My patient caused her own code.

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Specializes in NICU.

So I was taking care of a patient yesterday who had major abd surgery about a week ago. She was intubated and she was quite a complex patient. She was in restraints because she was constantly messing with her lines and ET tube. She was sedated with a fentanyl drip but she would become alert with stimulation. It was a crazy day in our ICU yesterday. We had already had a code and an emergency intubation all before 11AM. It was about 12:30 and I grabbed another nurse to help me reposition my patient before I went to lunch. The RT came in at the same time to check her vent setting ect.... So we turned and repositioned my patient, did PROM on her arms ect ect... I asked her if she was in pain and she shook her head no.... but then she started biting her ET tube. We tried to get her to stop by reassuring her and telling her not to bite down. I went and got some prn morphine to help calm her down and gave it to her..... But she continued to bite her ET tube forcefully. We tried to pry her mouth open without any luck. I don't know what her problem was but ultimately her sat dropped and she brady'd down. It was only after she went unconscious that she let go of the dang tube.

We got her back after 2 rounds of CPR and some atropine but geez woman!! Stop biting your tube!!!

The scary thing is. When she had a death bite on her tube. I said "If you want to live, stop biting your tube." She sure didn't let up......

She got a bite block after that.

:uhoh3:

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I've never seen the biting go that far but I've definitely had to bolus a patient with versed to get him to stop biting. Unfortunately, often when patients are on sedatives, there is no "reasoning" with them . . . telling them that they're killing themselves doesn't do any good. From talking with some of my patients once they're alert and oriented . . they have some bizarre nightmares under sedation . . . your patient might have thought you were shoving a stake down her throat (the ETT) and she was trying to keep you from doing it!!

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Specializes in LTAC, Telemetry, Thoracic Surgery, ED.

I've had to use paralytics because of the same thing

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One way or the other.....they WILL stop chomping on that ETT.

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Specializes in ER/Geriatrics.

oh my god....if I am ever tubed I pray to whoever is listening to sedate me properly....it is a skill! When someone is delerious they can't be "reasoned" with and bringing up the "your gonna die" card is really cruel.

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oh my god....if I am ever tubed I pray to whoever is listening to sedate me properly....it is a skill! When someone is delerious they can't be "reasoned" with and bringing up the "your gonna die" card is really cruel.

I don't think this nurse purposefully tried to be cruel or not fully sedate her pt. It sounded like a very busy busy day, and it was unfortunate that this pt had to code bc of biting her ETT. And I do agree that pts do not always know what they are doing when they are on diprivan,fentanyl, or versed. Should sedation have been titrated up, yes, but I dont think this nurse knew about it until it happend, like I said a code and an emergency intubation can cause you to be busy. Hindsight is always 20/20. :twocents:

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Specializes in Critical Care.

>>She was sedated with a fentanyl drip

The patient was clearly not adequately sedated. Fentanyl is not a sedative.

Tied up, tubes in every available orifice, and being told that "you're going to die" if you don't stop doing something you're probably not even aware you're doing.

Sounds like the patient had an even rougher day than the staff..... :-(

Agree with the previous poster who said administering proper sedation is a skill. I really think it is beyond awful to not sedate a patient properly in the ICU and I see it all the time. You come in, the patient's heart rate is through the roof, they're straining against the restraints, diaphoretic, bucking the vent. You look at the drips and the propofol or ativan or versed is at a piddly rate and the order clearly allows for room to titrate up.

The excuse for not going up? "Oh, I didn't want his blood pressure to drop" or "he's okay as long as you talk to him" or "as long as he is asleep he's fine."

Straining and bucking and just plain terror puts a lot of stress on an already stressed body.

Just pisses me off. Think of yourself or a loved one in that situation and act accordingly.

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Specializes in NICU.

Well we are trying to wean her off the vent so she doesn't end up with a trach. I can't keep going up on the fent or she won't initiate her own breaths. And that was the first time she bit her tube. I don't routinely tell my patient they are going to die. I was doing everything I could to keep my patient alive.

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Specializes in NICU.

And I didn't tell my patient "you're going to die."

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Do I agree that fentanyl is an analgesic and not a sedative? Yes. Do I stick to my physician orders of ramsey of 2-3 and make sure my pts are not in any distress and titrate when needed? Yes. Do I wean my pts off of sedation when it is time for weaning parameters and always continue to assess? Yes. I think BOTH the nurse and patient had a bad day and I dont think that you have to be so harsh when another fellow nurse is venting about a bad day. If you feel there could have been more done then say so, just do it tactfully.

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Specializes in Critical Care.
Do I agree that fentanyl is an analgesic and not a sedative? Yes. Do I stick to my physician orders of ramsey of 2-3 and make sure my pts are not in any distress and titrate when needed? Yes. Do I wean my pts off of sedation when it is time for weaning parameters and always continue to assess? Yes. I think BOTH the nurse and patient had a bad day and I dont think that you have to be so harsh when another fellow nurse is venting about a bad day. If you feel there could have been more done then say so, just do it tactfully.

Well, when a post is put up on this forum I guess one should expect that there will be varying opinions regarding the post. It's a public forum and that's going to happen.

No, I don't think the patient was properly managed, but that's just my opinion, of course.

Hopefully the OP learned from the experience but judging from the accusational title of the thread I have to wonder. I have to say that the choice of words for that title kinda floored me. I consider that title really "harsh."

Now let's talk a bit more about "harsh."

Let me tell you what would have happened had the team been unable to bring the patient back and she had died. There would have been an inquiry into why this happened. It would have been classified as a sentinel event, maybe even an ME case. And yes, they would have pointed the finger of blame at the nurse.

Why? Because, in the end, you are the final clearing house as far as the care of your patient goes. Not sedated enough? It's up to you to advocate for the patient. It's easy to blame the nurse---easy target for the docs, the families, and risk management. "Busy" is not an excuse. Again, it may be a reality but it just does not fly as an excuse. This is the tough, tough reality of nursing but especially critical care nursing where things happen so quickly and the consequences of not comprehending the possible enormity of even seemingly insignificant signs can be fatal.

If you think my previous post is "harsh" you should see what happens during a sentinel event investigation. No, I've never been directly involved in one but I've seen what happens and it is not pretty. The blame is very often heaped neatly upon the primary nurse, especially in ICU where the patient/nurse ratio is what it is.

There are ways to adequately sedate a patient during the weaning phase. As previously stated, it's a skill. From tiny doses of ativan to the use of Precedex, it's done on a regular basis.

Again, fentanyl is NOT a sedative. Yes, it can make a patient dopey but that is not sedation. Fentanyl can also cause nightmares and anxiety. If a patient says they are not in pain but they are agitated, don't go up on the fentanyl simply because it is the gtt that happens to be hanging there---go get an order for an anxiolytic. I've had versed, propofol, and fentanyl running at the same time on quite a few patients (and then added Precedex in anticipation of extubation). They all do different things and it's a balancing act but you really can get your patient to a state where they are comfortable and the stress on their bodies is reduced immensely.

I've noticed that nurses that are new to the ICU, especially, are hesitant to titrate up their sedation and pain med gtts. I guess the fear of overdoing it is always present but sedation and pain relief are very important parts of taking care of ICU patients. Inadequate sedation and/or pain relief can lead to increased ICP, increased bleeding, MI's and, as the OP knows firsthand, can even end up causing a Code Blue.

I'm not sure if the "new to ICU" nurse is a factor here, not knowing either Tiger or Cait, and forgive me if I have read you guys wrong but I sensed that in your posts.

Yes, both the nurses and the patient had a crappy day but the patient could have died. I would say that the patient's near-death trumps whatever happened to the staff in the Crappy Day contest. :rolleyes:

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Specializes in NICU.

WindWard,

I'm sorry you think the title of my thread was harsh. My thread title does not define me as a person or especially as a nurse. Having a busy day in the ICU had nothing to do with how I cared for my patient. My patient had been very comfortable all morning. We had just turned her and done PROM on her. That is why she was awake. You do not know any details about this particular patient or her situation. Maybe you shouldn't be so quick to judge.

I hate that I am a member of a forum where I get bashed for venting about my crazy day with crazy patients. How you are so easily able to judge me as a person from it makes me wonder.

I care deeply for my patients and I do everything I can everyday to make sure they are comfortable and pain free.

Cait,

Thank you for your support.

Tiger

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