Category: Respiratory

Methaemoglobinaemia

Q: Why are Smurf’s Blue? 

A: Methaemoglobin (MetHb) of course!

MetHb is produced by oxidisation of the Iron in Haemoglobin (Hb) from Fe2+ to Fe3+

Fe3+ prevents Hb carrying oxygen (thus produces symptoms of hypoxia)

Often due to chemical ingestion, but may also be genetic

Treated with Methyl Blue & supportive measures

Read more

COVID-19 (Which Covid Test)

Once the “Decision to Admit” has been made, an appropriate Covid-19 Test will need to be performed

  1. Select the appropriate patient group below
  2. Perform Test
  3. Clearly document which test was performed

Suspected Covid-19 Positive Patient

Patients with Covid-19 symptoms should have 2 swabs taken immediately

  1. PCR Testing – sent to lab
  2. Lateral Flow Devices – in ED for result after 30mins.

Record result on EPR as “Covid-19 Antigen Lateral Flow – POCT”

Patients Admitted To: Stroke (HASU), Paeds (HDU) OR Requires “URGENT” Result

Any patients identified by site commander as needing urgent result for flow reasons

(This also includes direct ward admissions to gastro and oncology)

  • Test swabs on ROCHE LIAT machine (performed by)
    • Site Commander
    • Night Matron
    • Stroke nurses
  • In ED prior to transfer – Results are in 90mins.

Record result on EPR as “Covid-19 RNA PCR – POCT”

NO Covid-19 Symptoms Present

A swab MUST be taken and sent to the lab for PCR testing.

Patient does not wait in ED for result.

CPAP Set-Up

NIPPV 3 machines are used throughout the trust to deliver NIV and CPAP – and should be commenced in ED if transfer to ward/ICU is adding significant delay

  • NIV/CPAP  is an Aerosol Generating Proceedure (AGP)
    • Staff must wear full APG PPE
    • In Side room with a door
    • Door Marked with APG sign – HERE
  • CPAP/EPAP levels of 8-15cmH2O

This video demonstrates how to set up CPAP on the NIPPV 3

 

Covid-19 (4C Mortality Score)

The 4C mortality score has been developed by ISARIC[BMJ], based on 35.463 UK Covid-19 patients.

If cases climb prognostication may become more important and this appears to be a good tool developed on a UK population.

4C Mortality Score tool – Click HERE

Factors:

  • Age: <50(0), 50-59(2), 60-69(4), 70-79(6), ≥80(7)
  • Sex: Female(0), Male(1)
  • Comorbidities*: None(0), 1(1), ≥2(2)
  • Respiratory Rate: <20(0), 20-29(1), ≥30(2)
  • Oxygen Saturations (Air): ≥92(0), <92(2)
  • GCS: 15(0), <15(2)
  • Urea: ≤7(0), 7-14(1), >14(3)
  • CRP: <50(0), 50-99(1), ≥100(2)

*Comorbidities inc:  Chronic cardiac disease; chronic respiratory disease (excluding asthma); chronic renal disease (estimated glomerular filtration rate ≤30); mild-to-severe liver disease; dementia; chronic neurological conditions; connective tissue disease; diabetes mellitus (diet, tablet or insulin-controlled); HIV/AIDS; malignancy; clinician-defined obesity.

 

Risk Score (sum of the factor scores)

  • Low 0-3: 1.2% mortality
  • Intermediate 4-8: 9.9% mortality
  • High 9-14: 31.4% mortality
  • Very High ≥15: 61.5% mortality

4C Mortality Score tool – Click HERE

 

Trust Dalteparin dosing

Trust Guidance varies slightly from BNF for those patients over 100kg

Non-Pregnant PE/DVT treatment

Dalteparin Cr Clearance >29ml/minDalteparin Cr Clearance 20-29ml/min
Weight (kg)DoseWeight (kg)Dose
<45kg7,500 units OD<63kg5,000 units am
2,500 units pm
45-56kg10,000 units OD63-80kg5,000 units BD
57-68kg12,500 units OD81-98kg7,500 units am
5,000 units pm
69-82kg15,000 units OD99-116kg7,500 units BD
83-100kg18,000 units OD117-134kg10,000 units am
7,500 units pm
101-115kg10,000 units BD135-152kg10,000 units BD
116-140kg12,500 units BD
>140kg15,000 units BD

Pregnant PE/DVT treatment

Weight (kg)Dose
<50kg10,000 units OD
50-69kg12,500 units OD
70-79kg15,000 units OD
80-89kg18,000 units OD
90-109kg20,000 units OD
110-124kg22,500 units OD
125-139kg12,500 units BD
140-154kg15,000 units am
12,500 units pm
155-169kg15,000 units BD

Covid-19 (dexamethasone)

You may have seen in the news early results from the RECOVERY trial.

In Covid-19 patients requiring either Oxygen or Intubation, dexamethasone has been shown to reduce mortality.

  • Oxygen – 20% reduction in mortality
  • Intubation – 35% reduction in mortality
  • No respiratory support required – No benefit found

Inclusion: Covid-19 patient requiring oxygen or intubation

Medication: (RECOVERY study protocol)

  • Dexamethasone administered as an oral (liquid or tablets) or intravenous preparation 6 mg once daily for 10 days.
  • In pregnancy or breastfeeding women, prednisolone 40 mg administered by mouth (or intravenous hydrocortisone 80 mg twice daily) should be used instead of dexamethasone.

Post Dex Glucose monitoring:

  • Glucose should be checked every 6hrs (ideally fasted i.e. before meal)
  • If Glucose ≥12, follow the chart below either guided by their normal Total Daily Dose (TDD) of insulin, or weight if insulin nave, or unknown.
  • Full protocol – HERE