I'm Taking a Poll

[NotReady4PrimeTime]

I would like to know how many units out there are following the VAP bundle to the letter with their open-sternum post-op cardiac patients. By this I'm specifically looking at elevating the head of the bed and angle of torso to at least 30 degrees. If you're doing this, what kinds of cardiovascular and hemodynamic concerns are you seeing? If you aren't doing this, what are the reasons and are you seeing VAP in these kiddies?

Our NICU uses either isolettes or Ohio overbed warmer units for all their babies. It's impossible to have the head of the bed and angle of torso at greater than about fifteen degrees, yet their babies don't seem to develop VAP. In our PICU we have no choice but to elevate them so that they're cantilevered on a pile of rolled up linen, unless we can get an order to nurse them at a lesser angle... regardless of their post-op status. Diaper changes are a two or three person job, even on the tiniest of babies, because our medical director insists that the only time the HOB can be lowered is for xrays, and sometimes not even then. My mind quails from the thought of the tip of that mediastinal chest tube flailing around inside the open chest... So I appeal to my colleagues everywhere for your experience.

[NotReady4PrimeTime, RN]

Perhaps I shouldn't admit this in public but I've always landmarked by eye-balling the sternum midline between the nipples. I only used the xiphoid landmark in the class...

41 degrees here today and sunny. Lots of melting, but still tons more to go. Potholes are unreal! The roads look like a moonscape.

[bwpccedu]

We do not follow all of the VAP regulations. We orally intubate our kids and we rarely see VAP.(maybe 1 or 2 in the past 6 months.) We do howerver use in-line suction caths on everyone.The only HOBs we put up are Glenns. Our open chests are sedated and paralizedthen weaned off gradually. Occasionally we need to do a methadone protocol, but usually only if they been down for weeks on end.

[NotReady4PrimeTime, RN]

We're part of the 100,000 Lives Campaign collaborative (http://www.remakingamericanmedicine.org/lives.html), and so we have to incorporate VAP, catheter-related bloodstream infection and pressure injury bundles and whatever is next to come down the pike into our care. Now, I'm not saying that improving the quality of our care and outcomes isn't a worthy goal, but there has to be some critical thinking applied! Yesterday we had a little 20 day old POD 1 post her second coarct repair + ASD repair and with an open sternum sitting up in bed with her feet dangling over a roll made from soakers. We had to overdrive pace her at 185 to keep her BP up, giving her fluid boluses actually caused her BP to drop, and she was already on 0.17 of epi... Her LV function isn't good and neither is her ventilation, and she's in renal failure +/- septic shock but we had the HOB at 45 degrees!

We use in-line suction on everybody... in a manner of speaking. The in-line is there, but the RRTs routinely take the kids off the vent, bag them and then suction them, so any benefit of having the in-line there is gone. Of course, with only one suction canister set-up, when we need to do oral care or nasal decontamination of all the sinusitis goo, the in-line is disconnected from the suction tubing which is then attached to the Yankauer or Little Sucker and used for that job, then the connector from the in-line is picked up off the bed and reattached to the suction tubing again. Nobody sees a problem with this! I'm pretty anal about flushing the tubing and cleaning off the connector with chlorhexidine before reconnecting the in-line, but I don't see too many others following my lead! I say if we're buying the car we need more than just the chassis!

[AliRae]

We use in-line suction on everybody... in a manner of speaking. The in-line is there, but the RRTs routinely take the kids off the vent, bag them and then suction them, so any benefit of having the in-line there is gone

Our head of respiratory hates in-lines with a passion, which really gets my goat. So much to the point that we don't even have more than 2 or 3 sizes on the unit at a time if we even wanted to put the kids on. I had a boyo yesterday ... 7 years old, enormous liver mass with mets everywhere. We're trying to wean and maybe get him extubated so he doesn't die on the vent, and I wanted to do everything possible to keep him comfy. That definitely included in-line, because the more we woke up, the more he needed suctioned and he HATES being taken off and bagged. Hates it with a flaming passion. I suggested it to the RRT, had my head bitten off, went to find it and hook it up myself, and we didn't even have the size. =( However, since I've been reading about this whole VAP bundle thing on here, I did elevate his HOB a bit and I've been incorporating some of the interventions. I'm a one-woman campaign against VAP! I think I have to do an inservice for a "clinical advancement" thing soon, and I think I have my topic!

Oh, and I've never even given a second thought to using the same suction tubing for suctioning the nose and attached to the in-line. Yikes! You better believe I'll have 2 canisters set up from now on! Why do you only have one?

[NotReady4PrimeTime, RN]

Oh, and I've never even given a second thought to using the same suction tubing for suctioning the nose and attached to the in-line. Yikes! You better believe I'll have 2 canisters set up from now on! Why do you only have one?

$$$$$$$$$... and poor bedside planning. There are only three vacuum outlets per pillar, and we often have multiple chest tubes all needing their own outlet (the sumps have to have a canister set-up... see my poll about mediastinal sumps chest tubes on this forum), nasogastric suction a lot of times and then our airway. If the chest tubes are to pleurevac (they're all converted eventually) there can be two to an outlet using a y-connector.

There are good things about the VAP bundle, and I can see how some simple interventions will save lives and money. But as I said, where's the critical thinking? The baby in my previous post had a really rocky night that same day of my post (hypotensive arrest), and OMG!!! Last night was a catastrophe. She nearly died; her arterial BP was 30/19 MAP 22 for about 30 minutes... we cranked up the epi to 0.6, started norepi at 0.1, gave her epi and calcium boluses, talked about ECMO, eventually we got her ABP back up into the 50s and lowered the head of the bed for a chest x-ray... then left her almost flat. Made a huge difference. We never did get a written order, but at that point nobody cared much! Her heart is so stiff that pushing anything centrally, even the epi, almost caused her to arrest. Her poor dad sat at the foot of the bed, just out of the way, and shook for an hour. It won't shock me if I go back Tuesday and she's gone.

[AliRae]

Her poor dad sat at the foot of the bed, just out of the way, and shook for an hour. It won't shock me if I go back Tuesday and she's gone.

Isn't there a point where you can thumb your nose at the dang bundle and just lower the bed? You have NO sympathetic docs who realize that, yes, nurses know what they're talking about and this patient might have a shot if we lay her flat?

People and their politics make me sick sometimes. The other night, during that double code, I just found out that the anesthesiologist who intubated into the stomach then vec'ed the kid, pulled out the tube and stood there hollering "Get me meds! I need meds! I have another case to go to! You're all wasting my time!" Praise the Lord that family was out in the waiting room. (Actually, he's getting better ... he's the kid in my post up there! )

[NotReady4PrimeTime, RN]

We're a teaching hospital and a lot of our physicians are second year residents who are terrified of their own shadow when they first come to PICU, so they are easily brainwashed into believing that what our attendings tell them is the absolute gospel. As a result, the experienced nurses have to do a lot of "tweaking" and "suggesting" when it comes to orders and plans. There are times when I bypass them altogether and go directly to an attending with an issue. Last night we had one of our fellows on, and he's very reasonable, at least most of the time. (He's also the one who switched the GT lorazepam to IV when I mentioned that the volume, 6.3 mL, and coldness of this refrigerated med seemed to cause agitation in my medically complex patient and that I was thinking I'd warm it up, dilute it and give it over several minutes next time instead of shooting it on in there as my preceptee and three nurses before her had done, then documented increased agitation and distress... problem solved, we'll give it IV...NOT!!!!:trout: ) He didn't have an issue with us leaving the HOB down, but I'm sure that if our medical director was on service today, the first thing he'd say on his first walk-through is "Oh, gotta get that head up!" He and I don't much like each other...

[AliRae]

We've got the residents too! It took me a bit before I wasn't scared of my own shadow and was ready to tweak like you said. Now, I'll tell them just what I think. And most of our attendings don't mind if we come to them, as long as we can prove we made a concerted effort to at least FIND as resident. I love how you get to know the residents after a bit and you know who you can ask for orders and who's going to turn around and say "What's the dose for that supposed to be?" ... ... ... I thought that's why YOU went to med school? We just recently had my best buddy (the guy who will go straight to a computer when you ask him for an order and will interrupt his lunch to come see your patient when the parents are freaking out) replaced by the one who cries like clockwork at least once a shift. We sometimes take bets as to which of us is going to be the one to prompt it ...

[NotReady4PrimeTime, RN]

Yeah, ain't they fun? Every once in a while we get a really stellar one, but many of them are duds. One of my very favourite residents is now back doing a fellowship with us. Rock ON! She's got her head screwed on straight for sure. One thing I really like about her is that she isn't inbred... her med school degree is from the University of Saskatchewan, her peds residency is from the University of Calgary (she came to us for a PICU elective because of her intention of doing a fellowship, and their PICU isn't quite as acute as ours) and now her fellowship at the University of Alberta. I find that the ones who have never been anywhere else are very narrow-minded, there's really only one right way of doing things... know what I mean?

We have four fellows at the moment, the guy with the lorazepam who is from Argentina, a woman who has done an ID fellowship already who is from Russia, a woman who had intubated several stomachs who is from Brazil, and the one I just talked about.

I hate July because of the new crop of wet-behind-the-ears green-as-grass baby docs pretending that they aren't scared spitless of doing night call in our unit. By now, most of them have had some good experiences and some bad experiences and have a sense of what they can do and can't. But then, the other night our resident-du-jour stood at the side of the bed the whole time that baby was trying to die, palpating the brachial pulse while our (male) fellow made all the decisions. I wonder what she learned.

[8great]

how many of you use sugar in the open chest? That ia regular table sugar

[NotReady4PrimeTime, RN]

We don't do anything with the open sternum, not even dressings. The OR team has to take care of that. We can reinforce the Ioban but that's about all.

[Semele]

I have only seen one case of VAP in our unit and it was a situation where we couldn't rise te head of the bed because of un undone fundo and the child was orally intubated or three weeks or longer.

We also only have orally intubated kiddos. In fact I have never encountered nasal intubation. But we don't do cardiac at all.