Description of Event or Problem · 1
PATIENT WAS ADMITTED WITH NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION (NSTEMI). THREE DAYS LATER, THE PATIENT WAS ON AMIODARONE, HEPARIN, AND NOEPINEPHRINE DRIPS. DURING THE NIGHT SHIFT, THE NURSE ON DUTY HAD TO TITRATE NOREPINEPHRINE (CONCENTRATION 8 MG/250 ML) FROM 0.06MCG/KG/MIN, TO 0.07 ONE HOUR LATER, TO 0.08 SEVEN HOURS LATER. BP HAD BEEN MAINTAINED APPROXIMATELY 88/68 BY ARTERIAL LINE, 90/63 BY CUFF UNTIL THE END OF TITRATION. SEVERAL HOURS LATER, THE PT WAS ON 0.4 MCG/KG/MIN AND BP 205/123 BY ART LINE, 182/133 BY CUFF. AN HOUR LATER THE CONCENTRATION OF NOREPINEPHRINE WAS CHANGED TO 32 MG/500 ML AND DOSE WAS AT 0.4 MCG/KG/MIN. BP CONTINUED TO BE 161/102 BY ART LINE, CUFF PRESSURE 111/26. WITHIN 10 MINUTES, THE NOREPINEPHRINE WAS WEANED TO 0.2 MCG/KG/MIN. THE DOCTOR EXPRESSED CONCERN AS PATIENT WAS REPORTED AS BEING ON 0.08 MCG BUT FOUND THE PUMP AT 0.8 MCG. WHILE THEY WERE TROUBLESHOOTING THE RESPIRATORY THERAPIST CAME IN TO ASSESS ARTERIAL LINE AND AFTER LEVELLING AND ZEROING BP WAS FOUND TO BE SO ELEVATED. THE PUMP WAS REPROGRAMMED TO INITIAL MEDICATION CALCULATED WEIGHT FROM ICU. THE PUMP WAS TAKEN OUT OF PATIENT ROOM AT WHICH TIME THIS EVENT IS REPORTED. PUMP "BRAIN" CE 76034, NOREPINEPHRINE CHANNEL CE70420.