CVSICU Post Op Pt

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    Hi everyone. Need some advice. I'm coming off orientation soon and I need some guidance. I've admitted many post op heart pts and one of the things I'm still not completely comfortable with is the waking up/extubation part.

    When it's time to reverse them and shut off the propofol, I'm so nervous bc sometimes they are all over the place and its hard to calm them down. I normally have fentanyl right there if I need it. I wish there was a recipe to make them wake up and calm.

    Does anyone have any tricks from their exp? Thanks for listening.
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    We wean down the sedation starting at 4am, ativan and soft wrist restraints are also used if they are wild.. When we are attempting to extubate, we tend to stay with them and talk to them once the sedation is low enough for them to understand and "know" what we are saying and we continue to talk to them once it's off..Talking goes a long way, we tell them, you had surgery, it went well and we are trying to get the tube out, in order for us to do this, you have to help us by staying calm.. Some are just snatch and go and hope they fly

    We also like to place the pt on cpap or pressure support mode before extubating, this allows them to do most of the work.
    Altra and Esme12 like this.
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    There's no one magic solution. You try to figure out why they are agitated. Most importantly, do you know they aren't in tamponade? Because that will make them try to crawl out of their skin. Chest tubes are all patent and draining? HCT is good? CI and SVO2 good? BP good? Yes? Pain under control? (sometimes you just have to guess). Sometime's it just their personality. They are going to be a jerk because that's who they are and they are going to 'buck the vent' until they go home. Got a gut feeling that something ain't right? Just can't put your finger on it? Re-sedate and figure it out. Don't feel bad about it. If they're breathing good, gasses are good, just pull it. If you were wrong, well, you gave it your best and just go from there. Just rule out the nasties first so you know there isn't something else besides the ET tube making them crazy, and go from there. It just takes a while to get a feel for it I guess. (15 years of experience here)
    Last edit by Biffbradford on Jul 1, '13
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    Including the above......The first thing is STAY calm. Patients will feed off of your anxiety.

    They think HOLY CRAP I'm lying here and SHE"S SCARED!!!!!!!!

    Wean the sedation til they are hearing you but not fully awake. Shutting it of after the OR is truly startling them awake...they think WHAT THE HECK!!!!!!!!! they are frightened, they can't talk they have something shoved down their throat gagging them they can't talk...they wonder if they are the alive. Tell them each and very detail in a calm assertive manner. Make god eye contact. Establish that trust.

    Be calm....Make eye contact.....tell them the operations over..... they did fine....relax....the breathing tube will be out soon....they can't talk right now because of the tube.....they can't feel the air in their nose and mouth like normal..... making them feel like they aren't getting enough air....assure them that they are and it's in the end of the tube.

    What would you want to hear if you woke up with a garden hose down your trachea and in your chest with other the tubes in your neck and nether regions.....make sure they are medicated for pain.

    Take those few moments to let them know it's all ok.
    Altra likes this.
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    I realize many times we don't have the opportunity, but if you do I feel pre-op teaching is paramount. I feel as if in my experience when I get to really go over the weaning experience pre-op the patients do so much better. I always tell them what to expect and to always listen listen carefully to what their nurse is telling them. Reassuring them that I will not leave the room and will remain with them constantly through the process. It definitely makes a difference.
    Sugarcoma and Esme12 like this.
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    "Has anyone told you what to expect when you come out of O.R.?" "No" Been there, done that!
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    Great feedback. Thank you everyone. I agree with giving pain med but I had a provider tell me no bc they don't want to make them too sleepy where we can't get them extubated. I don't agree. We normally give fentanyl 25/50mcg. Thoughts?
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    Quote from Stormy8
    Great feedback. Thank you everyone. I agree with giving pain med but I had a provider tell me no bc they don't want to make them too sleepy where we can't get them extubated. I don't agree. We normally give fentanyl 25/50mcg. Thoughts?
    I try and avoid ativan/versed because while it works initially, it has a strong potential to just make delirium worse as the benzo starts to wear off (necessitating more benzos producing more delirium and on and on). While benzos might delay extubation, I don't think it's appropriate however to hold analgesia just to get the tube out a little quicker. They'll definitely be more awake if they're in excruciating pain, that doesn't mean that's a good thing. Early extubation is important but it's not important enough to ignore all other aspects of good patient care. Fentanyl has a very short half life and shouldn't significantly delay extubation, although you stick to minimum amount necessary for effect.
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    Depending on patient size, 25 to 50 of Fentanyl isn't jack. Often, patients are real sensitive to analgesics and there is a fine line between giving them too much, thus reducing their respiratory drive, or not enough so they have so much pain from the chest tubes and sternal incision that they can't take a deep enough breath. Precedex is supposed to be good, but I NEVER had good luck with that in post op hearts, the blood pressure always dropped too low. Bottom line, Fenanyl 25 at a crack until you find a happy medium. It ain't always easy though.
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    Quote from Stormy8
    Great feedback. Thank you everyone. I agree with giving pain med but I had a provider tell me no bc they don't want to make them too sleepy where we can't get them extubated. I don't agree. We normally give fentanyl 25/50mcg. Thoughts?
    When we receive pt. from OR we routinely start Morphine running 1mg/Hr. After 4 hours post-op we normally check abg if gasses are good, put to PS mode with 40% FiO2. Provided they are not drowsy and able to obey commands.(indications that they are ready for extubation) If not, wait until they are more stable to be extubated.

    Hope this one, will make your thoughts clear


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