RN-LOGIC

You should have enough time to switch your lines without worries of an air embolism. Of course, do one line at a time. Most of the time you should have blood return from your lines. The key here is that once you change your pa cath pressure tubing is to aspirate blood from the three way connection coming from the pa to prevent bubbles and make sure that the line is completely prime. The cvp you definitely have to aspirate because you are connecting it to the slic in the catheter, aspirate in the transducer. Make sure that you flush your pa cath with the three way connector turn towards the pa cath so you can flush any remaining blood in the connector. Pinching the tubing would not hurt the patient. Your patient should be flat on the bed as a preventive measure. Hope this helps.

I completely agree with you. They are trialing a new core-valve called the Evolut that has been re-sized and gives you the option to re-position the valve giving a better anchored during deployment of the valve. This decreases the chances of depressing the purkinje system. The patient's with these valves come out without pacing wires and do well.

This handy image makes me giggle.

How did it go? Wishing you the best.

My advice to you is not to focus only on one hemodynamic number. You have to look at the entire picture and then some. For example, a low H and H is not the only factor taken into account when deciding to transfuse blood. Is the balance of 02 delivery and 02 demand adequate for the patient to meet tissue oxygenation? You don't know? Take a look at your svo2. Is it low? Is your patient bleeding or simply hemodiluted. Check a lactate or anion gap just to check its adequacy by correlation. *Side note* There are other factors that can influence your oxygen delivery such as oxygenation and cardiac output. Did I say cardiac output can affect your Oxygen delivery? Well, the less stroke volume, the less oxygenated blood circulating. So, maybe in this case giving plasmanate (albumin) can increase your 02 delivery without the unnecessary risks of giving blood in this instance. In the management of hypotension for post CABG patients, increasing the patient's heart rate by use of the epicardial pacemaker is the fastest way to see results in the BLOOD PRESSURE. Remember, the pacemaker is your best friend, use it. Now, we look at the cvp/cardiac index**** you must know your patient's EF/LV FUNCTION/Tricuspid regurgation/RVH/PULM. HTN. Give fluid? maybe not. Fluid challenge sounds better----> assess for fluid responsiveness. Look at your Mean arterial pressure and afterload considering AI/MITRAL STENOSIS/LVH----> hIGH AFTERLOAD WHICH TRANSLATES INTO HIGH BLOOD PRESSURE AND INCREASE HEART WORKLOAD AND INCREASED 02 DEMAND, NOT BUENO(GOOD). I suspect that your patient was vasoconstricted due to IDK maybe hypothermia or a compensatory mechanism or etc. The have started a whiff of nipride, yikes your friend dilate just showed up you better invite fill to compensate. Bang...............

My advice for you is to simply relax, dress well, and be yourself. Be there early, 10 minutes early is considered late to my opinion. If you have any questions, post them here. However, I would not be able to answer questions that would compromise the school's interview process. Best of luck to you.

I will be class of 2017 at Our Lady of Lourdes CRNA program. I am assuming that you have already interviewed for class of 2017. Best of luck to you. Please keep me updated. I have to say that I was impressed with Our Lady of Lourdes program. Out of all my interviews, I felt right away that this program was for me. What I like about the program is that it has a smaller class (10-12 students), leading to a more personalize education. I have done my research and its reputation is excellent. The interaction with the Director and assistant re-assured me why I have made this school my number #1.

It is basic physiology not a theory.

Hey Belgian RN, I would like to correct some of things said. you said: Neo gives relatively more venous vasoconstriction thus increasing preload somewhat more than levophed does. Sometimes that can convince them to add Neo instead of pusing more levophed. I do agree that vasoconstriction increases preload. However, increasing preload by vasoconstricting its detrimental for the patient. An increase in fluid status increases your END DIASTOLIC VOLUME which increases your stroke volume. Therefore, your preload increases. However, when you increase your levophed/neo up vasoconstrictions occur thus your afterload increases. This increased afterload increases your END SYSTOLIC VOLUME which may reflect an adequate preload but inadequate or decreased stroke volume. Also, even though levophed has beta receptors, the alpha receptors take complete control thus the beta receptors do not play a role. Every septic patient should be on vasopressin regardless.

I am a male RN. I highly doubt that my open chest, IABP and centrally cannulated ECMO female patient or her family have an issue with me touching such patient. I guess my definition of nursing and genders play a different role in my specialty. My advice, Focus yourself in the things that matter and stop the nonsense.

Typically a map above 60 is adequate perfusion. However, when dealing with hemodynamically compromise patients a map of 80 , just to say a number may not reflect an adequate body perfusion. A map can be affected by many variants.

The usage of a WEDGE is dependable in the patient's situation and knowledge of the provider or nurse. It should not be use for every patient.

what group are you on? I have the same article.

I start the class as well. A little bit nervous.

congrats.

I highly doubt that you were fired for such incident. Be truthful to yourself.

There is really no reason why he chose Neo over levo. I learned a long time ago that there are many ways to skin a cat. Things to keep in mind: Even though levo has Beta. It's very minimal and ALPHA predominates, avoiding BETA involvement. So levophed could have been used as well. I can use the argument that neo causes reflex bradycardia which would be devastating for a left ventricle not pumping. Right? Epi could have been used as well. How about rocket fuel? Yes that too. It all depends on the person skinning the CAT. I think that the issue here was not adequate stroke volume due to the dilation of the ventricle due to the PE. It sounds like right heart failure. The fluid is going to help temporarily but is not your definite answer. Your left side preload was not sufficient. Therefore, the patient's cardiac out dropped, raising your svr as a compensatory mechanism. I would say that also to much neo or levo would to a certain point increase your heart o2 demand by increasing heart workload. In this case, I would have drawn a SCVO2, a lactate or anion gap just to VERIFY adequate oxygenation.

It is my opinion that if you work with cardiac patients, you should need little to study. I found the test straight forward. I used the fast facts book by katty white for review.

Every lung transplant should get an epidural place before extubation. I have noticed that lung transplant patients with epidurals have a reduced length of mechanical ventilation and reduced respiratory complications. Epidural hematoma should not be an issue with the patient. I mean, if your patient has a normal coagulation profile then there is no reason why wait to place an epidural cath. I would be more worry about inactivity of patient r/t pain leading to other complication. Every lung patient gets an epidural before extubation.

Dobutamine vs Milrinone Dobutamine has a faster mechanism action. It takes about 5-10 minutes. Milrinone takes about 4 to 6 hrs to take effect. Both drugs are pro-arrhythmic. However, in my experience milrinone is the most pro-arrhythmic drug known to me. You may have a slight drop in blood pressure with dobutamine but even more with milrinone. Dobutamine may increase your heart rate, increasing your oxygen demand. Dobutamine: increases heart rate, increases your oxygen demand. (terrible for a weak or ischemic heart) Slightly decreases your SVR. (it helps your heart to overcome or push against your afterload) Increases your heart's contraction. Fast onset action and your body gets rid of it quite fast. Milrinone: It does not affects your heart rate. Great for an ischemic heart. Stronger vasodilator than dobutamine. It takes 4 to 6 hrs for onset of action and takes your body a longer time to get rid of it. used to help reduce pulmonary hypertension, super beneficial for the right side of your heart. Detrimental for patients in kidney failure. Dopamine: It increases your afterload which can increased your heart workload and increased oxygen demand. However, I have seen a decrease in afterload with low dose dopamine. I hope this helps.

the first question you should ask yourself is what causes metabolic alkalosis. it's the loss of hydrogen from gastrointestinal or urine system. right? i don't know. i mean, you are ready to push gastric contents to treat alkalosis. you should know that removal of gastric content does not lead to metabolic alkalosis. you asked why? then again you should know. it seems that you found a primitive and barbaric way to treat it. for every 1 meq of hydrogen loss you generate 1 meq bicarbonate, however, when this happens in the gi system its matched with pancreatic bicarbonate. in other words, you do not give contents back. you pretty much treat the underlying reason to treat the alkalosis. i'll tell you how to treat alkalosis. correct true volume depletion, potassium depletion, and chloride depletion. your practice is a joke............

What might work for one patient might not work for somebody else's disease process or the situation. For example, I think that if you have a patient ready to be extubated on pressure support then it would be dumb to be given any kind of sedatives/narcotics. Right? Now, you have somebody in assist control and it might not be the same or would it? Uhmmm maybe. Just had a patient recently that was on 400 mcg/hr/fentanyl, 12mg/hr/versed, 30 mcg/hr/precedex, 50mcg/propofol, and was not even touching the patient, breathing over the vent, becoming acidotic, and so on. eventually was paralyzed. I love propofol. Did I hear Resp. depression? Really don't care If my patient is intubated and needs it. It might drop your blood pressure but I seen work wonders with only 15mcg. I'll take the slight drop in bp. I love precedex little to no respiratory depression.Also, patients are able to follow commands and respond to verbal and tactile stimulus but fall quickly asleep when not stimulated. What a wonderful drug. However, most patients get super super hypotensive due the decreased in svr. versed is great for it quick onset and half life. It's a great drug for short term sedation. Ativan also great. it has roughly double the potency of versed and lack of metabolite activity. Great for long-term sedation. and can't keep on. I think and sleepy just talking about sedation. night.

Sounds like a joke to me. Giving 10 meq of kcl for a level of 3.2 its like having the appetizer without the entree. Giving 1liter of fluid within a hour for dehydration in this setting, I mean in the clinic doesn't make sense either. Only poor perfusion and low blood pressure due to hypovolemia mandate rapid volume replacement. Don't get me wrong. I have given fluids and blood products within a couple of minutes. 40 meq of kcl in 1 liter bag in a 2 hr period sounds more appropriate in your setting. The chest port is a central access so you can infuse large amounts of fluids. In this case, I don't think that the chest port or giving the fluid is the issue. The issue is what's right for the patient or the reasoning behind it, why am I doing this or is there a better way to do it? Also if your kcl is low I can assure you that his mag is low as well, patients like this need to have the mag given first than the kcl. The mag helps the kcl stay in the body. Did you checked a creatinine level? is it high due to dehydration or ARF? WOULD YOU TREATED DIFFERENT? AND REMEMBER. IT'S OKAY TO EDUCATE DOCTORS AS WELL, WE ARE PART OF A TEAM. JUST EDUCATE YOURSELF AND THEN VOICE IT.

wow.... you are embarrassed of your profession! well, i'm embarrassed of you making such a statement. you have all the right to be upset but none to classified our profession of embarrassing. get over it........

How can I explain this to you in simple terms? Let's see. I like to call the pa cath, ''GOD''. If you are proficient using it, it will safe a patients life due to your interventions using the numbers from the pa line. For example, a CABG patient with a Blood pressure of 70/40 and no pa cath. Can delayed tx of the real issue cause you can only assume of many things that can be going wrong with the patient. Now if you had a pan cath. You can easily tell if its a hemorrhagic event or maybe just a vasodilatory effect or weak inotropy of the heart. In conclusion, it should be use with the sickest patients to increase survival. By the time you would see s/s of distress in a sick patients by using a regular physical assessment then it would be to late for the septic patient without a pa cath.