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.
is it common to have to replace tons of blood products with these patients?
Well, on my unit it's usually the exception not the rule. That being said, it does seem to go in spurts...we'll get some patients back that are having clotting issues, bleeding like crazy, some times just can't get them to stop bleeding, sometimes sutures leak, etc. It can really get dicey and you definitely have to be on the top of your game. Then with multiple blood products, you run the risk of a TRALI reaction which can really throw a wrench into patient recovery. (TRALI: transfusion related acute lung injury). I had one pt that developed a TRALI reaction to some FFP....not only was blood pouring out of his chest tubes, we couldn't oxygenate him. He did eventually make it but it was close. Definitely a night where the ratio was 2 nurses for 1 patient most of the night.
So when you give all these products via Rapid infuser and pressure bags, do you always give each product through it's own individual line? We had to run I think 2 blood lines together into single lumen of Cordis, and another line with blood products into an open line of the triple lumen. Do you usually get a Cordis placed emergently for these patients? Just curious, as I have helped with a few bleeders/ DIC pts, but this was the first of my own and it was nuts. We did stabilize the pt enough to take for special procedure (TIPS), and by then my shift was over. Pt bled again after returning on next shift, and then care was finally withdrawn. Have you ever seen a hemolytic type of reaction from giving any blood products? I wonder if this contributed to the bleed, or the pt just started bleeding again spontaneously from gastric varices.
Specializes in CVICU, CCU, MICU, SICU, Transplant.
So when you give all these products via Rapid infuser and pressure bags, do you always give each product through it's own individual line? We had to run I think 2 blood lines together into single lumen of Cordis, and another line with blood products into an open line of the triple lumen. Do you usually get a Cordis placed emergently for these patients? Just curious, as I have helped with a few bleeders/ DIC pts, but this was the first of my own and it was nuts. We did stabilize the pt enough to take for special procedure (TIPS), and by then my shift was over. Pt bled again after returning on next shift, and then care was finally withdrawn. Have you ever seen a hemolytic type of reaction from giving any blood products? I wonder if this contributed to the bleed, or the pt just started bleeding again spontaneously from gastric varices.
Pt already had a cordis and a swan (as most of our heart surgery pts do). And that cordis had a lot of use that night.
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.
sounds like a night in my icu. one exception the attending will usually never be at the bedside, let alone return your phone call/page! and a CV fellow that's great, we usually just have an ICU intern! also reopro prior to surgery really sucks! good job
Plavix too. I'm sure that's why they didn't want to take the dude back, they figured you can't sew up oozy coagulopathy. What did his initial post-op chest film look like? I'd argue that it might be worth the re-op just to remove the big blob of goo that was probably sitting behind his heart. Wow, glad to hear he is neuro normal--sounded like he'd be a long term pump head at the very least. Good job!
Good god, that is ludicrous! That patient should have gone back to surgery. It sounds like the surgeon didn't think the patient would likely make it through a second trip to the OR and you got dumped on. This poor man probably won't make it anyway, but he could have had a chance had they addressed the bleeding issue instead of just giving him more and more blood products and thus screwing his electrolytes and likely putting him into CHF!
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."
Always makes me happy when a pt does a complete turn-around from death's door.
Wow, when I made my first response, I hadn't read this far down yet. Amazing! I can't believe that he did well after all that. Good job on your part!
Secondly, 30 yrs experience in cardiac surgery critical care nursing tell me that taking him back to the OR would not have helped at all and he prob would have died on the way to the OR or shortly thereafter.
This pt was massively coagulopathic. Mediastinal re-exploration only helps if it is a surgical bleed. In my place, they would have left his chest open, brought him to the unit, and we would have done exactly what you did. We would have used the newish cell saver device and would have just given him products out the wazoo, like you did. Whatever vasoactive infusions needed to maintain a perfusion pressure and keep the heart full enough to pump. Of course, you immed write off the kidneys and the lungs and know that a dude this old is prob not going to be able to survive the multisystem organ failure and SIRS that is undoubtedly going to happen.
If this pt survives a month without developing MOSF, which can happen even a couple of weeks out, you can know that you are responsible for his survival.
The surgeon saved his heart. You saved his life. The cardiac fellow gave you the 'orders' you needed. But, make no mistake, you saved his life. You outlasted the coagulopathy.
That is one strong old fart, if he lives.
Congratulations. Your butt-busting work did the job. Nursing at it's finest.
The antidote for Reopro is infusing platelets. Reopro causes a qualitative defect in existing platelets. Reopro is a GP IIb-IIIa receptor inhibitor. However, the half life of the drug in the circulation is only 10 min. Therefore, transfusing fresh platelets will reverse the effects of the drug. You probably already know that, but this is some of the current information out there about Reopro.
Specializes in CVICU, CCU, MICU, SICU, Transplant.
Well, first of all, you saved his life.
Secondly, 30 yrs experience in cardiac surgery critical care nursing tell me that taking him back to the OR would not have helped at all and he prob would have died on the way to the OR or shortly thereafter.
This pt was massively coagulopathic. Mediastinal re-exploration only helps if it is a surgical bleed. In my place, they would have left his chest open, brought him to the unit, and we would have done exactly what you did. We would have used the newish cell saver device and would have just given him products out the wazoo, like you did. Whatever vasoactive infusions needed to maintain a perfusion pressure and keep the heart full enough to pump. Of course, you immed write off the kidneys and the lungs and know that a dude this old is prob not going to be able to survive the multisystem organ failure and SIRS that is undoubtedly going to happen.
If this pt survives a month without developing MOSF, which can happen even a couple of weeks out, you can know that you are responsible for his survival.
The surgeon saved his heart. You saved his life. The cardiac fellow gave you the 'orders' you needed. But, make no mistake, you saved his life. You outlasted the coagulopathy.
That is one strong old fart, if he lives.
Congratulations. Your butt-busting work did the job. Nursing at it's finest.
Yea, I think you're right (now that I look back on it). He almost certainly would not have survived another trip to OR, or a trip anywhere out of the ICU for that matter.
I guess in the heat of the moment, the knee-jerk response to this situation is take him back. Fortunately, all he needed was a butt load of blood products lol I guess its just a simple matter of supply and demand and keeping him tanked up. Blood bank could hardly keep up with us that night, that's for sure.
I appreciate everyone's praises of my blood/sweat/tears that night, however it truly was a group effort. Go team!
It's been over a month or so since this event happened, and I'm still amazed that the pt came out of it with his brain, lungs, kidneys intact. Just needed some gentle diuresis a few days after, for all his edema. He certainly was a tough old bird. Didn't remember a thing. I talked to him several days after when he was stable and the dust had settled, and told him how close he was to death. Such a nice man too, he was completely shocked and thanked us all.
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.
Great Job!!! I read in one of your posts that the patient is doing well. That's great. It's good to have a patient like this every now and then. It's great experience.
highlandlass1592, BSN, RN
647 Posts
Well, on my unit it's usually the exception not the rule. That being said, it does seem to go in spurts...we'll get some patients back that are having clotting issues, bleeding like crazy, some times just can't get them to stop bleeding, sometimes sutures leak, etc. It can really get dicey and you definitely have to be on the top of your game. Then with multiple blood products, you run the risk of a TRALI reaction which can really throw a wrench into patient recovery. (TRALI: transfusion related acute lung injury). I had one pt that developed a TRALI reaction to some FFP....not only was blood pouring out of his chest tubes, we couldn't oxygenate him. He did eventually make it but it was close. Definitely a night where the ratio was 2 nurses for 1 patient most of the night.