Managing Vents and other PACU skills

[LMT2BSN]

ICU nurse with 14 months experience in neuro/stroke/sepsis ICU and code team. So, good experience but.....still a baby nurse :).

I'm super excited about my new job at a level 1 trauma tier 1 & 2 PACU that occasionally has ICU (surgical) overflow patients. I start in 1 month which means I've got time to brush up on stuff (and move across the country). I've been creating a list of study topics that I want to know like the back of my hand. However, what's stressing me out the most is managing vents with limited RT involvement. I know the basics with suctioning, lavage, bump their rate up a bit to blow off CO2, increase their fiO2 by about 10%? if their sats are dropping, switch them over to cpap/simv around 40% before extubating?

If anyone has tips and tricks for managing vents or just what PACU nurses usually do with vents, or your experience extubating, etc, etc I'd really appreciate the advice!

Also, I have a list of things I'm trying to learn/brush up on so I know about them very well, if you have anything to add that'd be great! Some of these I use all the time (propofol, morphine, ativan, zofran, dilaudid) but would still like to know them better.

Here's my list so far: dilaudid, demerol, morphine, fentanyl, versed, propofol, ativan, etomidate, pentothal, glycopyrolate, neostigmine, narcan, romazicon, zofran, ephedrine, vistaril, compazine, phenergan, jaw thrusts, chin tilts, what do the patients expect their pacu experience to be like, reqs for discharge to icu, floor.

[Double-Helix, BSN, RN]

I'm sure your orientation will cover how to use the ventilators in your facility. In general, you won't be left alone to manage them. Patients are most often extubated in the OR. Those going to the ICU will remain intubated. Those who will be extubated will have anesthesia there. I think you'll find that you aren't doing anything much more complex than what you're used to.

Couple things to add: Malignant hyperthermia: signs, symptoms, management. Pseudocholinestrerace deficiency. Dermatome levels and epidural management. Nerve blocks. Local anesthetic toxicity. Laryngospasm. Noncardiogenic pulmonary edema. Citrate toxicity.

A great reference is Drain's Guide to PeriAnesthesia Nursing. It was an immense help when I passed by CPAN exam.

[LMT2BSN]

I appreciate the helpful info! I'm actually waiting on Drains perianesthesia book to be delivered, so can't wait to look into that. I know that managing vents is not beyond my capabilities, so most of my hesitation comes from just being immersed into a new environment. From what I've been told by my employer, I'll be managing the vent (except for RT vent checks) and extubating with another nurse or sometimes the anesthesiologist. Hopefully there's a clearly set protocol for this.

[HeySis, BSN, RN]

We extubate quite a bit in our PACU, it was a skill I had to learn and until the anesthsiologist were confident I knew what I was doing they did it themselves... often leaving me doing a jaw thrust for 15 minutes or so until my patient was awake enough to hold their airway. Very few of our patients come without some airway support (OPA's, LMA's, or cuffed ET's).

I hear that having PACU nurses extubate is pretty rare, but this is the only PACU I've worked at and it's what I know.

We barely ever manage a vent, most of the surgical patients that will stay on vents go directly from he surgical suite back to ICU, so everything I knew about vents I learned in ICU and am probably forgetting now.

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Couple things to add: Malignant hyperthermia: signs, symptoms, management. Pseudocholinestrerace deficiency. Dermatome levels and epidural management. Nerve blocks. Local anesthetic toxicity. Laryngospasm. Noncardiogenic pulmonary edema. Citrate toxicity.

A great reference is Drain's Guide to PeriAnesthesia Nursing.

I second this!

I thankfully have only witness one case of malignant hyperthermia, but that just means it's not something I can stay knowledgable about without regular re-education.

We have quite a few nerve blocks, spinals, epidurals and we start the PCA pumps in PACU (both IV and epidural)

The last thing I had to brush up on was my PALS, and pediatric information, I had worked in a few different areas before PACU, but never with peds patients, it took awhile feeling comfortable giving peds patients narcotics (although it's a double check with each and every dose and I'm grateful for that) And I had to brush up on finding fetal heart tones, because most surgeons will order they be found and HR recorded after surgery.

I found my orientation to be fantastic. And while it didn't cover every possible scenario that can come up, our open room gives me immediate access to those RN's that have been doing this for 20+ years, and it's easy to ask questions or get help. I'm still learning new things and asking questions. I hope to do that my entire life/career.