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Clinical Course:
9/3 – When he arrived in the tertiary care ER, he had an IV nitroglycerine drip in place and was on oxygen at 4 LPM per nasal cannula. His SpO2 was 90%.
From the ER, he was immediately taken to the diagnostics area for a cardiac catheterization. The results showed that he had extensive 3 vessel disease and that the thrombolytic therapy had failed to reopen his occluded coronaries. It was determined that he was not a candidate for rescue PTCA or Coronary Stent insertion. He was taken immediately to the operating room for a CABG.
9/4 – The patient came back from surgery at 2300. He had a 5 graft coronary artery by-pass. He was late returning from the OR because they had difficulty discontinuing by-pass.
He was orally intubated with an 8.0 ETT secured at 24 cm at the teeth. The patient was on a Nellcor Puritan Bennett 7200 ventilator with settings of AC at a rate of 10 BPM, Vt 900, PEEP +5, FIO2 0.60, Peak Flow 60 LPM. The patient was not assisting at this time. Peak pressures ranged from 25 to 28 cm H2O, plateau pressures ranged from 23 to 26 cm H2O. Auscultation revealed bilateral rhonchi. Suctioning returned a moderate amount of tan secretions. The patient had 2 mediastinal chest tubes and 1 L pleural chest tube. He also had a pulmonary artery catheter with a fiberoptic lumen and a radial arterial line. His ECG was showing frequent R on T PVC's.
Hemodynamic values:MPAP = 25 mmHg, PCWP = 18 mmHg, RAP = 12 mmHg, C.O. = 3.0, BP = 115/55, SvO2 = 65%
Medications: Dopamine, dobutamine, lasix, cefazolin, heparin, morphine, IV fluids, and lidocaine.
9/5 – The patient’s CXR revealed severe pulmonary edema. Ventilator settings were changed to SIMV rate of 10, Vt 900, PEEP +5, FIO2 0.50. The patient began waking up and was so agitated he required sedation. The ventilator settings were changed from SIMV to AC at a rate of 10 BPM. Respiratory care orders were .5 ml albuterol /5 ml NS Q4. Crackles were present on auscultation.
Medications: Lasix, dobutamine, nitroprusside drip, milrinone, haloperidol, cefazolin, morphine, heparin, magnesium sulfate, and lidocaine.
9/6 – The ventilator settings were changed to AC at a rate of 5 with the patient assisting from 12 to 18 BPM. Peak pressures ranged from 23 to 29 cm H2O, with plateau pressures ranging from 20 to 27 cm H2O. The patient was extubated at 1050 and placed on BiPAP of 10/5. The patient's tidal volume was 480 ml with a SpO2 of 96% on a FIO2 of 0.50. The patient had a productive cough of a small amount of white secretions. The patient was also receiving aerosol treatments (SVN) with 0.5 ml of albuterol and 0.5 mg atrovent Q4 followed by postural drainage and vibration (PD&V) Q4. Breath sounds remained unchanged. At 1635 he was placed on a 50% facemask. Incentive Spirometry (IS) was ordered with inspiratory volumes of 250 ml - 500 ml. At 2140 he was placed on 4 LPM nasal cannula with SpO2s in the high 90s.
Medications: Lasix, dobutamine, milrinone, cefazolin, aspirin.
9/7 – Aerosol treatments are discontinued. Oxygen is decreased to 3 LPM. Breath sounds are clear to auscultation and he has a non-productive cough.
Medications: Discontinued lasix, dobutamine, milrinone, cefazolin. Started on metoprolol, lisinopril. Continued on aspirin.
9/8 – Oxygen was decreased to 1 LPM with a SpO2 of 99%. Breath sounds were clear to auscultation. He was discharged to go home at 1200.
