extubation after cabg?

rehab nurse · Mar 5, 2005

thanks begalli~

they don't know what the excessive blood loss was from. he normally takes plavix/ASA but had been off for 10 days prior to the surgery. at any rate, yesterday when i saw him, they were done with the blood, and his last hgb was 9.6.

his problems yesterday were nausea, vomiting, very low bp's (60/70 systolic), and very low blood sugars. he got up in the chair twice, but he tires very quickly. they took one of his swans out. i don't understand why they have him on a insulin drip, but no dextrose. five times yesterday he went unresponsive because of low blood sugars. my dad has hypoglycemic episodes every day, even when he was well. in the early afternoon, and about midnight, he will drop to about 60, and that's enough for him to be symptomatic. so anyways, they're checking his blood sugar every hour. but several times it is about 80 or so, and they won't shut off the insulin. then half hour later, his eyes roll back in his head, and they have to push an amp of d50. i don't understand their thinking at all. he hasn't been able to eat anything (they have him on clear liquids, but after he eats a few bites, he vomits). i know they want his sugars less than 110, they said they have a faster healing rate that way. so then they'll keep giving him iv zofran, but it's not working. i asked his night nurse if he could have something different but she said NO. i can't understand why they'll let him continue to vomit and be nauseated almost constantly. and then he has the problem with the low blood pressures. he is on dopamine, and cardizem.

so i don't know, i am definitely not an icu nurse. it is very hard for me to see him suffering like he was, and i can't do anything for him. they are giving him toradol only for pain every six, and where i work, most people get nauseated from that. so maybe it's that? i know my dad gets nauseated when his blood sugar is around 70-80. so maybe that has something to do with it also? at least he sleeps at intervals, but he says he really hurts about 3 hours after they give him the toradol. i told him he has to ASK for additional pain medicine, but my dad is too proud and won't. if he c/o pain while i'm there, i'll tell his nurse, then when she comes to ask, he'll say "i'm ok". his nurse must think i'm nuts. i wish they would just give him something. i never heard his nurse ask him voluntarily if he was in pain. i don't know what his fear is of getting pain meds.

sorry this is so long. i just feel so helpless when i am there with him.

and one more thing, i about fell out of my chair when the first surgeon he had gone to consult with (he went with the second surgeon) came in his room after he found out he was in the icu, and asked him why he didn't choose him? i thought that was very unprofessional. the reason he didn't go with him was because he didn't like his attitude/personality. he is very abrupt, and my dad didn't feel comfortable with him. my head still spins thinking about that incident!

heather

begalli · Mar 6, 2005

Hmmm. I can only tell you that where I work, everyone gets an insulin drip post-op if three consecutive sugars are >120 or they're diabetic, or they're on an epi drip. 80 - 120 is our goal. If at any time during the administration of the drip a patient's sugar falls below 80, first thing we do is shut off the drip and then push the D50. Then we recheck the sugar in 30 minutes. If it's >120 again, the drip is restarted at half of what it was when we shut it off. Check the sugar in another 30 minutes....without getting into the entire protocol (it goes on forever!), I can just say that I have never had a patient like your dad pass out from a low sugar. I wonder too why they're still giving the insulin like that, especially if he's not eating. (btw, we sometimes run D10 with our insulin gtts, but always at least D5).

His low bp could be from a couple of things, but I would think that he could be dry and in need of some fuilds (again, especially if he's got emesis and not taking things by mouth very well). Could be from the cardizem as well. After the drips are off we use nitro paste that can be wiped off when a patient drops their pressure. I hardly ever see cardizem post cardiac surgery, but different places do different things. His calcium could be low as well. If your dad has any kind of acidosis (metabolic due to the emesis or diabetes or respiratory due to shallow breathing because of pain) this can also contribute to a low bp.

It infuriates me when I hear that open heart patients aren't getting pain meds. It's one thing when a patient doesn't complain of pain and this is frequent in the elderly, but it's a completely different story when the patient is saying they have pain....even if it's not directly to me but to a family member. You would think that there would be a lot of pain associated with having your sternum cracked in half. What's different is that there aren't a whole lot of nerve endinging in this area, so frequently people will not experience the excrutiating pain that I imagine myself having with this type of surgery. At least they don't complain until they start moving around more and more and then they are just really sore sore sore which toradol IS good for, but not always adequate all by itself. Also, we only give toradol for 48 hours post-op then it's d/c'd. Also, also, toradol affects platelets. Don't want to give it to a patient who's bleeding, or not until after the bleeding is well under control and the platelets are pretty darned close to normal.

Anyway, they may want to be keeping his sugars low to help his healing but they aren't doing him any favors by not treating his pain. Untreated pain also stands in the way of his healing and his pulmonary status. It's a known fact that pain influences immune function. The stress of pain on the body releases catecholemines which in turn suppress aspects of immune funtion such as the white cells needed to combat pathogens. Your dad's going to have a harder time doing his deep breathing if he's in pain and what he will be able to do will not be enough to pop open those little alveoli and cough out the junk that sits in his lungs. This can lead to not only pneumonia but respiratory acidosis like I mentioned above.

If this were my dad, and this is just me, I would be a bit more adamant about treating the pain and I would not feel even a little bit bad about doing so. Maybe you can mention that to the nurse. Say what I bolded. Explain that to your dad too. When my dad was in the hospital, I did so much teaching!! Many older folk believe there is some stigma attached to needing pain meds. He won't get addicted and he certainly won't be looked upon as a drug seeker (well he shouldn't, some nurses are like that though and this depends on many factors like the nurse's own personal beliefs about pain - drives me crazy!). Maybe you could talk to your dad about "discomfort" instead of using the word "pain." Many people really do not feel pain as they perceive pain to be (harsh stabbing burning PAIN!), but they are able to easily describe their discomfort with moving and breathing and then try to convince him to treat his "discomfort."

I suppose I should attach a disclaimer to everything I'm saying, but I'm only responding to your posts from my experience working with these types of patients, not that I'm treating your dad. Maybe I'm giving you some ideas that you can bring up with the nurses and docs following your dad? I hope you don't mind me commenting on your dad's post-op?! Sheesh! What a buttinsky I am!!! :chuckle

begalli · Mar 6, 2005

p.s. What can you say about cardiac surgeons? They do incredible work and are masters in their field. Most have giant egos because they know they're good. Some are very likeable. Some are just pompous .

The docs I work with are some of the best in the world and while they know it, they share it, they don't flaunt it. I could never imagine any one of our guys, residents or attendings, ever saying anything like that to a patient.

Your dad made a good choice. :)

rehab nurse · Mar 6, 2005

no, begalli, i sure don't mind you following my dad's progress....in fact, i appreciate your wisdom on the subject. i don't have any friends who work with these patients, in fact, my friends are in every specialty except ICU, so i don't have anyone to listen to my dad's stories. i thank you for your replies and your insight.....and i understand about the not treating him thing. i know you're just going by your experiences :):icon_hug:

i did talk to his day nurse today, who was wonderful. there are two nurses there i am definitely sending some thank you letters to there. his first nurse, and the one today. excellent excellent nurses. i think everyone there is good, but these two went above and beyond their call for my dad, and i will thank them when he leaves.:flowersfo

his nurse today was treating his pain, he's off the toradol now because his BUN/cr were a little high, and they brought in nephrology to eval him. he had a low urine output today, like 20ml/hr, it's now up to 30ml/hr. he is getting only .9ns now. all his drips are off. he still has chest tube, foley, swan. he's getting ss insulin now, and checking bs q 4 hours. they have been running around 120-180. my dad was himself today though, rosy cheeks and all :) he wasn't disoriented, and had a little nausea when he coughed, but that's all. he kept down a little cream of wheat for breakfast, and couldn't eat lunch, but then ate some high protein pudding for dinner. he can keep ginger ale and water down as well, but no other fluids. his day nurse was giving him vicodin every four hours, which my dad says does the trick. he got up in his chair twice today. his bp's have leveled out and not dropped. i think he will only improve from here on out. i am hoping they can get him out of CVICU tomorrow. their main worries right now are obviously the kidney function, and his blood sugars. i am very happy for an overall good day.

i had to work today, so it was hard for me to be away, but his nurse was nice enough to call and tell me he's ok. and when i was out in the hall waiting, the first nurse he had sought me out to talk to me and ask me how things were. she's so very nice, even remembered my name. lol, i can't remember half my patients families names...i remember their face, but not their name. i was really surprised she remembered it.

so thanks, begalli, for listening to me, and sharing your insight! i'll post again tomorrow.

heather

zambezi, BSN, RN · Mar 6, 2005

Rehab nurse-

Glad to hear your dad is feeling a little better. Those blood sugars will probably even out once he starts eating a little more and his body is less stressed...As for his nausea- is he getting anything to help with that- zofran or inapsine or anything? It could be taking pills on an empty stomach that is making his nausea worse as well...mabye trying some crackers or pudding before he has to take a pill would help...Also I am glad that his pain is a bit better...I am sure that he will feel so much better after he gets those chest tubes out...most of my patients require less pain medication after the tubes are pulled...Anyway, just wanted to say hang in there...it sounds like he still has some fine tuning to make it through but is getting better and stronger each day...

URO-RN · Mar 6, 2005

no, begalli, i sure don't mind you following my dad's progress....in fact, i appreciate your wisdom on the subject. i don't have any friends who work with these patients, in fact, my friends are in every specialty except ICU, so i don't have anyone to listen to my dad's stories. i thank you for your replies and your insight.....and i understand about the not treating him thing. i know you're just going by your experiences :):icon_hug:
i did talk to his day nurse today, who was wonderful. there are two nurses there i am definitely sending some thank you letters to there. his first nurse, and the one today. excellent excellent nurses. i think everyone there is good, but these two went above and beyond their call for my dad, and i will thank them when he leaves.:flowersfo
his nurse today was treating his pain, he's off the toradol now because his BUN/cr were a little high, and they brought in nephrology to eval him. he had a low urine output today, like 20ml/hr, it's now up to 30ml/hr. he is getting only .9ns now. all his drips are off. he still has chest tube, foley, swan. he's getting ss insulin now, and checking bs q 4 hours. they have been running around 120-180. my dad was himself today though, rosy cheeks and all :) he wasn't disoriented, and had a little nausea when he coughed, but that's all. he kept down a little cream of wheat for breakfast, and couldn't eat lunch, but then ate some high protein pudding for dinner. he can keep ginger ale and water down as well, but no other fluids. his day nurse was giving him vicodin every four hours, which my dad says does the trick. he got up in his chair twice today. his bp's have leveled out and not dropped. i think he will only improve from here on out. i am hoping they can get him out of CVICU tomorrow. their main worries right now are obviously the kidney function, and his blood sugars. i am very happy for an overall good day.
i had to work today, so it was hard for me to be away, but his nurse was nice enough to call and tell me he's ok. and when i was out in the hall waiting, the first nurse he had sought me out to talk to me and ask me how things were. she's so very nice, even remembered my name. lol, i can't remember half my patients families names...i remember their face, but not their name. i was really surprised she remembered it.
so thanks, begalli, for listening to me, and sharing your insight! i'll post again tomorrow.
heather

Rehab nurse:

Glad to read about the progress of your dad. Sending positive thoughts your way.:)

begalli · Mar 6, 2005

i am hoping they can get him out of CVICU tomorrow. their main worries right now are obviously the kidney function, and his blood sugars. i am very happy for an overall good day.

I hope he gets out too and I'm sure he will. The environment of the ICU is a horrible place to heal!

Of course I don't know what your dad's blood pressures were before his surgery, but his kidneys may have been used to a higher perfusing pressure pre-op. We like to keep our post-op cardiac surgery people's presssures a bit on the low side to prevent blowing grafts. His low urine output may just be related to his body not being used to a lower pressure and once he gets more and more back to normal, his urine output will pick up. On the other hand, I have seen patient's need a few hours of diaylsis to jump start their kidneys, but they usually have other things going on that require this kick. If your dad's other systems are working well, especially his lungs, and he's not getting real fluid overloaded, then maybe just some good diuresing with lasix will help him along.

i think he will only improve from here on out.

In an earlier post you commented that you feel so helpless when you are there with your dad. While I know those feeling are so real, I think you should give yourself way more credit in knowing what's going on in his care than you think you do!!

:yeah:

I look forward to your daily posts Heather! Be sure to let your dad know that everyone's pulling for him, including those great nurses who are keeping a watchful eye on him.

rehab nurse · Mar 7, 2005

wow, thanks everybody for reading! and for your encouragement.

i saw my dad for only an hour today, as i had to work. ugh. but, when i walked into CVICU, the first thing i see is my dad up in his chair. he looked so good. he was alert, joking around like his old self.

last night, his blood sugar was 228, they gave him 8 units of regular as well as 10 units of lantus. he usually takes lantus at home, but later at night, this was at 4 pm. he hadn't eaten anything but pudding. well, hour later, his blood sugar was 45. luckily he didn't go unresponsive as he did the day before. they gave him some d50 and he was ok again. today he had the same nurse. they had endocrinology eval him, and lantus was dc'd this morning. somewhere along the line, another doc came in today and reordered it, though his nurse refused to give it. he could not reach his endocrinologist, or the doc who had reordered it. (as far as i know, i have never heard of a hospitalist coming to change orders from an endocrinologist that were not even 12 hours old? w/o consulting the endocrinologist?) so, he has just been getting coverage, and his blood sugars are running 120-200.

his blood pressures are fine, mostly 128-145 systolic. that has not been a problem the last 24 hours. his urine output is up to 40ml/hr, which they said is good enough. he is only getting 70ml/hr normal saline today. no more drips since yesterday. his chest tube is draining only mostly clear, not like before. (i am not familiar at all with chest tubes!)

his appetite is getting much much better. he is eating small amounts of things, and keeping them down. no more nausea today. well, only when he gets the hiccups every so often. he will be on a regular diet tomorrow. too bad his nurse will be off tomorrow, i will miss him! he is very courageous, he went to get his rn after he had lung ca, and had three lung surgeries, and three rounds of chemo! and here i am dragging my feet finishing school!

so tomorrow they are supposed to take out his chest tube, foley, and swan, take him off tele, and he'll be on stepdown. we'll see! i should also say, he shaved himself while i was there, brushed his teeth, washed his face and arms. i wanted to wash his greasy hair but he wouldn't let me! lol. he at least combed it....i was so proud of him today.

thanks everyone for reading!! and double thanks for all those critical care nurses who make such a big difference for people like my dad!!! and for that matter, all the nurses who make a difference every day....

begalli · Mar 7, 2005

Your dad's got a new lease on life!

Good for you all!

:)

rehab nurse · Mar 9, 2005

to begalli, and other who were following the thread~

my dad came out of icu on monday, and is coming home today (wednesday)

his experience in the icu was a good one, but i can't say that for the medical floor he was discharged too. he walked from his icu room to his new room (just across the hall) which was great. there was no nurse to help us with his ambulation, they just told us to walk on over there. (i thought for sure they would use a w/c??) well, i was with him, and he did fine. he sat down in his new room for about 10 seconds, because it was about 90 degress in there (the roommate told us he was cold, and figured out how to break into the thermostat because the nurses wouldn't turn it up). so my dad and i walk out to the nurses station, stood for about 5 minutes, then my dad sat down in front of the desk. i never saw anyone in scrubs. his room was just in front of the nurses station, so i turned on his call light to see if someone would come. about 15 minutes later, someone representing themselves as a nurse came to his room, and i approached her, telling her that the problem was, my dad couldn't tolerate the heat being that high. and that also the roommate had 9 visitors in the small room, sitting on my dad's bed, using all the chairs,etc. not one of them offered to get up when we walked in. the rule for visitors was two per pt. finally they got some of the visitors to get out, but they couldn't get all out. there was still four in there.

the "nurse" came back, and i asked if she was his nurse, and she said, "no, i don't know who his nurse is", and left. this was 6 oclock in the evening. my dad had not eaten, and he felt hypoglycemic. i pressed the call light. i walked out in the hallway. there was no one. i walked the hallway, no one. my dad in the meantime took his own blood sugar. it was 50. he has crackers and glucose in his bag, and he took some, because he was fast going down. by the time i found a group of people joking around, i asked if one of them could please come check on my dad as he was diabetic, hadn't eaten, and his blood sugar was dropping. they started laughing, "who's your dad?" i told them the room number. "oh, that bed is empty". um, no, he just came from CVICU. "he is?" yes. "oh, who's going to take him? who's charge?" they then started laughing, joking around. "i don't know who's charge, are you charge? are you?" i said can someone please get him something to eat! now? "allright, i'll go see him". (well, thanks for your courtesy i wanted to say!! i just wanted to start screaming!) she goes in the room and sees my dad with a tube of instaglucose. she says, "why are you taking that?" my dad told her, no one's checked my sugar, it was supposed to be done at four. i checked it myself, i was 50 and symptomatic. i have nothing to eat, and i couldn't find a nurse to come to my room. the nurse turns and walks out. finally got him a tray 10 minutes later. she never did come take his blood sugar with their machine. in the meantime, the first "nurse" came in and asked my dad if he wanted to get washed up (he had not been showed yet). her tag flipped over, and she's a PCA. i hated leaving my dad there. i left at 8 oclock, promptly when visiting hours were over. before i left, his nurse did come in with some lantus. thirty units. i asked her what she was doing, and she said there was an order for 30 units of lantus. i reminded her that no one had ever checked his blood sugar yet. she said, the aide did. i said no, she didn't. my dad said the same. the aide had written on his chart 135. i couldn't believe it. i told her no one has been in this room to check his sugar! my dad checked it when the nurse walked out, and it was 189. i can't fathom what would have happened if my dad wasn't alert enough to refuse the lantus. the aide who wrote the false accucheck on his record was now gone. at that time i had to leave, though i did not want to. i asked at the desk to speak with the manager, or the charge, they said there was no one available, but gave me the name of the day shift manager.

my dad said no one ever did go in to check his sugar, though the orders were q 4 hours. he checked his own. he refused the lantus the nurse wanted to give. the visitors in the next bed came and went all night according to my dad. so my dad got no rest. on tuesday, it was more of the same. my dad did his walks with no assistance other than me. i was there promptly for visiting hours. i talked with his doctors. his surgeon wanted him to stay until thursday. my dad told him what happened and refused. he said i will stay only until wednesday. my dad had to tell him, i have to take care of myself here anyways, there is no one to help. i check my own blood sugars, etc. the surgeon was apologetic, and said he could go wednesday am. i kept telling my dad, just one more night, and i will take you home. my dad was almost in tears tuesday night. my mom was scared to death to leave her husband. they keep looking to me, asking is it like this where you work? are they short of help? i had to answer yes. i felt incredibly helpless at that point. on tuesday, his blood sugar went down to 45 again, though no nurse caught it. my dad did. and he gave himself his instaglucose again. it was twenty minutes before a nurse could be found.

well, he is home now. the experience at that hospital was terrible. the icu nurses were great for the most part. but the nurses on the medical floor, well, i don't know what to say. i try to put myself in their shoes. maybe they were short. i don't know how many pts they had a piece, or their acuity. maybe they were having a horrible night. but the way they spoke to me, and to my dad, i didn't like it. now, my dad has a great sense of humor, loves to joke around, and did it in icu. but he doesn't feel like listening to nurses argue jokingly about who is in charge, when his blood sugar is 50 and he feels terrible. i try to see it from both sides. i tried not to be a nosy, busy-body family member who tries to tell the staff how to do their jobs. i never even told them i was a nurse.

gosh, i am tired. i haven't slept good in a week. i have to work tonight. my dad is napping now, and very very happy to be at home. overall, his heart surgery went well. his only complications in the hospital were because of his diabetes. i am glad he is at home now and can get some rest, and get back to his old routines.

thank you all so much for your support and answers to my questions over the past week. i am sorry this post might be a little hard to understand, but i am simply exhausted. i feel my lupus going into a flare. i sure hope i can get it under control before i myself am stuck in a hospital bed.

heather

begalli · Mar 10, 2005

the experience at that hospital was terrible. the icu nurses were great for the most part. but the nurses on the medical floor, well, i don't know what to say.
heather

Welcome to the club. I just want to let you know Heather that my dad also had a huge surgery. Only he didn't make it out of the hospital. My experience with the different hospital units were the same as yours. And I say this not to discredit floor nurses, but there is a difference between ICU and the floor that is like going from one world to another completely and different world. I'm not saying that I didn't question some of the practices on the ICU, what I'm saying is that at least they were there to question and portrayed some accountability and had some valuable thought and input for the care of the patient.

We NEVER just send a patient walking. They always go in a bed on a monitor with an RN. Not even a wheelchair - if anything were to happen on the way, it's much easier to lower and harden a bed than it is to get someone out of a chair and onto the floor!

I am just so discouraged by your story. And I'm very sorry you and your family had to experience this. I went through the same thing with my family for 4 months! This is the healthcare world our patients deal with on a daily basis in this country. I'm glad your dad refused to stay one minute longer than he had to. He will heal much better and quicker at home.

I can tell you that your dad is so proud of you right now and loves you so much and iff he's anything like my dad was, he doesn't say it, but he is and does. I know first hand what it's like to be the nurse daughter. It's not easy and you've done an INCREDIBLE job!

Glad to be here for you. I wish I had found the usefulness of this site before my dad passed. My co-workers and nurse manager were amazing, but it always helps to have somewhere to express your thoughts 24/7 with others who "know." And boy, I had some thoughts.

begalli · Mar 10, 2005

thank you all so much for your support and answers to my questions over the past week. i am sorry this post might be a little hard to understand, but i am simply exhausted. i feel my lupus going into a flare. i sure hope i can get it under control before i myself am stuck in a hospital bed.

Gosh, take care of yourself. Can you take a day to just be off and at home relaxing you know, a mental health day? Do something that makes you feel good (sleep? :chuckle ). I'd cover for ya if I could!!