There is an unfortunate human tendency to reach for the sparkly and interesting rather than sticking with the mundane tried and tested. We start from the premise that STANDARDISED care GOOD care. We can then elicit response(s) and reduce the influence of potential iatrogenic confounders - ThreadSky

benmorton.bsky.social • 101 days ago

There is an unfortunate human tendency to reach for the sparkly and interesting rather than sticking with the mundane tried and tested.

We start from the premise that STANDARDISED care GOOD care. We can then elicit response(s) and reduce the influence of potential iatrogenic confounders

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megaholt.medsky.social•100 days ago

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benmorton.bsky.social•101 days ago

So what should we do if a ventilated patient is severely hypoxic?

I'm not going to cover on emergency assessment and management in this thread, but instead focus on the patient who remains hypoxic after stabilisation measures have been instituted

First, we need to pick our SpO2 target...

megaholt.medsky.social•100 days ago

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benmorton.bsky.social•101 days ago

I've previously outlined my approach and how this might change as new evidence emerges:

https://bsky.app/profile/benmorton.bsky.social/post/3layxcpzgz22x

megaholt.medsky.social•100 days ago

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benmorton.bsky.social•101 days ago

The focus of this rant is not on treating the underlying cause, but on mitigation of iatrogenic harm.

Firstly we explore the ARDSnet ventilation strategy:

https://litfl.com/ardsnet-ventilation-strategy/

We use ulnar length, age and sex to set tidal volume. There's different ways to do this, key thing is to standardise

megaholt.medsky.social•100 days ago

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benmorton.bsky.social•101 days ago

Culturally, permissive hypercapnia and high PEEP (particularly at high FiO2) is sometimes still a bit of a challenge.

We talk about this and how to approach with multidisciplinary staff who may be less experienced or anxious about deviations from usual standard parameters.

megaholt.medsky.social•100 days ago

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benmorton.bsky.social•101 days ago

So, we've used these approaches and the patient is still dangerously hypoxic, what should we do next?

We discuss the ACURASYS trial

https://www.thebottomline.org.uk/summaries/icm/acurasys/

megaholt.medsky.social•100 days ago

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benmorton.bsky.social•101 days ago

What about pronation?

We discuss the PROSEVA trial

https://www.thebottomline.org.uk/summaries/icm/proseva-study-group-prone-positioning-in-severe-acute-respiratory-distress-syndrome/

georgeclews.bsky.social•101 days ago

I’ve definitely seen people use APRV as a panacea for hypoxia without doing the usual ARDS Net regime (and sometimes used inappropriately in the wrong patient group). Culturally, people are more concerned about high PEEP than they are about APRV.

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