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Friday, February 3, 2012

Worse Practice Medicine

So the SpO2 was hanging around 85 percent  on the end stage COPD patient wearing a 40% venturi mask.  I did an ABG and they looked like this:

Ph 7.43
CO2 60
PO2 57
HCO3 32
SaO2 87

These ABGs tell us that these are normal for the patient.  With a bicarb of 32 and a pH that's basically normal we can tell the patient has compensated for the higher CO2.  Sure we'd like to see a little higher PO2, but for this patient 57 is probably normal.

I called these to the doctor thinking worse case scenerio he wouldn't make any changes because he believes in the hypoxic drive hoax.  Yet instead he followed worse practice medicine guidelines and ordered me to decrease the patient's oxygen to 35 percent.  He was concerned the oxygen was causing her CO2 to rise.

The next ABG showed the following:

pH 7.44
CO2 59
PO2 53
HCO3 33
SaO2 85

The patinet was awake and alert and orientated and denied any respiratory distress.  However, the patient was recently extubated.

As a side note here, the patient was on CPAP the day before with an Fio2 of 50 and this likewise did not effect her blood gas; the results were similar to those above.

Based on these results he ordered BiPAP.

Surely I have no problem with placing the patient on BiPAP if the patient can tolerate it.  Yet to decrease oxygen proves nothing more than the power of the doctor clique that holds onto myths that are disproved every day. This is a perfect example of worse practice medicine.



Lung Lover said...

Things like this are so frustrating. It's hard when you have been following a patient - sometimes from ICU to the wards, or emerge to wards. The physician may change and not have the continuity that we have as the patient moves locations throughout the hospital. :( Unfortunately, even though it is frustrating for us, the ultimate result is that the patient suffers. Sigh.

Anonymous said...

Respiratory rate is the key here. If the patient's RR is 8-12 you know the CO2 is rising due to hypoventilation. If the RR is 25-30 you know it's due to air trapping. Since the pH was on the alkalotic side of normal, I'll bet he was hyperventilating slightly, possibly due to the hypoxemia.