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Old 12-25-2013, 02:43 AM   #1
Jtreon
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DNR - NO Artificial Ventilation and the use of a BVM?


So here is my situation and wanted to get people's opinion on a situation I encountered. I ran a call with a patient with respiratory distress and a valid DNR. In route to the ER I had the pt on oxygen @ 6 LPM via nasal cannula and on top of that I was switching back and forth between giving A&A treatments with a misty Nebulizer and a NRB @ 15 LPM. This way the pt was never with out oxygen. My QA/QI department told me that I should have used a BVM to get a better seal and higher oxygen saturation, and I told them I do not feel comfortable using a BVM on a patient with a DNR due to the "NO Artificial Ventilations". Even if I do not squeeze that bag and ventilate the pt does not mean that everyone else would question if I did ventilate the patient! So I guess my question for the masses is what is your thoughts on this, do you feel comfortable putting your self in question, am I wrong about not using a BVM, am I not understanding the DNR correctly? Even legal views on what to and not to do as of CYA type of thing, remember I work in Texas if that changes any legal standings...


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Old 12-25-2013, 03:36 AM   #2
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So they wanted you to place the mask on their face, but do not ventilate them?

If your that far down the hill.. why not CPAP?
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Old 12-25-2013, 03:50 AM   #3
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So they wanted you to place the mask on their face, but do not ventilate them?

If your that far down the hill.. why not CPAP?
I would have considered CPAP as well in this situation I think.
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Old 12-25-2013, 04:02 AM   #4
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My thought was giving medications to open up the airway only switched to NRB to increase Oxygen%
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Old 12-25-2013, 04:19 AM   #5
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I grasp your concept. but if your giving meds to open the airway up some, assuming your giving albuterol, and the first treatment was unsuccessuful patient saturations are still in the toilet, and you moved up to the NRB, keep going to improve saturations. CPAP in line albuterol is your friend.

Solumedrol and Decadron can be your friends but they take forever to work.

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Old 12-25-2013, 04:56 AM   #6
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I grasp your concept. but if your giving meds to open the airway up some, assuming your giving albuterol, and the first treatment was unsuccessuful patient saturations are still in the toilet, and you moved up to the NRB, keep going to improve saturations. CPAP in line albuterol is your friend.

Solumedrol and Decadron can be your friends but they take forever to work.
I actually gave an inline neb tonight. Worked wonders.
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Old 12-25-2013, 05:18 AM   #7
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I actually gave an inline neb tonight. Worked wonders.
I did a code, a Lethargy call which i think was a accidental beta blocker OD since her heart rate was in the low 40's. and she said she screws up her meds all the time. And some dudes varicose vein decided to rupture and squirt like ol faitful. Not a bad night. But the SNF hates when I get a release on Codes.
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Old 12-25-2013, 05:21 PM   #8
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Originally Posted by Jtreon View Post
So here is my situation and wanted to get people's opinion on a situation I encountered. I ran a call with a patient with respiratory distress and a valid DNR. In route to the ER I had the pt on oxygen @ 6 LPM via nasal cannula and on top of that I was switching back and forth between giving A&A treatments with a misty Nebulizer and a NRB @ 15 LPM. This way the pt was never with out oxygen. My QA/QI department told me that I should have used a BVM to get a better seal and higher oxygen saturation, and I told them I do not feel comfortable using a BVM on a patient with a DNR due to the "NO Artificial Ventilations". Even if I do not squeeze that bag and ventilate the pt does not mean that everyone else would question if I did ventilate the patient! So I guess my question for the masses is what is your thoughts on this, do you feel comfortable putting your self in question, am I wrong about not using a BVM, am I not understanding the DNR correctly? Even legal views on what to and not to do as of CYA type of thing, remember I work in Texas if that changes any legal standings...
That's a situation where CPAP (if available) with in-line nebs should work well. Using the mask part of the BVM would work, but I see issues with maintaining a seal while also allowing for the neb to work OR the oxygen to continue flowing and allowing YOU the ability to continue assessing the patient's status.

If you don't have access to CPAP, you then should do what you did: Non-rebreather mask with nebs. The DNR does limit the interventions that you can use unless the patient rescinds the DNR.

That's my 2 bits!
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Old 12-25-2013, 06:00 PM   #9
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If a DNR precluding artificial ventilation is in force, any measure creating positive pressure of viable gasses (O2, room air) would be precluded.
A passive mask or cannula dependent upon the pt having independent respirations would not.
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Old 12-25-2013, 06:10 PM   #10
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Originally Posted by Jtreon View Post
So here is my situation and wanted to get people's opinion on a situation I encountered. I ran a call with a patient with respiratory distress and a valid DNR. In route to the ER I had the pt on oxygen @ 6 LPM via nasal cannula and on top of that I was switching back and forth between giving A&A treatments with a misty Nebulizer and a NRB @ 15 LPM. This way the pt was never with out oxygen. My QA/QI department told me that I should have used a BVM to get a better seal and higher oxygen saturation, and I told them I do not feel comfortable using a BVM on a patient with a DNR due to the "NO Artificial Ventilations". Even if I do not squeeze that bag and ventilate the pt does not mean that everyone else would question if I did ventilate the patient! So I guess my question for the masses is what is your thoughts on this, do you feel comfortable putting your self in question, am I wrong about not using a BVM, am I not understanding the DNR correctly? Even legal views on what to and not to do as of CYA type of thing, remember I work in Texas if that changes any legal standings...
Well, NOT using the BVM that still got your actions questioned, didn't it? People will ALWAYS be able to question why you did or didn't do something. In that regard, you are damned if you do and damned if you don't. So you might as well just do what is right and worry about the explanations later.

As long as you do what is right for the patient and document your actions and the rationale for your actions, you are good to go. That doesn't mean you'll never be questioned, it means you will have done the best you can do to both care for your patient and defend your actions later, if need be.


FWIW, I seriously question whether any clinically significant benefit is offered by a BVM vs. a NRB anyway. I know a BVM with a good seal can theoretically deliver 90% 02 vs. the 70% (maybe 80% on a good day) you might get with a NRB, but that 90% is best case scenario, meaning you consistently maintain a great seal and have no room air entrainment. Realistically I don't see anyone maintaining a perfect seal consistently throughout transport - especially when you are giving nebs, etc. So a NRB makes much more sense to me. Now if you are preoxygenating prior to an intubation attempt it makes sense to use a BVM, because you are motionless and you need to have the BVM out anyway. But during transport I don't think you are likely to be able to maintain the kind of seal you need to reap the added Fi02 available from the BVM.
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