Code Review

1. Code Review August 26, 2010

2. July ‘10 Dr. CART Stats

3. July ‘10 Hypothermia Stats

4. Cases for review

5. Case Presentation • The patient is a 48-year-old woman with past medical history of coronary artery disease status post CABG in 2007, admitted on 6/27 for syncope and chest pain. Left Heart cath 6/29 showed a 95% lesion of the native vessel at the anastomosis with the RIMA. • PMH: • CAD- DES to LAD in 2006, CABG in 2007- LIMA to OM and RIMA to LAD, and DES to LAD and left circumflex in 12/2009. • CHF, ejection fraction of 25% s/p ICD placement on 08/17/2007 • Moderate-to-severe MR, Moderate-to-severe TR. • Diabetes with complications including retinopathy of the left eye(2004) • End-stage renal disease on hemodialysis • Hypertension. • Hyperlipidemia. • Obstructive sleep apnea on C-PAP of 9. • Morbid obesity.

6. Admission CXR

7. Admission EKG

8. Hospital Course • Patient went to the OR on 6/30 for High-risk redo CABG (recycled right internal mammary artery to distal left anterior descending, saphenous vein graft sequential to first circumflex OM1 and OM2), mitral valve repair, and tricuspid valve repair. • Post operatively the patient slowly improved and was eventually weaned off of pressors, but remained on Dobutamine and Amiodarone gtts. Her vitals on the days preceding the code were notable for hypotension with BP’s ranging between 60’s/30’s to 80’s/50’s

9. Nursing Notes on 7/25 • 17:07- Pt had bowel movement. Pt turned to L side to clean bowel movement. When pt turned to back-she was not responding and had blank stare on her face. Episode lasting approx 1 min. Pts BP 88/62 HR 112, 100% on 4 L nc, blood sugar 146. RRT called then canceled as patient became responsive. Pt able to state name and squeeze with both hand. Pt requesting BI-PAP to be placed. Resp therapy in room and placed equipment on patient with appropriate settings. Pt drowsy but arousable. Awaiting EKG to bedside. • 19:35- Report given to night RN. Responded to alarm-low O2 saturations. Pt found drooling w shallow respirations. Pt placed on Bi-PAP O2 100% BP 102/47 HR 118. Pt unresponsive and gradually became responsive with residual drowsiness. Service and night RN at bedside • 21:13- Dr. Cart called

10. Compressions begin

11. Poor pad contact Ongoing compressions

12. Pulse/Rhythm check

13. Shock #1

14. Rhythm check

15. Pulse check

16. Pulse check

17. Pulse check

18. Pulse check

19. Pulse return

20. Pulse return 10s

21. Pulse check

22. Brief pulse return

23. Shock #3

24. Anticipatory charging

25. Shock #4

26. Pulse check

27. Shock #5

28. Anticipatory charge

29. No shock

30. Anticipatory charge, long pause

31. Pulse check

32. No shock

33. Labs • ABG: 6.863/50/32/20% • Calculated HCO3: 9

34. Anticipatory charging, pulse check

35. Shock #7

36. Am J Cardiol 2002; 90: 853-859

37. Resume chest compressions

38. Pulse check 10s

39. Pulse return

40. Loss of pulse Compressions?

41. Shock #9

42. Great compressions

43. Anticipatory charge, pulse check

44. No shock, pulse return

45. Rhythm change

46. Shock #10

47. Rhythm change

48. Shock #11

49. Compressions resume Compressions resume

50. End of code- Pt made DNR