Description of Event or Problem · 0
PATIENT WAS TRANSFERRED MEDICAL ICU (MICU) @1800. PATIENT ARRIVED ON STABLE DOSE OF 25MCG/MIN LEVOPHED AND WAS SWITCHED TO MICU PRESSORS @1820. PATIENT BEGIN TO HAVE CARDIAC INSTABILITY SHORTLY AFTERWARDS. UNABLE TO OBTAIN BLOOD PRESSURE READING VIA NONINVASIVE BP CUFF. VASOPRESSIN ADDED @1830 AND EPINEPHRINE ADDED @1840. EMERGENT ARTERIAL ALINE PLACED AND LEVOPHED MAXED AT 100MCG/MIN. PATIENT BEGAN CHEMICALLY CODING. RECEIVED 3 AMPS SODIUM BICARBONATE, 1G CALCIUM CHLORIDE, 150 MG AMIODARONE, 1G MAGNESIUM, AND 2MG EPINEPHRINE PUSHES BEFORE STABILIZING ON 100 MCG/MIN LEVOPHED/ 0.04 U/MIN VASOPRESSIN/ 10MCG/MIN EPINEPHRINE. AT 1955, BAXTER PUMP ALARMED "UPSTREAM OCCLUSION" ON THE PUMP RUNNING LEVOPHED. RN NOTED THAT THE BLUE CLAMP WAS PARTIALLY OCCLUDING THE INFUSION LINE AND THAT THE LEVOPHED BAG WAS STILL COMPLETELY FULL (250ML) DESPITE PUMP DISPLAY READING OF "VOLUME TO BE INFUSED" SAYING ONLY 8ML REMAINING IN BAG. UPSTREAM OCCLUSION RESOLVED BY RN, WHICH RESULTED IN THE PATIENT'S BLOOD PRESSURE SPIKING TO 211/98 (133) ON ARTERIAL LINE. RN ABLE TO IMMEDIATELY WEAN COMPLETELY OFF EPINEPHRINE AND WEAN LEVOPHED INFUSION TO 15 MCG/MIN + 0.04U/MIN VASOPRESSIN. LEVOPHED INFUSION RAN FOR 1 HOUR AND 35 MIN AT A FAST RATE (@ 187CC/HR) WITH PARTIAL CLAMPED INFUSION LINE BEFORE EVER ALARMING AND PUMP WAS NEVER SILENCED DURING PERI-CODE.