Nrp

BittyBabyGrower, MSN, RN · Nov 23, 2004

Looks good in the book, but in my experience, we aren't counting out loud..we bag and compress and get the heck out of there ASAP. It's hard to count and run at the same time too.

Jolie, BSN · Nov 23, 2004

Question....
When you are doing chest compressions and ventilating a baby, is it always by NRP guidelines? Let me be more specific... NRP says: one and two and three and breathe.....and one..
But is that always the case? I don't want to give too many details but I saw a nurse give continuous ventilations without pausing for the compressions. NOW... I have thankfully not been involved in a neonatal code that involved chest compressions until a few days ago... and as a Labor nurse who has only been in the field for 1.5 years, I am probably still very idealistic. I just want to hear from some more experienced nurses about how it's done out there. It just makes sense to pause and have a well-coordinated effort with compressions and ventilation. I mean, if you are compressing, are your ventilations going to be very effective? I realize that if the baby is intubated and has a dedicated airway then it might not be so critical... BUT... Let me stop and hear from some more experienced nurses! Thanks in advance! T.

Most codes do not run like a well-oiled machine, even with very experienced practitioners! While it is desirable for the person giving compressions to pause for ventilation, it just doesn't always happen.

I believe there is research that indicates that pausing for ventilations is more important when a patient is being bag and mask ventilated, than if the patient is intubated. Also, if an O2 sat monitor is available, and can be quickly applied, that may help to assess the effectiveness of compressions and ventilations.

SheaTab · Nov 23, 2004

Let me add here that this particular instance was bag and mask.

Jolie, BSN · Nov 23, 2004

Sounds like the baby needed a tube. If the baby didn't respond (with an increased heart rate) after a minute or so of bag and mask ventilations, then a more reliable airway was probably needed.

I know you want to be careful, but can you add any other details?

SheaTab · Nov 24, 2004

Sounds like the baby needed a tube. If the baby didn't respond (with an increased heart rate) after a minute or so of bag and mask ventilations, then a more reliable airway was probably needed.
I know you want to be careful, but can you add any other details?

The strip (G1P0) was completely beautiful... FSE, good beat-to-beat. Then all of a sudden heart tones dropped to the 60's. Luckily the MD happened to be at the bedisde because we were talking about using forceps at the time because she had been pushing for some time. Quickly delivered the baby and the baby was flaccid, white, apneic... started ventilations... no heartrate... started compressions and ventilations. NICU arrived at the bedside 3 minutes into the code and intubated the baby and took over care.

Our best guess is AFE. Mom is fine after ICU stabilization and 7 units of blood. An absolute miracle! But baby is not so lucky... at this point, intubated, multi-organ failure...considering dialysis... Please put this beautiful family on your prayer list, if you don't mind.

I have been in absolute shock over this. This is the worst thing I have ever experienced in OB. I have a question though... As you can imagine.. with mom losing so much blood and the baby and near mom code, the room was a wreck... I was extremely busy with heavy interventions for more than four hours (central line start, blood on pressure bags, fluid,

Thanks!

PLEASE, if you can, pray for this precious family.

Jolie, BSN · Nov 24, 2004

My heart goes out to all of you!

I understand and sympathize with your legal concerns. I have been fortunate to never experience anything so completely overwhelming for both mom and baby.

In the codes and emergency situations I've dealt with, we've always tried to get a "recorder" to the bedside ASAP. That alone becomes a full-time job. Afterward, it is also helpful to sit down with the chart and all the participants (docs, nurses, consultants, RTs, etc.) in order sort thru documentation, orders, etc. and make sure that the medical record is as complete and accurate as possible. It also serves to "debrief" everyone. Your risk management department should be involved as well. And not to scare you, but if you carry personal Liability Insurance, it is probably a good idea to notify them of the situation. I do not mean to imply that the patient or family will sue, but anytime there is an event that may lead to litigation, it is best to get all your thoughts and recollections written down ASAP. Imagine trying to piece this all back together 2 or 3 years from now!

Finally, in my experience, whether a patient /family chooses to sue may have more to do with how they are treated after the event than whether any malpractice actually occured. A number of years ago, our OB unit had the misfortune of having 2 fetal demises (during L&D) on the same day. Without giving too much information, let me say that in one case, the physician made a tragic error in judgement which likely cost the baby's life. He went to the parents immediately, told them the truth, and genuinely grieved with them. They accepted his explanation and never sued.

In the other case, the patient came in in a crisis, and there was probably never any hope of saving her baby. But her doctor, who lacked communication skills, never sat with her, never explained anything, and pawned her care off on an associate. He was sued, even though he did not do anything medically wrong.

Please seek out this family and offer your genuine concern. And seek guidance from your manager and experienced nurses on your unit as to how you can work on documentation in future emergencies. I know you provided the best care possible, and it may be that your assessments and early interventions are what saved this patient's life.

Prayers to you all.

SheaTab · Nov 24, 2004

Thank you Jolie for your hearfelt response and helpful advice. This is never easy... but in a unit of our size... one of the biggest in the country, we see more than our fair share of scary situations. I love this board... Thanks again.

palesarah · Nov 24, 2004

I haven't been in a situation as awful as you patients' (who will be in my prayers!) but we were going over code situations recently at work. We decided that anytime there are that many people involved with one pt's care- whether it is an official "code" or not- the main nurse should delegate recording to one person. Have one person write everything that happens when it happens, and when people come, go, and are called/paged.

We realized, in going over recent "near codes", that 2 or 3 people would run to initiate the same task, leaving other tasks undone. Looking deeper it looked like the reason no one knew who was doing what/when, was we didn't always have a recorder and someone (even the recorder, if not the main RN) delegating tasks or ensuring that everything that needs to be done is being done by the proper people to do it.

I'm a bit sleepy, so if that didn't make a whole lot of sense, I'm sorry!

KRVRN, BSN, RN · Nov 25, 2004

It sounds like the bag/mask respirations and chest compressions were accidently unsynchronized. I did see one code in the NICU where it was an already-intubated tiny preemie that had already been on high frequency ventilation and during the code they inflated the PEEP to about 15-20 (instead of 5-6) and then gave mulitple continuous tiny breaths even during the compressions. Rationale was that it approximated the HIFI ventilations. I had my doubts at the time but it didn't really matter too much because the baby had a poor outlook in the first place. The baby died.