Young Patient/ Went downhill Fast!

[cdibley]

Hi all!

So I had the strangest thing happen to one of my patients this past week, she was a 30 year old post op day 1 from a MV repair, so I work in a CVICU and we rarely get patients this young and she was also really healthy, many times if they are young there are a mountain of co-morbid conditions that I believe lessens their reserves and ability to "bounce back". So onto what happened. Got report with pressures in the 90s-100s MAP>60, urine output okay 30-50ml/hr, but definitely a decrease as she had put out 1500ml the last shift, also required Cardene overnight but for the last few hours hadn't and got 3 Albumins, I have her another, really no improvement. Patient nauseous and in a bit of pain, gave Fent, no change in BP but pain relieved. Patient overall looked good. Family and patient states she normally has a low BP. CVP = 8

1 hour later, patient says she having a hard time breathing and doesn't feel well, has history of anxiety, calm her, listen to breath sounds, o2 sat good, put her on a little O2 for comfort. THEN her BP starts dipping to the 80s then back to 90s and so I grab the NP in the hall let her know what's going on that the patient just doesn't seem OK. Upon coming back to the room BP now 70s, then 60s (very fast) like in less than a minute from 90s to 60s, cuff pressure correlates, open up saline bolus that I already had hanging, give another albumin too. Looks like she's 2 seconds from coding call for more help.

Run Istat, see CO2 is 13! Do ABG patient has metabolic acidosis with a BE of -15!!!! I've never see a base deficit that high in a patient that up until 2 seconds ago, looked good. Thank God she was fine, gave fluids, Bicarb, trended lactates and they improved, no kidney dysfunction which is also crazy to me! Like seriously no bump at all, Thank God!!! After many amps of bicarb, fluids, a little Levoped, patient felt much better and looked great.

So my question is, is this normal for younger patients? It was so weird that it happened so fast and all it was a fluid issue (no tamponade) which is what I thought. MD said that sometimes younger patients are more leaky and the fluid just goes out into the tissues. Any comments are much appreciated. In hindsight I wish I had given her fluid earlier based on the UO decreases by half, but we don't normally do that we are okay with 30ml/hr. Even the NP and surgeon saw her 10 minutes before this all happened.

[AJJKRN]

I think younger pts just have more reserve...until they don't.