Help with post CABG pts

Cheers_G, BSN, RN · Sep 13, 2019

On 9/5/2019 at 7:48 PM, AspiringCRNA22 said:
We care for post op CABG patients in our large SICU.
Alot of understanding how to take care of post of CABG, MVR/AVR, sternotomy patients is understanding proper hemodynamics and gtts that effect these hemodynamics. All of our patients come out with a swan ganz or on a vigeleo, so you must give volume ( LR, albumin, bolus), titrate gtts ect based upon these numbers you are receiving through their hemodynamic catheter. Also, very important to understand ABG's and how to wean to extubate on your post op heart patients.
Something that really helped me connect the dos was taking and studying for my CCRN. The Barrons CCRN book has a great hemodynamic section that tells you what gtts effect what. I still look at it every now again again for a refresher.
Good luck, taking care of CABG patients is a fun journey.

Thank you so much for your input, appreciate it!

Gingeriffic · Sep 17, 2019

Anesthesia and usually the surgeon and or/surgical fellow will being the patient to you. You’ll (hopefully) have helpers to hook the patient up to your vent, monitors, suction, etc. while you are looking at the patient and his numbers to establish a baseline, while you get report from the surgeon and CRNA. Surgery might have different parameters than your intensivists. If your chart isn’t up to date with significant events like excessive shocks coming off pump, products/fluids/meds given, (net fluid balance is especially important to know at all times with fresh hearts). Clarify with CRNA if the patient’s paralytic was reversed - usually they will verbalize it as they are push the reversal during handoff. The a quick drip check for IV meds. As soon as that report is done, start assessing. It’ll be a super busy first few hours keeping track of assessment findings, chest tube output amounts, urine output, monitor values, labs, med and fluid titrating, and vent changes. Trend lactated, ^ can indicate need for crystalloid. Acidosis will increase vasoplegia. And make sure you are warming the patient because he/she will probably be 34.9 when he gets to you. Once he’s warmed up (& watch how hemodynamics and cardiac output change once normothermia acheived!), not bleeding, and the rest of your ducks are in a row, work towards vent weaning and extubating. He’ll be begging for ice chips in no time!

I hope you get lots of great experiences, I LOVE my fresh hearts. The sicker the better (rocket fuel? Yes, please! Unplanned IABP? Certainly! Might as well just leave the chest open too! ?) it’ll take lots of time and practice to become familiar with drips, when to start/stop/switch them around, and over even more time you’ll see the all of the different typical #Post-opProbz will have (to various degrees), as well as how to intervene depending on med response and fluid requirements, acid-base issues, coagulopathy, typical SIRS response, sedation (as well as waking from sedation which often causes big vagal effects = hypotension!!)

So exciting, take good care of those patients and have fun ?

PresG33 · Nov 2, 2019

I worked in a CVICU and am now a CRNA who primarily does hearts. A few tips:

- There are lots of nurses that know WHAT to do but not WHY. They know that adding milrinone will make the cardiac index go up and they might need to put on some norepi, but don’t really know why. The best RNs will understand the mechanisms of drugs and will be able to proactively see side effects of them and treat them before they become a problem. Always know the WHY! And to know this you need to read outside of what you are told at work.

- As a RN I was taught the first 3 solutions to a heart that wasn’t doing well were volume, volume, volume. I can tell you now that this is misguided. Crystalloid neither carries oxygen nor clots, which are the two things a post op heart needs. Optimize preload, but don’t forget about heart rate (pace), contractility, SVR, and enough afterload to optimize cardiac function.

- And my pet peeve: listen to the CRNA or other anesthesia provider’s report when they drop off the heart. They have spent the last 3-8 hours giving the patient different types of medications and have learned how the patient reacts. I have some RNs who listen intently and I can clue them in on things to make their life easier (“Inferior wall looked sluggish on echo, he will prob need volume, and he reacts better to norepi than phenylephrine”). Some RNs literally just want to know what they need to fill out their report sheet (Is and Os, what drips, what lines, nothing else). I think that they then struggle trying to “figure out” what the patient does best with when they could have learned that in 3 mins talking to me. That being said, some anesthesia providers give crappy reports and then you’re on your own!

I aways loved hearts and love them even more as a CRNA. In my opinion, recovering a post-op heart is the closest thing in nursing to being a CRNA taking care of sick patients in the OR. Have fun and try to learn everything you can. If you love recovering hearts, chances are you will love being a CRNA and think about that path the future!! Good luck.

Cheers_G, BSN, RN · Nov 2, 2019

On 9/17/2019 at 4:30 PM, Gingeriffic said:
Anesthesia and usually the surgeon and or/surgical fellow will being the patient to you. You’ll (hopefully) have helpers to hook the patient up to your vent, monitors, suction, etc. while you are looking at the patient and his numbers to establish a baseline, while you get report from the surgeon and CRNA. Surgery might have different parameters than your intensivists. If your chart isn’t up to date with significant events like excessive shocks coming off pump, products/fluids/meds given, (net fluid balance is especially important to know at all times with fresh hearts). Clarify with CRNA if the patient’s paralytic was reversed - usually they will verbalize it as they are push the reversal during handoff. The a quick drip check for IV meds. As soon as that report is done, start assessing. It’ll be a super busy first few hours keeping track of assessment findings, chest tube output amounts, urine output, monitor values, labs, med and fluid titrating, and vent changes. Trend lactated, ^ can indicate need for crystalloid. Acidosis will increase vasoplegia. And make sure you are warming the patient because he/she will probably be 34.9 when he gets to you. Once he’s warmed up (& watch how hemodynamics and cardiac output change once normothermia acheived!), not bleeding, and the rest of your ducks are in a row, work towards vent weaning and extubating. He’ll be begging for ice chips in no time!
I hope you get lots of great experiences, I LOVE my fresh hearts. The sicker the better (rocket fuel? Yes, please! Unplanned IABP? Certainly! Might as well just leave the chest open too! ?) it’ll take lots of time and practice to become familiar with drips, when to start/stop/switch them around, and over even more time you’ll see the all of the different typical #Post-opProbz will have (to various degrees), as well as how to intervene depending on med response and fluid requirements, acid-base issues, coagulopathy, typical SIRS response, sedation (as well as waking from sedation which often causes big vagal effects = hypotension!!)
So exciting, take good care of those patients and have fun ?

Thank you so much, these are awesome pointers!!

Cheers_G, BSN, RN · Nov 2, 2019

6 hours ago, PresG33 said:
I worked in a CVICU and am now a CRNA who primarily does hearts. A few tips:
- There are lots of nurses that know WHAT to do but not WHY. They know that adding milrinone will make the cardiac index go up and they might need to put on some norepi, but don’t really know why. The best RNs will understand the mechanisms of drugs and will be able to proactively see side effects of them and treat them before they become a problem. Always know the WHY! And to know this you need to read outside of what you are told at work.
- As a RN I was taught the first 3 solutions to a heart that wasn’t doing well were volume, volume, volume. I can tell you now that this is misguided. Crystalloid neither carries oxygen nor clots, which are the two things a post op heart needs. Optimize preload, but don’t forget about heart rate (pace), contractility, SVR, and enough afterload to optimize cardiac function.
- And my pet peeve: listen to the CRNA or other anesthesia provider’s report when they drop off the heart. They have spent the last 3-8 hours giving the patient different types of medications and have learned how the patient reacts. I have some RNs who listen intently and I can clue them in on things to make their life easier (“Inferior wall looked sluggish on echo, he will prob need volume, and he reacts better to norepi than phenylephrine”). Some RNs literally just want to know what they need to fill out their report sheet (Is and Os, what drips, what lines, nothing else). I think that they then struggle trying to “figure out” what the patient does best with when they could have learned that in 3 mins talking to me. That being said, some anesthesia providers give crappy reports and then you’re on your own!
I aways loved hearts and love them even more as a CRNA. In my opinion, recovering a post-op heart is the closest thing in nursing to being a CRNA taking care of sick patients in the OR. Have fun and try to learn everything you can. If you love recovering hearts, chances are you will love being a CRNA and think about that path the future!! Good luck.

Wow these are great. I have to say some of the anesthesiologists give crappy reports, or they come up and state "The pt had a valve replacement so I made them nicely hypotensive for you". Oh no... now I'm gonna have to chase BP. Things like that. Overall, fresh hearts are cool and everything is so sensitive/labile, love it so far! Thanks again!