Sunday, July 14, 2013

mini-live blogging on the maybe-ECMO patient

1200: We thought we had a green light for ECMO. They changed their minds. They want us to oxygenate him with 100% FiO2, then turn the paralytics off and try again. If (when) he tanks, I'll bolus him with vec, the paralytic du jour, and restart the drip. Hopefully, he'll recover. This will prove (at least to ECMO, no one else needs convincing) that he absolutely must get cannulated for ECMO. Then that will happen tomorrow.

If he doesn't improve when I restart the paralytic?

I don't like playing games like this. I am pushing buttons right now only after clear confirmation from the ICU attending and no one else. I'm not sure the resident and intern feel like this is even their patient.

1300: FiO2 is increased to 100%, will pre-oxygenate him for 30 minutes until turning off the paralytic, which will take up to 30 minutes to wear off. Group huddle with family. I encouraged his wife and daughter to walk around and stretch before the paralytic wears off.

1330: Paralytic off.

1400: Paralytic should be out of his system. Train of Four is 4:4 (four out of four).

1440: ICU Fellow tells us to continue routine care (bath, ET tube tape changes, turns, etc) per usual, if not with an extra degree of caution.

1445: Couging attack begins. I bolus versed and fentanyl. His sats drift into the 80s, he comes back up. I bolus more, repeat. His wife tells him over and over he's ok. Her mantra works. He recovers to the 90s and we don't have to start the vec. I swab the back of his throat with lidocaine and pour lidocaine down his ET tube. We got through this one somehow.

1545: Patient's heartrate suddenly increases to 138 with loss of blood pressure, appears to be afib. Rate then decreases to low 100s, irregular, EKG arrives. Patient in and out of afib/sinus/frequent PACs with intermittent need for pressors.

1645: Patient's secretions are causing him to have low tidal volumes and coughing. We take him off the vent and bag him with a PEEP valve, suctioning intermittently, to remove large amounts of tenacious secretions. Patient desats to 60s, but recovers to 90s within one minute. Victory!

1730: Patient is bathed and ET tube tapes changed without coughing or desatting.

1900: We can't believe we made it to the end of the shift without incident! I leave him with pressors off, satting well, off paralytics. I hug his wife goodbye. I know I'll spend the next few days wondering if he's still alive, and hoping that he gets his lungs.

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