PRN fluid boluses post open heart?

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    Just wanted to know how other units do things. When we have a post op open heart they come back with all kindsa orders to manage them hemodynamically (as probably all open heart patients across the country do). But we technically do not have orders to give volume as we see appropriate. So lets say someone comes to the unit on a little dobutamine to keep the CI greater than 2 and then whatever else to keep your BP where it's supposed to be. If a patients index starts to trend down you can treat it in several ways, increasing preload, afterload reduction, or increasing contractility with inotropes. Most of the time they just need more volume and so we all the doc saying things like "My index is dropping, my urine output is dropping, and my PA and CVP have been steadily decreasing. What in the world do I do??" Doc: "Oh well it sounds like they just need some volume what dont you do this ___." Nurse: "Oh great idea! Wish I would have thought of that." Is this basically how it works at other units or do you have orders to give x amount of fluids based on some parameter? I'm not really saying our way is that bad either but it just seems odd that I can have freedom to increase inotropes and pressors as I see fit but don't have a way to give more volume which is usually going to be a much safer alternative to treat the low cardiac output (or BP or urine output or whatever). How does everyone else do things?
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  4. 10 Comments so far...

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    We have PRN orders for albumin or crystalloid to maintain a certain CVP/PAWP/PAD
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    I think it depends on where you work. We have to call for volume also. I work in a teaching hospital with residents/fellows around to talk with right away though....I have worked in community hospitals as well where there are 4-5 pages of standing orders (including volume - crystalloids/colloids) where you could basically do what you want. I do think it's a little silly, because we usually have orders for 4 or 5 vasoactive gtts and usually when we they come out of the OR, they are only running two or three -- so basically we have the freedom to start vasoactive gtts without talking to anybody, but we can't give volume.

    Some of our nurses get around this by keeping the IVF from the OR up and infusing if necessary. It's usually only crystalloids -- LR or NS, but it does the trick. I prefer Hextend which needs a phone call.
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    We have free reign to give up to a liter of LR and a liter of Albumin, and then we are supposed to call; but the understood rule of thumb is that up to 3 liters is generally considered ok. Our docs tend to prefer more fluids vs more pressors though.
    lkwashington likes this.
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    We have orders to give 500cc albumin x2 for CI<2.0 and EITHER SBP<90 or CVP <12. We are not, however, allowed to titrate inotropes w/o approval (unless pt is in trouble).
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    i use to work in a unit that nurses just gave products(blood, ffp, etc...) and then got orders after the fact... it was called "cowboy nursing"
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    Our unit has PRN orders for up to 1L Albumin and standing orders to transfuse 1 PRBC for Hgb < 10.0. If it is felt more is needed we call the doc.
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    Quote from RNTwin
    i use to work in a unit that nurses just gave products(blood, ffp, etc...) and then got orders after the fact... it was called "cowboy nursing"
    I've heard of places like this and I do understand the appeal, but didn't you ever worry? You're basically doing the CT surgeons job for him and if you do it wrong all he has to do is say, "I never gave that order" and he would be right. I'm not saying you actually practiced medicine without a license or condoned it or anything just wanted to bring it up for discussion. ICU is a place where nurses often make adjustments and write "telephone orders" but giving blood and FFP without an order is getting pretty extreme.
    fiveofpeep likes this.
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    We can give up to 3 liters of LR, which are part of the standard CABG order set. After that, we must do the dance described by the OP.
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    The unit I used to work in is half full of CV surgeons who don't mind if you give a little volume. Unfortunately, the other two surgeons are micro-managers who want to be called for every measly change that could easily be fixed with protocol fluid orders. Because of them, we currently have no PRN fluid bolus orders on our post CABG order sets. I'm hoping this is different at my new job.


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