I finished off the week having the same patients for the last 4 shifts. This was really nice to treat the same couple people each night and be able to really assess their status from the shift before. Last night felt like a constant battle with two of them. Both were intubated and sedated, Covid positve and pretty much in end organ failure. One patient started on hemodialysis earlier in the week and he has been receiving it when I get on shift and ending about 3 hours into it. Last night after the dialysis nurse disconnected him from everything and gave me a report, I went in to check on him and he was in a new onset AFIB with RVR at a rate of 180. This started causing his blood pressure to be low and his o2 sats started dropping. Before this happened he had been off all pressor medications for about a day which was awesome. So I told the residents and they didn't want to cardiovert, they wanted to treat the rate with beta-blockers which also lowers BP, so I was in and out of his room titrating his sedation and adding pressors until we could get his heart rate lowered and his BP (MAP) above 65. I was running. After a few hours he had stabilized. He was in a manageable AFIB with a rate of 110 and his MAP stayed around 70. By the end of the shift I was able to remove him from all pressors again.
My other patient has been tricky all week. She is in severe Acute respiratory distress syndrome (ARDS). We have been trying to use proning protocol with her but it has caused hypercapnia and acidosis. I spoke with the attending doc about this and he explained that sometimes when patients in ARDS are placed prone the pockets that have not been oxygenated for awhile just become deadspace and dead tissue, so the gas exchange is so poor and the lungs retain a ton of extra CO2 which causes acidosis. Her Co2 levels were 65 (normal 35-45) and her PH was 7.06 (7.35-7.45). These numbers improved after flipping her supine, but they tried the therapy twice with the same results both times. Quick lesson on proning and when and how it works. Patients in ARDS or severe pneumonia will get pockets in their lungs that don't get enough oxygen because of how the pressure and gravity of their body are while lying supine. When you flip them prone gravity and pressure are changed and oxygen can reach these pockets and oxygenation and gas exchange improve. (unless these pockets are deadspace and/or dead tissue because of chronic hypoxia). Anyway, When I arrived at work her MAP was 43 and I had to play with Levophed and Vasopressin until we reached a decent MAP. but then two hours into the shift she became very hypertensive. BP 196/124. So I turned off all pressures and went up on her sedation of propofol and Fentanyl. After a few hours of this her BP stayed around 150/100. Not great but better than high and low. Things seemed to be going okay for her, but when me and my aid went in to turn her and clean her when we were done her MAP dropped to 40 AGAIN! So I titrated the Levo up and added Phenylephrine. The docs wanted to try and titrate the levo down because her HR was 140 and she was dehydrated which also causes problems when someone is on pressors. The patient finally got to a good MAP of around 70 and when I left work this morning both patients were stable. But I felt like I was running from one room to the other trying to balance and stabilize their vitals all night.
Most patients on my floor are so hemodynamically unstable that when we turn and move them to clean them, it causes a shift in fluid and as their bodies try and compensate they are so sick that sometimes their vitals become very unstable. I have seen this several times since I've been here. Sometimes when I open a door and go in to perform a task I almost feel like I need to tiptoe and breath quietly and slowly so I don't cause them to crash. (completely unreasonable thinking, it's just the mindset of they can crash at any moment)