Download Clifford L. DeBruce RN CLNC

CASE STUDY
Death in Cath Lab recovery
Clifford L. DeBruce RN CLNC
I have no relevant financial relationships
History of Patient
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66 y/o female
Recently retired RN (Critical Care)
Known history of Chronic back pain
Hypertension/Hyperlipidemia
Family History of Cardiac disease
Obese (5’3” – 249lbs)
Most recent medical event was steroid Injection
of lumbar region
• NKDA
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Initial chest pain Sunday
Husband transported her to ER
12 lead indicated inferior wall abnormality
Chest pain relieved by Nitro
Admitted to telemetry unit
• Cath Scheduled for Monday
Medications Pre Treatment
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Had taken 325mg aspirin at home
Received 6000 unit bolus Heparin in ER
600 Plavix
Heparin Drip per hospital protocol
Pre cath Monday
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IV NS 50ml Hr.
NPO since Midnight
Distal pulses 1+ bilaterally
5mg Valium PO, Heparin drip DC’d 10 min prior to
cath
• V/S : HR-66, BP: 166/89, EKG: Sinus rhythm with
slightly elevated QRS L2
• *** Stated to pre op nurse Verbalized concern
over groin complications ( in Deposition)
Heart Cath
• 6fr sheath inserted right groin (Noted that femoral
access in excess of 10 minutes)
• Mild disease to LAD and Circumflex, 95% lesion of the
mid RCA, LV normal 55% EF
• Patient’s RCA Stented with DES, no residual areas
noted TIMI 3 indicated flow post stent placement.
• 300mg Plavix PO
• Angiomax used as anticoagulant, Integrillin (double
Bolus)
• Orders state sheath to be removed 3 Hrs. post cath
Post Cath Recovery
Hour 1
• Integrillin continued per protocol:
• Patient conscious oriented x3 (V/S taken every 10
minutes)
• C/O pain to lumbar and right groin area (pain level 4)
• V/S B/P 166/86, HR-76 Sinus no ectopy, post cath EKG
noted no abnormalities, skin normal warm dry, denied
any SOB or chest pain. On O2 @ 3lpm
• Patient given 4mg Morphine for groin and lumbar pain
• Distal pulses were 2/2 bilaterally
Hour 2
• Patient stated lumbar and groin pain level
increased to 5
• Distal pulses 2/2 bilaterally
• No obvious hematoma at sight, palpation of right
groin noted as “supple non tender”
• V/S BP 130/66, HR 92 regular, EKG normal sinus,
no ectopy noted, skin normal warm dry
• Patient verbalized to recovery nurse “Just don’t
feel right”
• Nurse calls MD, order of 4mg Morphine for pain
Hour 3
• Patient stated that pain to Lumbar and groin
still level five
• Distal pulses 2/2 bilaterally
• Noted mild nausea, given Zofran 4mg, IV
• V/S BP 114/76, HR 98, EKG NSR, skin slightly
moist, but pink, groin sight supple non tender,
• Recovery nurse elected to remove sheath per
order, second recovery nurse noted distal
pulses to Right lower extremity 2/2.
Hospital sheath removal Protocol:
• 20 minute femoral arterial pressure with 5min
total occlusive, 5 minute ¾ pressure, 5 minute
half pressure and 5 minute light pressure, if
noted re-bleeding restart protocol sheath
removal process.
• Note that if patient experiences Vaso-vagal
response place patient in Trendelenburg position,
administer fluid challenge and Atropine .5mg,
Notify Cardiologist of any Vaso-Vagal events.
5 minutes into sheath removal:
• Patient stated to recovery nurse that back and groin
pain was level 6, nurse responded that “she knew that
the patient had Hx of back pain and that is to be
expected during this process”
• V/S BP 108/56, HR 102, nurse indicated that distal
pulses were 2/2 on RLE, Nurse log stated at this point
st
patient experienced 1 Vaso-vagal response, patient
placed in Trendelenburg position, fluid challenge
administered 250ml NS, episode of nausea and vomit,
patient given 4mg Zofran
• Physician
NOT notified of this event.
15 minutes into sheath removal
• Patient returned to supine position, conscious and oriented
C/O pain to lumbar and groin area level 6, nurse log notes
no hematoma noted, area supple non-tender Distal pulses
2/2 RLE. Skin cool moist to touch
• V/S 96/64, HR 112 Sinus tach, Nurse increased IV to 100 ml
HR, Nursing notes indicate that 2nd Vaso-Vagal response
and placed patient in Trendelenburg position, increased
fluids to 250ml hr.
• Continued to hold pressure , noted V/S log that B/P
increased to 104/46 HR 120 sinus tach, denied SOB ,
• 4 minutes later patient placed back into supine position,
Nurse decided to hold extra 5 minutes of pressure due to
Vaso-vagal responses
Post Sheath removal:
• Patient C/O pain to Lumbar, right groin and lower
abdomen,
• Log noted V/S B/P 88/65, HR 118, ST, Skin pale,
moist and cool to touch, nurse logged “palpated
groin no hematoma noted area supple nontender”
• Nurse calls cardiologist to inform of pain to groin
and abdomen, Cardiologist in an emergent case
unable to talk. 21 minutes go by.
Post sheath removal:
• V/S log: at 25 Minutes post sheath removal:
• B/P 78/56, HR 132 ST, (no mention of
observation of patient)
• Patient C/O lower abdominal pain, back pain,
groin pain
• Nurse leaves unit to go to CCL to see if he can
talk with the physician in person
• Returns to unit 7 minutes later,
Post Sheath removal:
• V/S log at 32 minutes post sheath removal
• V/S. B/P-67/---, HR 132 ST, (No mention of
observation of patient)
• Order for patient to have CT.
• No Mention of Treatment or meds.
• Patient transported to CT, 17 minutes go by
• Patient returned to recovery unit at 49 minutes
post sheath removal
• V/S log : B/P 69/43 , HR 128 ST (No mention of
observation of patient)
Post sheath removal:
• V/S log 54 minutes post sheath removal:
• B/P 56/---, HR 136 ST, (no mention of observation
or treatment of patient)
• Nurse makes second call to cardiologist in
emergent procedure (Cardiologist has already left
the procedure and gone home)
• 57 minutes post sheath removal, nurse pages the
cardiologist he returns call and advise to increase
fluids and he would return in 20 minutes.
Post Sheath Removal:
• V/S log 1 hour and 15 minutes post sheath
removal,
• B/P 66/---, HR 139 ST, (No mention of observation
or treatment of patient)
• 1 Hour 22 minutes patient experiences
cardiac arrest
• Code blue protocol initiated, ER physician arrives
• 43 minutes of CPR ensue, code terminated,
cardiologist arrives at end of code
Evaluation?????????
• Cause of death noted as sudden cardiac arrest
due to acute stent restenosis.
• Autopsy was performed at family request:
• CT findings: massive Extravascular bleeding at
sheath entry site NOT retroperitoneal!
• 18 separate punctures of both femoral artery
and femoral Vein
What did you see?
• NO Clinical
Picture!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
What did you see?
• VASO-VAGAL!!!!!!????
• During pressure holding EVERY distal
pulse check noted 2/2 to RLE
What did you see?
• Who turned off the Integrillin?
• It was noted during the code, an ER nurse turned
it off
• Was the Back pain and groin pain a sign?????
• Lumbar, abdominal and groin pain is a sign of
bleeding
• Did you see the gradual decrease in the V/S’s?
• In the 3rd hour the MAP in the V/S log began to
drop significantly.
What did you see?
• Did this nurse fail to do EVERYTHING
possible to intervene in this patients
behalf.
• WHO RANG THE
BELL!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Thank You!!!!!!!