OR patients bypass PACU for ICU

Specialties PACU

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Just wondering if anyone else out there is seeing a trend toward patients who should go to the PACU being sent to general ICU's directly from the OR instead? This is a common practice for our open heart ICU and the staff of that unit receives extensive training to safely provide this type of care. They also have 1:1 staffing. Our general Medical and Cardiac ICU's generally have 2 to 3 patients per nurse and we are not trained to care for surgical ICU patients (but often get their overflow). We are also not trained in anesthesia reversal. Any thoughts or input would be greatly appreciated!!

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Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.

Our ICU receives post-op heart pts., and post op fem-pop and ax-fems. The staffing for that pt is 2 nurses to 1 pt. If that staffing is not available, the pt. goes to PACU instead.

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We are also not trained in anesthesia reversal.

Can you please elaborate on what exactly you mean by "anesthesia reversal"?

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Specializes in cardiac/critical care/ informatics.

our Cardio-thoracic care unit takes open hearts directly from OR, they don't go anywhere else, sometimes they will have to move out other patients to get them in, for example an ohs patient that is couple days post op and for whatever reason isn't ready to go to the step down unit then they would move them to another ICU.

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Specializes in Emergency.

I don't have much to say from the adult ICU prospective. But in a year of PICU time we would get a few children directly from the OR. More often than not as opposed to what the original poster noted as anesthesia reversal it was more like continuance/maintenance. Most the time the pts we got you wanted to keep asleep or at the least sedated. There were even a few patients that certain doctors want kept paralyzed as well..

I would be willing to hypothesize its true will certain adult patients as well. And considering we anesthetize pts in the ER/ICU with RSI its not all that big of an issue.

Rj

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Can you please elaborate on what exactly you mean by "anesthesia reversal"?

Think Narcan; reversal-bringing pt. out of the anesthesia necessary for surgery, something usually done in PACU. In my ACCU, we see extremely critical patients, and sometimes overflow come directly to the ACCU. Usually they are patients that can not be immediately extubated.

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just wondering if anyone else out there is seeing a trend toward patients who should go to the pacu being sent to general icu's directly from the or instead? this is a common practice for our open heart icu and the staff of that unit receives extensive training to safely provide this type of care. they also have 1:1 staffing. our general medical and cardiac icu's generally have 2 to 3 patients per nurse and we are not trained to care for surgical icu patients (but often get their overflow). we are also not trained in anesthesia reversal. any thoughts or input would be greatly appreciated!!

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we have a dedicated area called tcvpo (thoracic-cardio-vascular-post-op), we called the "po" which does exactly what it says - it bypasses pacu. additionally we have an nnicu for immediate neurosurgery post-op, depending of the acuity of the case. i can't imagine not having the appropriate training for immediate post-op pts - it jeopardizes the care and well-being of the pts and staff. additionally, each of these post-op units has an on-staff intensivist/pulmonologist who oversees immediate post-op care. our anesthesia residents regularly float through these units as part of their learning. there has got to be some education and accountability chains for this.

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Think Narcan; reversal-bringing pt. out of the anesthesia necessary for surgery, something usually done in PACU. In my ACCU, we see extremely critical patients, and sometimes overflow come directly to the ACCU. Usually they are patients that can not be immediately extubated.

I'm in anesthesia and was wondering why staff RNs should be doing the job of anesthesia. Narcan is not an anesthetic reversal either, nor should it be used as such. Staff RNs should not have to do anesthesia's job, nor should they be expected to.

We take patients to the unit intubated all the time. If the decision is made to leave a patient intubated, either by anesthesia or surgery, then that person is going to be intubated for at least the next 6-12 hours. So at the end of surgery, we will redose our sedation and paralytics and hook up the patient to some form of sedation (usually propofol) upon unit arrival. Pts are placed on AC modes of ventilation. Same goes with our post-op hearts. We do not fast-track our hearts.

At other institutions where I have clinicals, they DO have fast-tract hearts. We will take these patients up to the open heart unit, fully reversed of all paralytics and breathing on their own, but with an adequate amount of versed and fentanyl on board. These patients are placed on any mode of ventilation that suits them and extubated within four hours.

My point in this is that staff RNs should not be reversing anesthetics or paralytics. A competant anesthesia provider should be doing this as his or her job - that is the individual's area of expertise.

There are many components of anesthesia - inhalational gases, narcotics, paralytics to name a few. Narcan only reverses opoids.

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Specializes in CCU/CVU/ICU.
I'm in anesthesia and was wondering why staff RNs should be doing the job of anesthesia. Narcan is not an anesthetic reversal either, nor should it be used as such. Staff RNs should not have to do anesthesia's job, nor should they be expected to.

We take patients to the unit intubated all the time. If the decision is made to leave a patient intubated, either by anesthesia or surgery, then that person is going to be intubated for at least the next 6-12 hours. So at the end of surgery, we will redose our sedation and paralytics and hook up the patient to some form of sedation (usually propofol) upon unit arrival. Pts are placed on AC modes of ventilation. Same goes with our post-op hearts. We do not fast-track our hearts.

At other institutions where I have clinicals, they DO have fast-tract hearts. We will take these patients up to the open heart unit, fully reversed of all paralytics and breathing on their own, but with an adequate amount of versed and fentanyl on board. These patients are placed on any mode of ventilation that suits them and extubated within four hours.

My point in this is that staff RNs should not be reversing anesthetics or paralytics. A competant anesthesia provider should be doing this as his or her job - that is the individual's area of expertise.

There are many components of anesthesia - inhalational gases, narcotics, paralytics to name a few. Narcan only reverses opoids.

Dont fret, ICU nurses arent dabbling in anesthesia stuff. What the OP was reffering to is patients being recovered in ICU rather than a stay in PACU. I would also inform the OP that when a patient bypasses PACU and and is sent to ICU it's usually a case of a very involved surgery or an unstable patient...and these patients should/need to be 1:1 for at least an hour (longer if unstable). I agree that an ICU nurse who is caring for "2 or 3" patients should not be recovering directly from OR unless they're 1:1 for at least that first hour. THe unit/hospital is setting itself up for trouble otherwise.

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If our patients bypass the PACU for the ICU, it's almost always because they're going to be on a vent anyway, so there're no reason for respiratory to set everything up twice or move a vent. If you take care of ventilated patients anyway, there's no reason you can't take care of an immediate postop patient on a vent.

The reason rn29306 asked what you meant by "anesthesia reversal" is because we usually don't "reverse" anesthesia. The only thing we routinely reverse are muscle relaxants, but anesthetic gases are just breathed out. Narcan is NOT something we use routinely - we actually try and avoid giving it.

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Dont fret, ICU nurses arent dabbling in anesthesia stuff. What the OP was reffering to is patients being recovered in ICU rather than a stay in PACU. I would also inform the OP that when a patient bypasses PACU and and is sent to ICU it's usually a case of a very involved surgery or an unstable patient...and these patients should/need to be 1:1 for at least an hour (longer if unstable). I agree that an ICU nurse who is caring for "2 or 3" patients should not be recovering directly from OR unless they're 1:1 for at least that first hour. THe unit/hospital is setting itself up for trouble otherwise.

:yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat:

Thanks-I didn't think to explain or make a long post explaining everything that goes on...We usually make these patients 1:1 until there is some stabilization in their status; usually a combination of MD set parameters and nursing judgement-not a timed limit. Paralytics are never continued in our ICU, but propofol is the standard sedation. Our team is very organized and with excellent protocols. Nurses never "dabble" in anesthesia, unless of course, they are CRNAs; the post I was replying to was someone asking what "reversal" was. I am more than aware of what Narcan can and can't reverse; I was using a "for example" that would be easy to identify.

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Patients that are not planned to be extubated in the next hour or two, should go directly to the ICU. Why keep them in the PACU? Agents are going to be worn off by then. And why move them unnecessarily? If they are going to remain intubated, I do not see an issue.

If the patient is stable, then having them 1:2 is not an issue. What if an ICU patient intubated went for a wound closure or debridement, and went to the OR intubated and comes back still intubated, as they should. They should not require 1:1 nursing care. If it is a patient that is coming back on pressors, and has other issues, then it is another story.

Rules are changing. I have done single bypass CABGs, that were done off pump, with a thoracotomy approach, and were extubated in the OR, just like many typical cases. There was a team waiting to admit them in the SICU, and the patient was awake and able to talk.:)

It is going to be specific to the patient and the unit..........that is also what a charge nurse and manager are there for. As well as your unit director.

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