What has been your sickest patient

Specialties MICU

Published

I haven't been in SICU that long, but recently I had the sickest pt I've ever had helping out on a 2:1. He had a MVR/AVR and dropped his pressures in the OR so they gave epi and he developed "stone heart" (cramped heart) and dropped his pressure to almost nothing. So they put in a IABP but that didn't really seem to help so the surgeon put in a LVAD. So this pt has been sitting in SICU for the last 4 days on 40 of LeVo, maxed out Vaso, 5 of dopa, high dobut, diprivan, lasix, insulin, getting a-line MAPs of 59 and IABP pressure 55/50 with aug of 60. The day before he had a LBBB for his underlying rhythm so we paused to check it out and he was asystole (sweet....). The perfusionist turned off his LVAD and we turned his IABP to 1:3 from 1:1 with no perfusion on the a-line except the little bump on every third beat from the IABP. CVP was anywhere from 10-15 with a PA of low 20's/low teens. I shot a index just for fun and it was 1.1 with CO of 2.9 (which just happened to be the same flow as the LVAD... :-/) SVR like 900. He was bleeding out just about everywhere; IABP (d/t difficult placement/cutdown), cordis, CT, PICC, etc. We were checking Hgb every 1-2 hrs and just dumping in blood. Couldn't get it above 8. CT was putting out around 400 an hour. His ABGs were fine. Coags weren't terrible 1.5 INR and a little low on her fibrinogen. Gave her some FFP for that. I'm wondering how long you all have seen MDs keep someone like this on the LVAD. It's not like he was getting better or getting worse. I would've thought she would be getting acidotic by now if hewas going to go in the wrong direction. The rest of his body wasn't bad. Vent was SIMV 10 TV 600 PEEP 5 on 50% FiO2(was 30% but I guess RT isn't supposed to put FiO2 lower than 50 with an LVAD).

Specializes in ICU/Critical Care.

The sickest patient I had was a gift of life patient. I came on shift at 7pm, Docs did the apnea test, patient failed, patient pronouced at 8pm. Patient had gsw to head. After gift of life took over, patient had to be bronched, swanned, pressors started because the BP was in the dumps, labs every 4 hours, placed patient on a sport bed for chest pt, had to give 2 units of prbcs, 4 units of FFP. Ok, it probably wasn't my sickest patient but I never released how hard it was to keep an essentially dead peron alive. I did get a lovely note from Gift of life though, thanking me.

Up Vote Up Vote ×
Still just a nursing student, but today in the CCU I had the sickest patient I have ever seen. A woman who was only 40 years old with a 3 yr history of CHF. Admitted a week and a half ago with exacerbation of CHF, and has steadily gone downhill. Last night they put in an IABP and a swan. Her heart rate was in the 140s during the night, and slowly creeped up and was a-flutter in the 210s-220s all throughout the shift. She was maxed on levophed, and also on dobutamine, vasopressin, neo-synephrine, and bicarb. Her hands and feet were blue, pulses were neither palpable nor dopplerable. pH was 7, so liters and liters of bicarb had been pumped into her during the night, and there was no urine output, so she was extremely edematous. CI was 1.9, SVR 1100s, EF 13%, PAWP 38, CVP 28, BP 70s/40s. CXR revealed her heart was twice the normal size. Docs and nurses kept arguing over whether the IABP should be at 1:1 or 1:2. Didn't seem to make a difference either way. Her heart was beating so fast that the rarely filled all the way. Very sad, because woman was so young, and had a young son.

I'm new in ICU myself so I still try to put everyhting together... would she not have benefitted from an amio drip? or Procor?

Up Vote Up Vote ×
Specializes in M/S-Ortho-Renal-Peri-Op.

your enthusiasum..( spelling??) is very refreshing......which brings me to the issue of "nursing eating their young"!!!! Do not let this happen to you.....and do not allow anyone to stifle your excitement to begin your new profession!!! You are what our profession needs!!!!!

Up Vote Up Vote ×
Specializes in SICU.
Sounds like she needed a VAD a week ago. Just curious, why would you turn the IABP down in that case to 1:2? Sounds like severe biventricular failure.

I can't exactly answer the question about why they didn't do a VAD since I'm still a student :-) I do believe that they wanted to turn the IABP down because with the patient's HR being in the 210s, the balloon was not inflating all the way because it didn't have time to fully inflate in between each beat. It inflated all the way maybe about 1 out of every 3 or 4 times. The other times it might inflate to about 5ccs or so. So the reasoning was (I think) that by decreasing the ratio to 1:2, the balloon could inflate all the way more often, providing more benefit. Besides, with the heart beating so fast, there was no way to sync the balloon inflation with the heart beat, so I guess it's better to have it inflate all the way for every second beat, instead of every 3 or 4 beats.

But there were some doctors and nurses who wanted it 1:1, some who wanted it 1:2. No consensus whatsoever.

Up Vote Up Vote ×
Specializes in CTICU.

Hmm... odd. The IABP should be able to time pretty well on R-wave deflate ("real timing") up to a HR of about 160bpm. It would be unusual to have only a 5ml inflation (and you can't actually tell that, only guess).

Annony_RN: Amiodarone would not help if she was tachy because of congestive heart failure --> The heart is unable to pump due to a failing LV muscle, so it tries to go faster to increase the cardiac output (HR x SV = CO). Unfortunately, that causes an even more negative effect, because the faster it beats, the less blood is ejected and the less the stroke volume is...etc. Hence cardiac decompensation.

The patient was already on dobutamine, which some docs prefer to milrinone (Primacor), if that was your other question?

Up Vote Up Vote ×

My question is in what cases were these LVADs placed? Could you describe what led up to these problems? For eg> a pt we've had in our unit for quite some time just passed, but they ended up on Epi, Vaso, Neo, Levo, and Dopamine all maxed out with pressures barely 30's-50's (sys.)...after trying to explain to family there really wasn't much help left....maybe there was--would this be something for this type of pt?

Up Vote Up Vote ×
Specializes in SICU.
My question is in what cases were these LVADs placed? Could you describe what led up to these problems? For eg> a pt we've had in our unit for quite some time just passed, but they ended up on Epi, Vaso, Neo, Levo, and Dopamine all maxed out with pressures barely 30's-50's (sys.)...after trying to explain to family there really wasn't much help left....maybe there was--would this be something for this type of pt?

I'm curious, too. I wonder if the pt's just get so bad that it's almost pointless to consider. Especially with such an enlarged heart, I think the only way an LVAD would help is to keep the patient alive until a new heart was available. Then again, I know nothing, I'm still a student!

Up Vote Up Vote ×

Annony_RN: Amiodarone would not help if she was tachy because of congestive heart failure --> The heart is unable to pump due to a failing LV muscle, so it tries to go faster to increase the cardiac output (HR x SV = CO). Unfortunately, that causes an even more negative effect, because the faster it beats, the less blood is ejected and the less the stroke volume is...etc. Hence cardiac decompensation.

The patient was already on dobutamine, which some docs prefer to milrinone (Primacor), if that was your other question?

Thanks... I reread the post I was asking about and not sure at all what made me think of amiodarone? Just a major DUH moment, I guess. But thanks for answering about the Procor. I didn't p[ick up on the dobutamine. We don't use that much where I am. At least I have never had a pt on it.

Up Vote Up Vote ×
Specializes in CTICU.

The question of when to put in a VAD and who to put it in, is debated by cardiac surgeons and is a hard one. You want them to be sick enough that it's worth risking a huge operation, but not so sick that they have no chance of surviving.

Basically you want someone who has decompensated cardiac failure (high CVP/PCWP, low BP, low CO/CI), but no secondary organ failure yet (no deranged BUN/CR/LFTs).

VADs can be implanted wither as a bridge to transplant or as permanent therapy for patients who don't want (or don't qualify for) transplantation.

The new devices are much smaller, silent, less invasive surgery and less bleeding/strokes etc than the older devices. Some sites:

http://www.thoratec.com, http://www.abiomed.com, http://www.ventracor.com

Up Vote Up Vote ×
+ Add a Comment