by rickard

I work in a CVICU the does approx 200 - 300 open heart procedures a year. Early mobilization means, in my unit, that a pt gets out of bed after PA catheter is removed < NEVER OOB with, and pt stays in the chair several hours. later on post op day 1 pt is expected to ambulate a short distance. On post op day 2 pt usually remains in critical care pt is expected to ambulate several times. I have seen frequent occurrences of post op ileus. If you repond to this post (please do) i am trying to decrease the frequency of ileus, please be specific with times and distances and if you work at a large very well known heart center please name it. Thanking you in advance Richard Dingwall RN, CCRN-CSC

Re: Early Mobilization after Open Heart (what does this mean to you?)

We had a very high acuity level for our post-operative CABG/Valve patients. The gold standard was to try to get them extubated if stable within 6 hours. To try to get them to dangle at the bedside the night of surgery and to have them in the chair by 0600 the next day. The majority of these patients went to the telemetry floor within 18 hours of their surgery. All of them had swan lines. Just because of a patient has a swan ganz doesn't necessarily mean that they can't get out of bed. Evaluate the patient individually, and go from there. If you haven't I would check the literature for what best practice is. I would also suggest you look at your NG/OG placement process. Are they being placed, when are they removed, are they being hooked up post-op?

Re: Early Mobilization after Open Heart (what does this mean to you?)

Our open hearts are OOB within 2 hours of extubation with very little exception, whether the swan is out or not, and they generally ambulate three times on POD #1 (only twice if the swan doesnt come out until after lunchtime). All of our patients have NG/OG tubes hooked to LIWS while intubated. I have been working in this CVICU (highest # of open heart surgeries in the state) for 3 years and I have only seen 2 cases of post-op ileus and both cases were patients who were intubated for several days after surgery.

Re: Early Mobilization after Open Heart (what does this mean to you?)

Our goal is for early extubation within 6 hrs end of surgery-we are about 80% on that goal. Pt is dangled within 2 hrs, if still hemodynamically stable, and is OOB by next AM prior to shift change-swan in during this time. Pts are typically transfered to CVU/stepdown by 1100-1300 POD1. The swan is pulled prior to this and first ambulation in the halls, blakes are typically removed at the same time as the swan. On occasion, say 10% of pts will need to stay an extra day and need the swan in place- we have ambulated pts with swans, but these are not pt's I would want to see trucking down the hall too far from their rooms-about<30 feet is far enough,to quantify it for you. I could not find any best practice data, but just the thought of that catheter bouncing around in the PA, migrating in-out-wherever, is enough for me to be conservative with activity.
Demographics: 200 bed regional center about 200 CVS /yr-busy for us!

Re: Early Mobilization after Open Heart (what does this mean to you?)

Our goal is off the vent in 6-8, to chair 2-4 hrs post extubation, ambulate within 18hrs of adm to the CVSU. Ambulation is 2-3 x per day in critical care. As for Swans- all our patients have them. They are d/c d just before transfer to tele on POD1 or 2. In 20 years of CVSICU nursing I think I have seen 3 post open heart ileus patients- (we do about 200-300/yr). The docs aren't in the gut- I don't understand where your ileus problems are comming from. Certainly inactivity and post op narcotics can contribute, but research I have seen recently indicated activity had very little effect on bowel function- It may be an old nursing practice that dosen't hold up to evidence based practice. My best advise is looking into your Salem Sump or NG placement and length of use. If we have a nasal placed Salem Sump we try to leave it in till close to 5am POD1.

Re: Early Mobilization after Open Heart (what does this mean to you?)

At my facility we do a "4x4" goal...

So as soon as the patient has arrived in the ICU room... We have 4 hours to extubate.

Restart the clock...

Then the 2nd block of 4 hours is trying to get the patient to dangle at the bedside.

Restart the clock...

The 3rd block of 4 hours is goaled to remove the PA catheter if the patient has been off of vasopressors for at least 2 hours.

Restart the clock...

Then the last block of 4 hours is dedicated to getting the pt up to a chair for a couple hours and ready for transfer to the floor.

Hope this helps!

Re: Early Mobilization after Open Heart (what does this mean to you?)

I have also rarely seen ileus in open heart recovery, I have worked in many diff units across the U.S. as I am a travel nurse. The current facility I am at does the up to the chair the next a.m. (although many don't until the swan is out-that is just how this facility is) then swan out later in the morning POD1 (here they also are different in that they pull it no matter just about what drips they are on!) and walking 3-4 times the first day, around the entire second floor. They really push the pts here, they are not allowed to get back to bed until night shift comes back in. Here they just leave the OGs clamped unless they are planning to sleep the pt over night. So not sure where all your ileus's are coming from...even in places that didn't mobilize their pt's quickly, I still didn't see a lot of them...

Re: Early Mobilization after Open Heart (what does this mean to you?)

Ours is similar to yours but we plan to extubate in 4 hours, sometimes they come out extubated, but we get them into the chair 4 hours after extubation with swan and drips.

Originally Posted by ele4life

At my facility we do a "4x4" goal...

So as soon as the patient has arrived in the ICU room... We have 4 hours to extubate.

Restart the clock...

Then the 2nd block of 4 hours is trying to get the patient to dangle at the bedside.

Restart the clock...

The 3rd block of 4 hours is goaled to remove the PA catheter if the patient has been off of vasopressors for at least 2 hours.

Restart the clock...

Then the last block of 4 hours is dedicated to getting the pt up to a chair for a couple hours and ready for transfer to the floor.

Hope this helps!

Re: Early Mobilization after Open Heart (what does this mean to you?)

I work on open heart ICU.... our gold standard is stable, extubated within 4 hours and up to chair within hour of extubation. of course that is the gold standard.... many many times... well it just doesn't go that way as we all know!.
our patients also have extended stay in the ICU as the doc doesn't trust anyone but the icu to care for his patients. haha....