So I am about to write another pretty sad post. All my shifts so far have been very similar in tragedy. Talking with a bunch of other nurses from my agency, it sounds like my ICU is seeing some of the worst of the worst. They are treating people and seeing people not be intubated and remain stable. I think it's important to know that I am seeing the sickest of the sick and not to lose hope or create an unnecessary fear. I was talking to the attending physician on my floor and he says when people ask him what they can do to get better if they get sick, he says no one knows. He says some people recover and others don't and its not as simple as it sounds. But I totally understand what he is saying. In my three shifts I have watched people deteriorate and have thrown every possible solutions at them without any successes, but on other floors people are having minor symptoms and are responding positively to treatment options. What I have learned is 88% of patients that are intubated at my hospital die. 92% that require 2 or more pressors to maintain a MAP >65 die. So vents and medications to sustain life are not the answer. But when people needs those we have no choice but to use them. Another I have seen is you think people are improving and they decline so rapidly...
So last night when I got to work I went to check on my Hispanic lady. She was lying prone (more about prone positioning later) still intubated with max sedation of Propofol, versed, fentanyl and precedex along with norepi, phenylephrine, and vasopresson. However, her o2 sats were 100% which I had not seen and her heart rate was 110 which was improved from the day before, so my first impression was she was improving or at least medical therapy was working. Well, about at 0200 her blood pressure started to soften so I started to titrate my LEvophed. I let the doctors know the situation. I went from 8 mcg to 30 mcg in an hour without any changes. So all three of my pressors were maxed out. The Doc told me to add Epi, which over the next 30 minutes I maxed out still without improvement. I turned the propofol all the way down to 5mcg and the versed from 30mg/hr to 15, hoping that would help.. it didnt. At least point it is obvious she is in cardiogenic shock related to myocarditis which is being seen a lot. At 0600 am me and the attending were bedside seeing what else we could do and she went into a idioventricular PEA then asystole. So for the third shift in a row I had to put a patient in a body bag. This one was the most personal because she was my first patient and she was talking and stable when I received her to the floor.
An added note of something I have learned. Patients with nasty covid lungs are placed prone on a 16 hour prone 8 hour supine rotation. Intubated or not. The research shows that it really helps or it can cause respiratory failure even faster. With my patient I actually think it was working because her o2 sats and blood gases levels were good, It was the cardiogenic shock that killed her.
These are my patients drips. I actually ended up adding two more after this pic was taken. The drips are Norepinephrine at 30mcg/min, Vasopressin at .04 U/m, Phenylephrine at 180 mcg/min, epinephrine at 12 mcg/min, Propofol at 66 mcg/kg/min, versed at 30mg/min, fentanyl at 200mcg/min, and precedex at .9mcg/kg/hr.
you can actually see in the picture that the patient has stable(ish) vital signs. b/p 125/70, HR 113 and o2 sats 100%. This was taken about 90 minutes before she started to deterioate.