jbp0529

Here is another thing to keep in mind about y-siting drips: Lets say you have 4 drips all y-sited together (not with a "chicken foot", but one y sited with another, which is y sited with another and so on). By the time you have them all hooked up, the entry point of your 4th drip is a considerable distance away from your patient (increased dead space). And if that drip is going at a slow rate, lets say 10 cc's/hr, it will take a LONG time to actually reach the patient and produce it's desired affect. (Levophed) ============== >>>> {patient} / / (Neo) =========== / / (Dopamine) ============= / / (Versed) =========== So my drawing is crude, but hopefully it will better explain my point. In this case, if you needed to make an adjustment to the versed, the solution will have to travel through all those other y-connected drips before reaching the patient. When ever I see this at work, I get really upset and put on a manifold or chicken foot device, so that all my drips are approximately equal in distance from the patient.

Wouldn't have it any other way.

It's kinda like the sterotypical school bully. If you stand up for yourself, most of the time you will be left alone. It's even possible that you will make a new "friend" once the dust settles. I've seen it several times...the doc and nurse get into it, and then the next day they are both laughing about it and have a new mutual respect for each other. Some days you just have to put on your big boy/big girl undies, do battle, brush it off, and go home to your loved ones.

I hate to label people or specialties, but I would say surgeons. I work with them every day (cardiothoracic). They will use you for a doormat if they dont chew you out first. Once in a blue moon I run into a nice one and it's like a vacation. Seems like the best way to deal with them is to give them attitude right back. I guess one can compare it to the bully at school...if you stand up for yourself, you are usually left alone afterward.

I work in the same hospital as my significant other, his brother, and his mother. We all work separate units so there isn't an issue, except trying to coordinate times for all of us to meet for lunch :-)

My thoughts/feelings exactly. I'm hoping this falls out of style quickly. I dont know how expensive this stuff is, but I'm sure that being relatively new it isn't cheap. Coupled with discarding the un-used portion q 4 hours + the cost of a set of IV tubing q 4 hours...no doubt it adds up $$$. I agree with you. IMHO, they tried to reinvent the Cardene/Nipride wheel and failed.

Hello all: My unit just started using this new anti HTN drip (well, new to us anyway), called Cleviprex. It's a calcium channel blocker, looks like propofol, is run in mg/hr. Apparently someone has won over the minds of our surgeons on this drug and we were told "expect to see it quite frequently". I used it for the first time last week (first time for our unit too) on a fresh carotid endart. Orders were to first use hydralaizine iv push... if unsuccessful in lowering the bp, then start the Cleviprex. Hydralazine didnt touch her, so i started the drip. Her bp was 190/something, surgeon wanted to keep her less than 150. Let me just say that my first impression is that I HATE this drug. First of all, its fairly labor-intensive in that we were told we have to change the bottle AND tubing every 4 hours, whether the entire volume is infused or not. Second, with the drip running at max rate (16 mg/hr if i recall), her bp was only down to 165. Hate it, hate it, hate it ! Maybe I'm just resistant to change, but I called the surgeon and got her switched to SNP and got her pressure consistently on target within 30 minutes.

Julie, funny story: I had a similar thing happen to me several weeks ago. I work in ICU and its still a big headache and kinda stressful for a few minutes. My pt (who truly was AOx3 and appropriate), intentionally pulled all 3 of his chest tubes out!! Yes, he knew what he was doing!! He didnt want them anymore, said they were bothering him, and "oh...well i was told they were coming out in the morning." I knew he was kind of a butt and self centered before it happened, but never imagined he would do THAT. LOL. Guess he had no idea that he could have made himself worse. Maybe he didnt care. idk The worst part was...I was at lunch when this went down. A fellow nurse saw it happen after-the-fact, came into the breakroom holding my "presents" for me, and smiled :wink2: I knew right away what happened. I ran out to my pt's room, assessed him (he was fine and the sites were already covered w/ an occlusive drsng). I then proceeded to scold the heck out of him (actually got him to apologize)! But what are you gonna do? What's done is done. Wasn't like he had an indication to be in restraints and wasnt. And the tubes really were gonna be d/c'd in the AM. But I still had to notify the doc at 2 AM and have some humble pie for dessert ...uh, I could have slapped that patient. So angry.

Just wanted to vent a little, I apologize ahead of time... I recently moved to a smaller, private hospital in one of their ICU's, from a larger teaching hospital. I am appalled how a handful of the docs at this new place treat the nurses. They frequently throw tantrums, curse, whine, expect us to clean up their messes, and/or simply dont want to be bothered with anything. Sound familiar? I know, its a tale as old as time, and the subject of many rants on many posts here, and a problem in many places. However, I'm just having one of those days where I need to vent about it & share some info. When someone at my facility tries to stand up for themself, the issue is either quietly swept under the rug by management, or the nurse is thrown under the bus and blamed. And this is supposed to be a Magnet facility! To make things worse, instead of nursing having a united front against such behaviors, there are a few influential nurses who have worked there for 15-30 some odd years (my hospital being the only place they have ever worked, in some cases), who are buddy-buddy with these docs, kiss their butts, and take their side in these matters. It's such a disgrace. Whenever I hear one of these nurses say, "well, yea, he/she hung up on you and swore at you, but if it wasnt for Dr So-and-So, we'd have less patients, the hospital would have less $$," and blah blah blah... ...Well that may or may not be true, but nevertheless, it's a cop-out. Nobody should be a doormat to someone else. That certainly can be said of any relationship in life, be it professional or personal. Anyway, sorry for the long and slightly poisonous post, but my ultimate (and hopefully positive) point is: from one professional nurse to another...thank you to all who take wonderful care of your patients, despite sometimes difficult odds. Thank you for your hard work, on sometimes little rest. Thank you to those who take a stand, who are an advocate to your patients, as well as fellow nurses, and are not always assimilated into the collective.

Ditto that. If one of our prospective nurses mentions CRNA during the process, its automatically a big red "X". I'm not personally saying that having CRNA as a goal is good, bad, or indifferent...its just my unit's written/unwritten stance on the matter.

So here's my situation: a few months ago, I changed jobs from a teaching hospital CVICU (for personal reasons), and thought I'd try out another CVICU in a private hospital. Interview process went well, staff are friendly, facility is nice looking, etc. Well, it wasn't till after I started working that I noticed how strange things are at this place (I guess that's true with many jobs - you dont really see how things truly are till after you start). Alot of the surgeons at this new place are very old and set in their ways. Here are examples of what I mean: - surgeons routinely use glass bottle chest tubes - only labs done on arrival to ICU are: potassium and hct - vent settings ordered with no peep and/or no pressure support - no ABG prior to extubation...you are just expected to pull the tube - once extubated, many of the surgeons here dont want incentive spirometry. no one has given me a good rationale for this. maybe post op pneumonia/atelectasis is a good thing? - insulin gtt's are rare; no clear indication when to start. I've had many a pt at this place with sugars in the 200-300 range and been told to just continue with subcutaneous insulin. - chance of the pt having a swan is bout 50/50; when they do have one, surgeons dont care about critical #'s when called. - rarely does the pt come back with pacing wires. - one surgeon (who is especially old) uses a transthoracic swan. its tunneled thru the sternal incision into the PA. its essentially useless except for PA #'s. Cant infuse thru it or shoot outputs since its directly in the PA. - no propofol and/or any other type of gtt for sedation. they dont even come out of the OR with anything on board but what anesthesia pushed. if we can't get them extubated, or are told to keep intubated, we have to use morphine and valium iv push around the clock (seldom use versed). - if a pt is crashing,... start up an "Epi-Cal" gtt (we have to mix this ourself, I dont think pharmacy this is in pharmacy's formulary. its basically 4 mg of Epi and 2 gm of calcium chloride) - If a patient has a IABP...OMG the whole place just about shuts down! The pt is kept 1:1, which is fine, although I've had many an IABP paired with another pt in the past. Cath lab and OR do not run their own balloons at this place, only the CVICU nurses. If an MI is in cath lab and needs a balloon...cath lab doesnt know how to set it up, our nurses have to go. If a pt has a balloon pre-cabg, our nurses have to go to OR and sit thru the entire surgery and run the pump. It's truly ridiculous, but as I'm frequently reminded, "this is how its done here." I really hate to be the type of nurse that comes into a new place with exerience, complains about the status quo, and says things like "well at my last place this is how we did it"... so I dont. I just keep my mouth shut and go with it for now. Occasionally I do regret leaving my former, more "progressive" CVICU, bc IMHO this new place needs an injection of fresh ideas and practices.

Very interesting (and heated) thread. I, too, work in an ICU, but would like to weigh in just the same. I can truly understand both sides of this discussion. The ER needs to move ppl out for other sick patients, and the ICU needs to keep close monitoring and continue treatment of the sick patients. So where does that leave us? Perhaps there is a middle ground of some sort? I guess, at the end of the day, its all about the patient, and patient safety. Perhaps, there are several keys to making such a policy work. 1) there has to be a clear policy set forth by the hospital, laying out the details of pt transport from the ER to the ICU. 2) it has to be uniformly supported by all of the ICU's in that particular hospital (if there are more than one ICU). 3) everyone from the bedside nurse all the way up to hospital administration has to be supportive of such a policy. 4) there has to be a little "give and take" between the ICU and the ER, without either side abusing the system. If the ER has multiple criticals waiting on beds, or lots of traumas rolling in, then the ICU should be understanding of this and make arrangements as quick as possible to help transport up pts waiting on unit beds. Likewise, if the ICU is consumed with a critical patient or a code, or whatever, and isnt able to come bring a patient up, then a reasonable time frame should be set. I am all in favor of change and for making the system work faster and better. I guess the bottom line comes down to making our patients the priority (whether in the ICU or ER), making sure everyone is on board with whatever transport policy is in place, and keeping the relationship between the ICU and ER a professional and understanding one. We both do hard work, we both have sick patients, we both deal with crap from unruly patients, families, and doctors, and we are all great nurses. Just need to work together and communicate. If nurses are constantly in-fighting and bickering, then its no wonder certain doctors/patients/families dont give us the respect/credit we deserve. Ok, I'm off my soap box now :wink2:

pH 6.7, mixed metabolic and respiratory nightmare. Came from ER intubated, advanced sepsis. Bicarb drip at 250 ml/hr, maxed on multiple pressors. Chest xray a total white-out. Vent changed to an osscilator on arrival, quinton placed for CVVHD. Family called in to say their good-byes, and the pt passed within about 5 hrs after being made DNR.

We usually single fresh open heart patients for at least a few hours (another RN babysits your other patient, if you have one), but longer if they come out unstable or on a balloon pump. Otherwise, if its an uncomplicated surgery, or relatively stable pt, then the nurse may have the fresh heart plus another patient that is less busy. At my facility (a 25 bed CVICU), that averages 6-8 heart surgeries a day, it can be quite challenging, as far as staffing goes, to completely single each and every fresh heart surgery...there just isnt the staff to do it without tripling or quadrupling the assignments of the other nurses. Not to mention, the budget would be out of control. However, balloon pumps are always kept 1:1, as well as CVVHD's. Our daily assignment sheet does keep track of the 1:1's, though.

Yea, I think you're right (now that I look back on it). He almost certainly would not have survived another trip to OR, or a trip anywhere out of the ICU for that matter. I guess in the heat of the moment, the knee-jerk response to this situation is take him back. Fortunately, all he needed was a butt load of blood products lol I guess its just a simple matter of supply and demand and keeping him tanked up. Blood bank could hardly keep up with us that night, that's for sure. I appreciate everyone's praises of my blood/sweat/tears that night, however it truly was a group effort. Go team! It's been over a month or so since this event happened, and I'm still amazed that the pt came out of it with his brain, lungs, kidneys intact. Just needed some gentle diuresis a few days after, for all his edema. He certainly was a tough old bird. Didn't remember a thing. I talked to him several days after when he was stable and the dust had settled, and told him how close he was to death. Such a nice man too, he was completely shocked and thanked us all.

Pt already had a cordis and a swan (as most of our heart surgery pts do). And that cordis had a lot of use that night.

Yes we did use the rapid infuser. And pressure bag at the same time.

Update: So, go figure,...several days now since the awful night, and the patient is doing remarkably well. Neuro intact now, creatinine down trending, bleeding stopped, all lines out except the a-line, all drips off, 2 liters NC, probably gonna get tele orders today. Tonight was the first night the patient saw me/spoke with me (had been off several days prior to tonight). LOL I told him, "you just have no idea how busy you kept me a few days ago." Always makes me happy when a pt does a complete turn-around from death's door.

The next night I worked, the pt was still alive and relatively stable vital sign-wise. Kidneys took a huge hit, obviously, after all that. CVVHD is likely in the very near future. Neuro status was questionable....sedation was off for a while, pt only thrashes around in the bed, doesnt follow commands. Bleeding stopped. Plans of extubation not even being considered at this time; was told that the CXR looks awful. ABG not so good... PO2 was only about 70 on 80% FiO2, +8 peep. Thus, looks like we will have another long term "guest" in our unit. Trach will most likely happen in a week if things dont improve. I should mention that most of our patients dont come out this bad, nor do we have such poor management from the docs. I've cared for quite a few unstable CV patients, but this one will certainly be memorable :nuke:

Had a horribly night a few days ago: My only patient: Came on shift at 7pm, got a pt who just arrived 30 min ago s/p a triple-jump cabg, 80 y/o male (ugh). A day prior had a cardiac cath; interventional cardiologist was unable to cross the lesions despite multiple attempts and even partially perf'd his LAD. Was on Reopro prior to surgery. H/x of HTN, CAD, DM. Went to surgery, had a long pump run, massive bleeding in OR, multiple blood products/fluid, difficult to separate from bypass per OR team, required an IABP and high dose drips. Unstable on arrival to my unit, bp 70-80's, filling pressure low per the Swan, AV paced rate 90 with the epicardial wires, IABP 1:1, gtts= Epi, NTG, Insulin, Dopamine, Milrinone, propofol. Mediastinal output on arrival ~ 500 cc's. Left pleural chest tube found to be "out" on arrival to ICU (apparently wasnt sutured in good enough lol ). OR team/anesthesia pushing their syringes of Neo, Vaso, calcium, & hanging 500 ml albumin and their last remaining blood products that they took with them.....get his pressure up to a modest 90's and then run for the hills. Attending MD @ the bedside, nods, gives me a pat on the back, smiles, takes off too. I'm left alone with the resp therapist and the CV Fellow, and a few of my nurses. Over the next few hours, bp 60's - 80's, about 200-400 cc's q 1/2 hr out the mediastinal. Fellow making multiple attempts to reinsert the left PCT, finally gets it in. 600 cc's out right away. Hanging blood and albumin like its going out of style. Dont have time to chart anything I'm doing. Started Levo and Vaso. BP ranging from 60-200 systolic, all over the map. The Fellow barking orders and cursing at me and the charge nurse; titrating all of the drips q 3-5 min. I kept on telling the Fellow that making such drastic changes so frequently is just going to put us in a neverending cycle, and that we NEED TO GO BACK TO OR. But no. I'm running RBC's, platelets, cryo, pushing novoseven. BP down to 50's-60's, now pressure bagging fluid and blood along with running fluid/blood thru the rapid infuser. Cant keep up with the pt's demand. Vent on +10 peep. Changing out all the pleur-evacs, already filled up, only been a few hours since arrival. Fellow calls the attending, trying to get the pt to back to OR. The attending says no, keep doing what we're doing!!!! I can't believe it!!! Family outside the unit, getting more freaked out by the minute (as they should). Charge nurse pulls in another nurse to make my patient 2:1. Then the pt's BP drops to the 30's, then lose the Aline waveform, barely any palpable pulse, push an amp of Epi, get a pressure back again. This goes on an on till 1 AM. Relentless cycle of dialing up the drips, giving blood, dialing the down the drips, and giving more blood. Still no one wants to take this dude back to OR. I'm ready to scream. Then, magically, my hemodynamics "stabilizes" at a grand total (6 hr point) of: 20 units RBCs, 8 platelets, 6 FFP, 6 cryo, 4 novoseven's; NS ~ 3000 cc's; Albumin ~ 4000 cc's. Epi @ 0.17 mcg/kg/min, Levo @ 0.2 mcg/kg/min, Vaso 0.03 units/min, NTG off, Milrinone 0.3 mcg/kg/min. CT output ~ 5 liters total, draining ~50 cc's/hr now. Electrolytes and calcium are in the toilet. Pt is 3rd spaced beyond belief. Lungs are soaking wet. Urine output total ~ 200 cc's. Havent had a chance to even do a focused head->toe assessment till now. .....this pt should have gone back to surgery the minute he rolled into the unit. Just my humble opinion.

Very true, and well-said. Autonomy is HUGE. I also work CVICU. Our surgeons (for the most part) want you to act first, then call them. Otherwise, you could be on the phone, or waiting for a call-back...all the while your patient is crashing harder and harder. Understanding and being comfortable with hemodynamic and vasoactive gtts is essential. You have to be able to walk into that unstable pt's room, with the IABP, Swan, vent, 4 chest tubes, 6 different drips and be able to quickly and accurately assess the situation and take action. There's very little room for error, usually. It sounds scary, and it is. Fortunately, however, not every cardiac surgery pt is like this. Most do fairly well and have predictable plans of care. But, like everything else in life I suppose, things can change in an instant. On a less dramatic/scary note,...once you get comfortable with the stress and energy level, and start to know your stuff...your surgeons become more and more comfortable with you, usually let you do more stuff and cut a few apron strings, and you experience an ICU nursing tempo that is like no other (IMHO). One of the best feelings for me is having that really unstable pt get better bc of my actions; makes me feel like I made a difference. And also...having that no-nonsense, no-room-for-errors surgeon tell you that you did a good job.

I cant believe it (but I do). I have never heard of such a ridiculous and degrading thing as this, though. This just goes to show....in many places (fortunately not all), administration is so blinded by "making the 'customer' happy" and sweeping BS under the rug with a smile on their face, that all else is expendible...including valuable staff members. And its equally sad that our society has regressed to some twisted form of a spoiled childhood, where only their needs matter and everyone's butt must be kissed nonstop. I understand that you may not be able to resign on the spot, but perhaps at the very least you can start looking for a new job? And by new job, I mean in a different facility all together. This place sounds like bad news. If it were me in that meeting, though, it would have been worth resigning on the spot, and then proceeding to tell this pt and her husband exactly what I thought. Would have been one of those once-in-a-lifetime, golden moments that I could cherish forever.

We have a couple of rooms which seem to get the same type of patient over and over...its like deja vu. Stay away from our room H if you are getting a lung transplant...you will be there for months and most likely reject. Or Pick door #2. Have an esophagectomy and go to room M, get aspiration pneumonia and ARDS, a trach, end up in LTAC. Our unit is in the shape of a large rectangle. On one end is the entrance to the unit, on the opposite end our 4 large transplant rooms (which we also use for our patients with lots of equipment - basically our sickest of the sick)...for example the other week we had a horribily sick post op patient on: a ventilator, nitric oxide machine, IABP, Bi-VAD, and CVVHD. All that hardware,...we had no choice to use one of the large "cursed" rooms. General rule of thumb for us is to try and place our patients toward the front of the unit, they usually have better outcomes.

Dont have anything nice to say about it, so I will leave it at that.

Here is what I know and what I found out: The ideal way to prone is to have a specialty bed (ex: Rotoprone from KCI). I am including a link to the Rotoprone website but here's a few bits of info: According to KCI, the recommended time in prone position is about 3 hrs 15 min, then back supine for ~ 45 min. While prone, pt should be rotated 40 degrees side to side. ~ 18 hrs a day in prone position. Lines should have enough slack, as well as ETT. The Rotoprone bed has a special set of "hooks" coming out near the top of the head rest, thru which all IV's/invasive lines/ETT come through and are secured. The bed itself looks like a big enclosed "tanning bed", so its not possible to have tubing come out the side... plus, if you think about it, when the bed rotates, things could get pulled out if they came out from the sides. Transducers for pressure lines are secured outside the bed near the head as they come out of that special hook device. Since the transducers arent lined up next to the pt's side (mid axillary line), you just have to kinda estimate phlebostatic axis. Pressure reading can fluctuate with rotation some. Contraindications would be: spinal fractures, high ICP. Need aggressive sedation and/or paralytics. As with anything related to t/x of ARDS...the sooner implemented, the better. Anyway, here's the link i found, probably explains it better: http://www.kci1.com/Prone-RP_Guidelines_for_Use_2-B-138.pdf