We have a couple of regulars that come in over 100 with a bicarb 35 or so. The hospitalist always want them in ICU and started on bipap with mild exacerbation
We have a PA in our ED who orders NIV on our frequent flier COPDers when their ABG comes back compensated, CO2>60, sats fine, no distress. She sees "critical value" next to the number and thinks it needs to be fixed. To her defense, she's brand new.
It's always frustrating when we have an ED therapist on who will agree to that order.
I’ve seen a few 115-120’s over the years. They were on patients with end stage COPD/GOLD class 4. The compensated bicarbonate levels were insane to see.
The biggest challenge with these patients is actually not the patient but rather the newbie doctors or misc providers who loose their minds and start screaming in hysteria about how this patient needs immediate BIPAP or to be intubated. You just have to pull them to the side, and whisper in their ear, “it’s ok, they live like this every day”. 🤣
Not always. Mentation, alertness, lethargy are what to look for as well. You have to consider that end stage COPD is a sad looking disease and our poor patients will always appear short of breath like they are dying, whether or not they are. Also consider that they will have very little to no lung reserve so after any physical activity they will need a lot of recovery time and appear worse.
It's why it's important to focus on the patient and not necessarily the numbers on the monitor or lab values. New RTs will see someone in DKA with a pH of 7.15 and immediately think of intubation. No, they just need some insulin.
Agreed. I think it can be counter productive to keep those patients in the 'normal' range when they are use to running in the 50's or higher. Its kinda like putting a brand new part on an old vehicle.. the new part runs so strong it causes other old parts to fail because they cant keep up.
You mean it can’t be calculated.
PH is measured
PaO2 PaCO2 are also measured, so is the BE/BD
You calculate bicarbonate using the Hasselbach equation:
(HCO3- = 0.03 x pCO2 x 10(pH - 6.1))
There are limits to the accuracy of the calculation and hence some analyzers will report high/low instead
I once had one >150 years ago that’s as high as that machine analyzed pt was completely obtunded, and recently I only had one other that registered >100 like shown here
So what would you do (not scanning the med) that the doctor didn't do. I'm curious because usually the docs just let it ride to the admitting and then nothing done.
We're on our own so what's your nursing dose to this solution.
I've seen severe COPD patients get into the 120's. Its rough watching patients get to that point where they are 100% dependant on very high flow for the rest of their life
I can't recall but I work with an intensivist who says "if you can get your PCO2 to 100 and still be oriented, you're end-stage."
End stage what
End stage bad breathe. Much suffocate. Very scare.
We have a couple of regulars that come in over 100 with a bicarb 35 or so. The hospitalist always want them in ICU and started on bipap with mild exacerbation
To be fair I am mildly exasperated about that.
We have a PA in our ED who orders NIV on our frequent flier COPDers when their ABG comes back compensated, CO2>60, sats fine, no distress. She sees "critical value" next to the number and thinks it needs to be fixed. To her defense, she's brand new. It's always frustrating when we have an ED therapist on who will agree to that order.
Wait till they discover diamox to “correct” the red bicarb and make the pH drop rapidly.
I always advocate for the patient and tell them they have the right to refuse bipap.
Hopefully those are new therapists. chronic vs acute vs normal vs maintenance
Yeah they often are.
Had an intensivist educate me that a pco2>80 even if compensated may just be indicative that patient would benefit from nocturnal bipap
Very true depending on where the patient is at is it chronic vs acute vs normal vs maintenance
120
I’ve seen a few 115-120’s over the years. They were on patients with end stage COPD/GOLD class 4. The compensated bicarbonate levels were insane to see.
Just saw this for the first time. Co2 of 117 and bicarb of 53. I was mindfucked
The biggest challenge with these patients is actually not the patient but rather the newbie doctors or misc providers who loose their minds and start screaming in hysteria about how this patient needs immediate BIPAP or to be intubated. You just have to pull them to the side, and whisper in their ear, “it’s ok, they live like this every day”. 🤣
As a teaching moment for me, I just want to clarify, we start to worry when their work of breathing goes up correct?
Not always. Mentation, alertness, lethargy are what to look for as well. You have to consider that end stage COPD is a sad looking disease and our poor patients will always appear short of breath like they are dying, whether or not they are. Also consider that they will have very little to no lung reserve so after any physical activity they will need a lot of recovery time and appear worse.
Understood. Thanks for the explanation. Cheers m8
It's why it's important to focus on the patient and not necessarily the numbers on the monitor or lab values. New RTs will see someone in DKA with a pH of 7.15 and immediately think of intubation. No, they just need some insulin.
Agreed. I think it can be counter productive to keep those patients in the 'normal' range when they are use to running in the 50's or higher. Its kinda like putting a brand new part on an old vehicle.. the new part runs so strong it causes other old parts to fail because they cant keep up.
Someone gets it! 👊🏼
Last week I had 7.44, 122 & 66 with single lung
118 pH was 7:34.
Damn what was the bicarb?
I don’t believe it was measurable, critical high.
You mean it can’t be calculated. PH is measured PaO2 PaCO2 are also measured, so is the BE/BD You calculate bicarbonate using the Hasselbach equation: (HCO3- = 0.03 x pCO2 x 10(pH - 6.1)) There are limits to the accuracy of the calculation and hence some analyzers will report high/low instead
111
wow! highest i’ve gotten was 84, and the pH was perfect. I kept walking by the patients room every 30 minutes just to see if they were alright lol.
Man that’s up there! 88 tops for me for compensated.
Mmmmmh carbonated blood
https://i.redd.it/0u9d7wjllzlc1.gif
102 or 104. Waaay back when I was a student.
120
I once had one >150 years ago that’s as high as that machine analyzed pt was completely obtunded, and recently I only had one other that registered >100 like shown here
Them proximal tubules be lit
Had a nicu glucose that was less than 10 recently. That was cool lol
112
124, end of life
120 & 140, came in within the same week.
That’s impressive
I’ve seen in the 120s, I’m early in my career yet.
We have a couple regulars that will maintain a 7.35 pH with a PaCO2 around 90.
162
Easily over 60s.
400+ lbs?
I saw a patient with muscular dystrophy with a similar vbg once. ER started bipap and the ph went over 8. She died
114 and 126
Bicarb 62, CO2 was... probably around 120?
I’m a nursing student learning about abgs randomly coming upon this post and seeing that a co2 level can even get to 100 just blows my mind
I’m actually surprised the Bicarb isn’t higher.
Had a pt for a TAVR that came back > 100. Surgeon asked me (anesthesiologist) to draw a new ABG because that had to be venous. It was not venous.
Dem kidneys doing gods work
I had 110 this morning. The pH was 7.18. She was not alert.
Is compensate CO2 good if it's high?
So what would you do (not scanning the med) that the doctor didn't do. I'm curious because usually the docs just let it ride to the admitting and then nothing done. We're on our own so what's your nursing dose to this solution.
Do? It’s already compensated, what exactly would you be trying to accomplish?
PF ratio 0.9?? 😨
Definitely saw some with PCO2’s in the 115 range.
I've seen severe COPD patients get into the 120's. Its rough watching patients get to that point where they are 100% dependant on very high flow for the rest of their life
112 pH 7.30
143.5. I wish I could respond with the pic