Heart transplants and high risk cards, oh my

  1. 0
    Long story short, I spent the last 3 yrs working with almost every type of ICU patient except day 0 open hearts, transplants, burns, and anything under the weight limit for adult ACLS. The hospital I worked at was excellent trauma/neuro but lacked a lot in .. everything else, as I have found. I got my CCRN with flying colors, and quickly got offered a job in a fantastic area at a very large, extremely high acuity hospital that deals with all transplants (including hearts), ECMO, high risk cardiac patients, neuro, etc etc just no trauma/burns. I was given a short (5 days) orientation to the basic population I'm expected to take w/ no extra training and that's cool, 95% of that I understand every intervention in regards to disease management etc.

    I came here to see if anyone is able to provide me a starting point to better understand those 5% I don't feel as strong with and also some starting points for better understanding the patients I will want to take as I progress in my new facility.

    (I am also currently on night shift, and the residents do most of the noc work so their understanding is often not 100% either--or they are afraid to explain. I try to ask experienced co-workers when we have time, but there's not always enough time considering the acuity of our patients)

    1) WTH is all in the heart transplant work up? I asked a bit about why we do some of this stuff and ppl kind of give me a blank stare cause a lot of us TRULY don't know why we do gastric emptying studies and so forth. [[Specifically post transplant: There's also a lot of drugs ppl throw around I have only heard of in CCRN studies or briefly see in pharm books like Isuprel that get used frequently that I am not sure as to why. A starting point for me to read on the aftercare of heart transplant and ECMO in a clinical setting would be fantastic!]]

    2) All the different VADs. Where I worked, if you needed more than a balloon pump, you hoped you could make it 2 hrs to the nearest "higher acuity cardiac center" or you went on comfort care. Here, we have like 5 different VADs at least. Why do we choose a heartmate over an impella? How about the one a patient went home on for like a year? How does the work up actually work (kinda got some answer that work ups generally use a PA line and either milrinone or dobutamine and possibly other pressors, see how much support is required, and from there if a pt needs a VAD right now, soon but can wait with medication management, just needs a different medication management, or your heart is **** get a new one). I am not expected to take these yet, but they are usually one of the first to get trained into (along with CRRT).

    3) PA line troubleshooting. Where I worked, we didn't use them. Almost ever. Now I get them on daily basis. The new ones are fantastic, beautiful wave forms, wedge perfectly, etc. The ones that have been in for >72 hrs? Start to have problems with dampened waveforms (primarily), "catheter is sitting up against the vessel wall", etc that simply flushing doesn't seem to help but some of my coworkers seem to be able to fix with magic fingers. This is barring the pressure tubing/NS levels cause I have learned in my very long experience with alines and CVPs how often those get overlooked and are usually my first go-to point. Also, is it coincidence, or do morbidly obese people and PA caths usually get questionable waveforms? I honestly don't know how body mass affects the catheter.

    4) Possibly because it's been transplant work ups, and also because its very MD directed, I'm not always sure what we are titrating gtts to in particular with the PA line in severe CHF. Their PA #s are always extremely high and rarely anywhere near normal, and the MD directs the nursing staff to titrate up/down on milrinone on what can appear as on a whim. If it's dobutamine/levo combo or just dobu, it's usually RN directed and parameters are set in our MAR which is easy enough to figure out and follow. It doesn't help my past experience with milrinone is limited on textbook knowledge that is a inodilator etc.

    5) Is Natrecor used anywhere anymore?

    6) Is peridex/chlorhexidine qshift for oral care for vented pts a standard in your ICUs? For some very odd reason, this is the ONLY issue I've run into with my new place, they don't believe in ordering it for all vents. I have always known it to be a gold standard in VAP bundles etc.

    Any ideas for reading for general transplants would be awesome too, granted kidney/panc/VERYSTABLE livers are not that complicated, there's just a few things that we do that don't make sense--and I have asked our ACNP why we do them, and the answer is, "We always have done that, I have no explanation I'm afraid". Can't just take that for an answer, of course. :P

    It's kind of a lot in this post, thanks for reading.

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  2. 3
    #1 - There is a ton of stuff involved with a transplant work up. It's very complicated and there are many rules We used to give Isuprel to increase HR in Sinus brady, but not with post-of heart transplant patients.

    Taking care of a Post-op heat transplant is much like a CABG with a few exceptions. Anti-rejection meds are priority - you need to have an understanding of what types of induction meds your center uses. It's important the the anti-rejections meds are delivered on time.
    Otherwise, you really want a new heart transplant to have a HR 100-110. Our patients usually have pacing wires- I have had to pace them to keep their HR up.

    I've had a few new post-op transplant patients acutely reject, after which we will usually place ECMO for BP's refractory to pressors.


    #2 - An impella is a short term VAD, so it may be used in place of an IABP for a patient that needs extra support.

    The impella is not used as much in the units I've worked because it requires an Echo to verify placement. The older models could very easily migrate. One of the perks is that it can be placed in cathlab.

    In my unit, since I work in Open Heart, if a patient requires extra support, we will use centrimag as an LVAD or BiVAD.

    Heart Mate II is long-term VAD for support as a bridge-to-transplant & one of the only devices that is approved for destination therapy (no transplant). Usually indications for a LVAD is EF < 10%, but this changes from center to center. For instance, a patient may be able to be managed on home primacor.

    Every LVAD has different Pro's & Cons. Heartware is becoming more popular, but works best for smaller people. HMII is still the most popular device.

    The Cetrimag is still our go-to device for RV Failure.

    #3 - Some on here may disagree, but POWER FLUSH! Most importantly, its important to develop a culture of taking care of your lines. If you can't get a good waveform, sometimes slightly inflating the balloon will float the PA back into place. THat's my magic fix.

    4) Their PA #s are always extremely high and rarely anywhere near normal, and the MD directs the nursing staff to titrate up/down on milrinone on what can appear as on a whim. If it's dobutamine/levo combo or just dobu, it's usually RN directed and parameters are set in our MAR which is easy enough to figure out and follow. It doesn't help my past experience with milrinone is limited on textbook knowledge that is a inodilator etc.


    #4 - We tend to try to keep out PA pressures out of the high range in heart transplant patients. This is because of the RV. If PA's are high, the RV will have to work against that increased pressure. We usually give Nitric Oxide or Ventavis gas to help dilate the pulmonary bed.

    #6 - Some units I've used chlorhexidine for oral care, others I have not.
    ICURNBSN, Kim R, and Esme12 like this.
  3. 0
    Gastroparesis following lung transplantation can complicate medical management leading to malnutrition, weight loss, and erratic absorption of immunosuppressive medications, which are all important factors in the success of grafts.

    Isuprel is used because the heart has been De-nervated and it will not respond to atropine. Cardiac transplantation results in complete afferent and efferent denervation of the donor atria and ventricles. This denervation includes both sympathetic and parasympathetic divisions of the autonomic nervous system.

    PA line these patient will frequently have "dampened waveforms" pre-transplantation due to poor flow. Flush them frequently. They will typically have PA pressure that are higher then the B/P due to the poor function of the heart.

    Drugs fall in and out of favor. Natrecor I have seen more post op.

    Have you asked your educator?

    What else do you need....the care is complicated and vast.
  4. 0
    These are some excellent responses, thank you! I'm not completely sure who, or which, educator I would direct questions to. At previous facilities they had like 1-2 educators that kind of did all the ICU stuff, granted previous facilities did not have this type of variety. We have like the ECMO CNS, cardiology CNS, cardiovascular surgery CNS's, transplant CNS, etc etc. that act as educators and quality improvers. They often teach the classes that will train for their various specialities, so I have 0 idea who the ECMO CNS is because 1) I'm not day shift 2) I'm far off from being able to take the class yet, for example. I think it's unfortunate that we do not have the educators like at my previous facility that are easy to get in contact with, but I can also see why my facility has gone the route it has. The clinical manager will frequently send out articles, fliers, and AACN online classes for education on certain things or updates that the CNS's pass to him for easier distribution. I do learn a lot from my charges and other experienced nurses, as well as the residents. I have been fortunate to teach them too recently, as we have had an upswing in brain bleeds which a lot of my coworkers are not comfortable with, but I know those in and out..

    I did ask my clinical manager a bit ago about how I can learn more on these newer patient populations, and he responded I'll pick up the basics by just helping nurses with the pt, and further trained in classes when they open up again. That's fine and all, but it doesn't satsify my curiosity as it is now. It probably doesn't help that the particular topics I want to learn about are considered very advanced specialities even for critical care, so AACN rarely runs a journal article on these specific topics it seems [truth be told I've been busy with a ton of OT and moving to a new apartment, so I haven't kept up on the articles in the past 4 months].


    Just to make clear, they didn't simply drop me w/o skills into a high acuity ICU with 1:1 type pts (I can take some 1:1's, like brain dead donors, severe sepsises, paralyzed for severe ARDS--but not the VADs, fresh hearts, ECMO etc).. A majority of the pt population I know very well, but the exposure to all the new stuff makes me excited and curious!


    edit: Forgot to say, a lot of the "paper" protocols and policies were taken "out" simply because the facility feels it can better implement them using order sets via EPIC. This is fine, except sometiems when I'm having a slower night, that's how I learned as a new nurse about patients I hadn't had--I'd look up the protocols and piece together the why's and how's of the treatment and management process.

    Also, I'm getting the feeling that some of the questions I asked are possibly not as delineated as I might have thought... like the transplant work up question--I had a patient just the other shift where she had to go through quite a bit more than normal (according to my charge) because they really needed to rule out extra crap (her liver enzymes were normal, but hep B antibodies came back positive [but no prior immunization] so she needed a whole load more tests and a biopsy) that most of our patients don't need to endure. The PA catheter with medicine management (I don't know what to call this? my facility usually calls it the milrinone or dobutamine test) is standard as is gastroparesis testing, but from there it seems to vary. I'm thinking I might learn more if I was on day/evening shift where I could see more of the testing and thought process of the day time physicians rather than just reading their notes (which are not often detailed--many of them are new to EPIC heh) if I have the time.
    Last edit by Catchall_RN on Mar 7
  5. 0
    OP, have you contacted your facility's medical librarian? I bet he or she would be an immense help in searching for answers to your questions. You have really honed in on your specific topics already.
    I would imagine there are some great articles on #1,2, and 3.
    There probably are some RTC's on #6.
    The literature is vast and the librarians really can find what you are looking for and email it to you. Best wishes.
  6. 0
    In the major heart ICU I worked at in the past, there was a progression of equipment and classes that you learned on: CVVH (usually first since it's relatively hard to outright kill some one with it if you screw up), then IABP, heart transplant class (first taking them a week out and working closer to fresh admission from O.R.), and the VADs / Total heart. After you've gone through all those classes, you've accumulated a box full of reference sources and have seen enough cases to answer the questions you've posed above. Additionally, you're talking with the surgeons daily and are able to pick their brains as well. It takes time, but you'll get there. Do you learn faster when on day shift vs nights? I don't think so. It's been my experience that I get to talk with the surgeons as they round first thing in the morning before their first case of the day. Once they scrub in, then you don't get much 1:1 time with them since they are so busy unless your pt is so sick that the doc parks right in the room with you for a while. Other RNs are usually so busy with their own messes, they don't have time to teach and share like they do on nights either.
    Last edit by Biffbradford on Mar 8
  7. 0
    Speaking about the chlorhexidine oral rinse. I work in a CTICU at a university hospital with a level 1 trauma center and we use chlorhexidine for anybody they plan on venting for longer than 24 hours really, and if there isnt an order we get one. Our VAP rates are relatively low due to this i believe.
  8. 0
    Quote from SHGR
    OP, have you contacted your facility's medical librarian? I bet he or she would be an immense help in searching for answers to your questions. You have really honed in on your specific topics already.
    I would imagine there are some great articles on #1,2, and 3.
    There probably are some RTC's on #6.
    The literature is vast and the librarians really can find what you are looking for and email it to you. Best wishes.
    I'm not actually sure if we have a medical librarian... I'm sure we have to--I'll have to go search around on the intranet about this.

    Thanks again for the comments!
  9. 0
    A lot of your questions will be answered by any literature on pre and postop heart transplant. ABTC has a course that leads to CCTN certification that has a good book about transplant.

    Re VADs: Ventricular assist devices: what ... [AACN Adv Crit Care. 2012 Jan-Mar] - PubMed - NCBI


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