Cardiopulmonary Emergencies

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Brenda Shelton, who will be talking with us about any and all questions you have regarding cardiopulmonary emergencies. Welcome Brenda!

 sheltbr 

Hi all! Welcome and send your burning questions!

 sheltbr 

How about if some of you share where you work and what has interested you in attending this chat?

 otterlady 

Interested in high incident of SVCS (superior vena cava syndrome) with implanted ports

 sheltbr 

Good place to start. We have looked at incidence of clots and the value of heparinization of ports and there is not clear evidence to support this, but those of us who have seen port related SVCS wonder if it would help.

 otterlady 

Do most places place pts on 1 mg coumadin or an ASA if ports present?

 sheltbr 

Remember active malignancies, especially mucin producing tumors or brain tumors cause more severe hypercoagulability and these may be patients with higher incidence.

 otterlady 

...As prophylaxis

 sheltbr 

There are some who do this practice, but NCCN and other guidelines sources do not say there is adequate evidence to provide prophylaxis.

 sheltbr 

You can find this detail in NCCN VTE prevention guidelines

 otterlady 

Thanks. Do you see less incidence with different types of access devices?

 sheltbr 

Absolutely! Single lumen, smaller catheter size and groshong type ends have less. The port is a big reservoir, big line.

 juliewalker 

Maybe you could describe the range of symptoms beginning with most subtle that clinic nurses may see.

 sheltbr 

I am thinking by symptoms you are looking for SVCS... more coming

 juliewalker 

yes

 sheltbr 

Early obstruction of the SVC reduced return of blood to the right heart, so initially subtle right finger swelling, enlarged right brachial vein, arm ache, then more upper body edema, eye puffiness worst in early AM, high blood pressure.. more

 sheltbr 

Later symptoms can be due to obstruction into head/neck with right JVD, headache, sensory changes, airway impairment.

 jsmatthews 

Hello! I am interested in updating the most pressing assessment parameters on EKG and lytes in pericardial effusion

 juliewalker 

very helpful, thanks

 sheltbr 

Are many of you OPD nurses?

 juliewalker 

OPD?

 Laurl at ONS 

Out patient dept!

 sheltbr 

Re; Pericardial effusion. When it has been proven by echo cardiogram, the best subtle assessments are pulse difference (higher in upper extremities), muffled heart sounds, pulsus paradoxus. More..

 otterlady 

yes

 jsmatthews 

No, I'm an oncology nurse/clinical instructor teaching junior level/first year clinical

 juliewalker 

I am NP in outpatient neuro-onc

 sheltbr 

If I knew my patient had a pericardial effusion, I would check heart sounds, look for bilateral JVD and take a manual blood pressure (left arm preferred) to check for paradoxus. We may keep electrolytes up to reduce dysrhythmias, but not usual symptoms. I would also check periodic ECG- ST elevation across all leads or low voltage likely increased effusion

 sheltbr 

Lots of variety of practice stetting. Did I answer your effusion question? We also may look for troponin leak, and will get frequent echos, esp with changes in symptoms. Any other questions>?

 Laurl at ONS 

Is the pleurex catheter replacing chest tubes for management of pleural effusion?

 sheltbr 

I have found us using pleurex and sending home often when we previously place chest tubes.

 lkrioux 

Is it still standard practice to obtain baseline and serial MUGAs with cardiotoxic chem o drugs? And would an EKG be just as informative?

 sheltbr 

The pleurex catheter is like a large Hickman placed in pleural space and patients can drain themselves at home. Most of our docs do only in discharge candidates.

 sheltbr 

Re MUGA- the echo tells us ejection fraction without qualifying the contraction force. The MUGA tells contraction force and areas of wall motion abnormality that is "always present" or perfusion dependent". More

 otterlady 

I see some docs do echoes instead of Mugas

 lkrioux 

I'm sorry; I meant is an echo as effective as a MUGA to monitor cardiac function.

 sheltbr 

RE: MUGA: Meaning the MUGA involves baseline look at EF and wall motion and then nuclear injection distributes and you see if wall motion improves. It helps tell if EF is ischemia dependent. more

 sheltbr 

So.. if no potential heart disease, Echo should be ok, but with possible pre-existing heart disease, MUGA is more helpful. Does this help?

 lkrioux 

Yes, thank you.

 jsmatthews 

Yes, as the patient I asked about had preexist heart failure

 sheltbr 

Great question- I really did not realize this for awhile myself. More questions??

 lkrioux 

I have read that a carbon monoxide diffusion capacity measurement is the most sensitive way to monitor pulmonary function. Can you explain what that is?

 juliewalker 

Has anyone had experience with methemoglobinemia in patients on prohylactic dapsone?

 sheltbr 

RE: Carbon monoxide:- this is better known as DLCO and is sensitive to changes in alveolar structure and carbon dioxide diffusion. We use in Chronic GVHD and with pulmonary toxic meds like tarceva, amiodarone.

 juliewalker 

My patient had respiratory distress and chest pain…

 sheltbr 

RE: methemoglobinemia: I can answer, but do any of you want to share your experience with methemoglobinemia?

 juliewalker 

…then hemolytic anemia following meth blue administration.

 sheltbr 

Methemoglobinemia occurs due to metabolic pathway of drug breakdown. Occurs with dapsone, and triapine... some others but can't recall. More..

 juliewalker 

Common with G6PD deficit.

 sheltbr 

Met hemoglobin classically presents with hypoxemia, dyspnea, chest pain. The ABG may not always tell the tale. so need to check met hemoglobin levels.

 juliewalker 

We are considering checking CD4 counts before prophylaxing with Dapsone in patients at risk

 sheltbr 

Met hemoglobin occurs with carbon monoxide poisoning, and many heme disorders. Can be debilitating. Sometimes can treat with tincture of time and supportive resp support rather than methylene blue that does cause hemolytic anemia.

 sheltbr 

We monitor CD4 counts in all chronic steroid therapy (BMT and brain tumors, even met brain tumors) and give when CD4 lower than 100. Though, many BMT get bactrim instead

 juliewalker 

How much time does it generally take to resolve without meth blue?

 sheltbr 

It depends upon the level or clearance of drug causing- e.g. triapine we wait for chemo to clear over a day, dapsone has long half-life and if not severe, clear in two dayish, but severe we may wait only as long as sxms tolerable and treat if worsening.

 juliewalker 

great, thanks

 Laurl at ONS 

Why do some patients with superior vena cava syndrome, a vascular abnormality require mechanical ventilation?

 sheltbr 

The causes of SVCS are centrally located masses (nodes, tumors, clots) and if the obstruction and venous congestion is severe and protracted there is extreme edema in the upper chest and neck that then compromises the bronchi.

 sheltbr 

Have any of you seen severe and acute SVCS treated with grafts?

 sheltbr 

Or stents?

 marewiz 

yes, just a couple of weeks ago

 lkrioux 

If a patient had severe SVCS  but required IV therapy, would it be best to administer fluids/meds via peripheral site or central?

 sheltbr 

RE: grafts or stents, Was it successful maneuver?

 marewiz 

A patient had stents placed on one side and then the other a week later.

 marewiz 

Yes, the edema resolved unbelievably

 TeriNine 

Quick resolution?

 sheltbr 

Re IV fluids for SVCS- It is best to use lower extremities. We  like to use initial femoral line but not essential. If needed we use external jugular as it is less affected than subclavian or brachial.

 lkrioux 

thank you

 marewiz 

We had to transfer her to another facility but it was resolved prior to the transfer

 TeriNine 

Thanks

 sheltbr 

Stents and graphs are wonderful new adjuncts to therapy but require interventionalists to place. I think it reduces sense of urgency to treat with anything quick and reduces need for radiation in some tumors.

 TeriNine 

Of the two, do you think stents make more sense than grafts?

 lkrioux 

Is anyone locking their central lines with CathFlo to prevent catheter related DVT?

 sheltbr 

Re stents vs grafts- Stents are best short-term, but may "reclot" over time, so graphs for longer life expectancy and clot related.

 marewiz 

RE: locking lines:we used to do that when iI did dialysis 5 or 6 years ago and it seemed to work well

 TeriNine 

Thanks.

 marewiz 

cathflo I mean

 sheltbr 

We do not use cathflo for routine lock, only for treatment of line occlusion and only AFTER x-ray confirmation of placement. How about some of the rest of you?

 marewiz 

Not routinely, just for occlusions

 jsmatthews 

Same

 spooky6 

Hi, Can you talk about concerns for central VAD removal in pts w/ catheter related thrombus/dvt formation? Lovenox therapy is started, then outpt removal of PCC's/hickmans.

 marewiz 

great stuff

 TeriNine 

Just occlusions at my facility.

 sheltbr 

Re: locking lines/clots: I am not the expert of this at all. I know we routinely attempt to resolve, but when the clot extends to the vessel, there are standards for removal- I should ask Mikaela Olsen or Aiko Kadaira who are our key VAD/ PIC nurse coordinators. I can post on transcript

 Laurl at ONS 

Are there any immediate treatments for tracheobronchial obstruction we may implement while awaiting diagnostic tests or surgical consultation?

 sheltbr 

They used to call tracheobronchial obstruction the death sentence, but I would say not anymore. Immediate hypoxemia and stridor treated with bronchodilators and heliox.. more

 sheltbr 

Heliox is a combination of helium and oxygen and all EDs will have for child asthma pts. The helium is lighter than oxygen and carries it past obstruction. This buys time to treat with chemo, radiation or plan for endobronchial treatment. More

 sheltbr 

We do endobronchial brachytherapy or laser if the tumor is inside airways, if scattered studding, we may do photofrin, and if simple obstruction, stent. More.

 sheltbr 

Last week we had new SCLC (small cell lung cancer) pt 40 year old with mainstem occlusion and we did stent to bring up lung to maximize radiation effects- something I never thought about=a collapsed lung will be  less effectively treated with RT

 juliewalker 

great topics but gotta run. Thanks everyone

 sheltbr 

RE: obstructions: We also give big doses of steroids to open airways for obstruction and occasionally a "clean out bronch" if full of secretions.

 sheltbr 

Questions????

 TeriNine 

I am not quite clear on using insulin/dextrose in TLS

 TeriNine 

Can you briefly explain rationale?

 sheltbr 

Re TLS- when patients have severe TLS, the dying cells release high amts of potassium and phosphate. Insulin and glucose is one way to push potassium back into cells, but not best first measure. More

 jsmatthews 

Please clarify - big doses of steroids - dose/schedule?

 sheltbr 

RE: TLS: If potassium is high, may not be able to wait for kaexylate, but best first measure is bicarb 1 meq/ kg, then calcium gluconate 1 amp, then if still not effect, glucose 50% 1 amp, and insulin 10 units. They all change pH and metabolic state to cause potassium to go back in cells. More

 sheltbr 

Caution- potassium back to cells lasts only about 15-30 min and require retreatment or dioalysis, or ..... help!!

 TeriNine 

EOL patient is whom I have experienced using that method with. Husband refused kaexylate.

 sheltbr 

Steroids- sorry I lost my words here- answering

 sheltbr 

RE: Steroids: We start with bolus 20 mg dexamethasone, then 10-20 three- fours times a day for 1-2 days, then half, and slow reduce

 Laurl at ONS 

We have about 5 more minutes-please continue to ask your questions! Also, at the end of today’s chat, please take a moment to cut and paste this URL into your browser and take our very brief survey - we’d love to hear what you think of these chats! The URL is: http://research.zarca.com/k/RsTUTRsRYVsVXVSVsPsP . Thank you!

 jsmatthews 

OK, 10-20 tid x 2D , then taper. is what we do...... thanks so much, this is very helpful

 sheltbr 

Good!!

 marewiz 

nice being here thanks

 sabdulja 

hey Sheltbr, what is the Dexamethasone for?

 TeriNine 

Thanks- TLS q clear now. First chat. What a great tool!

 sabdulja 

I missed it

 sheltbr 

We were discussing decadron in relation to tracheobronchial obstruction acute management. There is also racemic epinephrine to spray in oropharynx for short-term fix in oropharyngeal masses

 Laurl at ONS 

The transcript to today's (and all) chats will be posted by tomorrow- you can get the full story on this topic then!

 sabdulja 

aha, ok great

 sabdulja 

thanks sheltbr

 Laurl at ONS 

Okay folks, it looks like it's time to end.! What a great chat- thanks for your participation.

 TeriNine 

Thanks sheltbr

 Laurl at ONS 

Please come to the last in the series: metabolic emergencies this Friday at 7am ET!

 sheltbr 

Thanks to everyone for attending and participating. I look forward to having some of you join me for my last chat this Friday.

 Laurl at ONS 

Have a great day, folks!