Death in Cath Lab recovery CASE STUDY Death in Cath Lab recovery

Clifford L. DeBruce RN CLNC   I have no relevant financial relationships

History of Patient 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

Cath Scheduled for Monday 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 Had taken 325mg aspirin at home Received 6000 unit bolus Heparin in ER 600 Plavix Heparin Drip per hospital protocol

Pre cath Monday 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 patient experienced 1st 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 non-tender” 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!!!!!!!