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?