post-op cabg care

CVCNS50 · Jan 10, 2005

Hi:

I am a cardiovascular clinical nurse specialist-educator for a cardiac surgery unit.

We rely heavily on the individual's hemodynamic need for fluids post-op, as opposed to having a set amount of fluids. While it can easily cause fluid overload if a nurse is not watching the hemodynamic numbers, frequent assessment of fluid balance in every aspect (i.e. frequent I&O assessment, including UOP and chest drainage, PA catheter readings {if patient has one},

especially wedge pressure, CO/CI, SVR, lung assessment and CXR) is done.

Sometimes in those patients who receive lots of fluids in the OR, they begin to diurese on their on in the CV recovery unit and actually may become volume depleted.

I commend your efforts to try and keep from fluid overloading. We do an I&O sheet that looks at all intake and output from admission to the unit on a very frequent basis so that if it appears they are getting in a positive fluid balance, actions can be taken. Also one of our surgeons has a rule that if the total IVF intake is in excess of 125 cc's/hr, he is to be notified so that orders can be obtain to double strength infusions, etc. to decrease unnecessary fluids.

Sometimes we just "chase our tail" with the patient who has a big heart; they require high filling pressures to maintain cardiac output, yet end up needing lasix.

Said alot to say this -- hope this helps some!

CVCNS50 :)

begalli · Jan 10, 2005

These are our standing post-op heart orders:

2 liters of LR (use first) and then 500 ml of hespan for hearts (cabg/valves). This doesn't mean that we give all that fluid, but usually the post-op heart will need some fluid resusitation, especially if they come back peeing up a storm. It's up to the RN. If all of this fluid has been given and the hemodynamics are still labile, we will go for IV drips instead of more fluid boluses.

Our maintanence fluid (D5 .2 ns with 20 meq kcl) is ordered at kvo (5-10 ml/hr) and is started within an hour or so of the patient being admitted to the unit.

The patients always come back on a nitro drip (0.2 - 2), a little bit of dopamine (usually not more than 5), and a touch of propofol. This is a small amout of fluid/hr, maybe 10-30 ml.

Our goal is to wean the drips off as the patients wake up and to extubate. Several hours after a post-op heart is delivered to our unit, the only fluids that are probably running is the maintenance at kvo and ~0.2 of nitro (maybe 2 ml/hr or less). We will shut off the nitro after about 8-12 hours (sometimes ealier depending on bp).

Lasix on post-op day one is a standard order (not a standing order). It's almost always ordered 10mg IVP q 6/hr. Many times this order will change to PO. I'm not sure how long it continues at the step-down unit.

This is a routine/uncomplicated case. Of course, it can get a bit hairy if the patient doesn't recover by the book. In these cases, we will call the pharmacy to have the concentrations of drips doubled and the doc will write an order like all IV fluids not to exceed 75-100 ml/hr (this number will be based on what the overall I&O of the patient is--if the patient is postive a liter, we will do the math to figure out how to balance the I&O's to zero over a shift or 24 hours).

Many times we will run a lasix drip if the patient becomes overloaded usually because their kidneys may have taken a hit and they have an elevated creatinine...this is when it gets interesting and problematic because when the patient remains unstable and is not extubated in a timely fashion this complicates matters and the risk for pulmonary problems or VAP skyrocket.

cabgrn2 · Jan 12, 2005

What type of care do your fresh cabg patient require that is routine. I am interested in seeing how much FLUID other hospitals give their patients related to starting of IV gtts. I think we fluid overload a lot of our patients post-op then have to give lasix/bumex pod #1. Typically Our patients receive 2 to 3 liters( sometimes more) in the first 6-8 hrs postop and I feel this causes an increased # of pulmonary complications. What do your facilities do? :rotfl:

Our care map has the patient recieve D5W @ 50ml/hr and D5W (250ml) w/40mEq KCL @ 25ml/hr. Some doctors give even less fluid. Patients only recieve between 750ml and 1500ml of fluid before their IV is stopped. It is stopped after they are taking fluids orally.

Bruno Matos · Jan 19, 2005

In my unit we use the following to know how much IV fluids we can give (cc/h): Required basic fluid = BSA x 1000 / 24 (post op day 0) ; post op day 1 : RBF = BSA x 1500 / 24 ...

We have to pay attention to the other parameters like: Left ventricular function, creatinine, i & o balance, Right and left atria pressures...

CVCNS50 · Jan 19, 2005

Thanks -- BSA would be the body surface area? Thanks.

zambezi, BSN, RN · Jan 21, 2005

Post op our typical patients have running:

d5lr 30cc

Kcl gtt typically 2.5-5cc

Propoful 0-10cc

Fentanyl gtt 0-10 cc

Vasoactives as needed

We can use hespan or albumin for volume as necessary (depending on which surgeon one is working with).

Autotransfusion for CT output >200 or CellSaver CT output >600 (again depending on the surgeon...and time factors)

We have a standing order for lasix for a pawp >18-20 and UO

We do keep our patients a little "tanked up" as compared to the "standard normal" number for filling pressures...of course we look at the whole picture and the patient to determine what is best. Our standing orders are pretty complete and allow us to use our judgement...

chaosRN, ASN, RN · Jan 22, 2005

Our standard gtt for fresh post op CABG pts is 1/2 NS w/ 20meq KCL @50/hr.

We use albumin for low volume or b/p, and usually nipride or ntg for b/p control. :)

Bruno Matos · Jan 23, 2005

You always have a Swan Ganz catheter on your CABG patients ?

Teachchildren123 · Jan 23, 2005

Very interesting input guys! Keep writing!

Tina CTICU RN · Jan 23, 2005

You always have a Swan Ganz catheter on your CABG patients ?

Hi. I have worked at two different hospitals in the open heart unit and the patients always come out with Swan Gantz catheters. It is the only way we know for sure how the heart is functioning (cardiac outputs, SVR, PVR, etc.) following surgery.

Does anyone here work in the CCU? I posted internally at my hospital for a position in the CCU because I want off night shifts. Can someone give me a run down on what goes on in the CCU and whether or not you feel I can make the transition from the open heart unit?

zambezi, BSN, RN · Jan 23, 2005

You always have a Swan Ganz catheter on your CABG patients ?

We still use swans on 99.9 % of our cabg patients...the only time we don't is if it is a young person (20's) with say a VSD or ASD repair...

We usually pull our swans out the next day or two days out if extubated but somewhat rocky or still requiring lots of pressors....If the patient remains intubated we usually leave it in for a couple of days (unless the patient is not on any pressors)...