Respiratory Arrest Protocol?

[Apedro]

I've been working about 1 month and had my experienced my first code I work nights at a specialty hospital. The patient had COPD and new onset Type 2 DM. As soon as I got on shift I was told by the RT that she was desating into the 70s and that the doctor who was still present had ordered solu medrol. I gave the med and the RT had the patient on venti 40%. Throughout the night she would desat, the RT would give treatments (3 total - I'm ify about the 3rd - I checked on the patient at midnight and she was saturating at 85, I told the RT - RT said she would put her on the venti at 40, if she got up to 89 she would put her on 3L (which is what the patient was currently on) and if she didn't then she would put her on BiPap). The patient coded at 0018 - ended up in the ICU...she survived. She was found in the room with her venti mask to the side of her face and the O2 pulled from the wall.

After the code, the MD was angry (of course) and wanted to know why the ABGs weren't done. My questions are: Was there something else that should have been done? Is collecting ABGs something that is protocol when any patient desats and what do we do when we get the results? I know COPDers saturate low, but how low is normal (the highest reading I got was 90%)? I don't think she should have been on 3L (I think I remember in school, they said no more than 2L) because too much O2 shuts down the respiratory response in COPDers. The MD also said he told RT to put the patient on BiPap; should the patient have been on BiPap from the start? Her sugars were also high (533 at 2000 - I gave insulin, and 437 at the time of the code - taken by the CNA right before she yelled for help, when the patient was diagnosed her sugar was over 900). Could the high sugars have something to do with the code? Is there a difference in protocol for COPDers and non-COPDers?

Thank you for your responses in advance. Thank God she survived but I was scared. I want to know if there is anything I should do different in the future to prevent a code.

[HouTx, BSN, MSN, EdD]

Live and learn, right?

You need to follow (in order of priority) physician orders --> approved medical protocols/standing orders --> organizational policy & procedures. Based on the information provided, the patient's condition should have triggered a Rapid Response Team at the very least. If your patient's condition is changing, you have a duty to notify the physician. If you do not get an appropriate response, you need to go up the chain of command. Although RTs may be highly expert, do not ever assume that they have the authority to direct your actions.

From a physiological standpoint, the amount of time it takes for oxygen to decrease resp drive on a COPD patient is much longer than you think... it is not a consideration when the patient is in a crisis situation. You may want to take some time to review the multi-system impact of DM crises, systemic response to pH changes, etc. The value of ABGs in this situation? They would have provided insight into pH status. Also, FWIW, it is always a good idea to check BS on a DM patient who is experiencing any type of major change.

You'll do much better next time.

[VANurse2010]

Agree with the above, but wanted to note that many, many, many, MANY hospitals do NOT have rapid response teams. The primary nurse is it. RR is often taken for granted on this forum, but it simply doesn't apply in many institutions.

[Apedro]

As always, thank you HouTx, and yes VANurse we do not have a RR team.

[Altra, BSN, RN]

The physician's comments do make me wonder if the protocol / standing orders include an ABG (which they should) so he didn't feel he had to additionally order it. You need to know this -- ask a charge nurse, unit educator, or a nurse who precepted you ASAP.

And as an acute care nurse, please, PLEASE forget whatever bunk you may have learned in school about "too much O2" for COPDers. If a patient is in distress -- they need O2. Nothing good comes from hypoxia. And the SpO2 does not tell the whole story -- even without an ABG, what did the patient look like? Respiratory rate/effort, color, etc. These things can indicate the need for further respiratory interventions just as much as/more than an SpO2 number.

It also sounds like the hyperglycemia was not being treated aggressively enough. If the "initial" blood sugar had been 900, is there a reason an insulin gtt was not started?

When you have some free time -- do a simple search for "nursing myths" or "nursing sacred cows". The COPD/O2 myth will come up and you can get some direction for some further reading on the topic.

[GoBlueGirl15]

Even if you don't have a RRT or a standing order for ABGs, you can be the one to initiate the order for ABGs. Especially if your pt is having continuing respiratory issues, you would want to know if it's an acid/base problem. And if you find your COPD patient to have a decreased level of consciousness, your first thought should always be respiratory acidosis and you'd need to check an ABG to confirm.

Sometimes you have to drive the boat, you know?

[Apedro]

Altra, yes the patient was a an insulin gtt when she was first diagnosed at the hospital, by the time she was admitted to the specialty hospital where I work she was no longer on the gtt. Thank you for the topic suggestions, I will look them up. :)

thank you GoBlueGirl15 :)