[sirI]

Originally Posted by Surgical Hrt RN

Siri,
I agree with your assessment 100%. An inotrope would have worked wonders for this patient. A little Dopamine or Dobutamine would have gone a long way. RV infarcts always need volume and inotropes, not to mention a good ole' fashioned swan!

Thank you, Surgical Hrt RN ,

Probably would not have made a difference in this case, however. As you see, the patient refused any life-saving measures and subsequently died.

[SEOBowhntr]

John,
One thing to remember in many RV infarcts is that the Proximal RCA is the culprit, and the vagal thing is often times related to a loss of feed to the SA node. That being said, if the RV infarct is a result of a PDA solely or a more distal RCA occlusion, you may keep SA Node feed, and lack the Brady-arrhythmias, however in ALL RV infarcts you will have the hypotension.

Don't feel bad about this patient, she got something many of us will not get the dignity to do, she got to die with a little honor and dignity without someone coming in and over-riding her wishes. She was blessed to have a nurse care for her who cared as much as yourself, but she felt it was her time and got to settle this one on her terms. Keep your head up, you sound like you did a good job, but only so much can be done with a patient who doesn't really want drastic measure performed. Even with the best of care, many RV infarcts will die, that's just the beast of cardiac care that often times we have no control over. One of my best saves was on an open heart patient who shut down his RCA graft and even with emergent PTCA and a balloon pump for nearly a week, he very nearly died, and this was treated almost immediately!!!

Doug

[icyounurse]

Originally Posted by papawjohn

Hey Y'all

I did CoronaryCare 20yrs ago. When they introduced drive-thru cath labs and one-day heart attacks, it quit being so much fun and I migrated to Trauma.

Now I'm working in a small combined Medical-Cardiac unit. Mostly my old cardiac skills are worthwhile. Patients' hearts today are unchanged from those a few decades ago.

But I've had a little lady pt the last few nites that I wanna ask for opinions about. She's only 66. Old chart has a hint of previous mental illness--but she has not shown it during this admit. NursingHomePt due to remote spinal trauma and surgeries--bedfast and wheelchair dependent; moves everything & skin intact but very weak and 'deconditioned'. Comes in with Inferior MI. Refuses Cath and intervention.
So this is my question: She looks to me like a perfect model of R Heart failure. Very low BP (70's Systolic at times) and very very poor urine output (10-20cc/hr) and BUN increasing daily. Heart rate 70s & 80s. Chest clear as a bell; sats 98% with nasal O2 at 2L. Back when I knew anything, the answer was GIVE IV FLUIDS. The rational was that the high CVP would not translate into pulm edema because the weaked R Ventricle would not put so much fluid into the lungs that the undamaged L Ventricle wouldn't take it out, and the more blood that can be sent to the L V, the better.

But the Dr.s are not treating her this way at all!! I call and get no orders for fluids. They round on dayshift and even DC the KVO fluids. I did get one junior partner in the admitting Dr.'s group ("I don't know the pt but what's your question?") to let me give a liter of NSS overnight. The urine briefly picked up and BP was around 100 by the end of the shift. Then the Cardiologist 'rounded' the next AM and wrote "DO NOT SALINE LOAD THIS PT!!"

I'm pretty sure I remember my stuff. What's changed? Anybody?

This isn't a 'rant' by the way. I'm hoping to get a serious answer.

Papaw John
(scratching his thin greying head)

whats the bun and creatinine?

[Surgical Hrt RN]

Originally Posted by icyounurse

whats the bun and creatinine?

BUN and creatinine are lab values that tell how good or bad the kidneys are functioning, and how dry a patient is. The higher the BUN the drier the patient. Creatinine is more specific for kidney function though, the higher the creatinine the worse shape the kidneys are in. Hope this helps!

[papawjohn]

Hey ICYOUNURSE

This lady's cardiac output was real low; that's why the BP was in the toilet. And the kidneys weren't getting the pressure that they need to squeeze the blood hard enough to make urine. So the kidneys "thought" that she was dehydrated and produced very very little urine. The result was that body wastes were not being exceted.

(We know that kidneys don't "think" of course, but we talk that way, yeah?)

BUN stands for Blood Urea Nitrogen. Creatinine is just creatinine. The are nasty waste products left behind when proteins are broken down in our cells.

Papaw John

[ghmccart]

msybe the pts MI allthough inferior maybe stable and not in need of so many fluids, and with the mitral regurg. preload and pacing are still good for RV MI's