77 y.o. female arrived to ED with bradycardia and hypotension with c/o weakness and fatigue. She was found to have been just diagnosed of pulmonary hypertension after years of symptoms and was started on Optimist recently (though actual date is unclear).
Past Medical History: Pulmonary Hypertension, HLD, chronic atrial fibrillation and on coumadin.
Course of Stay:
11/24 -- The Optimist was discontinued, and she was transferred to the ICU where she was started on a dopamine gtt and started on fluids. She responded very well to both. Echo was performed which showed elevated pulmonary pressures and a severely dilated right ventricle. However LVEF was >70%.
11/27 -- She was then transferred to a medical floor. She was edematous and was being maintained on supplementary oxygen. She was started on IVP Bumex and started on PO Lopresser for the HF.
11/29 -- She became hypotensive again went into a hypercarbic respiratory failure per ABG analysis. She was unresponsive to fluid resuscitation and she was transferred back to the ICU. She was started on a Bipap She was given a total of 3 L of NS, 1 unit of albumin and finally started on a Phenylephrine gtt. Her afib HR increased while at rest, and she was started on a Cardizem gtt.
11/30 -- She was changed to 20 L of HiFlo. She was noted to not be producing any urine. She was transferred to the cardiac ICU. Swan catheter was placed which showed elevated PA and CVP pressures. PAOP unable to be obtained. SVR normal. MAP maintained on Neo gtt. HR controlled.
12/1 -- Her BUN/Cr and LFTs had increased. Patient still producing little urine. Upon assessment, patient demonstrated increased confusion, RR was elevated, and O2 saturation was variable 88% to 92%. She was placed on Bipap which appeared to help. ABG was performed showed metabolic acidosis. CRRT initiated per Renal consult. Pulmonary also chose to intubate.
Patient was started on a Fentanyl and Precedex gtt was started for sedation. Patient developed bradycardia so precedex and cardizem gtt were stopped. Later in the shift, patient was being boosted up in bed when she appeared to go into a PEA arrest. CPR was initiated, and 1 amp of Epi was administered before ROSC. CRRT discontinued. Cardiologist on consulted changed the patient from Phenylephrine to Norepinephrine gtt and Milrinone. Cardiologist also made a point that "Neo was the last thing you wanted her on." Patient then became tachycardic, HR in 140s-160s. Milrinone was discontinued.
12/2 -- CXR revealed pulmonary infiltrates, thought to be PNA. Patient started on Zosyn. CRRT restarted. Patient remained tachycardic with a HR in 140s-160s, Levophed titrated as much as possible.
12/4 -- Patient terminally extubated.
My issues:
Should she have been started on a Cardizem gtt in the first place?
Also, why did the cardiologist say Neo was the last thing she needed to be on?
Did we put her into a Left sided heart failure as well with the Neo?
