Pt is a 63yo male with a hx of a subarachnoid hemorrhage 30 yrs ago s/p clipping. Pt present early in June with a new Sah, from the same aneurysm. Pt was re clipped on the 16th, stayed intubated for a day or two and was successfully Extubated. Complicated by dvts s/p ivc filter and on prophylaxis heparin tid. Un able to be fully anticoagulated secondary to the Sah.
Pt was aox3, MAE and sent to the floor on the 19th. During therapy on the next day, pt became unresponsive. 4-5 rounds of acls were given and rosc was achieved. Pt TX to icu and again became pusleless 3 more rounds of acls as well as dopa and norepi infusions regained rosc.
Needle decompression of the right side was obtained, followed by chest tube placement. A swan was floated and artic sun was initiated, and nitric was added. Pt now on Vaso, norepi, dopa, milrinone and epi. A heparin gtt was initiated for presumed pe, and head ct was negative for bleed. Over night pt 'stabalized' and was weaned to 10 of norepi and Vaso. Vent settings are 28 by 650, . 40 percent with an abg showing 7.38, 40, 120. Pa pressures are mid 40s/20s. Co equals 3, Ci of about 1.5. Svo2 in the 50s
I come on shift the next am, and they want to take him to ir for mechanical retrieval. A long discussion was had, and the decision was made to take him. No impressive saddle pe, and a not very imposed right upper and middle lobe pe was retrieved. Pa pressures didn't change and his oxygenation and ventilation actually go worse. As well as his hemodynamics. Pt now on 28/ 700 and 80 percent with a gas of 7.29, 42, 86. Also, on Vaso milrinone norepi and epi. Pa pressures and Ci. Co are the same, svo2 now in the low 40s. 1 unit of blood is given with no response to svo2. Urine out put is 20-30mls, cr is normal. Trop is normal, echo shows a kinetic right sided heart.
Question is, why did we take him to ir when he was doing so much better?
Jun 23, '13
Why did the patient need a needle decompression of the right chest and CT insertion? ( i mean I know why.....but how did this occur) was it from trauma from CPR? what underlying pathology.
The decision to take him to international radiology would be based on many factors which are impossible to say without seeing the chart. I would assume it was made because he can't be anti-coagulated effectively, he was not a candidate for thrombolytics due to the bleed and he had already coded from a probable PE.
Something needed to be done.
Jun 25, '13
The needle decompression. That's a great question. I'm guessing, since he was pusleless and kept losing his pulse? I just heard the attending say, he needs to be decompressed. And he had a central line placed emergently on that side.??
Aug 19, '13
On another note.. Holy cow you guys use high tidal volumes on the vent!
Aug 19, '13
The guy was well over a 100kg...
Aug 21, '13
It's hard to say....I think I would wonder the same thing. His SvO2 was 50 the day before...not fantastic so maybe an early indicator that he was going to get worse regardless of whether or not you took him to IR. I'd imagine all his body systems were under stress after the arrest.
On a side note, I know what you are getting at. It seems that sometimes we (aka the doctors) get a little too excited and do things that don't make sense and possibly result in patient compromise. A few weeks ago, my unit had a multi-system trauma on the Rotoprone bed. His sats were in the 70-80s even prone. He had only been on the bed for a day. The docs talked to the family and we emergently transferred him (yes prone) to the CVICU for Ecmo. They had to supine him to insert the large catheter for Ecmo and he dropped his sats, coded, and died while they were working on it. When we found out about it, we were shocked. Clearly they knew they were going to have to supine him for the line. What was the rush? We've seen many people suck on the Rotoprone and then make a turn in a few days. He hadn't been on the bed that long and he wasn't getting any worse. How many ppl live with sats in the 80s? It just seemed like a gamble and an unnecessary rush.
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