Actually, "having dysrhythmias all night" was a bit of an exageration--he started bradying into 40's and 50's with corresponding drop in BP about 1AM--during the time I was giving him his bath. Thought at first maybe vagal response to tracheal, oral suction (mouth and trach care). This poor patient had endured a very complicated course during his hospital stay; had suffered a large inferior MI with blocked RCA late February (had passed out at church); in cath lab they had stented RCA, which was unsuccessful--low reflow--so remained blocked. Also, in cath lab, went into 3rd degree heart block and was transvenous paced for awhile. During my shift, he also started having SSS symtpoms with tachy-brady episodes, high junctional rhythm; was having some pauses--one 6.3 seconds
!!!. He had had dysrhythmias before due to blocked RCA (we thought)--but had been in a pretty SR (off pacer) for about a week. Put him on pacer pads with pacer at bedside. Sats were dropping also, making vent adjustments, occasionally being manually bagged. Could no longer get him to respond to peripheral nerve stimulator, so titrated vecuronium down, then off. Also turned off diprivan and morphine. Had oliguria during the night (dr aware), but thought perhaps was due to ileus (tube feeds turned off due to high residuals) and pt started on NS @ 75cc/hr. Lungs had been junky for weeks due to ARDS complication (had also had a PE in RULand was on a heparin drip). No significant changes in lung sounds, FI02 was turned up to 100% from 65%. Went ahead and drew his morning labs early, at around 3AM, ABG/lytes included. ABG very acidotic (7.15, I believe); BUN/creatinine high (creatinine had increased from 1.2 to 2.1 in one day!) and K+ increased to 6.3! Pt had gone into acute renal failure, the high K+ was contributing to the dysrhythmias/ ARF was causing dangerous build-up of medications in blood stream (kidneys not clearing) which contributed to his ileus formation and perhaps to bradycardia and low BP (one side effect of vecuronium is bradycardia and hypotension--also high morphine levels probably caused the ileus, also contributed to low BP, as would high diprivan levels--low BP). We gave him the usual regimen for high K+--D50 1 amp, 10 units RH insulin IV, 1 amp calcium chloride, 30 grams K-excelate via PEG tube 4 hours apart. Should have suspected messed up lytes earlier; also should have perhaps suspected dig toxicity since pt also on dig--level did come back normal @ 1.3, but was d'cd anyway due to bradycardic episodes and pauses. Learned a lot from this patient (have only been in unit 5 months)--its amazing what a high K+ will due cardiac-wise. Next night, was better, but K+ started going to other way--went down to 3.5. Maintenance fluids changed to D51/2NS with 20mEq KCl. Pt then went into paroxysmal atrial fib with RVR to 160's 180's around change of shift!!! (Drew another stat set of lytes at 7AM, including Mg++, ionized calcium, phos, K+). BP holding up much better. ARF had resolved during the night, BUN/creatinine much better, good urinary output. Have been off, so haven't heard how he has done since. Thanks for all your input--with each new patient, I learn so much; itreally helps to hear what other more experienced nurses have to say.