I have lurked the boards for a long time now but never posted. This week though I had a patient who is weighing heavily on my mind and wanted to get some other peoples input.
I work in a PICU and have about 3 years experience now.
I was taking care of a patient this past week in septic shock on ecmo (post ECPR). Pts background: multisystem organ failure with hx of seizures (none seen since meds reached therapeutic level). Obvious injury on head CT (we have portables) but can't quite tell if stroke or just general encepalopathy (which pt definitely has based on EEG & imaging). Pt is on NO sedation as we are trying to determine extent of neurologic injury. Pt has no cough/gag, pupils vary from 1mm to 4mm, sometimes brisk, sometimes sluggish. The last few days pt has had increased response to pain (slight withdrawal of fingers/toes to pinching).
Anyways I was changing lines and per my usual routine I hung his pressors & carrier ahead of time and ran them for a few minutes. Doses were not high, pt is a toddler, on about full ecmo support and we were tolerating lower maps (50's) in effort to take off fluid. When I changed the lines I expected a little fluctuation but his pressures just SHOT up, high 150's/100's. Ecmo pump started freaking out for a few seconds I immediately paused both the dopa & epi and pressures slowly came back down. Whole episode probably lasted less than 2 minutes of course when it's happening it feels like 30. I turned his pressors back on, at lower doses initially but titrated back to baseline and he never "slumped" his pressures returned completely to baseline. After this I took a quick peek at his eyes and his pupils were large, about 5's I would say. There was another, well experienced, nurse in the room with me through this who event and she immediately grabbed the flashlight and checked them, they responded equally though sluggish. She thought he was fine. I relaxed. About 15 minutes after this as I was sitting down to chart I noticed that his HR was about 10 bpm lower than he had been all day (had been consistently about 134-138 all shift, was now low 120's). I know that's not technically "bradycardic" but I have just been stressing out that I this may have caused further, significant injury, stroke or beginnings of herniation.
Any thoughts? This was at the end of my shift so I couldn't assess how the next few hours went. I am so worried and haven't been back to work in a few days, not until the end of the week.