Advice regarding student in Neuro ICU

pokey sn · Apr 26, 2004

I'm just a student as well but I just precepted in two of the ICU's at the largest hospital in the state three days ago. My preceptors were excellent!! They wanted me to remember: Make sure the MAP (mean arterial pressure) stays above 60, DOCUMENT DOCUMENT DOCUMENT, and stay organized. Good luck!

gwenith, BSN, RN · Apr 26, 2004

Keeping the MAP above 60 is good advice for a general ICU but in Neuro we usually like it a bit higher than that.

Why?

Trauma to the brain disrupts the normal autoregulation of blood so perfustion becomes "passive" relying on absolute values. This is why we like to keep the Cerebral Perfusion Pressure >60.

Cerebral Perfusion Pressure is MAP - ICP or Mean Arterial Pressure minus the Intercranial pressure.

In the case of the patient with subarachnoid haemorrhage (SAH) it is well documented that these patients develop severe vasospasm and although we do administer nifedipine to prevent or reverse the vasospasm many units still run SAH patients with very high MAPs i.e. MAP 100 - 110.

Entertainment is watching a neurosurgeon and a cardiologist discuss blood pressure:chuckle

DustinRN · Apr 27, 2004

Gwenith, you're just one big ball of knowledge. Ever thought about teaching?

Speaking of MAP and BP in general. I have a question. We received two pt's, husband and wife, from a motorcycle accident. Don't really know much about the wife (she wasn't our patient). The husband on the other hand was found to have a intracranial clot. The neurosurgeon removed the clot and placed a JP drain inside the scalp. Pt had Art line. Pt would open eyes to sound. He was trached. Pt localized pain. He was vomiting (aspirated). RT was suctioning and she aspirated some nice chunky stuff. Supposedly his family said they were eating at the Waffle House before the accident. He had a OG tube in place to decompress the stomach, but he was still coughing up chunks of this food. Just wanted to give you a picture of the patient.

My question is this. His BP cuff stated pressures in the 125-135/75-85 mmHg range. His art line pressures were 190-205/95-105 mmHg range. Which one do you use to guide your decision on BP medication? The nurse I was with wasn't too worried about the Art line pressures because the patient was fussy whenever we did 1hr neuro checks. The transducer was level with the patient's atrium. I just want to know what you would have done in this situation.

Thanks

This board is a wonderful thing!!!

PS---The MAP was around 130 on the Art line.

Elenaster · Apr 27, 2004

Hey Dustin,

Sounds like you have gotten some very good advice from some seasoned neuro nurses. I love your enthusiasm and it's great to see someone who really enjoys learning about neuro patients.

To answer your question about your trauma patient, as long as your transducer is level and zeroed, I would go by the art line pressure. Occassionally, the position of the tip of the catheter in the artery will result in a falsely elevated pressure and this can be determined by a very sharp upsweep in your waveform. However, if your waveform is nice and peaked and you get a good square wave when you flush the line, I would go with the art line pressure.

What were your parameters for SBP? Ours are usually something like 100-180 and I'll usually call for prn hydralizine or labetolol if they're sustained over 190. However, you did mention that your patient would become agitated with the frequent neuro checks and I'm wondering if you had any prn sedation ordered? If you think about it, his head probably hurts like crazy and here we are talking to him loudly and shining a bright light in his eyes every hour or so. If you have prn morphine or ativan, I would try giving those first and seeing if calming him down helps his BP. You might be amazed how well 2mg MSO4 will chill some patients out.

On another note, I learned a great analogy to how it must feel to be a neuro patient:

Imagine yourself just underneath the surface of the water. You can hear people talking all around you and trying to pull you out, but you can't make out what they're saying. It's mostly dark, but every so often the sun is so bright you can't stand it. You keep trying to break through the surface, but for some reason, you just can't quite make it.

Of course this doesn't apply to all neuro patients, but I'm sure you'll see ones that fit this description, if you haven't already. Keep up the good work!

DustinRN · Apr 27, 2004

Elenaster, the parameters for his SBP were anything higher than 160 needs to be reported. I read this in the chart and that is when I questioned about which BP reading do we use. That's when she told me we'll go with the cuff pressure because it was a more normotensive reading. She was convinced the Art line pressure was probably elevated due to his fighting us when we did neuro checks. But, it wasn't like his art line pressure would go down after neuro checks they would stay the same throughout the hour. We did have Ativan and MS4 ordered. We gave both. That didn't bring his BP down much at all. I have attached a drawing of what the Art line reading looked liked when she flushed it. You can tell me if that is what it's supposed to look like. The art line readings were peaking nice and high and she said they had a safe-set device on their because if it wasn't on there the peaks of the art line pressures would go sky high on the monitor. I guess because his readings were so high. I'm not sure. I need more teaching about art lines. They say you get that during your critical care training class.

Let me know what you think.

PS--I also printed out the little neuro saying that you had and posted it on my notebook. I thought it was pretty good.

Art line reading.bmp

Elenaster · Apr 28, 2004

Dustin,

By the look of that waveform, I can see why your supervising RN wanted to go with the cuff. I'm really impressed that you attached a drawing for me. I'm not that talented, but I did find a link that may help. The key to a good square wave test is the way the waveform oscillates (moves up and down vertically) at the end of the square wave.

I actually have this little brochure myself, but take a look at it and see what you think:

http://www3.medical.philips.com/resources/hsg/docs/en-us/education/hemo_mon.pdf

Also, what was the size of your BP cuff in relation to the patient?

Gotta go now, but I'll check back later...

gwenith, BSN, RN · Apr 28, 2004

Like Elanaster - that waveform does NOT look like a good waveform to me. When I have had discrepencies in BP the docs usually tell us to go with the one THEY like best i.e. if the BP is too high they will go with the lower reading - AAARRRRGGG!!!

Usually though it so depends on the patient. Sometimes if they suspect that there is a lot of cerebral vascular spasm they will opt for the higher readings and be happy with MAPS of 110-120.

DustinRN · Apr 28, 2004

Dustin,
By the look of that waveform, I can see why your supervising RN wanted to go with the cuff. I'm really impressed that you attached a drawing for me. I'm not that talented, but I did find a link that may help. The key to a good square wave test is the way the waveform oscillates (moves up and down vertically) at the end of the square wave.
I actually have this little brochure myself, but take a look at it and see what you think:
http://www3.medical.philips.com/resources/hsg/docs/en-us/education/hemo_mon.pdf
Also, what was the size of your BP cuff in relation to the patient?
Gotta go now, but I'll check back later...

Elenaster, I believe it was an medium (adult) size cuff. From the cuffs I saw we only have three different sizes, small, medium, and large.

I looked at the link you provided, but I think it confused me to no end. :uhoh3: I didn't quite understand what all of that stuff meant. I do appreciate the link though.

I'm sure I'll have more questions after I get back home from working Thursday night.

gwenith, BSN, RN · Apr 28, 2004

Dustin Try Mark's site I can't get the graphics to upload so I can't tell what the diagrams are like but usually his explanations are easy. I keep an eye out for a good site for artlines and other ICU stuff. I did start a websites sticky in the ICU forum but haven't got round to adding good heamodynamic sites yet.

Elenaster · Apr 29, 2004

Elenaster, I believe it was an medium (adult) size cuff. From the cuffs I saw we only have three different sizes, small, medium, and large.
I looked at the link you provided, but I think it confused me to no end. I didn't quite understand what all of that stuff meant. I do appreciate the link though.
I'm sure I'll have more questions after I get back home from working Thursday night.

Sorry Dustin! I didn't mean to confuse you :imbar

I just wanted you to look at the art. line waveforms and I should have been more clear about that. I would try to explain it, but I think without a visual aid it would be even more confusing.

I agree with Gwenith. Check out Mark's site to see if he explains it more clearly.

NeuroICURN · May 31, 2004

DustinRN...

Just wondered how it's going?

Hope you're having a good experience!

NeuroICURN

DustinRN · Jun 1, 2004

DustinRN...
Just wondered how it's going?
Hope you're having a good experience!
NeuroICURN

It's going hectically! I'm currently taking classes for my RN-BSN classes that will hopefully start in January. I have the NCLEX-RN scheduled for June 9th. If all goes well I will start my job in the Neuro/Trauma ICU on June 21st. Well, I will start orientation on the 21st. The actual nursing will take a week or two before I begin. I have just been so busy with classes and study for the NCLEX that I haven't had time to post lately.

Hopefully, it will slow down a bit after I take NCLEX. Then I begin ACLS, PALS, CC training course...ect Maybe I'll still be in a frenzy

:chuckle