Really bad day

[Zaphod]

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 paced-no underlying rhythm-complete heart block. Well he was very sluggish and difficult to keep pressures up, and his preloads were high due to his incompetent right ventricle(TEE showed).A nurse-not my preceptor, came by and said that if we upped the heart rate we might get better outputs and started to increase the rate 80 to 90. Immediately he went into VTach-Vfib. Had to shock twice, drugs, fluids wide open, pressures now in 300's then 80's, high preload, hh down 2 points but no tamponade or serious bleed.

I guess I am just replaying in my mind what happened or what I missed(many things for sure). I am questioning if she inadvertently hit pause as she had some problems unlocking the pacer, did he get too much fluids?Surgeon asked for a lot of fluids and milrinone/epi. I am exhausted and not even sure that Ill survive this specialty.

[HyperTension]

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.... :)

[aCRNAhopeful]

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.

[Zaphod, BSN, RN]

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.

[3ccBolus]

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?