Swan questions - page 2

I have a few question to ask about swan standards in your ICU's. In the ICU that I work we are considering a few changes in our policies. When you have a swaned patient how frequent do you... Read More

  1. by   begalli
    Quote from kesmith2314

    When you have a swaned patient how frequent do you obtain a wedge when the patient is stable?
    Medical ICU patients at least q 4hours. More frequently if the docs want it. We don't ordinarily wedge surgical hearts whether they're stable or not (that is if the post-op heart has a swan which is only about 20-30% of the time).

    Do you use saline or heparinized saline for the flush system with your pressure line?
    All patients from the OR come with a heparinized flush (that is unless they are or were bleeding, then it's NS). When the heparin bag runs out it's always replaced with NS. However, I personally replace the heparin bag asap with NS whether it's run out or full and ESPECIALLY when I plan to bolus the patient for cardiac outputs.

    Swans inserted at the bedside are always with NS.
    Last edit by begalli on Apr 24, '05
  2. by   clarkheart
    Our fresh hearts come back with Swans connected with heparinized pressure lines. I will wedge only after proper swan placement is confirmed with the postop cxr. I then may wedge only once a shift and when I'm curious about fluid shifts. I usu. like to use the PAD if I can. There are just too many risks when weighed against the few advantages in consistent wedging. You can always infer the diagnostic info you need from other sources.
  3. by   Phishininau
    I work in a MICU/SICU unit at a hospital that deals with a great deal of invasive cardoiology. We wedge according to doctors orders or per nursing judgement. Our protocol regarding PA catheters requires that PAWP be checked Q8. However, if a patient is symptomatic we can check it PRN. Most docs that we deal with write orders to check PAWP Q4 and CO/CI/SRV/and the indices Qshift.

    Occasionally, situations will arise where CO must be monitored more frequently than this and orders will be written for more frequent hemodynamic profiles.

    Most of the PA cath patients that we have are already on Integrilin/Lovenox/etc, so the heparinized system is not used due to the obvious increased risks of bleeding. Obviously, heparin would not be used in situations that contraindicate it, high PTT/PT/INR, thrombocytopenia, heparin allergy, etc.

    It seems that the younger docs tend to use a NS pressurized system while the older physicians gravitate towards the old heparin standard.

    Hope this was of use.

    Todd
  4. by   nurselily3
    If the patient is a fresh post op or unstable (even the hearts), we do a full set of vitals, swan numbers with wedges q1 (for at least 12-24 hours). We get hemodynamic numbers q2 or q4 depending on stablity. We only use saline in our flush bags due to chances of heparin induced thrombocytopenia. We are allowed to only pull the swan, not advance it. We use CCO swans, not the VIP ones. I traveled to a hospital where they didn't use swans that much, and the ones they did were VIP...the went through this whole bunch of crap with iced saline to inject....and only did their numbers once a shift. What's the point. We use our CCO to titrate drips, fluid bolus, etc. In all the time I worked in CTICU and in SICU I've never heard of a patient in any of our ICU's having a blown PA from wedging the swan.
    Last edit by nurselily3 on May 6, '05
  5. by   bellehill
    In our neuro ICU we wedge q1-2hr when we are attempting to keep the pt hypervolemic, we bolus based on the wedge. We argue with the docs all the time that we wedge too much but they will not listen. No blown PA but we blow a lot of balloons. Only once did I have a doc say to follow the PAD and he was a moonlighter.
  6. by   Heartman
    In over twenty years of critical care nursing I've seen one blown PA.

    Nothing you can do unless you have a thorasic/vascular team in the OR standing by.

    We didn't have this. MSO4 for comfort as pt. bled out.

    Make sure you get those consents signed and risks explained.

    Walt
  7. by   bluesky
    Per Dr.'s order only and NS for pressurized lines. According to unit legend, we once had a nursing fellow who blew a PA and the pt still died even though we had a CT team in house. What bothers me about wedges is... that even though we think of the measurement as end diastolic volume, it's really an approximation of end-diastolic pressure which is affected by any number of other variables such as PEEP and ventricular compliance. I don't find the benefit gained worth the risk, but that's just my humble opinion.
    Last edit by bluesky on May 14, '05
  8. by   begalli
    Quote from bluesky
    What bothers me about wedges is... that even though we think of the measurement as end diastolic volume, it's really an approximation of end-diastolic pressure which is affected by any number of other variables such as PEEP and ventricular compliance. I don't find the benefit gained worth the risk, but that's just my humble opinion.
    I agree with you bluesky regarding the numbers. Really, if you think about it, most of the numbers you get from a swan are simply "calculated" numbers. I think the benefit of such a line is to be able to watch trends resulting from measurements taken over time and not necessarily taking a single number at face value.
  9. by   tridil2000
    Quote from bluesky
    Per Dr.'s order only and NS for pressurized lines. According to unit legend, we once had a nursing fellow who blew a PA and the pt still died even though we had a CT team in house. What bothers me about wedges is... that even though we think of the measurement as end diastolic volume, it's really an approximation of end-diastolic pressure which is affected by any number of other variables such as PEEP and ventricular compliance. I don't find the benefit gained worth the risk, but that's just my humble opinion.
    i agree!
  10. by   KimberRN1
    We do CO and wedges per order......I work in a cardiac hospital in the MICU..usually it's q shift but varies with each order........Open Heart Recovery has their own protocol.....We use Saline for pressure bags....
  11. by   ladybug5982RN
    we do wedge and cardiac calcs every 4hrs when we do our full assessments,we use saline.we use saline on all of our pressure monitoring systems.our hospital only uses heparin solutions on picc lines.
  12. by   Zee_RN
    Our POLICY is every 2 hours in my med-surg/cardiac ICU. I really hate that. Esp. if the swan is three, four, five days old!! What's the point?! And with the increased risk! And the poor patient...our policy is do readings in supine position so every 2 hours, for days, this patient is flattened out, rezero'd, wedged, graphed, and repositioned and rezero'd again. Interrupting tube feeds, sleep, etc. And they wonder why ICU patients don't get any rest! If I'm working nights and I have a SG, I only wedge it every 4 hours and to heck with policy. And I still think that is a lot if the SG has been in for awhile. Our docs seem so reluctant to pull them!

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