everyone this video is going to start a new series of ours focusing on the uh diagnosis and management of post-operative complications and as you'll probably see from the name here talking about hypoxia as opposed to some sort of specific complication like a pe or pneumonia we're trying to really present these complications the way that would show up in the actual hospital and so what med students or what medical school really prepares as well for is getting all the data at once and then answering a url question correctly to do a diagnosis and unfortunately in the real world you're operating on limited data right you don't get a page that says doctor your patient has pneumonia what do you want to do you get a page uh your patient is hypoxic what do you want to do and so how do we systematically move from this kind of gray unknown area where we still need to do something because the patient is hypoxic and we can't just let their brain be started of oxygen for a long period of time but on the other hand we don't actually have a definitive diagnosis to give definitive treatment for so how do we temporize this acute issue uh and then systematically work towards the diagnosis while keeping the patient safe so an example page here uh maybe your patient's been fine postop up until this point and all of a sudden they're requiring six liters of nasal cannula and so like i said the med school way to think about this is oh what's the differential i have to know the differential before i act but that's actually usually not how the art and science of medicine works in real practice so when i get this page actually differential is moved down here towards the bottom actually the first thing i'm thinking about especially in something really acute like hypoxia here or maybe something like hypotension is we've got to think about the immediate treatment and if they're not oxygenating well enough on their current treatment we're going to have to bump that up despite not knowing the underlying diagnosis because this is just such an acute issue while i'm thinking about what treatment the patient needs i'm also thinking about that basic workup and if something's acute i don't want that workup to take forever so usually while i'm walking up to see this patient i'm going to put a few things in the emr that i know i'm going to want every time and that way the labs can get drawn the text with maybe the chest x-ray i can get up to the floor and take that image or i want those things to be in motion before i even start walking up to see the patient finally and usually related to your treatment is the level of care and we're going to talk about that spectrum but all places in the hospital are not equal and whether we're talking about the general care floor or the icu different treatments are available in different places and different uh patient clinical scenarios depending on their stability they belong in different places of the hospital so that's where that's what we're thinking about when it comes to the level of care then finally once all these things are settled we can really go back to that differential usually by this time some of our workups coming back we can start putting the pieces together and thinking really hard about what the differential is and that will lead us to our definitive therapy but like i've said before we can't wait for definitive therapy we don't have all the time in the world especially in some of these really acute issues so going to treatments first before i talk about these i want to just briefly review respiratory failure so as you should recall from i don't know your palm lectures or something like that there's two modes of respiration or two kind of main functions there's oxygenation and there's ventilation so oxygenation obviously deals with oxygen ventilation deals with the clearance of carbon dioxide and so you know from the page that your patient's having an issue with oxygenation but what you don't know is if they're having a trouble with ventilation so that's going to be part of what we're thinking about with our treatment as well so it'll come up later so now going to our treatments this is ordered like everything i think about there's a spectrum so there's least intensive oxygen therapy at the top and most intensive at the bottom so nasal cannula that's just a nasal prong goes in the nose delivers a relatively little amount of oxygen sometimes you want to step that up maybe they're a mouth breather an oxymask is essentially the same thing but the oxygen is delivered through a plastic mask that covers the mouth and nose instead of just going into the nose and then after that we start to think about types of oxygenation support that provide positive pressure so you see specifically down here this ppv stands for positive pressure ventilation that's cpap and bipap those are typically full face masks that go over the mouth and nose and cpap provides a continuous positive pressure or peep p e e p positive and expiratory pressure uh whereas the bypass by four two provides two levels one level for inspiration and one level for expiration if we think back to that oxygen versus co2 spectrum we were talking about the cpap is good for oxygenation while the bipap gives oxygenation in addition to co2 clearance and then right here in the middle i didn't talk about this one first because it's a bit of a hybrid so high flow nasal cannula uh it's getting a little messy uh nasal cannula is just like nasal cannula up here it's two prongs that go in the nose but this one is supercharged it's got the hf which stands for high flow and so you can give a lot more flow you can get more oxygenation support than with just normal nasal cannula or oxygen mask and you can get a little bit of that positive end expiratory pressure depending on who you actually have different numbers maybe around a peep of five obviously below high flow we talked about the positive pressure ventilation options already and then finally worst case scenario all these things are not working and you're thinking about calling anesthesia for an emergency intubation of your patient so pretty simple pretty straightforward but i find it's really good to just have this reviewed in your head and so if in the heat of the moment the room's stressed the patient's desating people are looking at you you know what do you want to do doc and you don't freeze you can just think very logically okay well they're failing nasal cannula or oxy mass maybe it's time to call respiratory and step them up to high flow maybe they're on high flow it's time to step up to bipap and uh if they're really struggling on that bypass and just not doing well you don't have to think about it you don't have to you know freeze or give it a ton of thought if they're failing you know your next step is going to be intubation and you can start putting the pieces in place for the right thing to happen without too much delay all right and now thinking about the workup so this like i said i actually like to order even before i go to see the patient if i have a patient then we're really worried about their respiratory status i always know i'm going to want a chest x-ray and it takes time for the text to get my order and get up there with the machine so i always want that in before i go up to see the patient i'm usually ordering a vbg uh once again thinking about those two modes of respiration the vbg is going to tell you about their ventilatory status so if i have somebody who's hypoxic and they're hypercarbic their co2 is really high then i'm definitely going to be choosing something like bipap as opposed to cpap if they're requiring that level of support all right and then moving on to level of care once again we have the spectrum of care so least intensive care and general care that's probably what you typically think of when you think of a hospital down here to the most intense being the intensive care unit or the icu most hospitals have a level of care in between that many places it's called the intermediate care or imc but your place might have different names for those specific units obviously people on general care they can be on room air they can be on things like nasal cannula oxymask and then depending on your institution usually when you start thinking about the more positive pressure strategies high flow cpap bipap things like that that aren't just for you know he wears the cpap at night type thing but for the acute treatment of hypoxia the patients are probably going to need to be in a higher level of care either the imc uh or the icu for something like that and of course intubated patients are almost always stepped all the way up into the icu and once again this isn't supposed to tell you all about these details just know that there's these multiple levels of hair get a sense of what they are at your hospital and then make sure you're thinking about that spectrum as well when you're talking about the acutely ill post-op patient all right now finally we can start thinking again about our differential so what's nice is we've dealt with all these acute issues we've started our initial treatment we've worked on getting our initial work up so these things now that they've been sent off usually we'll start coming back our chest x-ray our vbg maybe some other labs if i thought they were warranted at this time and our patient is at the appropriate level of care that they need and now we can go back and think about our differential hopefully your patient when you went and saw them was alert and oriented enough to talk to you so you are also thinking about the elements of your h p that will give you a ton of info as to what might be going on and really going to the differential itself is not the point of this video uh there's way too many things to cover we can't give you the amount of details about all of them uh a short list might be things like atelectasis pulmonary edema pneumonia bronchospasm pe pneumothorax opioid overdose i mean the list goes on and on and on and that's really uh where you apply that med school knowledge to the clinical situation in front of you but that what we've done to get us to this point has kept the room calm kept the patient safe and uh really allowed you to now put your full attention towards figuring out this difficult problem uh rather than being stressed about oh my gosh what should i do the patient's descending um you know a million things going through your head and then once you have your differential in mind now you can get that specific treatment maybe antibiotics maybe anticoagulation depending on what the underlying cause is but once again this is usually the last step and if something acutely goes wrong with your patient they get really hypoxia there's you know something a severe issue that needs your attention right away you're very very rarely going to have a uh final i should probably say diagnosis um to work with so hopefully this video helps you get there at least four post-op hypoxia this is not intended for clinical purposes this is for education only to not use this to diagnose or treat any diseases and we will see you next time