What has been your sickest patient

jbp0529 · Jun 23, 2008

Wow, that sounds awful.

Sickest pt I've had within the last month or so was: 20 something yr old girl, with a congenital anemia (called Diamond BlackFan Anemia) and awful CHF. Came to our hospital, coded, was resuscitated successfully. CV surgeons got on board very aggressively (in a good way), took her to OR w/ plans to put in a bi-vad. Ended up almost coding in OR, so instead came out on ECMO (hardly ever happens, we cant even remember our last pt on ECMO). Open sternum, high doses of Epi, NTG, Milrinone, Dobuta, Dopa, Vaso, Amio, Levophed, Insulin. Heparin for the ECMO. Sedated/paralyzed w/ Fentanyl and Vec. Bled like crazy post op. Pressures up and down constantly. Tons and tons of blood products given. Tons and tons of antibiotics also. Perfusionist glued to the bedside. MD's worried about ALI from all the blood, started HFOV (was still being vented while she was on ECMO). She also had severe underlying sepsis prior to surgery (blood cx's grew out nasty stuff, cant remember what, and her temp on arrival to ICU from OR was 102.5 on the Swan Ganz!!) She stayed on all this for almost 5 days before stabilized and they started weaning everything one by one. Later took her back and switched her to a Heart Mate II VAD, closed her chest. Progressed slowly to extubation after weaning from the osscilator. Fast forward about a month of arrival, and she's off almost all her drips, VAD working well, no focal neuro deficits, ambulates well, eating well, good oxygenation, decent renal function, severe edema gradually improving. Moved her to the telemetry floor. Probably going home soon with the VAD as destination therapy (doesnt qualify for heart transplant d/t the Diamond BlackFan). We never thought she'd make it so far and do so well. We were prepared for her to die on day 1. Amazing family... very supportive, concerned, and appreciative. Kudos to all my fellow nurses who cared for her, and the CV docs who were so aggressive :yeah:

allnurses Guide · Jun 24, 2008

What type of LVAD? Sounds like it was put in too late - put a VAD in a dead person, you get a live corpse. Unfortunately it then becomes difficult to know when or how to draw the line to withdraw support. With few exceptions, most cardiac surgeons avoid "rescue" or "Crash and burn" VAD implants these days.

You have me confused saying they "turned off his LVAD and turned up the IABP" - I can't think of any LVAD that you "turn off" and then turn back on... unless it was a centrimag that was weaned down to see what happened...?

Basically it's hard to envisage a good outcome.. if someone is that sick, they need BiVADs in an emergent situation (and even then, there is very bad prognosis).

allnurses Guide · Jun 24, 2008

By the way, my sickest patients over the years were mostly VAD patients too (or those too sick to put VADs in)... also one patient who had CABGs and was a Jehovah's Witness... did not end well!

richard1980 · Jun 24, 2008

What type of LVAD? Sounds like it was put in too late - put a VAD in a dead person, you get a live corpse. Unfortunately it then becomes difficult to know when or how to draw the line to withdraw support. With few exceptions, most cardiac surgeons avoid "rescue" or "Crash and burn" VAD implants these days.
You have me confused saying they "turned off his LVAD and turned up the IABP" - I can't think of any LVAD that you "turn off" and then turn back on... unless it was a centrimag that was weaned down to see what happened...?
Basically it's hard to envisage a good outcome.. if someone is that sick, they need BiVADs in an emergent situation (and even then, there is very bad prognosis).

It was my first LVAD, not sure what kind it was. I'm guessing the perfusionist turned the flow down to nothing. We didn't turn up the IABP we changed it from 1:1 to 1:3 to see if he was beating on his own. Yeah it's a hard call because he wasn't really getting worse but he sure wasn't getting better.

richard1980 · Jun 24, 2008

By the way, my sickest patients over the years were mostly VAD patients too (or those too sick to put VADs in)... also one patient who had CABGs and was a Jehovah's Witness... did not end well!

I bet, did they have to do it off pump because of his/her wishes?

joeyzstj, LPN · Jun 25, 2008

My sickest was very similar to this. 2:1 with IABP, LVAD, VENT, Every drip know to man. We have older LVADs, so anytime they are set up its a big production. We have big rooms so they turn the room into a lab essentially. The patient I had died during surgery in the CVICU room.

I haven't been in SICU that long, but recently I had the sickest pt I've ever had helping out on a 2:1. He had a MVR/AVR and dropped his pressures in the OR so they gave epi and he developed "stone heart" (cramped heart) and dropped his pressure to almost nothing. So they put in a IABP but that didn't really seem to help so the surgeon put in a LVAD. So this pt has been sitting in SICU for the last 4 days on 40 of LeVo, maxed out Vaso, 5 of dopa, high dobut, diprivan, lasix, insulin, getting a-line MAPs of 59 and IABP pressure 55/50 with aug of 60. The day before he had a LBBB for his underlying rhythm so we paused to check it out and he was asystole (sweet....). The perfusionist turned off his LVAD and we turned his IABP to 1:3 from 1:1 with no perfusion on the a-line except the little bump on every third beat from the IABP. CVP was anywhere from 10-15 with a PA of low 20's/low teens. I shot a index just for fun and it was 1.1 with CO of 2.9 (which just happened to be the same flow as the LVAD... :-/) SVR like 900. He was bleeding out just about everywhere; IABP (d/t difficult placement/cutdown), cordis, CT, PICC, etc. We were checking Hgb every 1-2 hrs and just dumping in blood. Couldn't get it above 8. CT was putting out around 400 an hour. His ABGs were fine. Coags weren't terrible 1.5 INR and a little low on her fibrinogen. Gave her some FFP for that. I'm wondering how long you all have seen MDs keep someone like this on the LVAD. It's not like he was getting better or getting worse. I would've thought she would be getting acidotic by now if hewas going to go in the wrong direction. The rest of his body wasn't bad. Vent was SIMV 10 TV 600 PEEP 5 on 50% FiO2(was 30% but I guess RT isn't supposed to put FiO2 lower than 50 with an LVAD).

meandragonbrett · Jun 27, 2008

My sickest here recently involved 30 units of packed cells, 40 liters of crystalloid, 14 of FFP and 80 of platelets. vasopressin, epi, norepi, THAM, multiple electrolyte gtts, insulin gtt, and an emergent re-do ex-lap at the bedside.

glamgalRN · Jul 3, 2008

Ohmygod! You guys are making me nervous! I just found out today that I passed the nclex (as you can see I wasted no time in changing my user name) and am starting in the SICU of a very busy urban hospital in August! Just reading your story makes me wonder if I will be able to handle this right out of nursing school! The scary part is I have no idea what most of those abbreviations stand for in your post (but I'm going to look them up and try to lear all about them! :specs: ) Ahh.. I have soooooooooooo much to learn!

I seriously can't wait until I get a patient and feel comfortable on the unit by myself. I have been looking forward to that day since my very first day of clinical and unfortunately I think I'm going to have to wait another year or two.

I'm going to spend this next month trying to review stuff and purchase a book on critical care nursing. I know it's going to be rough, but I'm sooo up for the challenge and ready to start learning as much as I can!

Thanks for listening and I'm excited to be here!

TLCinCICU · Jul 8, 2008

My sickest was just recently. He was a Marfan's patient who arrested while swimming laps. By the time my shift was over, there was a vent and an IABP in his room. He had a PA catheter. He was on dobutamine, norepinephrine, phenylephrine, epinephrine, fentanyl, amiodarone, insulin and bicarb drips. He got multiple blood products for hemodynamic support. Every set of ABG results prompted giving 4 amps of bicarb - even with the drip going. The MAP was only in the upper 40s with all vasopressors beyond our formulary max (at the MD orders). He made absolutely no urine. Weird thing was he would wake to voice, track the speaker, and grasp to command. He went PEA on night shift and they were unable to keep him going, even after adding vasopressin. He was younger than me...

jspacegirl · Jul 11, 2008

Still just a nursing student, but today in the CCU I had the sickest patient I have ever seen. A woman who was only 40 years old with a 3 yr history of CHF. Admitted a week and a half ago with exacerbation of CHF, and has steadily gone downhill. Last night they put in an IABP and a swan. Her heart rate was in the 140s during the night, and slowly creeped up and was a-flutter in the 210s-220s all throughout the shift. She was maxed on levophed, and also on dobutamine, vasopressin, neo-synephrine, and bicarb. Her hands and feet were blue, pulses were neither palpable nor dopplerable. pH was 7, so liters and liters of bicarb had been pumped into her during the night, and there was no urine output, so she was extremely edematous. CI was 1.9, SVR 1100s, EF 13%, PAWP 38, CVP 28, BP 70s/40s. CXR revealed her heart was twice the normal size. Docs and nurses kept arguing over whether the IABP should be at 1:1 or 1:2. Didn't seem to make a difference either way. Her heart was beating so fast that the rarely filled all the way. Very sad, because woman was so young, and had a young son.

allnurses Guide · Jul 11, 2008

Sounds like she needed a VAD a week ago. Just curious, why would you turn the IABP down in that case to 1:2? Sounds like severe biventricular failure.