Really bad day - page 2

by Zaphod 3,363 Views | 15 Comments

Hi, guys-need some TLC Ive been precepting in an open heart unit and have had few hearts. Enough to get my confidence up I guess. yesterday I had a triple bypass with aortic valve replacement. He came on temp pacer fully... Read More


  1. 1
    sounds like a sensing problem. Did you do a wave review? With repsect to increasing the rate, it can help your pressure depending on your patient. Remember Starling's Law.............
    what was your ionized Ca++? Any chance of Hypoxia? Hypotension and Hypoxia are the two things that lead to arrest. As a long time OHRR nurse, the environment is stressful and you will never know everything. Hang in there......It is a tough place to work and we need you!
    Zaphod likes this.
  2. 1
    yeah don't beat yourself up too bad, it happens, and it's bound to happen. Our patients are extremely sick. We don't always find an answer as to why they do things. I had a patient code on me with no warning... I remember really beating myself up over it and trying to ask a million questions to figure out what had happened, but to no avail. Family decided not to do an autopsy so we'll never know. In retrospect, it was most likely hypotensive w/inadequate fluid resus, pt was on HD, vascular, only PICC access, and attending was unable to get a large central line in. But, the family had already accepted the fact that she was sick, so they withdrew after an hour. Like I said, our patients are sick and we won't always get all the answers.
    Zaphod likes this.
  3. 0
    Leaning towards just bad timing IMO. With regards to the variance between pausing the pacer vs. slow decrease in rate to see what the underlying rhythm, I have seen a difference in the hearts being "more able to tolerate" a gradual transition vs. abrupt (with pause). Having the time... well, thats a whole different ball of wax.

    Sounds like there was a lot of issues just below the surface that lead towards the compromise of this patient. Acidosis, O2 comsumption (both myocardial and systemic), grafted RCA.... Heck, the increased irritability of the pacemaker site alone with an RCA bypass alone ups the ante for bad events to happen. Pt. probably has a poor EF / cardiomeg, add stunned vent just with the surgery alone. Pts with a high grade AS are fluky until they get their CVP up as a general rule, but it's a fine line between maintaining a functional CVP vs. fluid overload (Starlings Law), add multiple inotropes, electrolye imbalance, H&H... metabolic acidosis refractory to poor organ perfusion... ohhh such fun.

    Thats one of the biggest reasons why I like OHS pts. It's the thinking behind your actions....
  4. 0
    Agree 100%. Tricky open hearts are my favorite patients. IMO theres not really any other challenge like it in nursing. You can get sick patients that are going to die in any ICU, but a sick open heart who may be experiencing ANY type of shock imaginable at any given time, just makes them #1 in my book.
  5. 1
    As an update. Patient experienced right sided heart failure(hence the high CVP), had an emergency IABP placed that night, avoided CRRT by a hair. And the best thing is he transferred to tele yesterday. Go, OH team. I was soo glad to see him survive.
    resumecpr likes this.
  6. 2
    Was your patient pacing in DOO, or ASYNCHRONOUS? This would be my bet for the cause of the patient's arrest, given that you said the patient had no underlying rhythm. I never, ever trust that the patient has _NO_ rhythm at all under the pacer, and so I switch them generally over to an inhibit mode of pacing, either DDD, AAI, or VVI if they come out in DOO. Even if your patient had no rhythm coming off pump in the OR, that does not mean that they will forever have nothing under there. In fact, quite the opposite, they will likely regain a rhythm at some point. DOO is really only good for either an extremely controlled environment (like the OR, with pump standing by), or an emergency when you can't get a pulse otherwise.

    As I'm sure you know, the danger with asynchronous pacing is having a the pacemaker trigger another beat during ventricular repolarization (R on T phenomenon) which can cause Vfib/Vtach arrests. Since it happened right when the other nurse adjusted his rate, that is my guess as to what happened. Do you remember the pacing mode being used?
    MoLee228 and Zaphod like this.


Top