A Shift in the Life — The Ongoing Story of a Critical Care Nurse
“The Dead Horse” -- Part 2 — by Matthew Nathan Castens, RN

As I finished up getting report from the night charge nurse, I looked at who she had assigned to be Bette's nurse (all names have been changed). It was Kellie. Great! She was new to critical care, but was an excellent thinker and agressive question-asker. I like that in the nurses I work with -- it makes life easier for all of us.

I walked into Bette’s room to assess the situation. Grim was the verdict. The nephrologist had just left and had written some new orders: wean off the dopamine and start an epinephrine drip.

Epinephrine is the same as the body’s natural adrenaline. The advantage to using it over the dopamine was that it could help the heart squeeze better than the dopamine, and with Bette’s damaged heart, it needed the bigger boost that the epi could give. The disadvantage is that it would make her heart rate even faster and use more oxygen. Like the dopamine, it was the lesser of two evils.

As I explained all of this to Kellie, she hung the epi drip and slowly started to wean off the dopamine. All was going well until the dopamine got down to about 10 micrograms. (Many critical drugs are so powerful that the doses are in micrograms -- one-millionth of a gram -- rather than in milligrams. Some newer drugs are even dosed in nanograms -- one-billionth of a gram!) When dopamine is at the higher doses(10-20 mcgs) it not only helps the heart contract stronger, it also helps the blood vessels constrict. When Bette's dose of dopamine got too low, her blood vessels opened up and her blood pressure dropped too low. Now what? I asked Kellie how she thought things through. I do this will all new nurses I work with so they have an opportunity to learn. I also figure that if everyone is thinking aloud everyone benefits. Her first instinct was to turn the dopamine back up, which was correct, but we needed to go one step further. As Bette's sepsis worsened and her blood became more acid the dopamine wouldn't work as well. Also, in order to get the vasoconstriction needed from the dopamine, we would also be stressing the heart more in combination with the epinephrine. We needed a powerful vasoconstrictor that wouldn't stress the heart: Levophed.

Levophed acts the same way as the body’s norepinephrine as a very potent vasoconstrictor. We suggested this to the nephrologist and he immediately agreed that it was needed. Levophed is so powerful that it is almost always the last-ditch drug to maintain blood pressure -- especially in sepsis -- hence its nickname, “Leave-em-dead”. In this case, I couldnt agree more.

Once we got the Levophed on and the dopamine off, Bette’s blood pressure started to stablize. I went off to round on the other patients in the unit and Kellie mentioned that she was going to "shoot" a cardiac output. Using the PA catheter, sterile sugar water of a known temperature is injected into the bloodstream traveling through the heart. The PA catheter has a temperature probe on the end of it and senses when the blood temperature drops to the temperature of the water. The speed at which this occurs allows the computer to figure out how well the heart is pumping, including how much blood is pumped with each stroke, the degree of vasoconstriction in the body, and the patient's fluid status.

Bette's cardiac output was as lousy as I expected. Her blood was so acidodic that none of the medications were working as well as they should have. We gave her some sodium bicarbinate to try to reverse the situation. We did to some extent, but not to the point where it would make a difference. The doctor had just finished talking yet again with the family. Half of them wanted to let her die. Unfortunately, the half with the legal power still wanted to try everything. The doc came back to us with a report. There was one last -- very last -- chance to turn the tables: CRRT.

Continuous Renal Replacement Therapy is amazing. It can best be described as a super-dialysis. Unlike conventional dialysis, however, CRRT more closely mimics the human kidney and is able to remove toxins from the blood that conventional dialysis cannot. Some of those toxins are refered to as cytokines, which are the poisons that make sepsis so dangerous. If we could use the CRRT to remove the cytokines in Bette's bloodstream, her body would better respond to our treatments. A dialysis catheter was placed and we planned to procede.

CRRT is complicated. For the first several hours at least (frequently as long as the patient is on CRRT) two nurses are needed to care for one patient. One nurse does the calculations and runs the CRRT machine, the other focuses only on the patient. Beside myself, the only other nurse that shift trained in CRRT was Marsha. Marsha and I get along quite well, but I can see how she might rub others the wrong way. She has a strong personality and tends to make unsolicited (but very good) suggestions. As she went into the room to set up, I realized that she and Kellie would not get along well. Great. This would be another situation for charge-nurse Matt to handle.

I pulled both Kellie and Marsha into a private room for a chat. Basically I told them to get along or else. Or else what? No one asked. Or else nothing, really. I did point out though that neither Bette nor her family would be well served by having two nurses snipe at each other over the bed. They agreed and Marsha went to set up her machine.

Kellie had another problem. She felt that Bette's situation was futile and that continued care was unethical. She wanted to be relieved of duty. I agreed but told her that there was nothing I could do. Our unit (and the hospital) was so busy that I couldn't get another nurse to take over. I also pointed out that realistically, Bette wouldn't survive much longer and that soon Kellie's nursing skills would shift from care of patient to care of family -- somthing that she not only excelled at, but found very fulfilling. As we went back to the room, we realized how right I was. Marsha took Bette's temperature for her calculations and got a reading of 105. I immediately suspected a neurological source. Bette had had a fever before now, but never this high -- and so fast! When the brain is severely damaged, either by trauma or illness, the temperature center short-circuits and severe fever results.

As Kellie shined a flashlight into Bette's eyes, it was confirmed. One of her pupils had grown as large as it could get and wasn't reacting to light at all. This "blown" pupil was the sign of herniation: Bette's brain had been so damaged by the illness that it had swollen up and was squeezing through the hole in the base of her skull. She was dead.

As a group we all sighed, "Finally," and went silent. Kellie went into family-nurse mode comforting and crying with the family. Marsha started to clean up the room and body to make them presentable for viewing. The doctor and I debriefed before going our separate ways. He went to see other patients and I went about other charge nurse duties. The shift finally started to quiet down and I did a silent cheer when I was able to let Kellie go home early.

At the end of my twelve hours I gave report to the oncoming charge nurse and left with a smile. I had the weekend off.

Ibuprofen overdose has become common since it was licensed for over-the-counter use.

There are many overdose experiences reported in the medical literature.[9] Human response in cases of overdose ranges from absence of symptoms to fatal outcome in spite of intensive care treatment.

Most symptoms are an excess of the pharmacological action of ibuprofen and include abdominal pain, nausea,
vomiting, drowsiness, dizziness, headache, tinnitus, and nystagmus.

Rarely more severe symptoms such as gastrointestinal bleeding, seizures, metabolic acidosis, hyperkalaemia, hypotension, bradycardia, tachycardia, atrial fibrillation, coma, hepatic dysfunction, acute renal failure, cyanosis, respiratory depression, and cardiac arrest have been reported.[10]. The severity of symptoms varies with the ingested dose and the time elapsed, however, individual sensitivity also plays an important role. Generally, the symptoms observed with an overdose of ibuprofen are similar to the symptoms caused by overdoses of other NSAIDs.

There is little correlation between severity of symptoms and measured ibuprofen plasma levels. Toxic effects are unlikely at doses below 100 mg/kg but can be severe above 400 mg/kg;[11] however, large doses do not indicate that the clinical course is likely to be lethal.[12] It is not possible to determine a precise lethal dose, as this may vary with age, weight, and concomitant diseases of the individual patient.

Therapy is largely symptomatic. In cases presenting early, gastric decontamination is recommended. This is achieved using activated charcoal; charcoal absorbs the drug before it can enter the systemic circulation. Gastric lavage is now rarely used, but can be considered if the amount ingested is potentially life threatening and it can be performed within 60 minutes of ingestion. Emesis is not recommended.[13] The majority of ibuprofen ingestions produce only mild effects and the management of overdose is straightforward. Standard measures to maintain normal urine output should be instituted and renal function monitored.[11] Since ibuprofen has acidic properties and is also excreted in the urine, forced alkaline diuresis is theoretically beneficial. However, due to the fact ibuprofen is highly protein bound in the blood, there is minimal renal excretion of unchanged drug. Forced alkaline diuresis is therefore of limited benefit.[14] Symptomatic therapy for hypotension, GI bleeding, acidosis, and renal toxicity may be indicated. Occasionally, close monitoring in an intensive care unit for several days is necessary. If a patient survives the acute intoxication, he/she will usually experience no late sequelae.


Availability
Ibuprofen was made available under prescription in the United Kingdom in 1969. In the years since, the good tolerability profile along with extensive experience in the community (otherwise known as Phase IV trials), has resulted in the rescheduling of small packs of ibuprofen to allow availability over-the-counter in pharmacies worldwide. Indeed there has been an increasing trend towards descheduling ibuprofen such that it is now available in supermarkets and other general retailers. The wider availability has meant that ibuprofen is now almost as commonly used as aspirin and paracetamol.