what ever the indication of intubating a metabolic acidosis patient the main aim of ventilation is to maintain their hyperventilatory state on ventilator, i.e (Pre ventilation level paCO2)

WE SHOULD NOT DO MORE HARM BY ADDING RESPIRATORY ACIDOSIS COMPONENT TO ALREADY EXISTING METABOLIC ACIDOSIS BY OUR DEFECTIVE VENTILATION.

PARALYSING AND DOING A USUAL VENTILATION PLAN (RR 12/MIN) WILL RESULT IN RESP ACIDOSIS, BECAUSE THEY NEED VERY HIGH MINUTE VOLUME.

SO NOW PREVIOUS METABOLIC ACIDOSIS + RESPIRATORY ACIDOSIS BY USULAL VENTILATORY PLAN (SIMV MODE WITH RESPIRATORY RATE OF 12/MIN WILL RESULT IN PROFOUND ACIDOSIS AND SUDDEN CRASHING OF THE PATIENT **

HERE IS PROPOSED PLAN

** Intubation is a challenge as well, because they are at one end of sympathetic drive .

1. pre ox to get max saturation possible. (high flow O2 preferably with a CPAP mask/non rebreather mask is also acceptable)

2. Here is an new suggestion KETOFOL for induction . (mixture of ketamine + propofol 50mg:50mg) + sux

3. RSI with or without CRIC

4.Count RR prior to intubation and ventilate at the near same rate till patient comes out of relaxant to trigger the ventilator( blood gas prior and after to know paco2)

5.A/C mode 6 to 8 ml (ARDSNET style -RR 18 to 30/min ) Aim -PRE and POST BGA Paco2 should be same) A/C mode will take over all the rates what ever the acidotic body needs. A/C mode has least work of breathing. A/C mode will support all the breaths which patient will initiate. so go for A/C mode to start if you are not planning to pull the tube out immidiately.this is the best choice in my opinion.

WHAT NEXT?

a. Revert back spontaneous as soon as possible after the relaxant wear off . (ventilate with peep and fio2 to maintain saturation above 92%)

b. Maintain the aim of not adding respiratory acidosis to metabolic acidosis .

c. Doing this you just buy time but dont forget to treat the pathology which is the main issue

Finally A/C MODE A/C MODE A/C MODE