Latest Comments by harryalexx

harryalexx 2,151 Views

Joined: Apr 26, '10; Posts: 18 (39% Liked) ; Likes: 15
Pediatric Cardiothoracic ICU RN; from US
Specialty: 4 year(s) of experience in Critical Care, Pediatric

Sorted By Last Comment (Max 500)
  • 0

    Quote from NRSKarenRN
    Please take advantage of PHARMACIST discussion regarding medication and infusion compatibilities. They are a tremendous resource often overlooked and should be go-to person to help devise a policy regarding Lipid infusions.
    Thanks so much for the reference...I wasn't even aware of this resource! I'll check in over there as well.

    Since initially posting this, I took this problem (with a couple other nurses) to a higher administrative council within the hospital. Basically, it came down to the fact that our unit uses too many infusions of milrinone to have our IL 20% in-line (Y-site) with MIVF + drips. C'est la vie.

    Thanks for everyone's input and practice experience. Much appreciated

  • 0

    Thanks for the responses. googabin02: I'm surprised that they run alone all the time. We routinely run lipids with Laxis or fentanyl +/- a few other drips. We also run TPN with the manifold/drips.

    janfrn: Usually, the PN is such a concentration that we also run it centrally out of necessity. And yes, lipids with Lasix or fentanyl (and sometimes hydromorphone, although compatibility charts say otherwise). A few comments on your infusion situation, though. I can't believe you're still mixing your own gtts! I haven't mixed a drip in my home unit for so long. We have compounded drips in our Pyxis, and pharmacy makes all the rest. As for the volumetric pumps, we had the same problem, but recently upgraded to a "steady-state" infusion pump. It has a rolling device that delivers a steady amount. No big swings, and so far I'm super impressed. Even with MIVF carrying drips @ 3mL/hr, I don't see issues. So we almost always run our amino-acid-dextrose solutions with our drips. Although newer staff still have trouble figuring out what I mean when I say "double pump" to avoid a hypotensive crash. Oy.

    So I m getting that you two at least don't run lipids with drips. Helpful, thanks!

  • 0

    I also work in a cardiac PICU, and know 10-15 people (MDs and RNs) who've all done work with ICHF or other organizations. Some hospitals even sponsor the trips. It's a cool experience from what they've said because the cases are all rather..."salvagable". In short, good outcomes for the week with a lot of rewarding family-patient time. Very hectic, and you better know what you're doing. You are stripped of all the fancy tools at home. Basic assessment becomes aboslutely essential, as well as getting by with limited equipment.

    I've done several relief trips with non-cardiac peds +/- PICU patients. Similar thing, except a difficult because you don't know the diagnosis getting a patient, and diagnostic tests we are so reliant upon are a rare thing. I would strongly encourage anyone to experience this. It makes your realize how much you know, and will also improve your nursing as a whole.

  • 0

    CCRN-P is pretty much the gold standard for PICU certification. Even my friends who work on the floors say that CPN is very, very well-child focused. It's basic pediatric things that should arleady be in your brain in order to do PICU.

  • 1
    Joe V likes this.

    Hi PICU nurses,

    I have a question regarding practice in your unit about intralipid infusions (20% fat emulsion). Do you run them independently of the PN (if PN is also on board)? Do you run them via central access if possible? Most importantly, do you infuse them with your drips (inotropes or otherwise)? Specifically, with milrinone. I am working on changing practice on my unit, and possibly coming up with a lipid initation guideline. It would be SO convenient if I could tell everyone to run them with drips, but it seems that milrinone is the only inotrope that is documented as being incompatible. Practice trumps compatibility suggestion, though, and just wanted to see what other places are doing.

    We run our lipids through PIVs most of the time, but it seems like it's pretty harsh on those little veins. Our unit is 100% cardiac, so just about everyone is on milrinone

    Thanks in advance for the feedback!

  • 0

    Good luck, dankat! It sounds like you have a good head on your shoulders.

  • 0

    I think part of the orientation and reeducation of RNs in an ICU should include a basic physics overview. And why we do what we do. I don't like how a lot of people do things out of habit or "just because." Let's just take over the world, eh?

  • 0

    The only thing I'll add to what janfrn said (as my unit is quite similar):

    The med lines we use have a slide-clamp. We recently (2 years ago?) standardized its location to be between the tubing expiration label and the hub of the med line (or gtt line). That way, you can clamp the line to prevent air entry, scrub the hub of the line per protocol, top off with saline, and administer the med.

    I'm involved with the CLABSI/PI stuff on my unit, and our CNS recommends not using needless adapters (like you're describing) due to the risk of air entry as well as pathogen entry. I know they have fancy ones that claim no chance of air trapping and antimicrobial plastic pieces, but the most basic setup is also the easiest to manage and monitor.

    As janfrn mentioned, vasoactive infusions are not interrupted for medication administration. Peripheral access is more likely to be obtained than interrupting milrinone or other infusions for a medication. The only exception is that we run our electrolyte replacements "in front" of our drips if needed. I personally don't like this if it's avoidable, as a neonate with MIVF running at say 3mL/hr will have a change in BP if there are multiple gtts going. The change in rate causes swings in my experience.

    Hope that helps.

  • 1
    NotReady4PrimeTime likes this.

    What she said...hahaha!

    Janfrn, I wish I worked with you. I have a lot of coworkers who think that a patient who has moved, or changed bed position, or sat up, needs to have their pressure lines all re-zeroed. I slap my forehead and try to explain sometimes, but it's ingrained. Oy.

  • 2
    Aerielle and Sinman like this.

    How awesome for you! Congratulations! PICU is an amazing place to be for learning. I hope that the unit gets you involved and loving PICU.

    As for advice, I would say start off with what you think a good peds nurse would be. Review developmental practices and just focus on being comfortable with kids. A lot of the more technical stuff you'll get in any job (central lines, meds, drips, etc.). Like any preceptorship/practicum, of course act interested. Nurses will pick up on your level of interest. Be careful of what you say, as you'll be judged on what you say and how you act quickly since you don't already have longstanding relationships with the nurses.

    This is silly, but I was with a nursing student last month who spent most of the time on the cell phone or the computer working on assignments. Practicum can have slow times (duh!), but if you've got a personable preceptor, take advantage of it! Ask questions, be interested, volunteer to get your hands dirty.

    I hope you enjoy PICU nursing

  • 4

    Like everyone else has mentioned, 8 weeks is such a short period of time in the grand scheme of things! The orientation the new hires on my unit get STARTS at 8 weeks, and goes from there. It's kind of an expectation that everyone comes with different experience and learning styles. I work peds cardiac ICU, and it is a very tough job. The learning curve is gigantic! Be easy on yourself, friend

    As for how to improve and get more efficient, try asking a preceptor/charge nurse/experienced RN their opinion. The managers get their information from these people and are forming an evaluation based on the collective response. Go to the source and figure out areas that you can work on. For what it's worth, 2 patients in a CICU is very tough. The acuity and pace of the patients is unlike anything else. I would recommend getting very familiar with the routine meds on the unit...major safety issue and tends to slow newer nurses down. Also take a bit before starting your shift to choose the most important things to do. Separate out the "do by the end of the shift" stuff from "Oh crap! I needed to do that 10 minutes ago!".

    Finally, of course you need to know defects. Cincinnati has a good interactive website for the defects and their repairs. Or maybe your hospital has an internet resource. You don't need to know every surgical intricacy at this point, but major nursing considerations as well as "trace the blood" type of stuff.

    Stick with it This is a super rewarding area to work. And in a year, you'll see how far you've come!

  • 0

    Hi ekr15,

    I also work at CHLA full-time, as well as a per diem (3x/month) in a PICU by where I live. It's true that CHLA doesn't pay top dollar, but you can comfortably live in LA with what you'll make FT. The PICU is an awesome unit, and as vivasmom said, very high acuity. CHLA also has a CTICU (my love)...congenital heart surgical ICU basically. Highest acuity in the hospital; I would argue in LA. Super fast-paced unit, all hearts. Message me if you'd like more info about other hospitals in the area or nursing in LA in general.

    Go PICU!

  • 0

    One of the reasons I work strictly CTICU - at least the injuries (defects in this case) are not inflicted by another human being. Well, unless you count in vitro gone wrong, which happens quite a bit. But that definitely doesn't have the same impact (on me) that abuse does. Bless you for doing what you do!

  • 1
    kessadawn likes this.

    I work in a CV (CT) peds ICU and we use Precedex (dexmedetomadine) quite frequently on the hard-to-sedate post-op children. We're a large center on the West Coast and do a lot of cases. I've found that when titrating up - even quickly - that the bradycardia issues aren't such a big deal. When they're super-agitated with HRs 180+, the effect isn't very noticeable. I will say, though, that it isn't the first line drug of choice for most patients.

    We're currently working on a sedation protocol, and I believe that it is written in the "staged sedation" for post-op day 4 or 5 if the typical morphine/ativan +/- fentanyl aren't working.

    For what it's worth, I've had only the best experience with Precedex. Especially considering that you can extubate on Precedex, it helps get through the critical/dangerous intubated periods. Look up some of the clinical trials - the drug is associated with fewer ICU days, intubated days, and shorter hospital stays in general. There isn't much that's peds specific yet, though, and that's saddening

    Hope that's helpful for you!

  • 0

    The hospital in which I work hires new grads into a 22-week long "RN Residency." It's amazing! It's a pediatric teaching hospital (Magnet status). Send me a PM if you're interested in more information.