Vent: CV pt that should have gone back to OR (long)

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Specializes in CVICU, CCU, MICU, SICU, Transplant.

Had a horribly night a few days ago:

My only patient:

Came on shift at 7pm, got a pt who just arrived 30 min ago s/p a triple-jump cabg, 80 y/o male (ugh). A day prior had a cardiac cath; interventional cardiologist was unable to cross the lesions despite multiple attempts and even partially perf'd his LAD. Was on Reopro prior to surgery. H/x of HTN, CAD, DM.

Went to surgery, had a long pump run, massive bleeding in OR, multiple blood products/fluid, difficult to separate from bypass per OR team, required an IABP and high dose drips.

Unstable on arrival to my unit, bp 70-80's, filling pressure low per the Swan, AV paced rate 90 with the epicardial wires, IABP 1:1, gtts= Epi, NTG, Insulin, Dopamine, Milrinone, propofol. Mediastinal output on arrival ~ 500 cc's. Left pleural chest tube found to be "out" on arrival to ICU (apparently wasnt sutured in good enough lol ). OR team/anesthesia pushing their syringes of Neo, Vaso, calcium, & hanging 500 ml albumin and their last remaining blood products that they took with them.....get his pressure up to a modest 90's and then run for the hills. Attending MD @ the bedside, nods, gives me a pat on the back, smiles, takes off too. I'm left alone with the resp therapist and the CV Fellow, and a few of my nurses.

Over the next few hours, bp 60's - 80's, about 200-400 cc's q 1/2 hr out the mediastinal. Fellow making multiple attempts to reinsert the left PCT, finally gets it in. 600 cc's out right away. Hanging blood and albumin like its going out of style. Dont have time to chart anything I'm doing. Started Levo and Vaso. BP ranging from 60-200 systolic, all over the map. The Fellow barking orders and cursing at me and the charge nurse; titrating all of the drips q 3-5 min. I kept on telling the Fellow that making such drastic changes so frequently is just going to put us in a neverending cycle, and that we NEED TO GO BACK TO OR. But no. I'm running RBC's, platelets, cryo, pushing novoseven. BP down to 50's-60's, now pressure bagging fluid and blood along with running fluid/blood thru the rapid infuser. Cant keep up with the pt's demand. Vent on +10 peep. Changing out all the pleur-evacs, already filled up, only been a few hours since arrival. Fellow calls the attending, trying to get the pt to back to OR. The attending says no, keep doing what we're doing!!!! I can't believe it!!! Family outside the unit, getting more freaked out by the minute (as they should). Charge nurse pulls in another nurse to make my patient 2:1. Then the pt's BP drops to the 30's, then lose the Aline waveform, barely any palpable pulse, push an amp of Epi, get a pressure back again.

This goes on an on till 1 AM. Relentless cycle of dialing up the drips, giving blood, dialing the down the drips, and giving more blood. Still no one wants to take this dude back to OR. I'm ready to scream. Then, magically, my hemodynamics "stabilizes" at a grand total (6 hr point) of: 20 units RBCs, 8 platelets, 6 FFP, 6 cryo, 4 novoseven's; NS ~ 3000 cc's; Albumin ~ 4000 cc's. Epi @ 0.17 mcg/kg/min, Levo @ 0.2 mcg/kg/min, Vaso 0.03 units/min, NTG off, Milrinone 0.3 mcg/kg/min. CT output ~ 5 liters total, draining ~50 cc's/hr now. Electrolytes and calcium are in the toilet. Pt is 3rd spaced beyond belief. Lungs are soaking wet. Urine output total ~ 200 cc's. Havent had a chance to even do a focused head->toe assessment till now.

.....this pt should have gone back to surgery the minute he rolled into the unit. Just my humble opinion. :D

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Specializes in Adult Critical Care/Neonatal ICU.

Wow! That sounds like a horrible night. It sounds like you rocked and did what you could do. :yeah: Did he survive and/or go back to surgery?

I've been back on nights for 2 years (after 9 years on day shift) and feel that it is very hard to get the doctors to realize just how critical the patient is. Usually if I had a super critical patient during the day and couldn't get the doctor to listen, another doctor would come around and call the physician himself and basically say what I had been saying. Then, "all of a sudden", the patient was really sick and I got all kinds of orders. It just feels that you are "on your own" at night. What makes it worse, is I work weekends. I can't tell you how many times I've heard, "Maybe we will do that on Monday.", or "I'm just covering. I don't really know the patient." :banghead:

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Specializes in CVICU, ICU, RRT, CVPACU.
Had a horribly night a few days ago:

My only patient:

Came on shift at 7pm, got a pt who just arrived 30 min ago s/p a triple-jump cabg, 80 y/o male (ugh). A day prior had a cardiac cath; interventional cardiologist was unable to cross the lesions despite multiple attempts and even partially perf'd his LAD. Was on Reopro prior to surgery. H/x of HTN, CAD, DM.

Went to surgery, had a long pump run, massive bleeding in OR, multiple blood products/fluid, difficult to separate from bypass per OR team, required an IABP and high dose drips.

Unstable on arrival to my unit, bp 70-80's, filling pressure low per the Swan, AV paced rate 90 with the epicardial wires, IABP 1:1, gtts= Epi, NTG, Insulin, Dopamine, Milrinone, propofol. Mediastinal output on arrival ~ 500 cc's. Left pleural chest tube found to be "out" on arrival to ICU (apparently wasnt sutured in good enough lol ). OR team/anesthesia pushing their syringes of Neo, Vaso, calcium, & hanging 500 ml albumin and their last remaining blood products that they took with them.....get his pressure up to a modest 90's and then run for the hills. Attending MD @ the bedside, nods, gives me a pat on the back, smiles, takes off too. I'm left alone with the resp therapist and the CV Fellow, and a few of my nurses.

Over the next few hours, bp 60's - 80's, about 200-400 cc's q 1/2 hr out the mediastinal. Fellow making multiple attempts to reinsert the left PCT, finally gets it in. 600 cc's out right away. Hanging blood and albumin like its going out of style. Dont have time to chart anything I'm doing. Started Levo and Vaso. BP ranging from 60-200 systolic, all over the map. The Fellow barking orders and cursing at me and the charge nurse; titrating all of the drips q 3-5 min. I kept on telling the Fellow that making such drastic changes so frequently is just going to put us in a neverending cycle, and that we NEED TO GO BACK TO OR. But no. I'm running RBC's, platelets, cryo, pushing novoseven. BP down to 50's-60's, now pressure bagging fluid and blood along with running fluid/blood thru the rapid infuser. Cant keep up with the pt's demand. Vent on +10 peep. Changing out all the pleur-evacs, already filled up, only been a few hours since arrival. Fellow calls the attending, trying to get the pt to back to OR. The attending says no, keep doing what we're doing!!!! I can't believe it!!! Family outside the unit, getting more freaked out by the minute (as they should). Charge nurse pulls in another nurse to make my patient 2:1. Then the pt's BP drops to the 30's, then lose the Aline waveform, barely any palpable pulse, push an amp of Epi, get a pressure back again.

This goes on an on till 1 AM. Relentless cycle of dialing up the drips, giving blood, dialing the down the drips, and giving more blood. Still no one wants to take this dude back to OR. I'm ready to scream. Then, magically, my hemodynamics "stabilizes" at a grand total (6 hr point) of: 20 units RBCs, 8 platelets, 6 FFP, 6 cryo, 4 novoseven's; NS ~ 3000 cc's; Albumin ~ 4000 cc's. Epi @ 0.17 mcg/kg/min, Levo @ 0.2 mcg/kg/min, Vaso 0.03 units/min, NTG off, Milrinone 0.3 mcg/kg/min. CT output ~ 5 liters total, draining ~50 cc's/hr now. Electrolytes and calcium are in the toilet. Pt is 3rd spaced beyond belief. Lungs are soaking wet. Urine output total ~ 200 cc's. Havent had a chance to even do a focused head->toe assessment till now.

.....this pt should have gone back to surgery the minute he rolled into the unit. Just my humble opinion. :D

With the exception of the idiot fellow griping at you all night, that sounds like a pretty typical night in CVICU :D. Im fortune in that regard. We dont have fellows. That patient should have went back to OR after the 6th unit of PRBC's after all your coags were stabilized. 20 units of PRBC's is BS. If that patient makes it out of CVI, I see a trach/PEG/and a LTAC in his future. Just think of all the experience you gained from that situation.

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Specializes in CVICU, CCU, MICU, SICU, Transplant.

The next night I worked, the pt was still alive and relatively stable vital sign-wise. Kidneys took a huge hit, obviously, after all that. CVVHD is likely in the very near future. Neuro status was questionable....sedation was off for a while, pt only thrashes around in the bed, doesnt follow commands. Bleeding stopped. Plans of extubation not even being considered at this time; was told that the CXR looks awful. ABG not so good... PO2 was only about 70 on 80% FiO2, +8 peep.

Thus, looks like we will have another long term "guest" in our unit. Trach will most likely happen in a week if things dont improve.

I should mention that most of our patients dont come out this bad, nor do we have such poor management from the docs. I've cared for quite a few unstable CV patients, but this one will certainly be memorable :nuke:

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Specializes in CVICU, ICU, RRT, CVPACU.
The next night I worked, the pt was still alive and relatively stable vital sign-wise. Kidneys took a huge hit, obviously, after all that. CVVHD is likely in the very near future. Neuro status was questionable....sedation was off for a while, pt only thrashes around in the bed, doesnt follow commands. Bleeding stopped. Plans of extubation not even being considered at this time; was told that the CXR looks awful. ABG not so good... PO2 was only about 70 on 80% FiO2, +8 peep.

Thus, looks like we will have another long term "guest" in our unit. Trach will most likely happen in a week if things dont improve.

I should mention that most of our patients dont come out this bad, nor do we have such poor management from the docs. I've cared for quite a few unstable CV patients, but this one will certainly be memorable :nuke:

ITs happens to us all. Good Docs, Bad ones.............they all have their days. I live in an area that according to national STS data gets very very sick patients in comparison to the rest of the nation. This is due to comorbidities and people not seeing a dotor until they are 80. We have one of the top CT surgeons in the country who worked with Dr. Michael Debakey since the time he was about 14. He often takes cases that other docs write off as inoperable. Most of the time this guy performs miracles and saves these people, however once in awhile they go like you just described. Sometimes our unit is full of long term patients from this type of event and we have nowhere to put the new bypass patients. Its crazy.

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I've Had Those Days.....you're Opening Statement In Your Notes Is "report Taken. Pt Coding" And Then Your Ending Statement Is "report Given, Pt Coding"!

I Think Overall, The Advantage Of A Smaller Hospital Is That The Docs Take These Patients Personally. They Only Want (and Allow) The Best Of Us To Take Care Of Their Patients. And They Do Everything They Can To Get The Best Outcome. I Have Never Had One Of Our Cv Surgeons Refuse To Come In And

They Really Do Want Us To Call If We Feel Things Are Not As They Should Be!

And Though I Would Imagine It Would Be Helpful To Have Fellows And Residents In House At All Times, Sometimes They Are More Trouble Than They Are Worth!

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Specializes in Critical Care.
Had a horribly night a few days ago:

My only patient:

Came on shift at 7pm, got a pt who just arrived 30 min ago s/p a triple-jump cabg, 80 y/o male (ugh). A day prior had a cardiac cath; interventional cardiologist was unable to cross the lesions despite multiple attempts and even partially perf'd his LAD. Was on Reopro prior to surgery. H/x of HTN, CAD, DM.

Went to surgery, had a long pump run, massive bleeding in OR, multiple blood products/fluid, difficult to separate from bypass per OR team, required an IABP and high dose drips.

Unstable on arrival to my unit, bp 70-80's, filling pressure low per the Swan, AV paced rate 90 with the epicardial wires, IABP 1:1, gtts= Epi, NTG, Insulin, Dopamine, Milrinone, propofol. Mediastinal output on arrival ~ 500 cc's. Left pleural chest tube found to be "out" on arrival to ICU (apparently wasnt sutured in good enough lol ). OR team/anesthesia pushing their syringes of Neo, Vaso, calcium, & hanging 500 ml albumin and their last remaining blood products that they took with them.....get his pressure up to a modest 90's and then run for the hills. Attending MD @ the bedside, nods, gives me a pat on the back, smiles, takes off too. I'm left alone with the resp therapist and the CV Fellow, and a few of my nurses.

Over the next few hours, bp 60's - 80's, about 200-400 cc's q 1/2 hr out the mediastinal. Fellow making multiple attempts to reinsert the left PCT, finally gets it in. 600 cc's out right away. Hanging blood and albumin like its going out of style. Dont have time to chart anything I'm doing. Started Levo and Vaso. BP ranging from 60-200 systolic, all over the map. The Fellow barking orders and cursing at me and the charge nurse; titrating all of the drips q 3-5 min. I kept on telling the Fellow that making such drastic changes so frequently is just going to put us in a neverending cycle, and that we NEED TO GO BACK TO OR. But no. I'm running RBC's, platelets, cryo, pushing novoseven. BP down to 50's-60's, now pressure bagging fluid and blood along with running fluid/blood thru the rapid infuser. Cant keep up with the pt's demand. Vent on +10 peep. Changing out all the pleur-evacs, already filled up, only been a few hours since arrival. Fellow calls the attending, trying to get the pt to back to OR. The attending says no, keep doing what we're doing!!!! I can't believe it!!! Family outside the unit, getting more freaked out by the minute (as they should). Charge nurse pulls in another nurse to make my patient 2:1. Then the pt's BP drops to the 30's, then lose the Aline waveform, barely any palpable pulse, push an amp of Epi, get a pressure back again.

This goes on an on till 1 AM. Relentless cycle of dialing up the drips, giving blood, dialing the down the drips, and giving more blood. Still no one wants to take this dude back to OR. I'm ready to scream. Then, magically, my hemodynamics "stabilizes" at a grand total (6 hr point) of: 20 units RBCs, 8 platelets, 6 FFP, 6 cryo, 4 novoseven's; NS ~ 3000 cc's; Albumin ~ 4000 cc's. Epi @ 0.17 mcg/kg/min, Levo @ 0.2 mcg/kg/min, Vaso 0.03 units/min, NTG off, Milrinone 0.3 mcg/kg/min. CT output ~ 5 liters total, draining ~50 cc's/hr now. Electrolytes and calcium are in the toilet. Pt is 3rd spaced beyond belief. Lungs are soaking wet. Urine output total ~ 200 cc's. Havent had a chance to even do a focused head->toe assessment till now.

.....this pt should have gone back to surgery the minute he rolled into the unit. Just my humble opinion. :D

Gotta tell ya..with one exception sounds like a night from my journal. Done it so many times it ain't funny. Only diff: at night time , it's not a bleeding issue, it's a coagulopathy..no matter how much comes out, just keep giving product and correct those old nasty coags. Then amazingly enough, 7:05 am it becomes a bleeding issued and back to the OR they go. :banghead: Gotta love open heart!

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Holy moley,

What a night you had. My respect for handling it the way you did.

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Specializes in CVICU, CCU, MICU, SICU, Transplant.

Update:

So, go figure,...several days now since the awful night, and the patient is doing remarkably well. Neuro intact now, creatinine down trending, bleeding stopped, all lines out except the a-line, all drips off, 2 liters NC, probably gonna get tele orders today.

Tonight was the first night the patient saw me/spoke with me (had been off several days prior to tonight). LOL I told him, "you just have no idea how busy you kept me a few days ago." :D

Always makes me happy when a pt does a complete turn-around from death's door.

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wow! that's a lot of blood products! sounds like the gastric varices patient i had who bled liters the other day. we had them on the rapid infuser. did you also use the Level 1 rapid infuser for all these products?

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Specializes in CVICU, CCU, MICU, SICU, Transplant.
wow! that's a lot of blood products! sounds like the gastric varices patient i had who bled liters the other day. we had them on the rapid infuser. did you also use the Level 1 rapid infuser for all these products?

Yes we did use the rapid infuser. And pressure bag at the same time.

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is it common to have to replace tons of blood products with these patients?

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