0700: Pt arrived to ICU from ED at 0655, received report from Mary, RN. Pt presented to ED with shortness of breath, history of A-fib and anticoagulant use; initial H/H and coag studies reviewed with ED RN. Assumed care of pt. Focused assessment completed, see flowsheet. Pt tachypneic 28-32 with O2 saturation level 94% on BIPAP; denies pain, is restless. Spouse at bedside, calm environment promoted and plan of care discussed. MD paged to notify of patient’s arrival to the unit.

0720: Pt remains on BIPAP; tachypneic with RR 45. Pt complains of “not getting enough air.” WOB increased. O2 saturation 92%. MD return page received at 0715 and arrived at bedside at 0717 for evaluation. Will repeat ABG, H/H and coags; continue to monitor closely. Full assessment completed, see flowsheet. 2 units PRBCs ordered.

0800: MD paged for continued respiratory distress. RN and RT at bedside. Unit 1 of 2 PRBC infusing, no signs of transfusion reaction noted.

0820: WOB increased with O2 saturation level 73%. FiO2 increased from 80% to 100% on BIPAP. Spouse at bedside, attempting to calm patient. Pt agitated, attempting to remove leads and get out of bed. Pt monitored closely for safety. RN and RT at bedside.

0822: MD at bedside, ok to continue transfusion. Respiratory therapist has removed BiPAP and is manually bagging patient with BVM. MD explained need for intubation with spouse. Risk vs. benefit explained; spouse in agreement with plan of care.

0900: Code blue initiated at 0830 during intubation procedure, see code blue documentation. Frank blood in ETT. ROSC at 0840, BP 74/55, fluid bolus given and norepinephrine initiated at 0842 per MD order at 10mcg/kg/min. OGT inserted with return of 200 ml frank blood. CXR done to confirm ETT and OGT placement. Coags reviewed with MD. Unit 2 of 2 PRBC infusing. Foley placed with return 40 ml urine.

0930: MD at bedside to evaluate patient and update spouse. Norepinephrine titrated for continued hypotension. SpO2 87%, RT at bedside; vent settings discussed with MD and adjusted.

1000: ABG done and vent adjusted per protocol. Vasopressin started for hypotension refractory to norepinephrine. Arterial line ordered; RT will place. CBC and coags done.

1022: Additional family now at bedside. No sedation at this time, pt does not follow commands, no response to painful stimuli. Family updated and MD notified. Stat head, chest, abdomen CT scan ordered.

1030: Pt transported to CT scan.

1050: Pt returned to room. MD notified of completion of scan, images reviewed. RT at bedside to place arterial line.

1100: MD at bedside to discuss CT results with family. No decisions made at this time. Urine output remains low, 10 ml per hour. BMP done. Neurology consulted by primary MD.

1200: Assessment completed, see flowsheet. ABG done and FiO2 adjusted to 100%. H/H and coags done.

1245: Lab results reviewed with MD; 4 units PRBC ordered. Nephrology consulted by primary MD for possible emergent dialysis secondary to anticoagulant overdose and signs of acute renal failure. Neurologist in to see patient, discussed CT results with family.

1315: Pt tachypneic on vent, midazolam infusion initiated. Unit 1 of 4 PRBC infusing.

1400: Nephrologist at bedside and consulted with primary MD.

1415: Need for dialysis catheter placement discussed with family; risk for extensive hemorrhage  discussed with family. Social worker and pastoral care notified of family’s need for support and goals of care decisions. Unit 2 of 4 PRBC infusing via pressure bag.

1505: Unit 3 of 4 PRBC infusing. Pt remains tachypneic on ventilator despite midazolam infusion. MD aware. Lawrence from pastoral care and social worker at bedside with family. Epinephrine infusion initiated for persistent hypotension. No purposeful neurological response noted.

1525: MD notified that family would like to discuss goals of care. Will be in when able.

1600: Assessment completed, see flowsheet. O2 saturation 87% on 100% FiO2 and PEEP 16. MD speaking with family. Bleeding from rectum, NGT and ETT continues. No improvement in neurological status. Unit 4 of 4 PRBC initiated.

1615: Code status changed to DNR with no escalation of care.

1730: Additional family members in to see patient. Support provided. Pt on three pressers and max vent settings. Lawrence from pastoral care speaking with family as they discuss compassionate extubation and withdrawal of life support. Frank blood noted in ETT with suctioning; bleeding from rectum and NGT continues.

1800: Family requesting withdraw of life support. MD notified.

1810: Pt extubated and vasopressor support removed. Spouse and pt’s sister at bedside, extended family in waiting room with personal chaplain.

1815: Asystole on monitor. MD pronounced pt.

1855: Family provided privacy. Spoke with Lawrence from pastoral care; family grieving appropriately.

this is a fictionalized scenario that accurately represents the roller-coaster ride that is typical in the intensive care unit. It is sadly not uncommon to see devastating bleeds in patients taking anticoagulants, especially those that do not require careful monitoring. For more information about anticoagulants, see this post. Or, if you’d like to see indications for emergent dialysis, check out this one right here. Having trouble dealing with end-of-life issues? Then this post is for you. Most of all, take care of yourselves.


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