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jimmy_hat

jimmy_hat

TICU,CVICU,CCU,SICU,MICU
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jimmy_hat has 10 years experience and specializes in TICU,CVICU,CCU,SICU,MICU.

jimmy_hat's Latest Activity

  1. jimmy_hat

    Leveling art line to tragus for cpp???

    very interesting. Like I said, from the research I have seen it seems to be about 33% level at the EAC, and the rest at the phleb axis. All seem to use the same numbers/criteria for treatment. As posted before, I asked the AACN via thier website/email. The response I got was that the art line should always be leveled at the phleb axis and those numbers used for CPP calc, though she gave me no reference to research or a formal publication saying such. I find it shocking that there is such a variation in practice. No one else seems to care By my rough estimations the cpp would be a 14 point different. HUGE! I would love to see a formal document or position of an organization to defend either practice.
  2. jimmy_hat

    Leveling art line to tragus for cpp???

    We used both mannitol and hypertonic. We would also hyperventilate to fight spikes in ICP. BP is not our first choice but we often end up there when their sodium and serum osmolarity limit our ability to give the hypertonics or mannitol. It has been a couple years since I have done neuro. When I left they were thinking about chilling the patients heads, but I never saw it. I honestly can not remember what % saline we used. I want to say it was 5%. I will not swear to it.
  3. jimmy_hat

    Leveling art line to tragus for cpp???

    idonotgiveout, I wanted to PM you but it seems that neither of us the ability. I was wondering where you worked. Email me if you do not mind.
  4. jimmy_hat

    Leveling art line to tragus for cpp???

    Interesting. Thanks for the reply. That is what i was looking for. I have been unable to identify a unit NICU or SICU that actually does this until now. Like i had said before. I contacted the AACN and they said no one does this and did not understand my concern or really what my question was. I doubt the person was a specialist but she was CCRN (not that it means a lot). I would be happy to give you her name and contact info. What CPP do you treat for? We only treat to keep CPP>60 in most patients. (And 7.5% for any ICP >20) We would treat to the same CPP. greater than 60 or 65. Depended on the case. That was the CPP calculated with the MAP at the phleb axis and ICP leveled at the EAC. I have worked at a few different ICUs as a traveler and have never seen what you describe. I only learned about this in my current CRNA education. I am considering calling some of my contacts at Hopkins and seeing what they do there. Just kind of busy these days. We would use NEO to elevate the MAP to obtain that CPP. We had some pretty high BPs in attempt to obtain the CPP. What did you mean about the 7.5%? I do not understand your reference. I like you never thought of asking about this. Now I am finding different info. Europe already noted that they have a problem with this, but they did not come to a solution. I imagine if we did a survey here, we would see much the same info. I have a feeling about 30-40% of the hospitals level the art line to the EAC with the rest at the phleb axis. I think this is a pretty major confusion if someone wants to take the wheel and run with it.
  5. jimmy_hat

    Leveling art line to tragus for cpp???

    Talked with the AACN. They tell me that the art line shoudl be leveled at the phleb axis no matter what the patient position. This is also the position and number to be used for CPP. I have a couple emails to a couple different organizations including braintrauma.org and The Society of Neurosurgical Anesthesia and Critical Care (SNACC). I will see if their answers are the same. I doubt they are as the anesthesia texts say otherwise. Feel free to chime in. I would love to hear of a Neruo ICU that levels the ART line transducer at the tragus for calculations of CPP. Jimmy
  6. jimmy_hat

    Leveling art line to tragus for cpp???

    http://www.baccnconference.org.uk/downloads/presentations2008/014-Arterial-transducer-level--A-Variation-in-practice.pdf Seems like the UK has noticed these discrepancies. They did a survey in 2006 and found that 6 out of 20 leveled at the tragus. But all used the same calculations to monitor CPP. This seemed to spark debate about the wide variation in practice. In 2009 they did a lit review to establish a standard of practice. They found conflicting data and no agreement on where the transducer should be placed. The Brain Trauma Foundation Guidelines 2007 has no recommendations on placement. It seems that everyone agrees that only one way is correct. But there does not seem that there is agreement. I have been unable to find a standard of practice on this. Either the aortic root is overestimating CPP or the tragus is underestimating it. It can not be both. CRNAs and Anesthesiologist are taught to level at the tragus as law, but as I said before, I have never seen this performed on a unit. Here is a very detailed letter about CPP. I have not read it all to varify the math or rational behind it. http://www.apsf.org/resource_center/newsletter/2008/summer/11_modified_calculation.htm Anyone have any literature to back up one practice vs another? Anyone seen any SOP of a major nursing organization?
  7. jimmy_hat

    Leveling art line to tragus for cpp???

    From your comments I assume you are a CRNA. That is the lecture I heard this from, but had never seen this actually done in any of my ICUs including the NICUs. Just caught me by surprise. Thanks for your comments. I am curious if any bedside RNs in the NICU are doing this.
  8. jimmy_hat

    Leveling art line to tragus for cpp???

    i understand the A&P of doing it. My question I guess is does your unit level thier tranducers there when calculating the CPP in patients with ICP monitoring? (the ones i have worked for did not, but still used the same documented reference range for treatment and such)
  9. jimmy_hat

    Leveling art line to tragus for cpp???

    http://journals.lww.com/ccmjournal/Citation/2002/09000/Cerebral_Perfusion_Pressure_Calculation_in.51.aspx
  10. jimmy_hat

    Leveling art line to tragus for cpp???

    So why not level the transducer at the kidneys if your main concern is renal perfusion? The MAP I have always seen used for such a calculation was based on the Central or aortic pressures, Hence why it is leveled at the phleb axis. NO NICU I have worked for has leveled the artline in any position other than the phleb axis and that is the MAP we used to calculate the CPP. Is anyone leveling to the tragus or circle of willis? I understand the rational and anatomy behind using this but I have not seen anyone doing it. If this is the correct method, my unit was WAY off because that would create huge differences. This class was not a neuro class nor taught by someone well versed in neuro. This is why I have to question it. I am also unable to find any research or articles supporting this. I find it hard that the different neuro units I have worked on missed something so basic with such large ramification. Hmmm, just ran into an article that talks about maintaining the transducer at the tragus. Maybe those units just sucked, or this is a newer thing to do. It was a few years ago I worked neuro. Guess this might not be any different from the last CVICU that kept leveling the IABP transducer at the femoral insertion site............
  11. jimmy_hat

    Leveling art line to tragus for cpp???

    Hello all. I am taking a class that stated in a sitting/semi-fowlers patient that we have concerns with CPP, we should level the art line at the tragus (or where every you would level your ICP monitor). I have never done that in any of my neuro units. Art was at phleb axis and ICP at tragus and we used those numbers to calculate the CPP. That big of a difference would give you about a 20-30 mmhg difference (lower) pressures. These are huge differences. Anyone doing this? Does it modify your reference numbers for goal cpp? Jimmy The only articles I am able to find are ones from journals that state that the transducer should not be leveled to insertion site. I am shocked because I thought that was old news but the research based ones are from 2001 in CHEST. I was practicing back then but it was never taught to me as anything other that the phleb axis.
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