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

[jbp0529]

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.

[SusanKathleen, RN]

Dear jbp0529,

You are my hero! I loved reading this thread. Thanks for posting -very educational and very inspiring. I have great respect for everything you did. Well done.