How do you deal with unexpected death in the ICU?

[YP CVSICUnurse]

I'm writing this because I feel as if it's the only way I will be able to move on. Yesterday started out like any other day. I woke up at 0530 and was out the door and on my way to work by 0615. My coworkers and I joked around in the break room for a couple minutes before our shift started per usual, and I clocked in at 0638. I received report on one patient, a POD#1 thorascopic maze procedure, then received report on my sicker” patient, a POD#1 coronary artery bypass x 2 and aortic valve replacement. Unfortunately, this second patient was unable to be extubated the night before due to agitation and inability to follow commands. This assignment is not exactly typical and was quite busy, but I had no doubts I would be able to handle it. I received orders from the surgeon to try another type of sedation we typically use in the ICU, precedex, which is more of an anxiolytic. I went about my day and performed my first assessments on my patients. I performed a sedation holiday on the reportedly agitated patient, and like the night shift nurse reported, the patient was unable to follow commands and began to trash around in the bed. Worried that he might blow a graft or hurt his fresh sternotomy, I had no choice but to re-restrain him (per MD orders) and quickly turned the propofol back on. I started to titrate the precedex drip per orders. This patient was on minimal blood pressure support, 20-30 mcg/kg/min of neosynephrine, which is very normal for our cardiac surgery patient population on POD#1. Despite titrating up on the precedex all morning, the patient was still waking up agitated and unable to follow commands. Our critical care doctor insisted we draw another blood gas and extubate the patient anyway. With ABG within normal limits and minimal ventilator support, the respiratory therapist and I went ahead and extubated the patient per MD orders. When the patient was extubated, he was still extremely agitated, unable to follow commands, and unable to verbalize any comprehensible words. I paged our critical care MD and strongly suggested a CT of the head to rule out a post-op stroke. Like many doctors would, he believed this was ICU delirium. The MD came to assess the patient and remove his chest tubes due to minimal output the night prior and normal morning x-ray. Again, I advocated for (demanded) the head CT. He finally agreed and also ordered an antipsychotic, Geodon, so the patient would be able to safely tolerate the CT. In an effort to minimize danger to the patient during transport to CT, I discontinued his PA catheter (last cardiac index was 2.7 off neosynephrine). The patient tolerated the transport to CT and vital signs were stable upon return to the ICU. It was at this time I was finally able to take lunch break (at almost 1500/3PM), and I had our break relief nurse sit with the patient one-on-one. Please keep in mind that this entire time I had another patient in a great deal of pain that I had to take care of as well. Upon coming back from my lunch break, I went to the room to re-assess this patient's neurological status and vital signs. CT of the head was negative. He continued to have a stable blood pressure on no drips and though subdued, was still unable to follow commands. I then went into my other patient's room to assess his pain and also perform my 1600 assessment. I sat down at the nurses's station with my coworkers to begin to chart my assessments, when one of my coworker's walked past my patient's room. HELP. I THINK HE'S HAVING A SEIZURE.” I jumped out of my chair and ran into my patient's room. His eyes were rolled to the back of his head. He appeared to still be breathing and quickly I felt for a pulse. A pulse was present. We quickly yelled for the critical care doctor and surgeon to be paged STAT. Within a matter of minutes, the patient lost his blood pressure and had pulseless electrical activity. Quickly we began chest compressions and advanced cardiac life support. By this time, as using during a code, we have about 15 people in the room trying to help. The surgeon comes running in, I give him a synopsis of the patient's presentation, and he decides to open up the patient's chest at the bedside. As the surgeon and the scrub nurse prepare to open the patient's chest, my coworkers and I continue ACLS protocol to try to revive this patient with no success. The sterile field is quickly prepared and the surgeon opens up the patient's chest. To his surprise, the patient's heart is essentially empty with a chest cavity full of fresh blood. After filling up about 3 canister's worth of blood, the patient is asystolic, and he calls time of death at 1710. I rip my mask, cap, and gown off as I feel tears streaming down my face.

I've been a cardiovascular surgery ICU nurse for almost 5 years, and yesterday was the first time I was unable to revive a patient. Still, I had to go on, complete the appropriate documentation, notify the appropriate authorities, and take care of my other patient like nothing had happened. Not a moment to grieve… Because that's what you do. This is your JOB. So you cannot FEEL… you just have to move on. But what if you can't? There's a shocking difference in grief between a perceived unexpected loss and a patient who was suffering. I have lost many comfort care” patients after prolonged ICU stays and grandiose measures. Those losses aren't nearly as hard, because I can always tell myself they're in a better place now”. I keep wondering, was there something I could have done differently?” I did everything by the book, how did this happen?” Why did this happen?” What will my patient's disabled wife do now?” How do I move on?” I don't know the answer to any of these questions and right now I feel an immense guilt and profound sadness for someone I never even really talked to… but I was his nurse, his person, his advocate. So it must be my fault that he died. Although I know these thoughts are illogical and that we are trained not to let our emotions get the best of us, I can't help but feel human. Some days I wonder why I ever became a nurse. Why would anyone want to put themselves through this kind of pain? My husband keeps reminding me that I save lives daily… not to forget the other hundreds and hundreds of lives I've touched. But how do move on from one of the worst days of your career?

[Been there,done that, ASN, RN]

First and foremost, you did a great job. A first day post-op with TWO interventions and difficulty with weaning SHOULD have been a 1:1. Doubt that could have changed the outcome, though. I am not a cardiovascular surgeon ( I was a cardiovascular nurse for 3 years) but I am thinking one or both of his grafts blew. Nothing YOU could do would prevent his death.

Not all surgical patients survive. For ME , researching the mortality rates on various procedures would reassure ME that I did all that I could.

Let the emotions fade until reason can take over. Then, I am confident.. you will get back on the horse.

[TheCommuter, BSN, RN]

Moved to the Critical Care Nursing forum.

[YP CVSICUnurse]

Thank you very much for your comment. Sometimes I need to hear from other experienced nurses and face the reality that not everyone will make it.

[Scroll89]

Wonder why the chest tubes didn't show anything that would have given the hint of a hemothorax. Honestly with an ABG showing no hypoxia, clear head CT, no excessive drainage in the Atriums, and decent pressure off support I wouldn't have thought anything of it, and yes ICU delirium would have been the suspicion. I don't work in CV-ICU, but as a MICU/SICU nurse this case sounds pretty out of the ordinary. Is it possible that the PEEP on the vent was acting as a tamponade, and removal from pressure support caused the bleeding to start?

Clinical review: Positive end-expiratory pressure and cardiac output

Losing a patient sucks, and feeling defeated happens, but take it as a learning experience. You seem to know your stuff, just add this to the list of things to remember and keep saving those lives.

Edit: I should also add that our RASS/Vent worksheet has "Increased agitation and or Pressor support" as an absolute contraindication for extubation or weening attempts.

[YP CVSICUnurse]

Thank you for your reply. Yes, although it was against our ALL our extubation criteria for post-open heart surgery, the MD gave an order, which overrides the protocol. No signs of hemothorax or tamponade on morning Xray or before i dc'ed the PA catheter. When the patient was extubated and off neo, normal PAP's, normal CVP, CI was 2.7, SVR in the 800's, stroke volume in the 70's. After talking with the surgeon, there's a possible theory. He believes that the patient may have indeed been having a seizure and chest compressions caused trauma to an undiagnosed thoracic aortic aneurysm. In the end, I don't think anything could have changed the outcome, but I definitely needed time to reflect and get back on the horse.

[nurs1ng]

I get very wary about "minimal" chest tube outputs. Did your pt's chest tube output show a trend of decreasing drainage by the hour? Regardless of minimal chest tube outputs, I feel they should still be draining POD 1 and those tubes should always be left in until POD 2 or 3, maybe even up til day 4 but that's just my opinion (unless anyone can present with evidence based studies to show otherwise). I also had a pt who went into acute tamponade but there were no signs of suspicion until we looked at the trend of the chest tube output. It gets pretty tough but you did good and I'm glad you were a true advocate for your patient.

[Nalon1 RN/EMT-P, BSN, RN]

Every patient in the ICU is about to die. There is never an unexpected death.

A morbid and pessimistic view, but your never disappointed and always happy when they move to the floor/transfer out.

Many times patients die despite all we do. Sometimes they die when they are "all better". Sometimes they die and we just don't know why.

[DesertSky, BSN]

I know it's hard not to play the shift back in your mind and ask yourself "what did I miss?", but unfortunately sometimes there is nothing that you missed - some patients just have bad outcomes. You advocated for your patient at every opportunity and provided good, competent care. Be kind to yourself and realize you did all you could. :)

[OnceMorewithFeeling]

You did nothing wrong. You had an incredibly busy day by your account, and were still thoroughly attending to this patient. Even after the fact, you can account for his vitals, his gtts, his mentation...etc throughout the day. You did all you could for him.

I do agree with nurs1ing about your Unit's protocols for DC'ing chest tubes. Our patients need to be out of bed at least one time (and usually, 2-3 times) before we will DC chest tubes. Patients will retain a lot of fluid in the pericardium and pleural spaces that won't drain until they get out of bed. In addition, slow leaks can be identified by leaving the chest tubes in a bit longer. Perhaps your patient had a slow leak and developed tamponade after the chest tubes were pulled?

As far as the "undiagnosed thoracic aortic aneurysm," I would be very concerned if your CV surgeons are operating on folks with undiagnosed or identified aneurysms. It's pretty important to know, before a CABG or other open-heart procedure, if a patient has an aortic aneurysm.

[William2]

Very interesting case and theory by CV surgery.

I've had mixed luck with precedex either it works or it doesn't. One of our CC docs refuses to use it and if hes on call assuming care of other MD's patients he d/c's it rather quickly... surprised they use it for hearts though. Hindsight is 20-20 here but I would have pushed for an ativan drip or multiple PRN's to get this guy to calm down and then see if he would become purposeful( hard to probably achieve without snowing him, but oh well) Maybe? Or he was in an a lot of pain due to that unknown aneurysm possibly dissecting? Head CT was a great call though.

Seems like there's a rush to get people in and out all for statistics. We push for our hearts to get extubated by the afternoon/evening hours and then the next day "if" doing well d/c to floor. No harm no foul if not. CT's are never d/c'd that quickly for us...

[Thedevinestman]

The head CT was a good call given all the agitation, but I think the intensivist killed that patient by extubating early. You clearly did all that you could and I wouldn't loose sleep over it. Imagine if that same patient was in a third world country with the same problem, they never would have even been treated, certainly not with the excellent care you gave. Some people just aren't meant to live through cv surgery. Stay strongí ½í²ªí ¼í¿»