I am brand spanking new in the Surgical ICU at a level 1 trauma center. I've been a nurse for 2 years on general surgery so please excuse me but I am just curious. I'm brushing up on all things ICU right now - currently reading Essentials of Critical Care as endorsed by the AACN.
I had a POD 1 CABG that was still in SICU because of MAPs that would not sustain above 60. By the time we came into morning report the night nurse had titrated the Levophed to 0.2 from what he had left the patient at which was 0.07 with a MAP of about 65 - 70. With Levophed at 0.2 her MAP was barely 62 - 65. The CT surgeon proceeded to raise the temporary atrial pacing to 110 and instructed us to lower the Levophed and wean her off completely.
Eventually we did and her MAP sustained at 62 - 66 with the HR set to not fall below 110. Then she stopped making urine, unfortunately I did not return the next day to find out what happened but given her UOP dropped I think (and I know I'm just new) she needed some fluids.
Is it best practice to raise the HR so much on a CABG? In my mind I think I want to let their heart rest not put more oxygen demand.
It's not uncommon for the CT surgeons to set the pacer at 100/min for fresh CABG patients until the hearts intrinsic conduction system recovers. They usually wean off any pressors first before going down on the paced rate. Depending on the underlying problem of the patient, MDs sometimes would like to prevent post operative tachyarrythmias from occurring thus they program the pacer around 10-20 beats/min above what the patient's inherent rhythm. Providing temporary overdrive pacing can be an effective means of terminating reentry tachycardias such as atrial flutter, a-fib, atrial tachycardia or v-tac from occurring.
Resuscitation protocols are different for fresh CABG patients. You can throw what you learn in ACLS out the window for your CABG patient if something goes awry. Preventing any unwanted dysrhythmias is the goal right after a fresh CABG.
He ordered dobutamine next (renal dose) and ordered 20 of lasix to be given bc of the decrease in UOP
I disagree with these orders but I am also new so don't want to stir waters.
How is the lasix or renal dose of dobutamine going help if the issue was fluid deficit? I bet she was in serious need of fluids and I think we should have first checked her H/H.
Obviously the albumin wasn't cutting it? I wish I was there the next AM to see the whole chain of events.
How do you know this patient had a fluid deficit? From what you describe, this is pretty much standard care s/p CABG. Before you decide you know more than the board certified surgeon who has gone to medical school and then done a residency in general surgery and a fellowship in cardiac surgery, be very sure you understand the physiological effects of cardiopulmonary bypass and the fluid shifts that take place after surgery
It's not uncommon for the CT surgeons to set the pacer at 100/min for fresh CABG patients until the hearts intrinsic conduction system recovers. They usually wean off any pressors first before going down on the paced rate. Depending on the underlying problem of the patient, MDs sometimes would like to prevent post operative tachyarrythmias from occurring thus they program the pacer around 10-20 beats/min above what the patient's inherent rhythm. Providing temporary overdrive pacing can be an effective means of terminating reentry tachycardias such as atrial flutter, a-fib, atrial tachycardia or v-tac from occurring.
Resuscitation protocols are different for fresh CABG patients. You can throw what you learn in ACLS out the window for your CABG patient if something goes awry. Preventing any unwanted dysrhythmias is the goal right after a fresh CABG.
I agree 100% - postoperative heart surgery management is very specific.
Plus the places I worked post op cardiac CC patient were managed by cardiac surgeons and not cardiologists. Pacing right after surgery until conduction gets better helps in some cases as there is some edema in the surgery area that can lead to conduction problems.
To the OP:
Take advice from people who do not actually work in post surgery cardiac ICU with a grain of salt. Especially in larger teaching hospitals, cardiac surgery directs the care after surgery (ok -nowadays they also have their NPs but it is still directed by surgeons).
Management after cardiac surgery is not the same as general cardiology ...
Hemodynamic monitoring beside A line it is helpful but in the so called routine CABG you might not have the traditional PA or other expensive monitoring options.
Generally speaking - a patient after cardiac surgery needs to have urine output. If there is not at least like 30 ml/h it is a sign that something is not ok. If MAP is too low patients often do not make enough urine due to decreased renal perfusion. Sometimes it is a matter of volume when the patient was kept very dry during surgery. It is helpful to look at the anesthesia sheets and look at the pressures and volume during surgery to get an idea. Even one hypotension event during surgery can lead to renal perfusion problems in some patients with output problems and even renal failure. Often enough when I had pat with above problems it turned out that the patient was hypotensive during surgery at some point (I am talking real hypotensive not like 90 systolic).
Some surgeons prefers their pat to be on the dry side for a variety of reasons and those patients sometimes need some fluid after surgery because they have a volume deficit. But you want to do gentle hydration in most patients, which is why you want to figure out early if the patient is not putting out enough urine. If you find that early after surgery and throw in some fluid (per MD order) you can often avoid other problems.
But if the problem is not volume and renal perfusion problems but conduction due to conduction problems / arrhythmias - pacing can be helpful. In some cases positive inotrop meds like epi small amount will be more helpful initially. However, levophed is not my favorite medication because some people see it as a "fix all" medication when in fact it is not and addressing underlying problems is better (if it is a volume deficit that should be addressed). Having said all of that - you do not want your pat to dangle around with a low MAP for too long because of renal failure and so sometimes some pressors are needed until for example a fluid problem is addressed.
My advise for you as a new nurse in that kind of ICU is to find a mentor who is experienced and who does not mind you bouncing off ideas and problems.
Plus for every patient you have after surgery make sure you frequently (at least every hour) check the urine output and output from the drain (pleurevac or bottles or whatever you use).
Something nobody wants to hear is "the patient has no urine for 4 hours" or "heck - is it a problem if there is 1000 ml of blood in the pleurevac "...
After a while you will know which surgeon has the patients come out on the dry side. Always look at the anesthesia flow sheet if you see no urine coming out - an ok patient after heart surgery has to have urine output fright from the get go - if that does not happen there is something wrong and you need to report it and do some investigation...
Otherwise - be interested and learn but don't be a "know it all" because heart surgery is like no other specialty especially when you also have sicker patient who need IABP, artificial heart, ecmo, CVVHD, and get ARDS and what not. So much to learn - but the single best advice I got was to careful monitor and pay attention to urine output and drains ... has served me well.
DoBUTAmine is a Strong beta1 and weak beta2/alpha effects, resulting in increased cardiac output, blood pressure, and heart rate, as well as decreased peripheral vascular resistance. It's often used in cardiogenic shock. There isn't a renal dose of Dobutamine usually ( unless you are looking at the secondary effects of increase BP that will increase urine output,), you must be thinking about DoPAMine.
DoBUTAmine is a Strong beta1 and weak beta2/alpha effects, resulting in increased cardiac output, blood pressure, and heart rate, as well as decreased peripheral vascular resistance. It's often used in cardiogenic shock. There isn't a renal dose of Dobutamine usually ( unless you are looking at the secondary effects of increase BP that will increase urine output,), you must be thinking about DoPAMine.
When I spoke to the MD he specifically stated 4 of dobutamine for renal perfusion. He then entered 4 of dobutamine into the system. I totally understand what you mean by the pharmacology of dobutamine and I couldn't find a renal dose of dobutamine online to save my life. Perhaps he prescribed rather as you said to target those beta 1 receptors.
I know it's dobutamine that I gave because I'm writing everything I learn down in a notebook!
I did find a study online that states that dobutamine has no direct effect on renal :)
How do you know this patient had a fluid deficit? From what you describe, this is pretty much standard care s/p CABG. Before you decide you know more than the board certified surgeon who has gone to medical school and then done a residency in general surgery and a fellowship in cardiac surgery, be very sure you understand the physiological effects of cardiopulmonary bypass and the fluid shifts that take place after surgery
Never said I knew more than the MD, I had a hunch as a nurse and to ignore it is unsafe practice. There would've been nothing wrong with taking my hunch to the charge
I agree 100% - postoperative heart surgery management is very specific.
Plus the places I worked post op cardiac CC patient were managed by cardiac surgeons and not cardiologists. Pacing right after surgery until conduction gets better helps in some cases as there is some edema in the surgery area that can lead to conduction problems.
To the OP:
Take advice from people who do not actually work in post surgery cardiac ICU with a grain of salt. Especially in larger teaching hospitals, cardiac surgery directs the care after surgery (ok -nowadays they also have their NPs but it is still directed by surgeons).
Management after cardiac surgery is not the same as general cardiology ...
Hemodynamic monitoring beside A line it is helpful but in the so called routine CABG you might not have the traditional PA or other expensive monitoring options.
Generally speaking - a patient after cardiac surgery needs to have urine output. If there is not at least like 30 ml/h it is a sign that something is not ok. If MAP is too low patients often do not make enough urine due to decreased renal perfusion. Sometimes it is a matter of volume when the patient was kept very dry during surgery. It is helpful to look at the anesthesia sheets and look at the pressures and volume during surgery to get an idea. Even one hypotension event during surgery can lead to renal perfusion problems in some patients with output problems and even renal failure. Often enough when I had pat with above problems it turned out that the patient was hypotensive during surgery at some point (I am talking real hypotensive not like 90 systolic).
Some surgeons prefers their pat to be on the dry side for a variety of reasons and those patients sometimes need some fluid after surgery because they have a volume deficit. But you want to do gentle hydration in most patients, which is why you want to figure out early if the patient is not putting out enough urine. If you find that early after surgery and throw in some fluid (per MD order) you can often avoid other problems.
But if the problem is not volume and renal perfusion problems but conduction due to conduction problems / arrhythmias - pacing can be helpful. In some cases positive inotrop meds like epi small amount will be more helpful initially. However, levophed is not my favorite medication because some people see it as a "fix all" medication when in fact it is not and addressing underlying problems is better (if it is a volume deficit that should be addressed). Having said all of that - you do not want your pat to dangle around with a low MAP for too long because of renal failure and so sometimes some pressors are needed until for example a fluid problem is addressed.
My advise for you as a new nurse in that kind of ICU is to find a mentor who is experienced and who does not mind you bouncing off ideas and problems.
Plus for every patient you have after surgery make sure you frequently (at least every hour) check the urine output and output from the drain (pleurevac or bottles or whatever you use).
Something nobody wants to hear is "the patient has no urine for 4 hours" or "heck - is it a problem if there is 1000 ml of blood in the pleurevac "...
After a while you will know which surgeon has the patients come out on the dry side. Always look at the anesthesia flow sheet if you see no urine coming out - an ok patient after heart surgery has to have urine output fright from the get go - if that does not happen there is something wrong and you need to report it and do some investigation...
Otherwise - be interested and learn but don't be a "know it all" because heart surgery is like no other specialty especially when you also have sicker patient who need IABP, artificial heart, ecmo, CVVHD, and get ARDS and what not. So much to learn - but the single best advice I got was to careful monitor and pay attention to urine output and drains ... has served me well.
Thank you so much for your advice! We check our UOP every hour on our unit on every patient and the chest tubes are a BIG deal on our unit for these CABGs - that's drilled into my head I check those bad boys every 10 minutes or so - especially if they keep putting out. We have a whole protocol for that typed out in a book. (Increase PEEP for bleeding) so on.
I'll add my voice to those advising caution here. Not understanding something does not mean something's wrong. This idea is an unfortunate consequence of the culture of nursing education today that began many years ago, but that's for another post.
Not sure of something? By all means, the very first thing to do is run it by the charge or a trusted senior person. It is absolutely not to assume the surgeon doesn't know what he's doing.
Advice to the contrary with such little background information may not be too helpful.
I check those bad boys every 10 minutes or so - especially if they keep putting out. We have a whole protocol for that typed out in a book. (Increase PEEP for bleeding) so on.
Been there,done that, ASN, RN
7,241 Posts
:) One size fits all. Let us know how it's going.