Busy Day

Busy day! I know that a big city ICU has a lot more than we do, but these cases were interesting.

Patient 1 is a severely retarded person who now receives a tube feeding. Jevity is spit up, vomited, or the patient works to get it up all over herself. We need to get this patient off the TPN. I tried ProSoBee and it stayed down. Weird.

Patient 2 came to us in severe, end stage COPD. Tthe first rhythm strip I thought was a-flutter with 2:1 capture. The MD wanted to start Cardizem per protocol, so I bolused the patient with 20mg just after I started the drip at 5mg/h (5ml/h). No result. I increased it to 10mg/h, no result. I increased it to 15mg/h; the rate dropped to 100 for about 15 seconds and then back to 170-180. I rebolused with 25mg with no result. The SBP was in the 120's so I didn't worry about it and watched the monitor while I went about my other work. After a few hours with no result, I thought I would try Morphine 4mg IV, thinking the patient might be anxious. No result after 30 minutes, so I called the MD who was also watching the rhythm in ER (it was his patient); he said to wait a little longer. Finally, everything worked, and you can see the second rhythm strip.

Patient 3 is a chronic smoker, past CABG, insulin dependent diabetic, etc. Those are the XRays. The patient called EMS stating had a hard time breathing, by the time the patient got to ER the patient was in respiratory failure and needed to be intubated. What do you think was the unlying cause?

The patient was awake when he/she came to us. I used propofol for about 35 minutes but decided the patient was cooperative enough that I stopped it, figuring the patient was ready to be extubated. Respiratory therapist checked up on the patient and stated it would be ok to go on pressure support. The patient did well, but would occassionally have apneic periods up to 20 seconds. The vent alarm would wake the patient up. Because of that respiratory thought it best to keep the patient on the vent until the morning; the patient agreed to the plan.

Today they plan to extubate, but I'm not working. I'm sure they will be successful.