Description of Event or Problem · 1
THE PHYSICIAN STARTED THE PROCEDURE BY PLACING A SPIDERFX EMBOLIC PROTECTION DEVICE. THE PHYSICIAN THEN PREDILATED BEFORE ATTEMPTING TO PLACE THE PROTEGE RX. THE FIRST PROTEGE RX DEVICE WOULD NOT DEPLOY AFTER MULTIPLE ATTEMPTS. THE PHYSICIAN PULLED THIS SYSTEM OUT AND USED ANOTHER PROTEGE RX (SAME MODEL NUMBER) AND WAS SUCCESSFUL. PROCEDURE COMPLETED WITHOUT COMPLICATIONS AT 10:18 AM. PATIENT TRANSFERRED TO ICU PER NORMAL PROTOCOL. HOWEVER, PATIENT HAD MANY COMORBIDITIES WHICH COMPLICATED ISSUES POST PROCEDURE. WHILE PATIENT WAS UNDER GOING ROUTINELY SCHEDULED DIALYSIS AT 2:30 PM, PATIENT BECAME LIGHT-HEAD AND COMPLAINED OF ABDOMINAL DISCOMFORT AND NAUSEA. THE PT WENT IN VT AND ARRESTED. THE PT WAS BROUGHT EMERGENTLY TO THE CATH LAB AND ANGIOGRAPHY REVEALED AN OCCLUDED CIRCUMFLEX. THE PT UNDERWENT ASPIRATION THROMBECTOMY; PATIENT ALSO HAD A BALLOON PUMP PLACED AND A TEMPORARY PACER. PATIENT THEN RETURNED TO ICU AND DESPITE PRESSORS, BALLOON PUMP AND PACER, THE PACER NO LONGER CAPTURED AND AS SUCH BALLOON PUMP COULD NO LONGER FUNCTION. THE PATIENT HAD NO UNDERLYING PRESSURE OR RHYTHM AND THE PT DECEASED AT 4:49 PM. THE PHYSICIAN COMMUNICATED THAT THE PROTEGE RX STENT DID NOT DIRECTLY RELATE TO THE PT'S DEATH. UNFORTUNATELY, THE PT HAD MULTIPLE CO-MORBIDITIES THAT CONTRIBUTED TO HIS DEMISE.