I give up - page 2
OK...I need an answer...some support please,my siblings.... I have lost much sleep and have paced the floor for weeks over this "issue" and feel my mind (?) is convincing me that I am over the edge,... Read More
Jul 16, '02Thank you all ...I do appreciate your responses and was somewhat reassured (?) that "Hooterville Hospital" is not the only place where this is done.
Happened again last night...<sigh>...
Jul 16, '02Originally posted by Zee_RN
I think it's based on the theory that "You can't get deader than dead" so why not try it? [/B]
Jul 16, '02I still believe the rationale is with even perfectly performed CPR, the cardiac output and circulation is very low....so give the patient a chance to get some pressor action by putting a bolus into his circulation and you may see some response.
Actually I have seen this method work occasionally...short periods of bolus Dopamine (wide open). You may see a rebound effect of tachycardiac and hypertension but at least you have a chance at regaining some perfusion...and you can go from there. JMHO.
Jul 16, '02Interesting...very interesting. I'm also taking mental notes to help remind me why I don't want to work ICU.
I wonder if there have been studies done on this. Docs like to have statistics to back them up...don't know how/why a doc could justify the charges without some kind of research to back it up. I know, I know, just another opportunity for the insurance companies to rule medical care. I'll hush now.
Jul 16, '02I will never work ICU - I will never work ICU - I will never work ICU
I WILL NEVER WORK ICU!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!
Jul 16, '02I loved ICU. IF, I say IF there was the remote chance I had to be dragged back to working in a hospital kicking and screaming I would go back to ICU. No where else.
Jul 16, '02originally posted by badbird
during codes we have run dopamine wide open, if we are lucky enough to get a pulse then the patient is wisked off to the unit and a proper dose is set.
Jul 17, '02Originally posted by Zee_RN
Yes, have seen it. Not 2 bags though. If we are running dopamine wide open, there's very very little hope. We're just getting them every shot at it that we can. I've never seen even one whole bag infuse; we call the code before that.
I think it's based on the theory that "You can't get deader than dead" so why not try it?
I also DO NOT think that wide open vasopressors are part of ACLS, so likely you have some rationale for refusing to do it but tread carefully knowing that there is precedent, if not rationale, for the procedure
I think I read somewhere on the net--You know the code has gone on too long when the doctor is writing hyper-al orders during the code. Well, I think that you could also say that the code has gone on too long when you are on your second bag of Dopamine at wide open.
I think this quirky practice shows how far we will all go in this litiginous world to be able to say, "we did everything to prevent death," even when THAT is no longer in our domain.
Jul 17, '02Once you start resorting to wide open pressors I expect the patient is pretty much a turnip anyway. Along with a high risk to code again within an hour and NOT make it.
I would vote for calling the code at that point.
Jul 17, '02Where does it say to open the doapmine in the ACLS protocol? I would imagine that this should be considered the legal standard and I wouldn't touch the dopamine either.
Jul 17, '02Worked ICU 7 years, initially freaked with dopamine wide open. The rattionale is not for perfusion. Refer to CCRN... when dead all cell receptors are down regulated. Dopamine is an adrenergic drug, the purpose to give wide open is to stimutate the cell receptors and illicit a response. In severe down regulated states..death and severe sepsis... unusually high doses are required to obtain response... After pulse return occurs, dopaminie is returned to the pump set at hospital max dose. Ours is 20/mcg/kg/min. Micromedex suggests up to 50. Hope this helps
Jul 17, '02Been in many codes. When the MD orders wide open I would tell them it is at whatever mcg/kg/min...Would try to get it calculated based on weight, even a rough estimate, that way they have to say go up or go down, then you can say how far up or how far down do you want it. I had many fresh open hearts come out of wide open Neo drips, it would be connected to the end of the manifold flushing in all the other drips, and when we would ask the anesthesiologist what the rate was he usually would not tell us we would have to guess. So I would put it on a pump, and ask him what kind of dose he would like, he would usually say 'just titrate it', and I'm like titrate it to what, SBP, MAP, or the amount of snot coming out of the patient's nose. As for the Dopamine wide open thing, I would say in a crunch start it at a good rate (ml/hr), and if patient survives, calculate a dose, and titrate it to MAP. Last hemodynamics course I went to, really pushed looking at SvO2, CI, CVP, and PAWP, and not depending on only the SVR for perfursion, because SVR does not tell you anything about perfusion.
Current research shows that end tidal CO2 is a very good indicator of survival to discharge, so in those codes especially where chest coompressions are the main source of cardiac output, that go on longer than 15-20 minutes, ask yourself and the MD 'wonder what this patient's end-tidal CO2 value might be' because if it is less than 10 mmHg, then the chance of survival is ZERO. I know many pulmonologists that really are into the latest research, and are very good at advocating for DNR orders for those patient's that have no chance of surviving.
Hope this helps suzannasue.....