how quickly someone can go downhill.

Published

Always listen to your gut.

I had a patient who I'd had the previous night, and he had been complaining about not getting much sleep. I got him comfy, got him in a recliner, gave him some coffee and a blanket, he slept, had a ok night. That AM before leaving, I was running a little behind, and he gave me a hard time, saying "hey, you're supposed to be home by now!".

When I came back that night, he was ok, his wife was there nd she was going home. He was being moved to a private room, and I checked his 02 while walking, it was good.

The cardiologist wanted him to get some IV fluid due to a low bp during the day, and a little dizziness. I hooked him up, and over a hour he got a 100 mls. He called me because he was feeling short of breath, and his lungs sounded a little tight. I spoke with his doc and his cardiologist, got 40 of Lasix, gave him that, and told myself I'd be back in 10 minutes.

I came in, and he had just called me.

He was GREY, and sats of 88. Called the rapid response, got some help, he kept saying he was going to pass out, we got him back to bed, called the docs.....etc. etc. gave him another 40 of lasix, got him to the ICU. We hooked him up to the ICU monitor, he coded right away. got him back, coded again(shocked twice). I was there for 2.5 hours while we coded him 5 times, got him to the cath lab, and he coded 2 more times. Ultimately died on the cath lab table.

Figured out he had another MI(he had been admitted with one, and had a balloon pump with a regrafting 4 days prior).

I know I did everything I could, but it still upsets me. I've been taking care of patients for 5 years and have never had anyone code like this before. Just putting this out there. I hope his family finds peace.

Specializes in CCT.
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whether it was lasix or ntg, both could make you hypotensive.

and, ntg could have been better choice IF pt was hypertensive at the time.

we don't know, but do know his bp had been down earlier in the day.

agree about fluid redistribution vs overload, but your links (usalsfyre) weren't convincing, didn't prove anything.

couldn't make heads or tails over your 3rd link.

lasix iv has quick onset, as does ntg iv.

it was a crapshoot, either drug could have been effective...or not.

there isn't anything written in stone about acute mgmt.

op, you were right on top of it all.

it was his time.

leslie

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Your first study listed not only has small study size, but the abstract is misleading. The majority of patients did not meet inclusion criteria because they either improved with diuretic therapy or had too low of ABP. Of those that were included in the study that DID NOT respond to INITIAL treatment with diuretics, high dose nitro improved outcome.

The second article clearly states that there are two fundamental types of heart failure. By the sound of their descriptions, the OP patient had acute decompensated cardiac failure, the hallmark of which is low/low normal blood pressure. While the authors state that high dose vasodilators have shown promise, the studies quoted had patients initially treated with diuretics! The patients who were administered high dose vasodilators failed to show an increase in survival (p=0.61). Furthermore, high dose vasodilators in patients with low ABP will decrease CPP.

Lasix has an onset of action of about 5 minutes, not 15-30. Regardless of etiology, pulmonary congestion is an indication for diuretic therapy.

The OP DID indicate that the patient was hypotensive prior to the arrest, hence why IVF was administered. It is very possible this contributed to increased preload, and when combined with LV dysfunction, easily causes pulmonary edema.

I guess my point is that you act like another medication was a better choice and may have changed the outcome of this patient, but the current research doesn't support that claim.

http://www.ncbi.nlm.nih.gov/pubmed/17447137

I could list more studies, but I will leave that to you and other readers to read and decide on your own, instead of critiquing clinical decision of another nurse based on personal preference, not evidence based medicine.

Maybe a randomized double-blind placebo trial will come out proving diuretics are inferior to vasodilators, and then I will eat my words : ) Right now that is not the case.

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Specializes in Thoracic Cardiovasc ICU Med-Surg.

Dear OP,

I am sorry this happened. Sadly, even when we do everything right, sometimes people just die. I also work in TCV and I know firsthand how fast a patient's condition can turn on a dime.

After a bad code, I find I really have to center myself to be fully in the present moment I am working, otherwise I would go over and endlessly second guess myself and everyone else.

You sound like a good nurse. :)

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Specializes in Ortho, Neuro, Detox, Tele.

thank you again to all who have responded. After a few shifts away, I realize that there was not much more I could have done. your kind words, and attempted argument over treatment of choice, were what I needed to hear. I would ask though that the study argument people please make a new thread vs highjacking mine? I think I've made my peace with this. Please close the thread. and thank you all again, you great people of an.com!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

That's OK I got the joke!!!!! :lol2::lol2::lol2:

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thank you again to all who have responded. After a few shifts away, I realize that there was not much more I could have done. your kind words, and attempted argument over treatment of choice, were what I needed to hear. I would ask though that the study argument people please make a new thread vs highjacking mine? I think I've made my peace with this. Please close the thread. and thank you all again, you great people of an.com!

I think you did the best you could. Even after nearly a decade, when I have a pt crump, I am left shaking like a leaf after the dust settles.

It gets better, quit second guessing yourself. No one on this BB was there, none of us know the entire clinical picture like the you or the doctor who was making the orders.

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