation and simple linear regression. Data were evaluated using R® Version 1.2.1335 (R Foundation for Statistical Computing, Vienna Austria) and significance is noted at α < 0.05 (p < 0.05).Results:Patients were treated between 14APR2020 and 09MAY2020. The peak of COVID 19 related deaths in New York was the 15th of April 2020. There have been 202 movements to the prone position and patients have received between 1 and 15 IPPs. There are 32 patients in the reported cohort and currently 12 patients are receiving IPP each day. Patients were 58.3± 1.7 years of age (37 to 73 years), 77% were male and had a BMI (body mass index) of 27.9 ± 0.7 (21 to 35). Pressor agents were being used in 74%, 16% were receiving dialysis, the white blood cell counts were 17.0 ± 1.5 (103/mcL) and their D dimers were 4630.0 ± 1588.0 ng/mL. At the time of consultation for prone positional therapy the patient’s arterial blood gas analyses were pH 7.28 ± 0.02, PaCO2 63.1 ± 3.53 mmHg, PaO2 of 80.5 ± 5.3 mmHg, HCO3 of 27.8 ± 1.0 mmol/L.The PFr prior to IPP was 108.0 ± 5.4and 1 hour after IPP was 152.8 ± 11.2 (p < 0.001). PFr after the patients were placed supine was 128.8 ± 9.2 (p = 0.014). Pre-prone PaCO2 was 59.7 ± 2.4 and the 1-hour post-prone PaCO2 was 68.9 ± 3.5 (p = 0.017 compared to pre-prone). The PaCO2measured supine one hour after IPP was 60.7 ± 3.3 (NS compared to pre-prone).The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 hour after positioning was 131.5 ± 5.1 (p = 0.012). The SaFr after the patients were placed supine was 139.7 ± 5.9 (p < 0.001 compared to pre-prone).Using regression coefficients, the SaF ratios predicted by PF ratios of 150 and 200 are 133.2 and 147.3, respectively.Conclusions:A program for prone positioning of adult patients with severe hypoxic ARDS due to COVID 19 can be designed and implemented rapidly, safely, and effectively during an overwhelming mass casualty scenario. This report describes one simple method that does not require any additional materials or labor from the already overburdened staff at the bedside. This approach may be equally applicable in both traditionally austere environments and in otherwise capable centers facing situational resource challenges.

Popliteal artery cannulation as a saviour during prone positioning

2020 ◽  
Vol 13 (6) ◽  
pp. e234370
Author(s):  
Narayan Bala ◽  
Vinay Pathak ◽  
Shilpa Goyal ◽  
Nikhil Kothari
Keyword(s):  
Prone Position ◽  
Popliteal Artery ◽  
Blood Pressure Monitoring ◽  
Arterial Cannulation ◽  
Invasive Blood Pressure ◽  
Arterial Blood Gas ◽  
Artery Cannulation ◽  
Arterial Blood ◽  
Arterial Cannula ◽  
Invasive Blood Pressure Monitoring

The cannulation of the peripheral artery is a prerequisite for invasive blood pressure monitoring and repeated arterial blood gas sampling. Radial artery is commonly used site for inserting an arterial cannula. Many times, either during the change of posture or during prone ventilation, the arterial cannula gets displaced, and it is challenging to reinsert the arterial cannula in the lateral or prone position. In such circumstances, an alternative site of arterial cannulation needs to be looked into; we report a case in which the popliteal artery was used for arterial cannulation while the patient was in a prone position.

scholarly journals Prehospital Diagnosis of Shortness of Breath Caused by Profound Metformin-Associated Metabolic Acidosis

Healthcare ◽  
2021 ◽  
Vol 9 (1) ◽  
pp. 74
Author(s):  
Pietro Elias Fubini ◽  
Laurent Suppan
Keyword(s):  
Metabolic Acidosis ◽  
Hospital Setting ◽  
Blood Gases ◽  
Shortness Of Breath ◽  
Potential Harm ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Common Causes ◽  
Prehospital Diagnosis ◽  
Gas Measurement

Shortness of breath is a common complaint among patients in emergency medicine. While most common causes are usually promptly identified, less frequent aetiologies might be challenging to diagnose, especially in the pre-hospital setting. We report a case of prehospital dyspnoea initially ascribed to pulmonary oedema which turned out to be the result of profound metformin-associated metabolic acidosis. This diagnosis was already made during the prehospital phase by virtue of arterial blood gas measurement. Pre-hospital measurement of arterial blood gases is therefore feasible and can improve diagnostic accuracy in the field, thus avoiding unnecessary delay and potential harm to the patient before initiating the appropriate therapeutic actions.

scholarly journals Lung Mechanics in Type L CoVID-19 Pneumonia: A Pseudo-Normal ARDS.

2020 ◽  
Author(s):  
Lorenzo Viola ◽  
Emanuele Russo ◽  
Marco Benni ◽  
Emiliano Gamberini ◽  
Alessandro Circelli ◽  
...  
Keyword(s):  
Mechanical Properties ◽  
Respiratory System ◽  
Respiratory Mechanics ◽  
Blood Gases ◽  
Lung Mechanics ◽  
Prone Positioning ◽  
Arterial Blood Gases ◽  
Arterial Blood ◽  
Esophageal Balloon ◽  
Early Phases

Abstract Background. This study was conceived to provide systematic data about lung mechanics during early phases of CoVID-19 pneumonia, as long as to explore its variations during prone positioning. Methods. We enrolled four patients hospitalized in the Intensive Care Unit of “M. Bufalini” hospital, Cesena (Italy); after the positioning of an esophageal balloon, we measured mechanical power, respiratory system and transpulmonary parameters and arterial blood gases every 6 hours, just before decubitus change and 1 hour after prono-supination. Results. Both respiratory system and transpulmonary compliance and driving pressure confirmed the pseudo-normal respiratory mechanics of early CoVID-19 pneumonia (respectively, CRS 40.8 ml/cmH2O and DPRS 9.7 cmH2O; CL 53.1 ml/cmH2O and DPL 7.9 cmH2O). Interestingly, prone positioning involved a worsening in respiratory mechanical properties (CRS,SUP 56.3 ml/cmH2O and CRS,PR 41.5 ml/cmH2O – P 0.37; CL,SUP 80.8 ml/cmH2O and CL,PR 53.2 ml/cmH2O – P 0.23). Conclusions. Despite the severe ARDS pattern, respiratory system and lung mechanical properties during CoVID-19 pneumonia are pseudo-normal and tend to worsen during pronation. Trial registration. Restrospectively registered.

Arterial blood gases

2007 ◽  
pp. 319-326
Keyword(s):  
Decision Making ◽  
Pulse Oximetry ◽  
Respiratory Rate ◽  
Management Strategy ◽  
Blood Gases ◽  
Capillary Blood ◽  
Blood Gas ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Gas Measurements

Arterial blood gas (ABGs) analysis forms the cornerstone of emergency respiratory investigation. In many situations values obtained dictate management strategy and facilitate decision-making. It is an uncomfortable procedure for the patients and if repeated ABGs are required, consider whether less invasive measures, such as respiratory rate, pulse oximetry or capillary blood gas measurements could be used....

Comparison of SVO2, SpO2, and clinical parameters with arterial blood gases during ventilatory weaning after cardiac surgery

1994 ◽  
Vol 3 (5) ◽  
pp. 353-355 ◽  
Author(s):  
ML Noll ◽  
JF Byers
Keyword(s):  
Oxygen Saturation ◽  
Respiratory Rate ◽  
Artery Bypass ◽  
Arterial Oxygen Saturation ◽  
Bypass Graft ◽  
Blood Gases ◽  
Arterial Oxygen ◽  
Arterial Blood Gases ◽  
Arterial Blood Gas ◽  
Arterial Blood

Correlations of mixed venous and arterial oxygen saturation, heart rate, respiratory rate, and mean arterial pressure with arterial blood gas variables were computed for 57 sets of data obtained from 30 postoperative coronary artery bypass graft patients who were being weaned from mechanical ventilation. Arterial oxygen saturation and respiratory rate correlated significantly, although moderately, with blood gases.

scholarly journals Effect of Recruitment and Body Positioning on Lung Volume and Oxygenation in Acute Lung Injury Model

2008 ◽  
Vol 36 (6) ◽  
pp. 792-797 ◽  
Author(s):  
H. G. Ryu ◽  
J.-H. Bahk ◽  
H.-J. Lee ◽  
J.-G. Im
Keyword(s):  
Acute Lung Injury ◽  
Oleic Acid ◽  
Lung Injury ◽  
Lung Volume ◽  
Supine Position ◽  
Recruitment Manoeuvre ◽  
Prone Positioning ◽  
Dependent Lung ◽  
Arterial Blood Gas ◽  
Arterial Blood

The mechanism of oxygenation improvement after recruitment manoeuvres or prone positioning in acute lung injury or acute respiratory distress syndrome is still unclear. We tried to determine the mechanism responsible for the effects of recruitment manoeuvres or prone positioning on lung aeration using a whole lung computed tomography scan in an oleic acid induced acute lung injury canine model. Twelve adult mongrel dogs were allocated into either the supine group (n=6) or the prone group (n = 6). After the establishment of acute lung injury, three recruitment manoeuvres were performed at one-hour intervals. Haemodynamic and ventilatory variables, arterial blood gas analyses and CT scans of the whole lung were obtained 90 minutes after oleic acid injection and five minutes before and after each recruitment manoeuvre. Recruitment manoeuvres in the supine position improved oxygenation (P=0.025) that correlated with increase of the poorly- and well-aerated dorsal (dependent) lung volume (r=0.436, P=0.016). Prone positioning increased oxygenation (P=0.004) that also correlated with increase of the poorly- and well-aerated dorsal (nondependent) lung volume (r=0.787, P <0.001). However, the recruitment manoeuvre in the prone position had no effect on oxygenation despite an increase in ventral (dependent) lung volume. The increase in PO2 after recruitment manoeuvres in the supine position or after prone positioning is related to the increase of the poorly- and well-aerated dorsal lung.

Successful Treatment of Experimental Neonatal Respiratory Failure Using Extracorporeal Membrane Lung Assist

1986 ◽  
Vol 9 (6) ◽  
pp. 427-432 ◽  
Author(s):  
R. Fumagalli ◽  
T. Kolobow ◽  
P. Arosio ◽  
V. Chen ◽  
D.K. Buckhold ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Pulmonary Ventilation ◽  
Blood Gases ◽  
Blood Gas ◽  
Arterial Blood Gases ◽  
Arterial Blood Gas ◽  
Membrane Lung ◽  
Arterial Blood ◽  
Long Term Survivors

A total of 44 preterm fetal lambs at great risk of developing respiratory failure were delivered by Cesarean section, and were then managed on conventional mechanical pulmonary ventilation. Fifteen animals initially fared well, and 14 of these were long term survivors. Twenty-nine other lambs showed a progressive deterioration in arterial blood gases within 30 minutes of delivery, of which 10 lambs were continued on mechanical pulmonary ventilation (20% survival), while the remaining 19 lambs were placed on an extracorporeal membrane lung respiratory assist (79% survival). Extracorporeal membrane lung bypass rapidly corrected arterial blood gas values, and permitted the use of high levels of CPAP instead of the continuation of mechanical pulmonary ventilation at high peak airway pressures. Improvement in lung function was gradual, and predictable. Early institution of extracorporeal respiratory assist using a membrane artificial lung rapidly corrected arterial blood gas values and significantly improved on neonate survival.

Ventilation of a rat with a large-animal respirator

1986 ◽  
Vol 61 (3) ◽  
pp. 1192-1194 ◽  
Author(s):  
J. D. Wood ◽  
N. L. Herman ◽  
D. R. Kostreva
Keyword(s):  
Ventilation System ◽  
Blood Gases ◽  
Large Animal ◽  
Arterial Blood Gases ◽  
Sprague Dawley ◽  
Arterial Blood Gas ◽  
Normal Limits ◽  
Arterial Blood ◽  
Gas Measurements ◽  
Catheter Tubing

Rats were effectively ventilated with 100% O2 mixed with room air utilizing a modified tracheostomy tube and a Bird Mark 7 respirator to maintain arterial blood gases within normal limits. A 3-cm segment of rubber pilot tubing was attached to a 15-mm respiratory connector and a 3-cm piece of polyethylene catheter tubing was fitted snugly into the other end. The catheter was inserted and secured into the trachea of 250- to 500-g Sprague-Dawley rats with the adaptor hose of the respirator fitted onto the 15-mm connector following tracheostomy. Manometer and inspiratory flow rate controls of the respirator were set to their minimum operating position. Appropriate rate control adjustments were made when necessary as determined by arterial blood gas measurements. By use of the above ventilation system, adequate arterial blood gases of anesthesized rats can be maintained for greater than 3 h.

scholarly journals Open and Closed Endotracheal Suctioning and Arterial Blood Gas Values: A Single-Blind Crossover Randomized Clinical Trial

2015 ◽  
Vol 2015 ◽  
pp. 1-7
Author(s):  
Azam Faraji ◽  
Alireza Khatony ◽  
Gholamreza Moradi ◽  
Alireza Abdi ◽  
Mansour Rezaei
Keyword(s):  
Clinical Trial ◽  
Heart Surgery ◽  
Open Heart Surgery ◽  
Blood Gases ◽  
Open Heart ◽  
Blood Gas ◽  
Open Technique ◽  
Endotracheal Suctioning ◽  
Arterial Blood Gas ◽  
Arterial Blood

Aim. This study was aimed at comparing the effects of the open and closed suctioning techniques on the arterial blood gas values in patients undergoing open-heart surgery.Methods. In a clinical trial, we recruited 42 patients after open-heart surgery in an educational hospital. Each patient randomly underwent both open and closed suctioning. ABGs, PaO2, SaO2, PaCO2, were analyzed before and one, five, and fifteen minutes after each suctioning episode.Results. At first the pressure of oxygen in arterial blood increased; however, this increase in the open technique was greater than that of the closed system(P<0.001). The pressure of oxygen decreased five and fifteen minutes after both suctioning techniques(P<0.05). The trends of carbon dioxide variations after the open and closed techniques were upward and downward, respectively. Moreover, the decrease in the level of oxygen saturation five and fifteen minutes after the open suctioning was greater than that of the closed suctioning technique(P<0.05).  Conclusion. Arterial blood gas disturbances in the closed suctioning technique were less than those of the open technique. Therefore, to eliminate the unwanted effects of endotracheal suctioning on the arterial blood gases, the closed suctioning technique is recommended.

Measurement of arterial blood gases at the transition from exercise to rest

1983 ◽  
Vol 54 (5) ◽  
pp. 1340-1344 ◽  
Author(s):  
B. M. Lewis
Keyword(s):  
Partial Pressure ◽  
Blood Gases ◽  
Normal Subjects ◽  
Forced Expiratory Volume ◽  
Stair Climbing ◽  
Regulation Of Respiration ◽  
Arterial Blood Gas ◽  
Arterial Partial Pressure ◽  
Arterial Blood ◽  
Two Samples

Arterial blood gas samples obtained 5–20 s after stair-climbing exercise were compared with samples taken during the last 30 s of exercise in 137 subjects. Arterial partial pressure of CO2 (PaCO2) did not change significantly, and in 110 subjects the two samples were within the analytical variation (+/- 2 Torr), supporting the cardiodynamic hypothesis of respiratory regulation. Exceptions to this response were 10 subjects who hyperventilated (PaCO2 less than 34) during exercise and 15 with severe obstruction [forced expiratory volume in 1 s (FEV1) less than 70% forced vital capacity (FVC), and FVC less than 70% of predicted] in whom PaCO2 increased significantly. Overall, arterial partial pressure of O2 (PaO2) increased an average of 3.49 Torr (P less than 0.001). In the two groups in which PaCO2 increased, postexercise PaO2 did not rise. In addition, duration of exercise affected PaO2 response. PaO2 increased significantly more after brief (less than 2 min) periods than after longer (4–6 min) exercise, and this difference increased only when subjects with normal or borderline ventilatory function were analyzed. In 13 subjects in whom a second sample was taken 30–45 s after exercise, the increase in PaO2 was progressive and again the difference between short and long exercise was evident. Regulation of respiration to maintain PaCO2 and changes in O2-CO2 kinetics, leading to an increase in the gas exchange ratio at the exercise-rest transition, are the most likely explanations of these data which establish that the usual response to stopping exercise in normal subjects and most patients is an unchanged PaCO2 and a variable increase in PaO2.

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