[9309]

I am relatively new (4 years) and have worked only in a couple of places. I have seen some things I question, and wonder if they are common practice.

1. Electrode placement on a 5 electrode system. Particularly the "V-lead". I see this placed in various places, other than one of the 6 chest leads (V1-V6). I see it between V1-V2, or below the xyphoid process. I even hear it referred to as "the V lead". It seems you should chose a lead you want to monitor based on pt condition.

2. Trendelenburg, Far as I can tell, no study has shown any benefit to Trendelenburg for shock, and some have shown harm. There seems to be no evidence supporting this practice. I don't do it, but occasionally other nursed look at me as though I don't know enough to use Trendelenburg.

3. IV gtt's by gravity. Let's say you have a 50 ml bag of antiobiotic being given to a pt who will be discharged. No maintenence iv running, no need for fluids, you just want to give the ABX. Given the fact that the tubing can hold as much as 15 ml, how do you administer the full dose?

9309

[KatieBell]

Trenelenburg position will bring up a persons BP, but its a stop gap method, and is used pretty commonly everywhere I've worked. (Traveler, so lets see...about 10 facilities, level ones on down). but it is only to be used temporarily, as other methods to raise BP are being employed.

As far as the IV Abx, I put it on a pump. Some Iv abx administered too quickly can cause seizures and other wierd stuff. I have never seen anything like a seizure fromtoo fast administration, but I dont really want to either, so I justhang it up on pump tubing and pump it in at the appropriate rate. WHile I know some people will discuss not having a pump available, that is really rare. I worked in a six bed hosptial, and we always had a pump, not many other resources, but defintiely a pump.

[classicdame]

Actually, there has been research on Trendelenburg and it is not considered safe or effective any longer but try to tell that to people who have been doing it a long time. It actually stresses the heart more.

As for ABX, can it be delivered IM? If so, request another order. Otherwise, I guess they wait till it infuses.

[suanna]

Originally Posted by classicdame

Actually, there has been research on Trendelenburg and it is not considered safe or effective any longer but try to tell that to people who have been doing it a long time. It actually stresses the heart more

I wish I knew more about the parameters used in this study. When I have a post op patient with a SBP in the 80-flat is ok till they respond to drips, but if the SBP drops into 60s or 70s Trendelenburg will keep my MAP over 50 and my SBP into the low 80s until I can get a pressor on and fill the patient up with some fluid. I can't imagine the stress on the heart of trendelenburg being worse than a SBP of 65 or a MAP of 35. Not filling the coronary arteries and the carotids seems pretty stressful to me and my patient. Of course the goal is to see the hypotension comming and intervene before you need trendelenburg.
I'm not arguing with evidenced based data but I wonder under what conditions trendelenburg was used in this study, in what patient population, and for how long, what other interventions were substituted. Blanket statements like "...try to tell that to people who have been doing it a long time" may not be justified.

[9309]

I did a bit of reading on Trendelenburg.

http://ajcc.aacnjournals.org/cgi/content/full/14/5/364
Use of the Trendelenburg position has a history of widespread, ritualistic acceptance19 and is probably a good example of a nursing intervention that is based on tradition rather than on scientific evidence.18 A sustained, systematic effort, which must start at the level of early nursing and medical training and be part of continuing education, will be required to gradually dissipate "reflex or routine" use of the Trendelenburg position for resuscitation of patients who are hypotensive.

http://www.caep.ca/page.asp?id=DF617...5A593243E70058
Canadian association ofemergency physicians did a pretty thorough literature review.

Most of the best, most experienced, nurses I know utilize Trendelenburg. I don't- I am hard pressed to, given what I have read.

9309

[RNREMT-P]

I haven't clicked on the link to the study, but I beleive that Trendelenburg was developed by an Army surgeon for traumatic battlefield injuries during WW1. In fact the surgeon himself later recanted his claims and authored a paper against it.
The problem with it is that the baroreceptors get a false sense of security and then are unable to effectively regulate vascular tension in hypovolemia (either actual or relative).
It is a quick fix but I never use it on hypovolemic patients.

[MajorDomo]

Lead Placement: We recently switched from a 3 to a 5 lead system where I work, mostly due to the fact that over the course of about 6 months four of our twelve monitored beds leads got broken or vanished. I place the the V lead in V2, but have seen it in the areas you described, and as long as the monitor is not alarming V-Tach for SR, I am ok with the other areas.

2. Trandelenberg, read the same studies, and have educated people about it not being the best choice for a hypotensive pt, I still see it done by people who I work with. When I ask them about, I get the "I know, but..." statement, even by docs. I really think it is a knee jerk reaction by every one, we all want to do something to help a pt even if we don't need to. So what if the pt passes out, they are already lying down, and it makes more of an impression on the family when you "revive" the pt with a bolus or a pressor (joke)

Gravity IV gtts: For Rocephin, Ancef, Zyosyn, ect... with an infusion time at 5-30 mins, I tend to use a secondary line (10cc to load the tubing, not the 21cc of a normal gravity set) with a 100cc bag of NS in which I mix in the med. Our pharmacy tends to take 30 min to prepare the drug, and our only premixed abx is levoquin, avelox, and vanc in our pyxis.

[suanna]

I read the articles on trendelenburg and I still don't see any reason it shouldn't be used for very short term improvement in MAP/SBP. I have never seen it used for 10-15-30 min. By that time if your patient in in a profoundly hypotensive state you should have tried every pressor in the formulary and have gotten a couple of liters of fluid in. I am just afraid the blanket statement of "trendelenburg position is not effective" is misleading. It was effective in the studies in raising the MAP/SBP all be it at the expense of cardiac output. If your SBP or MAP is profoundly low it is still the fastest way to buy some time until you can get more theraputic measures in place.

[ZippyGBR]

Originally Posted by 9309

I am relatively new (4 years) and have worked only in a couple of places. I have seen some things I question, and wonder if they are common practice.

<snip>

3. IV gtt's by gravity. Let's say you have a 50 ml bag of antiobiotic being given to a pt who will be discharged. No maintenence iv running, no need for fluids, you just want to give the ABX. Given the fact that the tubing can hold as much as 15 ml, how do you administer the full dose?

9309

one advantage of being i nthe dark ages and only having premixed those that come premixed - even in the inpatient environment i bolus a lot of the ABx that can be bolused - but that reflects my Emergency dept background where bolusing ABX was common practice especially if patients were going to be transferred or the iv line was going to be removed prior to the patinet being discharged and then either coming back for review clinic or discharged on orals

[quecon]

Trendelenberg has been out for quite sometime. The baroreceptors in the aortic arch and the chemoreceptors in the carotid respond to low volume . and low O2 levels by initiating the body's compensatory mechanisms
By putting patients in Trendelenberg, the increased blood flow to these receptors tell them "everything is OK" and the cempensatory mechanisms stop. The other issue is that Trendelenberg presses all the abdominal organs against the diaphragm making it difficult for the patient to breath.
The recomended position is "modified Trendelenberg" in which the legs are raised 8-12 inches, this will allow enough blood to return to the central circulation without the above undesired effects.