Really bad day | allnurses

Really bad day

  1. 0 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.
  2. Visit  Zaphod profile page

    About Zaphod

    Zaphod has '4' year(s) of experience and specializes in 'ICU-CCRN, CVICU, SRNA'. From 'Miami'; Joined Jun '10; Posts: 188; Likes: 168.

    15 Comments so far...

  3. Visit  aCRNAhopeful profile page
    1
    Sounds like a similar circumstance I've seen in the past. Did they graft the RCA? I'm asking because with an AVR the surgeon can accidentally comprimise the ostium of the RCA and cause inferior wall/rv injury. That would explain the 3rd degree HB too.
    Zaphod likes this.
  4. Visit  Zaphod profile page
    1
    yes he did.
    RCA/LAD and OM were grafted. I just dont understand why as soon as she touched the pacer-icreased by few beats he went in to VTach-Is it a coincidence?She is really beating herself up and I feel pretty bad as well. Oh, and something else is that he swung from resp.alkalosis to metabolic acidosis within 3 hours. CV patients are such puzzles.
    thank you so much aCRNA hopeful-you have been a wealth of info
    Last edit by Zaphod on Oct 26, '10
    fiveofpeep likes this.
  5. Visit  aCRNAhopeful profile page
    0
    Well if she was turning up the rate there may be a slight chance that it pacer-spiked on the wrong part of a t wave. That shouldnt happen if the temp pacer senses appropriately but as we all have seen they often don't. Now, awhile back I was reading over a printed version of a power point presentation about our temp pacer it said that the right way to check an underlying rhythm was to slowly turn down the pacer rate until the intrinsic rhythm overrides the pacer rate and said NOT to pause the pacemaker. It showed a slide of someone pausing the pacemaker and then the person going into vtach->vfib. However that makes ZERO sense to me as to why that would happen. Anyone know?? Either way, no one should beat themselves up about it. Just try to figure out if theres anything you would do differently next time and learn. In this case, sounds like there really was no explanation and it was probably just a sick heart.
  6. Visit  Zaphod profile page
    0
    It is my understanding that you should never pause the pacer as some people are completely dependent on it. This person had no rhythm whatsoever when we slowly turned down the pacer on admision. Thank you for your insight. It is definetely a good lesson for me.
  7. Visit  Jenn329 profile page
    0
    Oh wow that must have been terrifying

    I'm a new grad in an open heart unit. I bet we can swap stories and information.
  8. Visit  helen willing profile page
    2
    Not following your collegues reasoning. Turning up rate would give the ventricle less time to fill, decreasing output thereby reducing blood pressure. In a sick heart this could add addition stress on the organ. Maybe leading to the situation you describe. Anyone else agree?
    SilentfadesRPA and chiuli like this.
  9. Visit  aCRNAhopeful profile page
    0
    She was talking about the cardiac output. No it wouldnt help blood pressure but it should help CO/CI. I really don't think going from 80 to 90 would be such an increase in rate to negatively affect ventricular filling but I couldnt say that I'm for sure. I suppose it would depend on a number of factors (EF, compliance, etc.)
  10. Visit  Zookeeper3 profile page
    1
    heart rate X's stroke volume = cardiac output (the surgeon was already giving additional fluids and on primacor.

    So it's a pump issue (hence primacore)
    Volume issue (more fluids ordered)

    I would have utilized a rate increase as well. If I was worried about myocardial O2 consumption, a SVo2 reading could be done after shooting another hemodynamic set of numbers.

    Its chicken soup- there are many varieties of it. that's why I love the ICU cook book
    resumecpr likes this.
  11. Visit  aCRNAhopeful profile page
    1
    Quote from Zookeeper3
    heart rate X's stroke volume = cardiac output (the surgeon was already giving additional fluids and on primacor.

    So it's a pump issue (hence primacore)
    Volume issue (more fluids ordered)

    I would have utilized a rate increase as well. If I was worried about myocardial O2 consumption, a SVo2 reading could be done after shooting another hemodynamic set of numbers.

    Its chicken soup- there are many varieties of it. that's why I love the ICU cook book
    Good response. I would challenge one point though, and maybe I'm misunderstanding you. I don't believe that SvO2 can be used to evaluate myocardial O2 consumption. SvO2 is used to determine oxygen consumption from the body as a whole. Giving inotropes should increase your SvO2 as it should increase CO and O2 delivery. Myocardial O2 consumption may be dangerously high while your SvO2 looks great.
    catshowlady likes this.
  12. Visit  Spode profile page
    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.
  13. Visit  IHeartDukeCTICU profile page
    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.
  14. Visit  HyperTension profile page
    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....


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