Latest Comments by CRNA1982

CRNA1982 3,328 Views

Joined: Jun 14, '08; Posts: 99 (61% Liked) ; Likes: 135

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    A clamped drain for an open crani is ok because the skull is open. The bone flap is removed and the brain is able to expand. ICP is no longer a problem.....Hyperventilation and medications can also be administered to provide for a "slack brain"

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    Quote from nursel56
    Lots of people manage home vents CRNA82 - including home health aides and one person who couldn't read or write, just so you know--- I guess it's legal because the state pays for an initial training.

    If the air doesn't meet resistance the low-pressure alarm will sound depending on the parameters on the ventilator. If it doesn't I wouldn't use it. We had an awesome RT who loved to talk ventilator shop.

    Look what I found - videos! Don't know if they cover your issues but I love to put links in my posts. They're instructional videos.
    I am perfectly aware that lots of people can manage home vents; including home health aides or even a blind person....they are easy to manage. The OP has been posting about this issue since October 2011. I ASSUMED that she was not the one responsible for the operation of this ventilator because she was not aware of how to activate alarm settings for low pressure disconnects.....for 3 months now. That is three months that she is caring for someone who requires ventilatory support without a working "low pressure alarm." Glad its not my grandmother on the other end of that circuit.

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    Cuddleswithpuddles likes this.

    Quote from nursedelia
    @CRNA1982..... I am familiar with and responsible for the LTV 950, and my only question was if the alarm would sound if the trach came out of the patient. IT DOESN'T! (reply #11) I know what all the alarms mean. Why is that even in this discussion? I am getting information from people who are familiar with the vents. (CLEARLY it's not you). That's why I asked the question here. Welcome to the world of nursing, where nurses are trained through baptism by fire. If you ever get your hands on a shiley, attach it to an LTV 950 and you'll see there is no alarm. Low pressure setting at 8. SHEESH....

    @Perpetual Student....Yes. I also agree that you should not rely on the alarms to notify you of a decannulation, for your reason and the reason I gave in reply #11.
    I was trying to help replying to numerous posts from you. Then you started getting ****** with me. Don't turn this around on me..... All ventilators that I work with have low pressure alarms; and they work very well. If I ever have a disconnect, the alarms sound like crazy. The only person that has tried helping you on this thread is me, so good luck finding people on this website who can help you with this matter.

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    I assumed you are not responsible for managing the vent because you clearly don't know how to manage a ventilator based on your previous posts. I can't answer these questions for you. I am not familiar with the vent that you are using and it is not in front of me to play with. Like I said before, I suggest finding someone who is more familiar with the vent you are using and have them go over alarm settings with you. The size of the teach should not matter with low pressure alarms.

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    Pt. came direct to O.R. from E.D. with frozen gerbil in colon. Exploratory laparotomy for removal or gerbil. Good times.....

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    fiveofpeep likes this.

    Quote from getoverit
    My personal experience: I usually use etomidate on a medical intubation (copd exacerbation, resp failure, CVA etc). I haven't seen etomidate work well on a trauma patient, esp a closed head injury. A caveat is that it can cause adrenal suppression.

    Anectine (or sux) is a great agent and I've used it on the majority of RSIs. I have used it on a child who had a hx of malignant hyperthermia (long story and I wish we had that information prior to administering the medication). He did just fine and had no untoward effects from it. Of course it goes along with a sedative and an analgesic (usually versed and fenanyl or mso4 based on their BP).

    I would never give a full loading dose of a non-depolarizing agent (vec/roc/pav, etc) without the airway secured. meandragonbrett gives some good advice, once the ETI is done ask the MD or CRNA why they chose the medication.

    Also I give 1mg/kg of lidocaine to blunt increased ICP in a known head injury. and premedicate peds with atropine to avoid bradycardia when passing the tube and stimulating the larynx.
    Nothing wrong with what you said about giving a non-depolarizer without airway secured; you can never be too safe. Therefore, you can never go wrong with Succs (As long as it is not contraindicated). As far as Lido, I always give 100 mg to any pt. prior to induction; with any drug.

    As far as Etomidate causing adrenocortical suppression, I would take that with a grain of salt. I use the drug regularly and have never had any issues.....Of course, there have been case reports of this. When dealing with a sick pt. with no blood pressure or an EF < 40%, you tend to run out of options with appropriate induction agents. I really don't see a lot of ketamine inductions anymore.....Every once in a while I will... but I personally just reach for Amidate everytime.

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    Crux1024, Altra, usalsfyre, and 1 other like this.

    Quote from Dempather
    This forum is a great educational tool for the person presenting the case, as well as the people contributing to the discussion. I feel compelled to add that identifying what's "wrong" serves absolutely no purpose, and is quite frankly, irritating. It neither changes what has happened or promotes openness in others when they want to share their cases. In addition to what I mentioned before:

    I work in the Emergency Room and was waiting for an ICU bed when the patient went into failure. He had arrived and the dopamine was started on the previous shift. There was no CVP monitor at that point, UOP was approx 300cc from when the foley was placed during the arrest and transfer to the ICU approx 2-3 hrs later. The patient was also incontinent of a large amount of urine during the arrest, ? seizure activity which led to it?. ABG showed pt. was in respiratory acidosis. Appropriate changes to the ventilator was made to accommodate for that (change in tV and RR). Lactic Acid was elevated, and with the concurrent hypotension, I'm suspecting the patient was suffering from a later form of septic shock, which (to my understanding) increases SVR? If I'm wrong, please correct me.

    In regards to the atracurium, this drug could very well be outdated. This hospital is outdated (no computer charting yet). I've worked for other hospitals where this isn't on formulary. While the patient was restless and out of synch with the vent, my thoughts were on improvement of ventilation and CO2 clearance. I found it interesting that you mentioned "the medical directors hanging on to personal preferences" because the ordering doctor was a previous medical director who, I strongly believe, was hanging on to his personal preference.

    With all the hubdub, his repeat ABG was normal prior to transfer to ICU.
    Thank you for your feedback, guys.
    You are right, this forum is a good educational tool for the person presenting the case. We often do Morbidity and Mortality presentations in our anesthesia dept to discuss "cases that went south" among anesthesia providers. The purpose of these presentations are to gain a better understanding from peers about what may have been implemented in order to see a better outcome. There is never animosity or hard feelings during these presentations. You must check your ego at the door. After all, its not about YOU it is about the pt. Everyone in a dept. comes with different levels of education and experience. This is why teamwork is so important, especially when collectively working together for the well being of a sick pt.

    Clearly, your attending ordered the the worst combination of drugs for both muscle relaxation and sedation; whether you find it irritating or not. And if this pt. were my mom who was hypotensive, on pressors and septic and I found these gtts hanging; I would be ******. Furthermore, If I were working alongside an ER attending and he ordered these drugs for the pt., I would call him out on it and politely ask what his rationale is for using those gtts. As far as what is on formulary at your institution, I highly doubt that Atricurium is the only muscle relaxant that you have "in house." This is the 21st century and a 10 mg single use vial of Vecuronium would have kept your pt. relaxed all the way to the ICU and then some, without the histamine release. This dose would have set your pt. back roughly..... 10 cents.

    As far as the SVR being elevated due to a "later form of septic shock" from the picture you have painted in your posts, you are wrong. Please don't get angry again, remember you wrote, "If I am wrong please correct me." Your pts. SVR was in the toilet.... Identifying what is "wrong" does serve a purpose. This is how professionals grow and learn from their mistakes. You have pts. lives in your hands. Don't you want to give them the best care that they deserve?

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    canoehead, Altra, Esme12, and 1 other like this.

    Wow! All the wrong drugs were used in this case for both muscle relaxation and sedation. What kind of a doctor orders these drugs? Atracurium is a dead drug.....I can't even believe that a pharmacy dispenses this to pts. on a unit. Atracurium causes significant histamine release; that is why it is rarely used anymore as there are much better muscle relaxants available at a similar price without histamine release. When dealing with a hemodynamically unstable pt. why give drugs causing histamine release leading to further hypotension? Then he orders a propofol gtt.....A little versed fentanyl get could have produced adequate sedation and analgesia without the massive drop in SVR that propofol would cause. Septic pts. already have no SVR, why add to the problem with a propofol gtt?

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    fiveofpeep likes this.

    Amidate is a pretty forgiving drug therefore it is a good choice for inducing critical care pts. It is very cardiac stable and often pts. will continue to breathe, unlike propofol which can completely depress respirations. Obviously, when intubating "in not so good conditions" such as the ICU it is always good to keep the pt. breathing or not paralyzed in case one runs into a "cannot intubate", or even worse, "a cannot ventilate situation."

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    Succs is avoided in pts who have been bedridden or pts with a high serum K. Due to the mechanism of action of the drug, it causes K to be released from the motor end plate. Therefore it is avoided in bedridden pts and ones with high K, because it could lead to a sudden surge of extra cellular K and cardiac arrest. Anesthetic drugs are all chosen with the specific pts comprbidities in mind so that they remain hemodynamically stable and safe.

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    "Succs" or Succinylcholine is a muscle relaxant. Etomidate is an anesthesia induction drug causing hypnosis. You never give Succs alone without Etomidate or some other drug for induction of anesthesia. Otherwise, you have a paralyzed patient with no hypnosis on board. For the most part, Succs does not effect cardiovascular numbers either. Although, it does cause some histamine release and bradycardia has been seen in pediatric patients; it is a very cardiac stable drug. Hope this helps.

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    I tried but it didn't come out right; sorry

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    Esme12 likes this.

    Hgb Na Cl BUN
    WBC>----- <Plt -----|------|------ <Glu
    Hct K C02 Cr

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    What mode of ventilation were you using? Who is responsible for managing the ventilator? I'm assuming that you are not. Talk to the person who is responsible for ventilator management in your unit; I'm sure they could educate you.

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    Blackcat99 likes this.

    I can't say I have ever seen a pt. with a carpal spasm secondary to C-spine nerve impingement. Usually they present with paresthesias (numbness/tingling in upper extremities)