My most disappointing case...

Published May 14

6 Posts

Specializes in Perioperative First Assist.

Today was a tough one. We had a 58yM with a 5.8cm AAA w/ a previous repair. A less than stellar provider 'fixed' this aneurysm many years ago. However, the provider was no longer in practice and we could not locate extensive operative reports from his prior case... aka a blind redo on an aorta... this would give any FA the chills. This lovely patient and his sweet family were not angry at what had happened years ago. They were accepting and wanted to move on. We discussed the risks and benefits... and this patient decided he could not continue to live out each day knowing he had a time bomb in his abdomen. He elected to proceed with an open redo aortic aneurysm repair. All was routine until we attempted to clamp. His graft had been sewn to aneurysmal segments and his aorta was impossibly friable. Our attempt at clamping caused tearing. Our next attempt was at thoracic clamping which required a clamshell thoracotomy due to a prior CABG with heavy adhesions. At one point, he went asystolic and we massaged for 8 min prior to obtaining ROSC - My personal goal for this at this point is that he would not die on our OR table, and that his sweet family, would get to say goodbye in person. We do our best to be as frank as we can with risk and benefit- but something in me knew this family was not prepared to loose him to this 'elective procedure.' So with 2 rapid transfuser, and (no kidding) 3 cell savers left in his abdomen suctioning and a dedicated anesthesia tech spinning and giving as fast as he could... we got him off the table and to ICU with a pulse. As we rounded the corner to ICU the intensivist gave me "the look" an asked what the game plan was. (AKA you really think I can save this one?). I told her I wanted the family to say goodbye in person. The ICU was slammed that night and the intensivist and assigned nurse had more than enough on their plate. I was grateful that night that I could reach back into my ICU nurse background. I stayed with the family, explained what would happen, how it would happen, and held the poor wife's hand as he ended his time with us about 45 minutes later. It was a calm and peaceful death in a way... one they could be there for as opposed to sending their loved one beyond the red line to never return. It was the first, and only, elective case we have lost. It haunts me to this day that he could still be alive... time bomb and all. It makes me grateful to keep up my ability to help families through loss as I did in ICU even though that is far removed from me these days. It reminds me even the best fail and it humbles me.