Thanks to those who tried to guess what caused the patient to code!
We’ll get to the answer in a bit.
So, yesterday there was still no response at all. At noon, we began to rewarm him/her. Our rewarming target is 37 C. We are rewarming him/her over 12 hours, so around midnight, he/she should have reached it. It is a slow process because rewarming can be dangerous, as well. We do it at like .35 C per hour.
Some of the side effects we tend to look for:
-Of course shivering (just like when cooling), which he/she was on fentanyl and propofol for. He/She never did show any signs of shivering, goosebumps, etc so we did not have to use any drugs to paralyze him/her.
-Also, rewarming can cause vasodilation and subsequently hypotension and even shock.
– Obviously, we’re also watching his/her electrolytes, like potassium (K+) because it could increase (hyperkalemia) due to the shift of K into the extracellular compartments. For non medical people, we like to keep K+ tight control due to cardiac arrhythmias, etc.
-Seizures.
Unfortunately, our patient has probably a <1% chance of recovery. He/She did not receive adequate blood flow (oxygen) to the brain for almost 2 hours (the duration of the code), and based on the neurological exam by us and the doctors, his/her prognosis is poor, to say the least.
The worst part, perhaps, is his/her family. Most of them live in another state, but he/she has a son who lives here. He is probably in his 20’s and apparently, he just got out of jail (for drugs) and according to a cousin, has another warrant out for his arrest. That isn’t the worst part. The worst part is that he has a young child, probably 4-5 years old. And the patient was the one who had custody of the child. Now social services is on the case to try to find eventual placement for the child since the father will more than likely be back in jail. I hope the kid doesn’t have to go to a foster home because that would be so incredibly sad.
The son is quite uneducated and has no knowledge of medical stuff. The situation is confusing as it is, but when you have a basic intellect to begin with, it makes it almost impossible to explain the situation. The first day, he definitely was not grasping the severity of the situation. How could he? The patient went in for a routine thyroidectomy! At one point, another family member called and asked when she could come pick up the patient! At this point, we told the son that he needed to call family and inform them of the situation. We kept telling him that the patient is sick, he/she more than likely will not survive. But he still kept saying, “But he/she will wake up, right?”
um, NO!! Believe me, we were explaining everything in the most basic form that we could!
Eventually, he did get it and broke down, throwing himself on the floor sobbing.
So, what caused his/her code and probably death?
Some mentioned the Vasotec and they would be RIGHT! If you remember from nursing school (or medical, whatever), one of the adverse effects of Ace inhibitors is severe angioedema. In other words, severe swelling. While in the PACU, he/she received the vasotec as a prn med due to some hypertension, which he/she has normally. It is a pretty popular and standard medication. Once he/she arrived to the floor, however, that is when the swelling began. And because everything was so swollen, they could not get the tube down his/her throat for intubation once in the unit (ie–get him/her on the breathing machine). And at this point, no one even suspected it was a drug reaction. Their initial thought was that it had to be bleeding/hematoma into the surgical site since he/she had his/her thyroid removed and that is in the neck area!
Why wouldn’t they think that, right? Of course, when they reopened the surgical incisions at the bedside, everything looked good!
It is quite sad and tragic. There is no way anyone would have known he/she would react to the vasotec in that manner. Ace inhibitors is now listed as one of his/her allergies, but it will not really matter at this point, since he/she is not going to survive.
Hopefully his/her kidneys or corneas will be used to help save someone else’s life.
