Magnesium Sulfate in Asthma

[VFlutter]

Good to know. I wish I had a way to see this first hand to solidify the idea.

A down and dirty example...

You pick up a IFT patient that was intubated for respiratory failure. Their ABG is something like this.

pH 7.16
PC02 70
ETC02 65

You put them on the ventilator with appropriate settings and monitor their ETC02, by the time you get to the receiving facility their ETC02 is now 45. So you changed their ETC02 by 20 (which should equal a PC02 of 50). So for each 10 change in C02 the pH should change 0.08 in the opposite direction. So for this patient it should change by 0.16 (0.8x2) You drove the c02 down so the pH should go up. When they draw a blood gas the patients pH should be 7.32 (7.16+0.16). If you wanted the patient to have a perfect pH of 7.40 then you would have to decrease their c02 another 10. If that makes sense.

 

[TXmed]

@VentMonkey i use ABA/BAB its a little too lengthy to explain on here. But ROME was nice to learn, thanks for sharing.


Since we are talking ABG's i also encourage people to research permissive hypercapnia.
Essentially we hurt asthmatics and copd'ers by striving for normocapnia. When a PCO2 of up to 80 (although i strive for less than 70) can be well tolerated with the absence of metabolic acidosis.

And with patients of other illness a slightly elevated CO2 can be beneficial. Example: ROSC patients get better cerebral blood flow when their CO2 is between 45-60.

But it is not for everyone.

 

[VentMonkey]

Now we're getting back on topic, thanks @TXmed. The article is over 10 years old, but it's still pertinent to protective lung strategies as far as I know...
https://www.ncbi.nlm.nih.gov/m/pubmed/15659946/

 

[TXmed]

Also a elevated co2 encourages patients to breath, so if you have a patient triggered ventilator you can just assist their breath.

I say assist because ive seen people freak out about patients begining to "overbreath" amd move to massive sedation and paralytic instead of treating a little anxiety and a little pain and just let the patient drive themselves

 

[VentMonkey]

Also a elevated co2 encourages patients to breath, so if you have a patient triggered ventilator you can just assist their breath.

I say assist because ive seen people freak out about patients begining to "overbreath" amd move to massive sedation and paralytic instead of treating a little anxiety and a little pain and just let the patient drive themselves

But would you agree this is patient/ physiological demand dependent?

While encouraging a patient to overbreathe when the end goal is weaning is one thing. The acutely intubated patient may stand to benefit from a little bit of mechanical dependency, at least in the beginning phases (e.g., out of hospital/ scene) of ventilator management.

 

[TXmed]

But would you agree this is patient/ physiological demand dependent?

While encouraging a patient to overbreathe when the end goal is weaning is one thing. The acutely intubated patient may stand to benefit from a little bit of mechanical dependency, at least in the beginning phases (e.g., out of hospital/ scene) of ventilator management.

Yes i agree with that, that is why i prefer using roc instead of sucs. Usually by the time roc has worn off i have established my treatment plan and ventilator strategy and thus they gradually come out of ventilator dependence. In the shorter term, and immediate treatment, i am mainly concerned with air trapping so as long as the SPO2 is adequate i will pop the vent/BVM off from time to time and push on their chest.

Our flight times range from 30min to an hour and a half so i have time to do this prior to getting to the hospital.

 

[bakertaylor28]

Is that really the reasoning behind Ca gluconate vs. Ca choride?

What happens to the chloride ion in the body?



Does elevated C02 cause respiratory acidosis?

Does that fact that a drug comes packaged in a mildly acidic formulation mean that it will actually decrease the serum pH? If so, how much would 4ml (2g) of mag at a pH of 5.5 be expected to change the serum pH?

Is this affected at all by the IVF you are using, and the rate that it is running at?

If the patient has good renal function (most asthmatics probably do), how does that factor in?

What can we do for an asthmatic patient to decrease their metabolic demand and C02 production?

Do we actually use sodium bicarb in arrest?

Why not just give sodium bicarb with the mag?

To address your points (not in any particular order):
1. Not so much what happens to the chloride ion, its the fact of the body being able to do it quick enough to maintain state Vs. what we're infusing. Infusing considerable amounts of NS on its own has been known to do this sort of thing, but we have to remember that there are ALOT of drugs out there that are chloride salts. (Things like Ringer's lactate, if my mind serve me correctly are basic and will mitigate the acidosis.).
2. Its basic theory CO2 causes acidosis when it builds up- CO2 itself is an ACID. Using Bicarb during an arrest was old-school protocol under the notion of correcting the acidosis caused by CO2 however, its fallen out of style in practice. (most probably because acidosis hasn't been systematically shown to correlate to isoelectric function of cardiac cells directly- though I'd tend to think that letting cells sit in their own waste product doesn't help things much.) However, if I remember correctly it has remained in the ACLS guidelines over the years, though anymore tends to be used after the code has been running a considerable length of time.
3. Even if our patient has good kidney function we certainly don't want to do anything that tends to promote renal failure.
4. Decreasing metabolic demand is probably a discussion thread in and of itself. One we're not having today.
5 . If we were to use bicarb to neutralize mag, we would end up producing significant heat without having a catalyst to control the speed of the reaction. And most likely will still end with unreacted bicarb - assuming that we don't consider that the two are likely going to react to form a third salt.
6. With reference to your point as to a mild acid altering serum pH it's not as straight forward as it appears. It depends upon (A) what the serum pH is to begin with (as the more acidic a solution is the less buffer it has) (B) How many hydrogen atoms are involved in the equation. among other things. Your probably not going to be able to work a chemical equation out to enough precision without doing the kind of math that is a leading confirmed cause of migraine headaches.

 

[TXmed]

And FYI, VentMonkey, I'm not here to give you, nor anyone else, a rim job. so I could really care less about what you nor anyone else "likes". Put that in your pipe and smoke it, buddy.

Damn bruh, you do realize you can just log off or ignore cyber bullying right ?

 

[VFlutter]

And FYI, VentMonkey, I'm not here to give you, nor anyone else, a rim job. so I could really care less about what you nor anyone else "likes". Put that in your pipe and smoke it, buddy.

You are going to have a great time in residency.

 

[TXmed]

well lets not let this stop the thread.

*Takes ritalin with red bull*

there is sooo much to talk about besides just mag drips, such as effectiveness of ketamine in non sedation dosages for asthma, questionable effectiveness of inline nebulizers for intubated patients, and have been itching to mention (although i cant remember where its from) i recently read a study that asthmatics have shown better outcomes with earlier RSI and effective ventilator stategies.

 

[FLMedic311]

To address your points (not in any particular order):
1. Not so much what happens to the chloride ion, its the fact of the body being able to do it quick enough to maintain state Vs. what we're infusing. Infusing considerable amounts of NS on its own has been known to do this sort of thing, but we have to remember that there are ALOT of drugs out there that are chloride salts. (Things like Ringer's lactate, if my mind serve me correctly are basic and will mitigate the acidosis.).
Your mind does not serve your correctly...

2. Its basic theory CO2 causes acidosis when it builds up- CO2 itself is an ACID. Using Bicarb during an arrest was old-school protocol under the notion of correcting the acidosis caused by CO2 however, its fallen out of style in practice. (most probably because acidosis hasn't been systematically shown to correlate to isoelectric function of cardiac cells directly- though I'd tend to think that letting cells sit in their own waste product doesn't help things much.) However, if I remember correctly it has remained in the ACLS guidelines over the years, though anymore tends to be used after the code has been running a considerable length of time.
Bicarb does not correct acidosis, ventilations do..

3. Even if our patient has good kidney function we certainly don't want to do anything that tends to promote renal failure.
Mag does not cause Renal Failure, but is the result of kidneys that have failed..

4. Decreasing metabolic demand is probably a discussion thread in and of itself. One we're not having today.
5 . If we were to use bicarb to neutralize mag, we would end up producing significant heat without having a catalyst to control the speed of the reaction. And most likely will still end with unreacted bicarb - assuming that we don't consider that the two are likely going to react to form a third salt.
Why would you use Bicarb to "neutralize" Mag

6. With reference to your point as to a mild acid altering serum pH it's not as straight forward as it appears. It depends upon (A) what the serum pH is to begin with (as the more acidic a solution is the less buffer it has) (B) How many hydrogen atoms are involved in the equation. among other things. Your probably not going to be able to work a chemical equation out to enough precision without doing the kind of math that is a leading confirmed cause of migraine headaches.
WHAT??

 

[VentMonkey]

And FYI, VentMonkey, I'm not here to give you, nor anyone else, a --- ---. so I could really care less about what you nor anyone else "likes".

Yeah, I have nothing more to say other than clearly you're the bigger person.

Damn bruh, you do realize you can just log off or ignore cyber bullying right ?

This made me laugh just a little inside; the context, not the definition itself.

n the shorter term, and immediate treatment, i am mainly concerned with air trapping so as long as the SPO2 is adequate i will pop the vent/BVM off from time to time and push on their chest.

I was just revisiting Bauer's YouTube channel about this technique with patients prone to "breath stacking". Again, the asthmatic/ COPD (obstructive) patient. Our scene flights aren't typically that long.

As an aside, the ASV mode that the T1 offers is phenomenal for just about every patient besides the barotrauma prone patient with a chest tube and high potential for an air leak, or the met. acidotic patient (e.g., DKA/ salicylate OD). It's quite literally adapts to the patients needs, and/ or physiological demands from PRVC, SIMV, to CPAP if they begin to spontaneously breathe. It's our go to "scene call" mode post-RSI.

 

[TXmed]

I have heard good things about ASV. I have no experience and have read only a little about it.

 

[VentMonkey]

I have heard good things about ASV. I have no experience and have read only a little about it.

It's definitely a fascinatingly adaptive mode, as the name implies; the dynamic lung is merely a cool added bonus. We're waiting (impatiently) on our vent mount though. Here's a pretty down and dirty breakdown on it (page 2). Side note, that's my partner, lol. He's a cool cat; super smart, too.

http://hallamb.com/wp-content/uploads/2017/01/HallMark-JanFeb2017-web.pdf

 

[CALEMT]

How much will a mag drip effect their pH?

About as much as normal saline. Around the same pH.

While I'm going to admit that I haven't read every single post on here yet and the fact that I'm still learning the pathophysiology associated with interventions acidosis is something to consider, but not on the top of my list. I'm more worried about the progressively worsening airway. Like Desertmedic66 said, mag sulfate we have to call for a base order and I've never seen it used but I have heard the wonder stories of it.

 

[TXmed]

It's definitely a fascinatingly adaptive mode, as the name implies; the dynamic lung is merely a cool added bonus. We're waiting (impatiently) on our vent mount though. Here's pretty down and dirty breakdown on it (page 2). Side note, that's my partner, lol. He's a cool cat; super smart, too.

http://hallamb.com/wp-content/uploads/2017/01/HallMark-JanFeb2017-web.pdf

several questions

1. how much was the cost?

2. surely the dynamic lung cannot give you an accurate representation with anyone with a lung pathologies (in asthma not every part of the lung is as obstructed as the next so air is introduced unequaly in ppv)? im guessing it is just a visual representation of the tidal volume/PIP/inspiratory time together?

 

[VentMonkey]

several questions

1. how much was the cost?

2. surely the dynamic lung cannot give you an accurate representation with anyone with a lung pathologies (in asthma not every part of the lung is as obstructed as the next so air is introduced unequaly in ppv)? im guessing it is just a visual representation of the tidal volume/PIP/inspiratory time together?

Cost per unit I couldn't tell you off hand; short answer? Not cheap. As far as the dynamic lung features. It adapts to the lung compliance, e.g., if the patient has ARDS it will represent as a "boxier" shape, vs. a "healthy" patient which looks more rounded. Here's a better breakdown @TXmed:

https://www.hamilton-medical.com/en...LTON-T1.html?gclid=COuC6Oew8NECFca4wAodamkDdg

 

[TXmed]

@VentMonkey wow impressive, i will remain skeptical till i try it myself, though very interesting thank you.

 

[VentMonkey]

@VentMonkey wow impressive, i will remain skeptical till i try it myself, though very interesting thank you.

NP, I've found skepticism can often be the
mark of an open-minded person; I remain the same with many things myself.

It's a fairly new concept in The States, and definitely reflects how far we've come in regards to ventilatory management.

 

[Nova1300]

Ummmmm, what in the hell is going on in this thread?

And who wrote this kid's physiology textbook?