post-op cabg htn

CVICURN2003 · Sep 24, 2007

Last week I had a redo Cabg pt on 50ml/hr Nitro and 50 ML/hr of Nipride, was pushing fluids and giving IV trandate q 10 min. Plus lopressor down the NGT. We do not routinely have come up with swans any more. So I just had CVP and HR to push fluids with. Eventually, she evened out and I was able to wean the nipride. She was an Pulm artery repair to so she was off circ for a LLOOONNNGGG time. So, she probably had lots of other "issues" as well. No it is not unusual to play musical gtts for a while. Nitro one minute, Levo the next minute. We give fentnyl up to 250 mcg for increase pressures to along with morphine. Good Luck.

nurseabc123 · Sep 24, 2007

Last week I had a redo Cabg pt on 50ml/hr Nitro and 50 ML/hr of Nipride, was pushing fluids and giving IV trandate q 10 min. Plus lopressor down the NGT. We do not routinely have come up with swans any more. So I just had CVP and HR to push fluids with. Eventually, she evened out and I was able to wean the nipride. She was an Pulm artery repair to so she was off circ for a LLOOONNNGGG time. So, she probably had lots of other "issues" as well. No it is not unusual to play musical gtts for a while. Nitro one minute, Levo the next minute. We give fentnyl up to 250 mcg for increase pressures to along with morphine. Good Luck.

Thanks. I guess, just most of the fresh hearts I had on orientation were pretty much smooth sailing. With my limited experience, I just don't know what's typical/what's right/what's wrong -sometimes. It's unusual for us to get hearts so soon out after orientation, we were just slammed with 6 scheduled and 2 emergents that day. Pretty much everyone got one. I think I'm going to invest in a good CV surgery book. Thanks for your reply.

meandragonbrett · Sep 25, 2007

You mentioned she had a hx of HTN. 140's-160's is likely her norm SBP. Why didn't you give the morphine and the versed together? They're excellent. Do you all use cardene or any beta blocker drips for pressure control? Glad your first heart on your own went well.....CVICU is great!:balloons:

nurseabc123 · Sep 25, 2007

You mentioned she had a hx of HTN. 140's-160's is likely her norm SBP. Why didn't you give the morphine and the versed together? They're excellent. Do you all use cardene or any beta blocker drips for pressure control? Glad your first heart on your own went well.....CVICU is great!:balloons:

Thinking back, Versed and Morphine together wouldn't have been a bad choice, since the Versed is so short acting. I'm always pretty cautious not to give too much sedation, if any at all, while we're trying to wean patients off the vent. We like to get patients extubated by the end of the shift, if possible.

Typically, we do not use any beta-blocker gtts for pressure control immediately post-op, usually only Nipride - which I know is kind of archaic. If a patient has been on the Nipride for a few days often they will try labetalol, and rarely esmolol. And I've never seen Cardene used at all in the unit, do you have good results with cardene?

I appreciate all of the replys. I love to hear others nurses' perspectives! Thanks!

Zookeeper3 · Sep 26, 2007

I don't understand this advice:o We fast track to extubate so no versed, morphine and versed will potentiate each other and can cause rapid drop in BP and collapse your grafts and prolong intubation. If it's your protocol to have both, I would give seperate. OUrs are usually hypertensive once waking up and weaning to extubate, cardene, and either nitro or nipride. Each heart is different and you can use some extremes in cardiothoracic. I think you did a great job, sometimes it takes multiple tries of agents to find the right one(s)

You mentioned she had a hx of HTN. 140's-160's is likely her norm SBP. Why didn't you give the morphine and the versed together? They're excellent. Do you all use cardene or any beta blocker drips for pressure control? Glad your first heart on your own went well.....CVICU is great!:balloons:

heartrn35 · Sep 28, 2007

I agree with the zookeeper. The idea with hearts is to get them extubated as soon as possible and get them moving. Narcs and such should be avoided unless obvious pain issues (most pt's should not be having this much pain post-open heart) or extubation is not a near possibility. It's not like the majority of these patients have problems with their lungs, they just need the anesthetics to wear off and then they can breath on their own.

For pressure control I personally like nipride for it's fast on fast off nature but it does cause shunting. One thing that you did not emphasize is volume loading. Some patients can be weaned off pressors with volume...the idea is fill the tank and the vasculature will relax.

Just think about hemodynamics 101...if your pt's pressure, heart rate, and SVR are up, think volume loss...if you replace the volume the reverse should occur. Give the body what it wants (ie hespan, albumin, or ideally PRBCs). Lots of people get caught up in giving more and more drugs, but tanking the pt can work (esp with Valves). Just my two cents but I have seen it work many times...dilate em out with some nipride (and by this I do mean dropping their pressure lower than normal) turn off the nipride and fill in with volume and let it settle out.

nurseabc123 · Sep 28, 2007

I agree with the zookeeper. The idea with hearts is to get them extubated as soon as possible and get them moving. Narcs and such should be avoided unless obvious pain issues (most pt's should not be having this much pain post-open heart) or extubation is not a near possibility. It's not like the majority of these patients have problems with their lungs, they just need the anesthetics to wear off and then they can breath on their own.
For pressure control I personally like nipride for it's fast on fast off nature but it does cause shunting. One thing that you did not emphasize is volume loading. Some patients can be weaned off pressors with volume...the idea is fill the tank and the vasculature will relax.
Just think about hemodynamics 101...if your pt's pressure, heart rate, and SVR are up, think volume loss...if you replace the volume the reverse should occur. Give the body what it wants (ie hespan, albumin, or ideally PRBCs). Lots of people get caught up in giving more and more drugs, but tanking the pt can work (esp with Valves). Just my two cents but I have seen it work many times...dilate em out with some nipride (and by this I do mean dropping their pressure lower than normal) turn off the nipride and fill in with volume and let it settle out.

Like I said, I usually do not give sedation/ or analgesia early post-op while trying to wean ventilation. I would have to say this was the first time I did. (And, if you're thinking it was your first heart on your own - I took a few late hearts before, and had several with my preceptor....) This was just a different circumstance. Thanks for the feedback.

CVICURN2003 · Sep 29, 2007

I agree with the zookeeper. The idea with hearts is to get them extubated as soon as possible and get them moving. Narcs and such should be avoided unless obvious pain issues (most pt's should not be having this much pain post-open heart) or extubation is not a near possibility. It's not like the majority of these patients have problems with their lungs, they just need the anesthetics to wear off and then they can breath on their own.
For pressure control I personally like nipride for it's fast on fast off nature but it does cause shunting. One thing that you did not emphasize is volume loading. Some patients can be weaned off pressors with volume...the idea is fill the tank and the vasculature will relax.
Just think about hemodynamics 101...if your pt's pressure, heart rate, and SVR are up, think volume loss...if you replace the volume the reverse should occur. Give the body what it wants (ie hespan, albumin, or ideally PRBCs). Lots of people get caught up in giving more and more drugs, but tanking the pt can work (esp with Valves). Just my two cents but I have seen it work many times...dilate em out with some nipride (and by this I do mean dropping their pressure lower than normal) turn off the nipride and fill in with volume and let it settle out.

Man...we have the "trifecta" most CABG patients...HTN, DM and COPD or smoking history. You must be really lucky with your patient population. I think every units goal is quick extubation. Our goal is extubated in max 6 hours and in chair within 8 hours. Usually, we make that goal. We don't wake up our hearts until they are hemodynamically stable. Which lots of times we are weaning on arrival but some times it takes a couple of hours to stablize them and we give them fentyl. Our docs have stopped giving as much blood becasue of higher mortality rates in patients have PRBC's post op. Personally, I have not seen these studies but that is what our docs say.. We give albumin and crystaloids. I would rather wait till my patient is stable and fairly sure they are not going back to OR or will tolerate being extubated.

heartrn35 · Sep 29, 2007

Man...we have the "trifecta" most CABG patients...HTN, DM and COPD or smoking history. You must be really lucky with your patient population.

Man I am so lucky! yesterday she was 5'5" and ~100kgs, 45 yr/pack/hx, off pump cold as blue blazes, and when I pulled the tape off her eyes they opened right up and surprize she was awake. She got the diprivan until I could get her above 94 degrees.

As far as the narcs are concerned, I've given tons of narcs, they have their place, just trying to show the neophyte that there is other ways to look at this issue. Sorry if I offended you MSU_nurse07 wasn't trying too, just trying to give you the benefit of my grey hair. Take into consideration that on one of my first fresh hearts I dropped their pressure to about nothing over nothing by bolusing the patient with a bunch of nipride. :nono: We have all been there but it gets better with time. Pimp your seniors for information (and if you have good surgeons them too).

PS the nipride thing, one of my co-workers had hooked my nipride to my cordis (with my volume) because she did not like to run her nipride through the VIP port with the other vasoactives.:trout: That's another rule of thumb, recheck what others have done for you.

CVICURN2003 · Sep 29, 2007

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PS the nipride thing, one of my co-workers had hooked my nipride to my cordis (with my volume) because she did not like to run her nipride through the VIP port with the other vasoactives.:trout: That's another rule of thumb, recheck what others have done for you.

AND ALWAYS WASTE and FLUSH your QLC and IV's...never know what Anesthesia has put in there....... :uhoh3:

Zookeeper3 · Oct 4, 2007

didn't mean to offend either, just generally using antihypertensives not narcotics for pressure controll. We are very agressive with extubation, sometimes they comeout extubated and I can pull my hair out managing pain and varying bp's as well. :uhoh3: