Boy, was today a long day! But it really flew by.
Here is the low-down: Pt in their 50’s in for thyroidectomy. Sx goes fine, pt transfers to medical floor. At one point, the patient receives prn (as needed) vasotec (ace inhibitor for blood pressure) for their BP to keep it nice and normal for the incision site. Pt is only on the floor for about an hour, I believe. Pt begins to have shortness of breath, they almost call a rapid response, but then he/she codes (PEA) and he/she arrives to the unit shortly before 1 am.
They proceed to code him/her for almost 2 hours. Surgery and anesthesia are at the bedside. They have a terrible time getting him/her intubated because of a lot of swelling at the incision site (neck). They reopen the incision site and find no hematoma or bleeding. At this point, the patient has received a crap-load of epi, vasopressin, and a bunch of other meds. He/She has also been shocked a few times. Eventually, he/she is intubated and on the vent. FiOs at 100%.
Fast forward to 6am when my shift begins.
He/She is on the following drips: levophed, amiodarone, epinephrine, LR.
During my assessment, the patient’s pupils are fixed and dilated, size about 6.
I could not elicit any sort of response from the patient: pupils unreactive to light, unreactive to corneal stimulation (ie–take cotton ball and touch eye ball), no response to pain what-so-ever.
For whatever reasons, the MD’s do not want a CT scan. Vital signs are labile. BP will be 135 systolic one minute and literally shoot up to 180/100 with HR in 70’s, and then minutes later, she/he is 95/60 with HR 58.
Intensivist decides around 8 that he wants to do Arctic Sun:
Basically, we cool the patient down to 33 C (make him/her super-duper cold) for 24 hours with the hope that the hypothermia will reduce some of the ischemic (lack of oxygen) injury to the brain and hopefully preserve some sort of function and then rewarm her 24 hours after we reach the set point temperature and then see how he/she does. It is pretty damn cool, you know, when it works. Apparently, it can reduce mortality from 35-39%. It has to be started within 6 hours after the patient arrests, and we were pretty much right on the 6 hour mark, with the hopes of cooling her to the set point within 2 hours.
(here is an article on Arctic Sun http://www.uihealthcare.com/news/pacemaker/2008/spring/articsun.html)
This automatically made the patient a 1:1 assignment, which means the nurse can only have this one patient and no other. Luckily, we only had an open room at this time, so we did not have to pawn any patients off to any other nurses.
We reached our set point at noon. At this point, the patient is now on: amiodarone, levophed, insulin, epinephrine, fentanyl (to prevent shivering since that will increase her oxygen demand), insulin, and propofol (aka–the med that Michael Jackson was taking. I know most people are familiar with this drug now because of that, but it is routinely given for sedation while in the ICU and on the ventilator).
We do not expect him/her to survive. We contacted LifeLink (organ transplant people) early in the AM and they are now following the patient.
Can any of the medical people guess what caused him/her to code?
Update tomorrow. This is a drama-filled patient.
As a side note, November is Lung Cancer Awareness Month!
For the month of November, I’ve been wearing my white ribbon:
And also a blue ribbon that was handed out to me today to show that I am a non-smoker! They also had cute keychains that said, “Don’t choke me with your second hand smoke.”
Lung cancer is no joke.
Statistics on lung cancer:
-Most common cause of cancer death
-Second most commonly diagnosed cancer in men and women.
“In 2008, more than 215,000 new cases were expected to be diagnosed and about 162,000 Americans were expected to die from lung cancer.”
Vist here for more information.
