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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.

I work in a transplant facility. The cardinal rule around here is NEVER hold the transplant meds. They have to be given as ordered at the times they are ordered no matter what. There is no safe IV alternative for FK506. Common sense should be the rule with other meds. If it is a once daily med like Dig or Synthroid then it usually can wait until after the procedure. If it is a oral hypoglycemic they shouldn't take it while not eating any way. Keep in mind to that the hospital orders an arbitary schedule for meds any way. For example at my hospital all the transplant meds are ordered for 0800 for consistancy in testing drug levels. All of the other meds start at 0900. This is the schedule set by pharmacy not the docs. At home a majority of the pts batch thier morning meds together at one time. Depending on how busy my day looks I will too.

The local Shopko's and casino's have well secured sharps containers in the restroom's around here. I does make sense. What struck me recently is that many malls and stores have "family" style restroom facilities but the large teaching hospital with large geriatric and pediatric clinics I work at doesn't. I was going to the cafeteria when I noticed an elderly man with his wife in a wheelchair. He was trying to help her out of the chair and into the public restroom. Poor man didn't quite know what to do. I stopped and offered to help walk her into the facility. There I realized she was also nearly blind. Once in a stall she was able to manage but walking unaided, finding the stall and then the sink were beyond her. Had it been a "family" style restroom the husband would have been able to go into the facility and care for his wife as he does at home. Seems rather strange that mall, stores and resturants provide adequate facilities but hospitals and medical offices don't.

Would your daughter allow you to go to an appointment with her to discuss the risks/benefits of this induction? My daughter and son-in-law live over 4 hours away and I still work full time. I may see if one of her appointments can be scheduled on my day off and I will make the trip. Her husband is not supposed to be deployed overseas for at least another 18 months. If a trip to Iraq is in the plans we haven't heard about it yet. I think my SIL is just anxious. He was very worried last month because they didn't have a crib yet. "What if the baby comes early?" I kept try to tell him "If it comes that early it will stay in the NICU until close to the due date and you can get a crib.":nuke: Her first US was done 2nd trimester. There is another US scheduled for next week. Again I am asking why and my daughter doesn't know. UGH. Of course as a PICU nurse I see the bad outcomes and long term problems. I keep reminding myself that not all babies are born with gastrochesis, microvillas, megacolon, ect. If just feels that way from work. Thanks for the replys.

Then when one of them asked her to check for a radial pulse, she blanked out and said, "what's a pulse?". Poor thing, she made it through school fine though:chuckle . I worked with a nurse once who was also a minister's wife. Very nice person, rarely flustered and NEVER known to say a swear word. One day one of her pt's went into VFib. Code was called, crash cart arrived and she grabbed the paddles (before hands off defib with patches were available). The paddles were labled with sternum and apex to help remind the user of proper placement. She took one look at the paddles in her hands and shouted loudly "What the H%&& is an APEX?" Pt did survive but the nurse thought she was going to die of embarrassment afterward.

My daughter is expecting her first child next month. EDC is March 25 or there abouts. Dates aren't terribly accurate because she was switching between the pill and Depo Provera for birth control. She called yesterday and said the military docs are "pushing" her to be induced. Her husband thinks an induction sounds good so he can plan his leave and make sure he is off when the baby comes. Many of her friends have also been induced for a variety of reasons lately. The way her friends were induced was to be admitted on Sunday for cervical ripening, then Pit on Monday. My daughter tends to be very passive and not ask many questions. Needless to say I have a few dozen questions and no answers. Is it common for docs and midwives to plan induction now? Is there a medical reason? Could they tell a medical reason to induce this far in advance? My concern is that dates are off and they will try to induce a baby that isn't quite ready to be born. Is this a legitimate concern? Can a EDC be accuratly determined by US now? My OB rotation was almost 25 yrs ago and I adopted my daughter when she was 6 yrs old. This area is totally forgien to me. Thanks.

I was working in CCU and it was our turn to have the code pager. We had just finished report when it went off for the PCU and I took off. Arrived in PCU to find both shifts still giving report asking "Where's the code?" They knew the call was for their unit but not which room had called the code and since all the staff were at the desk didn't know who called the code. We all arrived at the room to find the pt standing at the bedside screaming "I'm DEAD. You have to do something. See I'm DEAD. Help me!" The man in his 30's had been napping. When he woke to use the bathroom he pulled off a telemetry lead. When he looked at the bedside monitor he saw a flat line, knew from TV that meant he was dead so he called his own code. I backed out of the room trying very hard not to laugh while the pt became more irrate that we weren't doing anything about him being dead. Others were muttering "well if he really wants us to we could go ahead and treat him".

All the companies I have worked for required "peeing" the lines before hooking up the pt. Even those with a dry pack dialyzer. "Peeing" the line consisted of dumping about 500 ml of saline through the lines immediately before hooking the pt up. We were told this was to remove any residual chemicals in the line and dialyzer that may have come out during recirc. The national companies tried to make policy the same for inpt and outpt. So inpt we used a dry pack, set up at the bedside and were ready to immediately initiate the treatment but still had to do a 15 min recirc and then pee the lines of 500 ml of saline. The companies then wondered why we couldn't set ourselves up, tear ourselves down, move all the equipment from one bedside to another and do 2 four hour treatments without going over the 10 hour shift. The real fun came in when you had to drive across town to another hospital. I had one out of town manager tell me his nurses were able to return the blood on one pt, drive across town, set up and have blood through the dialyzer on their second pt all within one hour. I told him then his nurses were cutting corners and were unsafe. Needless to say I wasn't terrible popular.

In the acute unit we would dump the prime on someone in massive pul edema that we were dialyzing to keep off the vent. If the pt was frothing that extra 250 ml of fluid could be to much. We would also sometimes dump the prime if we were resetting up a system after someone clotted and their B/P was stable. This was a decision made only on a case by case basis after a thorogh assesment. I don't know that the outpt units ever dumped the prime.

In the acute setting with pt's who have developed Heparin induced thrombocytopenia we could not use Heparin. We would plan on rinsing the system with at least 100 ml of NS every 30 mins and planned a new set up at the midpoint of the the treatment. It means alot of fluid to add into the amount to be UFed off but it might save the system. The other thing you might talk to the Docs about the possibility of using Citrate instead as an anticoagulant. This carries it own set of risk factors. Heparin free runs can be very challenging.

:icon_hug: After 15 yrs working with adults and in adult ICU I now work in PICU. It is different to lose a little one. Even though you know in your head that withdrawal is the best choice your heart still fights the idea. With an adult the end may be painful for the family and seeing that pain can be hard for the nurse but there can also be a sense of completion. A sense that the circle somehow has been closed and the life completed. With a little one you are dealing with not only the loss and pain of the family but also the sense of betrayal and loss of the future or potential of that little one. The heart believes that all little ones are supposed to be born health, and grow up happy. Reality is that not all do. On some level there is also the realization/fear that this could happen to me. That adds another layer to the grief/emotions of the moment. You did the right things in staying with the assignment and supporting the parents through their personal hell. It may sound strange, but go back to the NICU. Talk with the staff. They know the story and are probably reeling as much as you. They are someone to talk with who you don't have to relive every detail with. They may also have special supports services in place for these types of incidents. I am not meaning to stir up trouble but I am suprised at your being given such an assignment as a float. This is the type of assignment that only the experienced staff in my unit would take. I am not meaning to imply you don't posses the necessary skills but the emotional toll for both you and the family was excessive. You have never been in the situation of a baby leaving. It is very different and an emotional burden you were not prepared for. When you accpet a position in NICU or PICU you KNOW you will lose little ones. You begin to try and prepare yourself for that fact psychologically. Before I every considered this move a thought long and hard about how I would deal with and even I could deal with the loss of little ones. When you got ready for work that night I'm sure it wasn't with the idea of "I'll float to NICU tonight and learn what it's like to make a baby a DNR." For the parents making these discisions without the support of someone familiar with them caring for their child it is also difficult. You are a good nurse who did an admirable job but to have a familiar shoulder to lean on and cry on may have been easier for the parents. All in all you had a night passing through the flames. You have every reason to grieve, and feel the pain of the burns. I wish I had some magic words to help.:icon_hug: