Fresh CABG Patients

[sway]

Our CABG patients ALWAYS come back with a Swan and multiple pressors running, often 5 or more. Some of my co-workers have told me that this isn't necessary, and that in some places they take the Swan out before the pt even leaves the OR, and all gtts are stoped, except maybe a little Dopamine or Neo. They say that these hearts do just as well.

Has anybody actually worked in a place that practices this way?

[zambezi, BSN, RN]

Almost all of our patients come back with swans...

Our patients only come back with pressors if they require them...but we have a lot of room on our standing orders to start various things as needed.

Edited to add: we usually start a touch of ntg for our IMA grafts/cardizem for radials if bp allows it...

[pricklypear]

Ours rarely come back with swans unless they have previous high pulm pressures or have valves replaced/repaired that were questionable or IABP. We use a less invasive system called a Pulseco that gives a real time CO/CI reading off the artline waveform. Before we got those, all patients came back with swans. We almost always have at least dopamine running.

[TREBORICUNURSE]

We use a less invasive system called a Pulseco that gives a real time CO/CI reading off the artline waveform.

Pulseco? Is this a PiCCO thermodilution system originaly manufactured by Pulsion?

( CVC + termodilution artery catheter = transpulmonary cardiac output + pulse counter cardiac output )

[pricklypear]

Pulseco? Is this a PiCCO thermodilution system originaly manufactured by Pulsion?

( CVC + termodilution artery catheter = transpulmonary cardiac output + pulse counter cardiac output )

I don't know if they're related, ours are by LidCo. Sounds alot alike, though. They are not always as accurate as a swan. Sometimes we'll have both, and totally different numbers on each one!

[PJMommy]

Always with Swans, always with dobutamine and neo or dopamine only if BP requires it. However, I'd also heard of "those places" where they come back without Swans. Makes sense because, last I saw/heard/read, research shows Swans do nothing to improve outcomes.

[Heartman]

Always with Swans. Usually with propofol, NTG and dopamine @ renal dose.

Docs pay no attention to PCWP. Swan is usually DC'd by following AM.

[begalli]

Ours rarely come back with swans, unless they're really sick - even then we never really wedge, maybe once just to see if the balloon is working properly. They are accompanied by renal dopa, a touch of ntg, amicar, and propofol which is all usually weaned off within 6-8 hours.

Of course there's always those patients who come back on a plethra of drips, a variety of VADs, IABP, bleeding, ice cold, in need of major resusitation, an open heart in the room, or a trip back to the OR. That's when the shift gets interesting! :)

Surprisingly, our heart transplants are usually the easiest and fastest patients to recover from anesthesia and to extubate. They usually come back with some epi and dopamine. Never a swan.

[clarkheart]

Our hearts always come back with Swans from Baxter and we use the Vigilance Monitor to receive continous CI,SVR,BT,and SV02 if necessary so we have continous trending on their hemodynamics. As far as pressors, it just depends on how they have responded so far from coming off pump. It's not unusual for them to be on nothing at all when they come to me. And of course that can change very fast once they start waking, warming,etc.

[my2sons]

I've worked in 2 cv recovery units. Both routinely used swans and a-lines, but the gtts they came back on were totally different. First one used dopa, dobu, and nipride, (and low dose cardizem if they were a lima/rima.) The second used epi, neo, (and ntg if rima/lima.) Kind of wigged me out to have epi and neo on hearts at first (first unit docs liked low HRs --70-80's), now HR 90's is typical. I have found that the gtts used depends more on what the anesthesiologists are used to using. Half the time the CV surgeons have no idea what gtts their patients are on. I had my first settle with a patient on Diprivan, very smooth, nice wean to extubate, I highly recommend it ! :)

[LCRN]

In the SICU our CABG/MVR's have their SWAN in but we do not wedge and the gtts our pretty standard-NTG, neosynephrine, Epi, propofol and sometimes a little Nipride (if HTN). If our hearts have a previous renal impairment we use low-dose dopa. All are on propofol for sedation with morphine/toradol for first 48 hours for pain relief.

Amicar is given in the OR and is off by the time we get the patient. Our Docs like to see a HR of 80 or above so we end up pacing them until their warmed and can maintain that consistently. As everyone knows it's a constant battle of the drips to get your patient where you want them hemodynamically. Hope this helps!

[Dinith88]

ours come back about 90/10 (90% with, 10% without)...depends on the surgeon and individual patient criteria. I wish they'd all come back without them...less 'spaghetti tangle' to deal with...