To code or not to code, that is the question

[icyounurse]

So I work in ICU and last night I took care of this lady who was 84 years old and had come in earlier that morning with acute abdominal pain x 1 week. She was admitted to floor, got shocky with low BP and high HR and very distended belly and was transferred to us. Stat EGD showed lots of impaction and fluid build up. When I arrived to work the night shift we were getting ready to send her to emergency surgery. So I get her to surgery and less than 2 hours later they call and say they are on their way back right now and that things went really poorly. She coded on the table and her bowels and other organs were blue. She had toxic megacolon apparently. Although she had no perfusion which means no O2 sat or BP for over an hour, she was externally paced and vented and had a paced heart rate and a dopplered pulse in her right fem. So they left me with this blue lady, with fixed puplis, no reflexes, flaccid, temp 34.7, no sat or bp. Family(who lives across country and is not here) wants everything done (sigh).Docs come in and write pages and pages of orders and I maz her out on Levophed and Epi drips and start a bicarb drip and push bicarb and transfuse and the whole nine yards. I get the crash cart in the room and wait. And wait. And wait. And somehow, the lady manages to keep a pulse the whole night and of course the heart rate courtesy of the external pacemaker.But thats all she keeps, there is little to no BP and sats only read off and on the whole night. So I figure the docs are all very aware of situation as I have been on the phone with them all night and I think I have done everything I could possibly do. But then an OR nurse who dropped her off comes in to check on her in the morning as I am leaving and cant believe she's still alive. She asks why I havent coded the patient because even though she has a pulse, she isnt perfusing so shouldn't we have coded her??I mean she was nice about it, but I really got a little offended because I had been running my tush off all night and I didnt like her suggesting that maybe I should have been doing things differently.

So my question is should I have coded the lady? The nurse I reported to seemed okay. The docs all knew the situation. Other than standing next to her doing constant CPR the whole night, not sure what else I could have done?? I mean I know that the epi and levophed are the only reason she has a pulse, but still its there. I have never heard of coding a patient strictly to perfuse if a pulse and heart rate and ET tube are in place. Would any of you nurses out there done different in my situation? I am curious and would appreciate all responses.

[Nightcrawler, BSN, RN]

Wow,on so many levels,so many people let you the nurse and this pt down.

A pt with no discernable neuro response, no appreciable b/p w/dead organs is already gone.Only pacer/gtts keeping her clueless body barely plugging away.Your charge should have insisted on a DNR order before the docs left. They(docs) left you in a vulnerable state,they took advantage of you I'm thinking because you haven't been there long.I don't think you can be faulted though. Hopefully you documented well. But you didn't let this lady down,the docs did by rushing her off the OR table so as not to screw up their stats.

And FYI,if you have a pt w/ a pulse who's B/P is less than 50 systolic you can pretty much start CPR on them b/c they will not be perfusing/awake and their rhythm will probably already be deteriorating to a V Tach/fib.

And the OR nurse dropping by with her 2 cents,pretty much uncalled for.

The patient was externally paced with a pulse. There was no indication for CPR as long as the pacer was capturing the myocardium enough to leave a palpable pulse, and CPR is not going to give you any more of a pressure. Pressors on board were doing all that there was to be done- which wasn't much.

[BelleKat, BSN, RN]

The patient was externally paced with a pulse. There was no indication for CPR as long as the pacer was capturing the myocardium enough to leave a palpable pulse, and CPR is not going to give you any more of a pressure. Pressors on board were doing all that there was to be done- which wasn't much.

I agree Nightcrawler,I wasn't saying that this pt would have benefited from CPR. I'm just saying that in other pts that you do have to take the B/P into account when deciding to do CPR. It would be very rare to do CPR on a pt with a pulse. You're pretty much doing CPR as the pulse is going away.