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I agree in an ideal world the room temp would be high enough that the pt is comfortable without additional blankets etc. Unfortunately I have to work in the room with the pt. I have to wear a full paper lab coat with long sleeves, gloves, and mask when on the floor. Standing at the center nurse's station requires PPE. Even with short sleeved scrubs underneath I am sweating in the middle of winter. Add a hot summer day to and I am dripping. Dripping onto a patient while changing a dressing, placing a tricky needle, or giving care is an infection risk. One of the larger male techs at the outpt unit always has large sweat stains on his back and chest during the shift. He will try wearing just a thin t-shirt but still obviously over heats. If the room temp was increased so that the pt with blood in the circiut is comfortable without additional blankets means the staff is sweltering. I'm sorry but I will happily give them additional blankets, adjust their personal quilts etc. Just keep the room cool enough so that I don't pass out.

Keep in mind that an Art line has a continuous flow of fluid INTO it from a pressure bag. A dialysis needle has to have the ability to withstand the continuous PULL of blood through the needle at a rate of 400-500 ml/min and maintain the pressure of that pull at less them 200 mm. Most plastic IV catheters with walls thin enough to not damage the vessel will collapse at that amount of suction. Pushing fluid down the catheter of an Art line or Central line will prevent the walls from collapsing. By the time the wall is strong enough to withstand the pressure it is very thick and/or very stiff. It seems it is not possible for needles to have both thin; smallest possible hole; and strong walls that don't collapse under pressure. Also, dialysis needles are not always placed going in the direction of the blood flow. The Art needles may need to be placed facing "downstream" or retrograde. The amount of pressure in the vessel would have a softer plastic catheter bending back on itself. Temporary dialysis catheter placed in the acute unit for short term dialysis are EXTREMELY stiff catheters that could go through the back wall of a vein quite easily. Heck, I had one that went through the wall of the heart and into the pericardial sac. Pericardial effusions don't dialyze well, no the pt didn't survive and yes the CXR had been read as good placement. I told the Doc when I started the treatment the blood didn't look right and the art pressure numbers were wrong. He told me he read the CXR himself and it was good placement. But back to the orginal question about incont NH patients. Not only is the lack privacy, supplies, staff, time an issuse in cleaning a pt up but there is also the risk to the other people in the room. Dialysis chairs are very close together. Keeping stool contained within a diaper, within clothes is much better then risking bacterial infection in the catheter of the patient in the next chair that is within arms reach. Not that the next person would reach over and play in the mess; though some would; it would be very easy to accidently brush against their chair, table, supplies, or belongs and not even realize it. It is hard to realize that the decision if someone lives or dies is based on if they can preform the simple act of personal toileting. Kathy

CRRT is continous renal replacement therapy. It is a long slow dialysis. Pt's in renal failure, either acute or chronic, who are to unstable to tolerate hemodialysis may be started on CRRT. Instead of being done in 3-4 hours the treatment ideally runs over 24 hours. I tell families that hemodialysis is like doing metabolic areobics, fluid is shifted rapidly, waste products are removed etc. CRRT is like doing a brisk walk. The waste and fluid is still removed but over a longer period of time. Someone who can't tolerate an areobics may tolerate a walk. Either way it is a sign that another organ system has failed.

Do you ever give Albumen as a prime for unstable pts or pediatric pts?

You should check the package insert that comes in the box of dialyzers to see manufacturers instructions. I know that the Optiflux dialyzers insert specifies that the prime be dumped prior to HD to prevent 'fibers' from going into pt blood stream. That is why we would "pee" the lines of 500 ml of saline immediately before connecting the pt. The prime could either be dumped or given after that. We would also sometimes give a 5% Albumen prime to help with fluid shifting to an unstable pt.

I have seen both adult and pediatric pt's survive CRRT. Granted the ones that don't far out number the ones that do but some do survive; especailly with the adults. We currently have several peds liver/sm bowel transplant pts that have required CRRT at some point in the past. It seems to go in cycles.

All of the hospitals in this area have the CNA's do the accu-checks. They report the results to the nurse who then act on the results. The hospital provides the training for the specific machine used.

Your MIL probably developed a heptaorenal syndrome pre-op and it is continueing post-op. When the kidney's are "shocked" or stressed they may quit function for a time and take a while to recover. Even though urine is present it may not be "quality" urine just yet. That should come in time. Right now just getting the excess fluid off will be a help. Dialysis will probably be decided on a day-day basis. It is still early days for your MIL. I have seen transplant done at this age. They sometimes take a little longer to recover but most do well.

Check with your local American Red Cross about a class. The AHA does do initial classes also; you may have to check with some of the local schools or the local ARC office. The only difference I found between the two is that the ARC expires in 1 yr and the AHA in 2 yrs. My employer will accept either card. After 25 yrs of doing AHA every 2 years; last year I did ARC. My card expired by 2 weeks and my new employer sent me home and would not allow me to work until I renewed. Fortunantly I only missed 1 scheduled day of work.

Almost 90 on Tuesday and snow today. Typical. This type of weather in March though is scary. Probably means the summer will be hiddously hot and long. The CPR class was short and good. I am actually glad to take the class with all the changes being implemented. I am sure in a real code I will still do a head tilt-neck lift and find hand placement by finding the zyphoid process.

Good Grief!!! Makes me even happier to be where I'm at. We are slowly converting over to computer charting and things like the Braden are already on the computer. We just don't have enough computer terminals between the med students, nursing students and parents. The amount of documentation we have to do to restrain even an intubated kid is horrible. Many of our kids are flat post-op also. Especially if they are on the HFOV and CRRT. I understand the burn out. We were so slammed with trauma this weekend that the PICU ended up with an adult closed head injury. He was admitted Friday night and Monday Trauma decides he needs to be transfered to the AICU. Family doesn't want him to transfer, I feel he is to unstable to transfer but transfer he must. I am hanging Dopamine on him, Neo is max'd, ICP climbing, CPP dropping, pupils unequal and fixed, family crying, and my manager stops in and tells me I have to leave work. What the HE... It seems last winter I did BLS through my previous employer through the American Red Cross. The ARC card is only for 1 yr. For the past 25 yrs I have done my BLS through the American Heart Association and the card is good for 2 yrs. My ARC card expired 2 weeks ago and I can't work until I retake the full class on Thursday. I so wanted to do my CPR demo on the trauma resident. The pt was expected to pass in the next 24-48 hours. Would it have been so difficult to allow the family to stay with the unit and staff they were familiar with? Would it have been to difficult for my manager to wait until after I was through with one crisis before dropping another bomb (suspension) on me? At least I only missed one shift today and the weather was beautiful. 80 degress today. Hard to believe we had 12+ inches of snow less then 2 weeks ago.

Interesting. The rational behind nasal intubation makes sense but the sinusitis would be a major deterent. We rarely have an incident of VAP. Many times our kids do have an NGT in one nares and an NJT in the other. These tubes are usually place during OR with order to not touch the tube post op. These kids also have an amazing tolerance for the tube. Rarely do we have one chewing or gagging on the tube. I have watched kids sitting up or propped up in a boppy in the bed playing around the vent tubing.

Sorry to be so slow responding. I have been bogged down working. Where would replacement solutions be running? We generally run replacement both into the arterial chamber prefilter and into the venous chamber post fluid. The theory being that the replacement solution will help to dilute the blood in the chambers in help prevent clotting. It doesn't always work that way but sometimes it does help. A complete system rinse doesn't work much better. A system flush will be done if clotting is suspected but not otherwise. IVPB and gtt titration is not dealt with on an hourly basis. Our docs look at approximately how much is given in a 24 hour period and figures the UFR. You are right you have to be aware of that volume or you won't have removed as much as expected. The other volume to consider is the prime and rinseback. The tubing and dialyzer holds about 200 ml depending on the type of dialyzer used. For example the pt is usually several kilos over dry weight when we start CRRT. In the past 24 hours they have received about another 2500 ml more then they put out. A UFR goal may be written as a net UF of 100-200 ml/hr as tol. Replacement sol is ordered both pre and post filter at a rate of 100 ml/hr. Personally I would start out with a UFR at 350ml/hr. That would be 200 ml of replacement, 50 ml for the prime and future rinseback, and a start of 100 ml/hr of net UF. As the pt tolerated the start of the treatment I would up the UFR. If they continued to tolerate, a few hours worth, it didn't look like a new system would have to be set up, and the pt is massively fluid overloaded I would call and ask about uping the UFR. I have seen systems clot in as little as a couple of hours even with replacement solutions infusing. Another thing to keep close track of is the lytes, phos and mag levels. SLED will wipe out phos and mag completely. Conventional dialysis doesn't have that effect on phos but the long, slow dialysis of SLED will eliminate it completely. We draw a set of lytes with mag and phos every 6 hours while on SLED. I am sure this is clear as mud but I hope it helps.

Sorry I can't help with the heart surgery aspect as we don't do any heart's. We do the major bowel and liver transplants. Some of our kids will be on the vent for months; one for neary a year before finally trached. Rarely will our docs nasally intubate a kid. We also do alot of Nimbex or Vecuronium if the kids are on the HFOV or moving to much. Ativan and Methadone are started early on in the process; as soon as oral meds can be given through the NGT; well before plans to extubate. If they can't be given per NGT or if the absorbtion is questionable we will give IV Ativan and Morphine on a scheduled bases. This is in addition to the continous Versed and Fentanyl gtts. When it comes time to extubate the gtts are turned off but the scheduled Ativan and Methadone continue. The docs are very good about making sure we have adequate sedation, even at extubation. Just curious as to why the preference for nasal intubation? One of our intensivist prefers the nasal intubation and will occasionally change a tube placement but it is rare. This docs also works at the Children's hospital in town that does all of the cardiac surgery.

I have done SLED with both the K machine and the older H machines with the additional CRRT chip. What kind of details are you trying to sort out? At this facility the Nephrologist orders the amount of fluid to be net UFed and the UFR set. It isn't changed on an hourly basis. Unless the doc orders to titrate the UFR it isn't changed at all. Some of the docs figure in the hourly IV rate when ordering the UFR others don't. ie. the hourly IV rate when they made rounds was 150 so a UFR of 250 is ordered. Others will write for a UFR of 100. Ask the doc how what they want done. BTW while I am a PICU nurse now working with these machines I used to be a Dialysis nurse setting them up.