Bad night with a heparin drip...

[nerdtonurse?, BSN, RN]

I freely admit, I'm venting....

Had a pt last night that I'd had before, anuric, on dialysis 5+ years, admitted for chest pain and rule out PE; frequent flier, but nice. PE was ruled out yesterday morning at 9 am, looked like she had just got dehydrated. So, I come strolling in for night sift, and take a look and think, "something's wrong." The lady that had been pleasant, A/O x4 is now awake, but lethargic, and just looked off. Her heparin drip was possibly infiltrated, and day shift had tried to restick and restart, but couldn't get a vein. So, I decided to take a quick set of vitals, check the chart to figure out why she was on a heparin drip and call the doc.

It all went to crap from there. BP 66/33. Stat APTT > 250! Did day shift notice the pt had blood oozing from her subclavian old temp dialysis port, the ABG stick site, and every other stick she'd had this admission? No, they tried to restart the heparin and they hadn't gotten the first APTT back on the pt. Their response to "where's the APTT?" is "lab couldn't stick her." Hello, blue port on the cath, did you call the doc to get an ok to use for blood draw? Nope, and this is the bad part, they would have restarted the heparin if they could have gotten a vein! and FYI, Lab came around and said no one had called them and told them the pt was back from dialysis to take the APTT...so this lady had unknown amount of heparin, with no APTT for at least 4 hours...

Doc orders FFP, 150cc bolus and a stat coag after the FFP goes in; I also called ICU and told them to hold a bed, I've got one that's probably coming their way. I got her naked and looked for every possible bleeding site, noting location and amount. I'm checking on this woman every 15 minutes, and suddenly she's got blood running over her shoulder and down her chest, and dripping steadily everywhere else. We put a pressure dressing on, and call the doc again. We get hespan 250, and her BP, which had come up to 96/71, starts falling like a rock. I roll her over and one of the RN's says "Holy XXXX!" because blood is pooling under the pt. Surgeon on call says to push protamine -- I told him about her pressures and her anuria, and he said push the protamine, we've got to reverse that heparin since she's got no kidney function to do it. I do the protamine, plus the rest of the bag of hespan, and open up a bag of NS trying to get her BP out of the toilet, and I'm yelling for the secretary to call the lab and get an emergency type/cross match for 1 unit of PRBC plus another FFP. Her BP goes down to 58/31. At this point, every RN (except 1, plus 2 LPNs to look after the other 35 pts) on the floor is in the room, we've got the doc on the phone, Pt then develops chest pain. nitro x2, morphine and xanax, no relief, we take her to ICU, and I watch her start spiking elevated T waves on the 12 lead in the ICU.

The things I can't figure out: why a pt with a ruled out PE (and who had normal PT/INR's on my last shift) is suddenly on a heparin drip, why day shift hung a heparin drip without a APTT, why they didn't STOP it when the pt started bleeding and had a LOC change, and why they didn't get a stat APTT to figure out what's going wrong.

That woman should have went home today. She's going to be lucky if she survives.

[TigerGalLE, BSN, RN]

HOLY CRAP. I don't really know what to say.... First of all was there an order for a heparin drip? Second a PTT must be drawn initially before starting a heparin drip. So that doesn't make much sense. Could they not draw the PTT at the start of dialysis? Did dialysis give her heparin with her treatment too?

Any news on how she is doing? Where was the blood pooling under her coming from? Her perm cath site?

Bad situation.. and poor nursing care from previous shift.. hope she survives...

Tiger

[chenoaspirit, ASN, RN]

Dang! All I can say is "good for you" for doing a thorough assessment and advocating for your patient. It sounds like you are a great nurse. Shame on the previous shift. I still cant believe they didnt draw a PTT prior to starting the Hep gtt. With our dialysis patients, the dialysis nurse draws any necessary labs once dialysis is complete. Please update us and let us know how the patient is doing.

[Nurse1990BSN]

Incredible! Makes me wonder.... and shudder. Just would like to add my two cents worth....dialysis caths are usually instilled with 5,000 units heparin and should be marked as such.

[Babs0512]

You did good girl!! You held it together, advocated for your patient, and transfered her where she could be closer monitored. What more could you have done.

Seems to me the previous shift f-k'd up, careless at the least, negligent at the most. Should be a write up in there somewhere.

I don't look at write ups as a way to "get people into trouble", I look at them as a learning experience -- I have been on both ends of a write up before, and I'm a better nurse for it.

Good job

[2shihtzus]

Yikes. Someone certainly dropped the ball. I dont understand not getting and initial PTT on the pt....before we start heparin, we always get a baseline PTT.

Write it up....not to get anyone in trouble, but to prevent another patient from being harmed in the same way. Looks like some of the staff need some education as well.

[nursemary9, BSN, RN]

You sound like a great nurse!! Good for you!! You could be my nurse, any day.

I do hope you wrote this up or will write it up; Not to get anyone in trouble, but to use this as a learning experience.

[locolorenzo22, BSN, RN]

GEEZ! OK, I'm not going to bead a dead horse, but still....uhh, baseline aPTT, coag times, some measurement, bleeding going on, NOBODY NOTICES? I'm saying "write-up" to ENSURE something gets done....somebody dropped the ball big time,

And thanks to you, we newbies now know to make sure we LOOK at the patient!

[nerdtonurse?, BSN, RN]

An update....

Pt is still in ICU, but she's still alive. I did do an incident report, not that I think it will do jack about anything, sadly enough....

Same nurse who was trying to restart the heparin had the pt across the hall; 2 FFPs were ordered at 1330, never hung on day shift, I got one hung and my charge did the second while I tried to keep the woman across the hall from bleeding to death. Needless to say, I didn't sign off admission orders (not the med orders, just the PT/OT/xray stuff from a 1330 admit) because of the pt bleeding out. Nurse scary had that one again, and still didn't sign off any orders. So now I get a call about why didn't I sign off admission orders on the pt across the hall...not the day shift who had her for 6 hours, and then all day yesterday, me who had a pt trying to freakin' die on me all night. And at our facility, we've got 24 hrs for admission orders, it wasn't like I was counting down to 2355 on the pt....can you say, "we'll get you for not covering for precious day shift?"

No good deed ever goes unpunished....:angryfire

[nerdtonurse?, BSN, RN]

Lessons learned: Never, ever trust day shift's Nurse Scary to have done her *@#$% job.

If I have a pt on a heparin drip, I'm stopping the heparin if there's not APTT until I get one, unless there's clear and present proof of a clot; even so, I'm ordering a stat APTT. I told my boss during the incident report that I'd stopped the heparin and she said, "did you have an order?" Ummmm....hello, pt bleeding like she had freakin' Ebola, no, I used my nursing judgement, stopped it and called the doc to get him to write the D/C order. Friend working last night with experience as a dialysis nurse told me that she thinks Nurse Scary gave them a bad body weight and they pulled off too much fluid, and the heparin drip should have been D/C'd when her CT came back negative for an embolus; her D dimer was high, but that could have also been due to the pt's other problems like arthritis.

All the nurses on my shift who were there told me I did a great job, and did all I could, but I still feel bad for the pt. Man, I wish I never had to follow Nurse Scary again....

[Indy, LPN, LVN]

Sounds like it's a possibility the patient could have gone into DIC ... but I wasn't there, just mentioning it. It's pretty darn scary to watch someone bleed and crash like that, and mindboggling to hear people say "gonna restart that IV so I can restart heparin" while you're watching the same patient just about bleed to death.

I'm sorry you have to follow people that don't know what constitutes "critical."