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Early Mobilization after Open Heart (what does this mean to you?)

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I work in a CVICU the does approx 200 - 300 open heart procedures a year. Early mobilization means, in my unit, that a pt gets out of bed after PA catheter is removed

We had a very high acuity level for our post-operative CABG/Valve patients. The gold standard was to try to get them extubated if stable within 6 hours. To try to get them to dangle at the bedside the night of surgery and to have them in the chair by 0600 the next day. The majority of these patients went to the telemetry floor within 18 hours of their surgery. All of them had swan lines. Just because of a patient has a swan ganz doesn't necessarily mean that they can't get out of bed. Evaluate the patient individually, and go from there. If you haven't I would check the literature for what best practice is. I would also suggest you look at your NG/OG placement process. Are they being placed, when are they removed, are they being hooked up post-op?

AmyCardsNP, RN, NP

Specializes in Cardiology.

Our open hearts are OOB within 2 hours of extubation with very little exception, whether the swan is out or not, and they generally ambulate three times on POD #1 (only twice if the swan doesnt come out until after lunchtime). All of our patients have NG/OG tubes hooked to LIWS while intubated. I have been working in this CVICU (highest # of open heart surgeries in the state) for 3 years and I have only seen 2 cases of post-op ileus and both cases were patients who were intubated for several days after surgery.

criticalHP, MSN, RN

Specializes in ICU,CCU, MICU, SICU, CVICU, CTSICU,ER.

Our goal is for early extubation within 6 hrs end of surgery-we are about 80% on that goal. Pt is dangled within 2 hrs, if still hemodynamically stable, and is OOB by next AM prior to shift change-swan in during this time. Pts are typically transfered to CVU/stepdown by 1100-1300 POD1. The swan is pulled prior to this and first ambulation in the halls, blakes are typically removed at the same time as the swan. On occasion, say 10% of pts will need to stay an extra day and need the swan in place- we have ambulated pts with swans, but these are not pt's I would want to see trucking down the hall too far from their rooms-about

Demographics: 200 bed regional center about 200 CVS /yr-busy for us!

suanna

Specializes in Post Anesthesia. Has 30 years experience.

Our goal is off the vent in 6-8, to chair 2-4 hrs post extubation, ambulate within 18hrs of adm to the CVSU. Ambulation is 2-3 x per day in critical care. As for Swans- all our patients have them. They are d/c d just before transfer to tele on POD1 or 2. In 20 years of CVSICU nursing I think I have seen 3 post open heart ileus patients- (we do about 200-300/yr). The docs aren't in the gut- I don't understand where your ileus problems are comming from. Certainly inactivity and post op narcotics can contribute, but research I have seen recently indicated activity had very little effect on bowel function- It may be an old nursing practice that dosen't hold up to evidence based practice. My best advise is looking into your Salem Sump or NG placement and length of use. If we have a nasal placed Salem Sump we try to leave it in till close to 5am POD1.

JF808Rn

Specializes in CCRN-CSC. Has 4 years experience.

At my facility we do a "4x4" goal...

So as soon as the patient has arrived in the ICU room... We have 4 hours to extubate.

Restart the clock...

Then the 2nd block of 4 hours is trying to get the patient to dangle at the bedside.

Restart the clock...

The 3rd block of 4 hours is goaled to remove the PA catheter if the patient has been off of vasopressors for at least 2 hours.

Restart the clock...

Then the last block of 4 hours is dedicated to getting the pt up to a chair for a couple hours and ready for transfer to the floor.

Hope this helps!

missnurse01, MSN, RN

Has 18 years experience.

I have also rarely seen ileus in open heart recovery, I have worked in many diff units across the U.S. as I am a travel nurse. The current facility I am at does the up to the chair the next a.m. (although many don't until the swan is out-that is just how this facility is) then swan out later in the morning POD1 (here they also are different in that they pull it no matter just about what drips they are on!) and walking 3-4 times the first day, around the entire second floor. They really push the pts here, they are not allowed to get back to bed until night shift comes back in. Here they just leave the OGs clamped unless they are planning to sleep the pt over night. So not sure where all your ileus's are coming from...even in places that didn't mobilize their pt's quickly, I still didn't see a lot of them...

Zookeeper3

Specializes in ICU, ER, EP,. Has 17 years experience.

Ours is similar to yours but we plan to extubate in 4 hours, sometimes they come out extubated, but we get them into the chair 4 hours after extubation with swan and drips.

At my facility we do a "4x4" goal...

So as soon as the patient has arrived in the ICU room... We have 4 hours to extubate.

Restart the clock...

Then the 2nd block of 4 hours is trying to get the patient to dangle at the bedside.

Restart the clock...

The 3rd block of 4 hours is goaled to remove the PA catheter if the patient has been off of vasopressors for at least 2 hours.

Restart the clock...

Then the last block of 4 hours is dedicated to getting the pt up to a chair for a couple hours and ready for transfer to the floor.

Hope this helps!

RNAEMTCC

Specializes in cardiac surgery ICU. Has 2 years experience.

I work on open heart ICU.... our gold standard is stable, extubated within 4 hours and up to chair within hour of extubation. of course that is the gold standard.... many many times... well it just doesn't go that way as we all know!.

our patients also have extended stay in the ICU as the doc doesn't trust anyone but the icu to care for his patients. haha....

Just read your blog and am very interested in more details about getting your post op CABG pts OOB. Do you have certain criteria to get them up and how many CV surgeons do you have? Where I work we have 5 CV surgeons who require different things. One CV surgeon has his patients up in the chair at 0500 as long as they are stable. Looking forward to your response. ZetaRn

aCRNAhopeful

Specializes in CVICU.

Wow I remember reading this same thread before I became a nurse and since then I've started to work with open heart patients as an RN. And just TODAY I started thinking about this thread again and wondered where my facility stacks up in regards to early ambulation of our open hearts. So I come to the CCU forum to look it up again and there it is, ressurrected by someone else without me even looking it up!:eek: That was wierd.

Ok that was just a strange coincidence but I wanted to contribute and I think it deserves bringing to attention again anyways. At my facility, goal for extubation in

In our unit the goal is extubation within 4 hours. If pt is stable ( no excessive bleeding, CI 2.4 or above, no pressors, etc...) we can D/'C swan and A lines at 0400. Pt is then assisted to a recliner by 0530. This is our earliest mobilization. If the pt has met above criteria they are transfered to the stepdown floor before noon, and they most always ambulate to their room. They are expected to ambulate at least 3 more times that day, and at least 6 times on pod 2. Distance anywhere 200' - 400' each time. All our pt's are also started on Colace 100mg bid on pod 1 to aid mobilization of another kind. If for some reason lines are not d/c'd, but the pt is strong and alert enough, we will still get them to a recliner on pod 1, and the doc will decide what he wants to do with the lines when he rounds.

RNTwin

Specializes in Critical Care Nursing AKA ICU.

work in a CVICU extubation was with in 2hrs of surgery, out of bed within 2hrs of extuabation and up to chair TID for at least 1hr but we still had alot of ileus, but we did a lot ot TAAAs

Our protocol:-Almost all swans are d/c'd in the OR,

Last post failed.

Our protocol:

swans are d/c'd in the OR (>90%)

OOBTC POD#1 before night shift leaves

Dangle/stand/Chair 1-2x that day

Ambulate and OOBTCx3 each day after

NO pts have NG/OG, and no problems with ileus or significant PONV.

Unless you're giving early enteral meds, probably don't need it.

The ileus you're seeing is probably narcs.

IHeartDukeCTICU

Specializes in CT-ICU. Has 4 years experience.

Ours is similar, extubate within 3 hours if stable, wean drips and d/c PA... usually within 5-6 hours, d/c swan and up to chair. Sometimes we'll have patients who come back w/o epi or low dose epi where we can wean off pretty quick and get the swan out. If that happens we'll get them up to the chair and walk em in the ICU 100-300 ft. I heard of a few occasions on our floor where we get people to the chair w/a swan in, but I think it's usually with people who have a swan in longer than expected, or someone who gets a swan put back in and is stable. Next morning they go out to stepdown, POD 1 they are expected to walk 3x 300ft, OOB to chair 3x.

Wile E Coyote, ASN, RN

Specializes in Critical care.

My speculation is probably moot by now, as the thread is > 1yr old. However, I'd recommend comparing your cross-clamp times/technique with those of other facilites and looking for correlation there.

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