Patient Death After Shift

[Dani_Mila, BSN, RN]

Background story: Received a pt who came up to the unit (progressive care unit/ telemetry) an hour before start of shift. He came in with NSTEMI, was on hep gtt, Venturi mask (non compliant with home CPAP). No significant cardiac PMH, just BPH, HTN and something else (couldn't recall).

Story: 

Pt came up in the ED just about an hour before I came. Pt was going in and out of A-fib with HR going up to 120s and 140s from report. I also observed it going up to 120s during change of shift. This has been addressed as pt had scheduled orders for BP meds. MD aware that he was going in and out of A-fib per day shift nurse. Pt was asymptomatic. He was on venturi mask with 50% FIO2 from the report it's because he did not want to use the CPAP and he is a mouth breather when he sleeps. He was non-compliant with his home CPAP. Pt came in for NSTEMI and was on hep gtt. Was made NPO for possible cardiac cath, no orders for NPO yet but I did tell the pt that just in case they send him the next day. Cardiologist was already consulted. During med pass, pt's HR was in low 100s, asymptomatic no CP. He received his night meds (metoprolol, flomax, lipitor, remeron), SBP in mid 100s that was his trends. There were 2 orders of metoprolol, an IVP and PO. I didn't give the IVP because per parameters. I asked him if he takes metoprolol or BP meds at home and he said yes he believe so, but does not recall dosage. He also takes his flomax as well at night. After he was medicated, he went back to sleep. He requested his CPAP on and off a few times because he felt uncomfortable with it. At midnight he was scheduled for metoprolol IVP, I rechecked his BP and it was in the mid 90s, HR normal and pt was in SR. I asked if he would like to go back on his CPAP and he said OK. I placed him on it and left. 

During rounds check at almost 2AM, I saw him sitting at bedside, diaphoretic and he felt uncomfortable. He was asking for a fan and I said we do not have it, but we do have ice packs which I can give him. He declined. I asked him if he wakes up in the middle of the night sweating like this before and he had said yes. He requested his CPAP off, venturi mask was placed back. I checked his BS and it was in the 190s. I checked his VS, pulse ox was good but he was hypotensive with SBP in the 70s. I asked him if he was having CP and he said no. I grabbed the manual and got one SBP in low 80s. Charge nurse came in to help out. I messaged the on-call doctor and got an order for EKG, trops, and 500ml bolus. I asked her if she would like to give him 1L instead. She said there is a concern that he is going into HF so she does not want to fluid overload him. EKG was read and she stated all normal. We started him another IV access for the bolus and drew more labs (on-call doctor ordered more labs for pt) . On-call doctor added the hospitalist and I believe she left the conversation. The hospitalist was asking a lot of questions instead of reading the previous conversation. Pt was still hypotensive despite IV fluids and symptomatic. Told the hospitalist that pt will be RRT, hospitalist had no objection.

RRT was initiated, all that was done was listed on the board. Pt was still hypotensive his SBP dropped again to 70s, desaturated in the 80s on the Venturi mask, RT said to place him back on his CPAP. Gave verbal report to the ICU PA notified her of why the pt was here, what happened, and what was already done for him. She ordered more lab work including lactic acid and another 500ml bolus. Troponin came back and it was in the 2K (he came in with trops around 5K) **Our trop levels are not by decimals. ICU PA stated that his troponin levels was going down so that was good. She assessed the pt. I did point out that his d-dimer result came back and it was slightly elevated from the previous result. ICU PA wasn't too concerned about it. Pt reported to ICU PA that he is now complaining of slight CP he stated 2/10. He stated it was the same CP like he had before coming to the ER, still diaphoretic, but AAOx4. We checked what meds were given to him last time, according to the ICU PA she thinks it was the metoprolol that was given to him that caused his severe hypotension. ICU PA wanted to keep the pt in our unit instead of bringing him to ICU. She thinks once the medication wears off his BP will go back up and to let the fluids infuse. ICU PA did lower his metoprolol dose, discontinued metoprolol IVP and I believe she d/c Lisinopril as well. Once they left, he was still complaining of pain and I gave him PRN Tylenol. He had PRN nitro but I can't give him that due to his hypotension. The bolus was finished and SBP went up in the mid 80s with MAP > 65. I messaged the PA and updated her on pt's pain and low BP. I asked her if there is something else we can give him for his pain. Pt was still complaining of 2-3/10 CP. I reported that I only gave him Tylenol. She said to wait and see if that works because we can't give him morphine or nitro due to hypotension. She also did not want to give him any more fluids and she stated she is OK with his BP as long it as the MAP is > 65. I reassessed the pt's pain and he said it was a little bit better 1/10. He asked if I was done because he wanted to go to sleep. His SBP was still low in the mid 80s, no longer diaphoretic, and didn't complain of further CP. I stayed with the pt until 6AM for close monitoring. His repeat trop value came back and it was down to approx. 1K. All his labs came back normal with kidney levels slightly elevated, lactic acid was normal. No further complaint of CP. Then, it was shift change, I gave verbal report to oncoming nurse. I stayed for an hour to finish documenting. Before I had left, the oncoming nurse was doing another EKG per order on that pt probably by the cardiologist, and was conversing with him. I was off for a few days.

After a few weeks, I had found out that pt was sent to cardiac cath that day (different hospital) and had died. I was notified that management would like my input and it will be a "learning opportunity". It is not mandatory, but now I feel inclined to join the meeting. Now, I feel so anxious and depressed. I keep playing the scenario over and over in my head thinking have I cause this pt's early demised? What could I have done differently? 

[offlabel]

Tough deal. As to the metoprolol, its pretty much beta 1 selective so if the HR wasn't in the tank, I wouldn't say his hypotension was due to that. You don't mention when his last dose was, but you don't mention bradycardia either. RVR Afib can cause demand ischemia and a fall in stroke volume and a fall in BP so controlling the HR in a situation like that would be important. Doesn't sound like his HR was really high during most of that but cardioversion is an option if it were. What I mostly don't understand is why they were pounding him with volume when the first bolus didn't seem to do anything, unless I missed something. Starting an inopressor like nor epi would have immediately stabilized this guy. My $ 0.02

Any you're not the reason for this guy's death.

[hppygr8ful, ASN, RN, EMT-I]

I think  you did everything you could do! On thing I have learned over the years is that when it's your time, It's your time. I mean you could have flogged the patient into a heartbeat and maybe even kept him alive to be placed in ventilated limbo but I don't want that for myself. I plan to die at home and if I have the strength I plan to quietly swim out to sea.

Hppy

[offlabel]

Oh, and a  surface echo on admission to the ICU would have answered a lot of questions.

[Dani_Mila, BSN, RN]

The dose was metoprolol 25 mg and when the medication was given his HR was in low 100s. Throughout his stay, pt did not have bradycardia. Also, I even asked the ICU PA if they will take him as we can't give pressors in my unit. I spoke to my charge nurse that night and I asked her too as to why can't they take him to ICU. Unfortunately, I don't make the call but the ICU PA. Although, I kept updating her on his low BP.

[offlabel]

Yeah, they had they're reasons for not taking him, and they had nothing to do with you. 

[heron, ASN, RN]

I want to second offlabel's remark that you're not the reason the patient died. Everyone dies - you don't get to control that.

As a high-acuity nurse, your goal must be to prolong life in the hope that meaningful recovery is possible. You use your knowledge, skills and best judgement to reach that goal. Self-reflection and debriefing, including taking responsibility for mistakes, are how you learn from experience and refine your judgment. However, blaming yourself for a death is like blaming yourself for the sun going down at night. The best you can do is all you can do.

[TiredNurse2]

You are not the reason he died. Metoprolol is reasonable for a-fib. When the first bolus was ineffective, he should have just been started on a pressor. You intervened the best you could, you had the PA and everyone you could get to bedside. The events that followed had nothing to do with your care. You advocated for him your entire shift, they should have sent him to ICU, but he still may have died. We can't save everyone. 

[Candy999]

Well. He died because of MI as I understood. You do not know what happened in a different hospital during cath. Could be anything really.

As I understood pt had MI that was unrecognized d/t his trop/EKG was negative. For MI you can only do cath, which is not even done in your hospital. I do not see what you could do differently since you did not have correct diagnosis and correct orders. The corrrect order in this situation should have been emergency transfer to Cath lab

[Dani_Mila, BSN, RN]

Just found out that the PT was stabilized in my unit, then was sent to cardiac cath in the afternoon. He had cardiac cath and post cath that's when he coded. This happened at a different sister hospital. Also, I wasn't able to attend the meeting. My Internet was acting up and I did not have any connection to attend the meeting.

[delrionurse]

It seemed there was a lot going on with the patient.  Since you did not give the IVP, but gave the Metoprolol 25mg PO, I highly doubt it was the Metoprolol. It seemed to be indicated. So this ICU PA says the severe hypotension was due to the Metoprolol? PO? I couldn't accept that hogwash. If the parameter by the PA was keep MAP over 65, then OK. 

But for the bp to tank like that seems unusual. To me diaphoresis w/ other equals cautious for heart attack. 

It seemed you monitored the patient, called RRT, and intervened for the patient. I'm not sure what meeting you have to attend since you took all the necessary steps to keep the patient stable. 

Patients do code in the cath lab.

[Popping Pony, BSN, RN]

I agree with the others. Try detach  and leave it behind. Take care!