Respiratory and metabolic management in acute tetraplegia.

Abstract

The management of the respiratory problems of acute traumatic tetraplegia has been discussed in previous papers. This paper presents a modification and extension of the same subject and, in addition, attempts to correlate the respiratory and metabolic facets of management into a pattern of treatment which will maintain adequate alveolar ventilation and nutrition and a normal fluid and electrolyte balance.The maintenance of adequate alveolar ventilation may be threatened by:(1) increasing paralysis of the muscles of respiration;(2) the supervention of either pulmonary consolidation or collapse. These complications are related to the aspiration of vomitus, the inability to deliver sputum to the mouth, and the inspissation of sputum;(3) pulmonary oedema, due to over-hydration of the patient.Arising from a knowledge of these potential complications, a respiratory regime is presented, which includes the timely use of tracheostomy and intermittent positive pressure respiration. In the management of a patient with a tracheostomy, the importance of the humidification of the inspired air, and frequent and adequate bronchial suction is stressed.The effect of body temperature or the oxygen requirements of the tetraplegic patient is also discussed, and the suggestion is made that there may be advantages in nursing such a patient at 34 to 35°C.The patient with acute traumatic tetraplegia may show one or more of a number of disturbances of function, each of which may stress homeostatic mechanisms for fluid and electrolyte. In particular, shock, paralytic ileus, vomiting and acute renal failure are common and gastric aspiration and intravenous infusion are almost always required. Among the more common disturbances of fluid, electrolyte and acid-base balance which must be prevented are:(1) Respiratory acidosis.(2) Alkalosis associated with loss of gastric hydrochloric acid.(3) Acidosis associated with loss of small intestinal secretions. This loss may be external or into dilated gut.(4) Acidosis associated with starvation—this may be made worse by coexisting hypoventilation or acute renal failure.(5) Hypokalaemia.The final pattern which may require correction by intravenous therapy could be the resultant of any combination or all of these disturbances. The principles of intravenous therapy are discussed.