Admitting an open chest pt
- 0Jul 18, '12 by volunteerpioneerI am a newbie in the CT-ICU and part of my orientation is admitting all the fresh hearts. Yesterday, the case scheduled was CABG x3; but ended up needing an AVR and IABP in OR. and when receiving report they stated he was going to have an open chest. They ended up keeping him in OR til the next shift, so I never got to admit my open chest pt
I wanted to know your thoughts on these pts, differences in admit and care, tips in managing these pts so I get an idea of what to expect for next time. Thanks!
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- 1Jul 18, '12 by Rose_QueenBe ready to run your butt off and have the crash cart very, very close, as usually the reason the chest is open is that they are unstable hemodynamically. The last patient I took to ICU with an open chest bottomed out when we tried to wire his sternum. We had to open him back up, and he was on levophed, dobutrex, epi, and neo.
- 1Jul 18, '12 by umcRNWell, I work in a pediatric cardiac ICU and I would say about 60% of infants return with open chests (small chest cavities do not accommodate swelling well). Be prepared for a LOT of bleeding and to be giving a lot of fluid. In an adult I suppose you would want the rapid infuser primed and ready. When your patient first comes up get a good look at their "window", the dressing area over the open chest, keep an eye on this, increased buldging of the window can be a sign that your patient is about to tamponade. Have your code drugs drawn and ready before your patient gets there, I like to think that the more drugs you have prepped to more bad "juju" you can ward off (doesn't always work that way but hey, at least you're prepared). We actually do turn our little ones with open chests but they are a lot easier to move than those adults
- 6Jul 21, '12 by umcRNQuote from IHeartDukeCTICUHaha I remember when I was on orientation and someone asked if they coded how do you do chest compression?Just look at the bright side... if they code, their chest is already open
Instructors answer: Preferably with gloves!
- 1Jul 26, '12 by BiffbradfordWell, just because they have an open chest, doesn't mean you have to have the code cart in the room. You may have to work hard to get 'em stable (fluids, blood, drips, correct any coag. problems), but then you should be okay. From there it's either diurese to get the swelling down, or crank up the 'ol CVVH to pull the fluids off.
NO TURNING! Not even if they poop. On rare occation you may have to 'levitate' 'em to change the blood soaked linens so you don't get skin break down (or if someone zeroes the bed scale by mistake - DOH!), that's always a good team buiding exercise.
Chest compressions??? Not on your life. It's direct heart massage, and I ain't doing that! Call the surgeon in for that one.
Often that's a 2:1 nurse to patient staffing ratio until they're stable.
- 0Jul 26, '12 by umcRNhmmm in my unit if they code someone better get their hands in their chest soon and massage, sure the surgeon will be there soon to put them on ecmo but till then someone better be doing something other than standing around starting at a coding kid!
and yes, I have seen both bedside RN, fellow or attending doing cardiac massage on our babies...of course on tiny little hearts its more of a gentle squeeze, but when the question was asked in my orientation our instructor wasted no time in making sure we knew that open chest or not compressions need to be done if a kid is coding
- 0Jul 27, '12 by volunteerpioneerEveryone thanks for the input.
Perhaps I jinxed myself because at yesterday's shift I got my first open chest-patient. start of shift the surgeons did a wash out at bedside and decided to keep the chest open since they were planning to do it again the next day :/ .. first time I ever smelled burnt human flesh.. anyway he was a 2:1, but not because of his open chest, but because he had a BiVAD. He was also on CRRT, had a IABP, Nitric with his Vent.. MAN! Anyway..
didn't turn him ( how could I).. and kept my eye on the cart :/
- 1Jul 27, '12 by BiffbradfordBeing the 'mechanic' can be fun on those paitients. Interesting to see you write 'nitric'. The big hosp. here stopped using nitric because of the $$,$$$ cost they weren't getting re-imbursed for. Went to Flolan instead. I guess if you gotta glove up and grab some heart, then you do ... but I'd be on the horn with the cutter on call long before then tellin' him/her that things ain't looking good and don't expect to get any sleep tonight! Fortunately where I work now, they don't do VADs. All that kind of excitement is behind me.