swolfe_2

I work in an inpatient pacu, yes we extubate.......everything, and without anesthesiology. RT is usually around if they need to be connected to the vent. The exception is when the anesthesiologist is worried about something, or pt had a difficult airway. In our pacu anesthesia is always available asap if we need them.

Shellabelle, Do you work in an inpatient hospital setting? We are getting ready to convert to phase I phase II in our inpatient pacu.

I'm glad you are learning about how to get your reimbursement. In the clinic, we reference MAC as a type of anesthesia and are not thinking in insurance terms. You know, like "nursing slang"....... Thanks for the info!

I am not disputing what MAC means.... As the link states, its not just for billing. In AZ both our hospital and outpatient surgery center policies clearly define that the use of propofol in a procedural setting requires "Monitored Anesthesia", because the training is not universal. We had an incident just last week when our anesthesiologist instructed our circulator to push 40 of diprivan during a lumbar pain block and VS were only taken twice during the 40 min procedure, pt was prone, no anesthesia cart, no airway available. She was unfamiliar with the drugs and gave it anyway, and anesthesia had it "under control". The patient was fine (it's not a question of skills) but her medical record is not. There is a plethera of evidence based practice utilizing these meds however the education is drastically different throughout the specialties of our profession. Mistakes will be minimized if the issue is more black and white instead of gray. Of course, CRNA experiences are on a more advanced level.

The choice of the physician to use propofol for consious sedation turns it into a MAC case. There is no way to tell at what dose the patient transitions from moderate to deep (until after the fact). All you OR/PACU nurses know that during a case the MD cannot perform Anesthesia duties and vice versa. (thus there needs to be 2) The nurses who use it in the ED need to be aware of the effect that it has on cardiac output. Even though the clinical effect is minutes, the half life of the drug is still hours. :) You may have never had an emergency yet but...... it happens!

"The only time I was responsible for giving propfol was on the med-surg floor, where we were giving it to a young woman dying of cancer. Her pain was just terrible and her morphine tolerance was through the roof. It was the first time anyone had given propofol on the floor and everyone was very nervous about it. It allowed her to die a peaceful death." I am all about no pain and peaceful death, and also take patient advocacy to the extreme. But, did you know you publicly posted that you took part in what some may consider "Euthanasia"? We all have our "nursing secrets" but we prolly should be cognisant of the things that we share with others........because .......you never know!!

"The best use I've ever see was a 19 year old male prostitute that was standing, naked, in the middle of his ICU bed. He was swinging his IV bag by the tubing and had already DC'd his Foley (bet THAT hurt the next time he had a trick!). He had his pulse ox cable and was threatening to hang himself from the ceiling, all because his hospitalization for a CHI from a assault made him miss is regular weekly well paying "john". He forgot he had a second IV and the charge nurse managed to get behind him and slide about 4 cc of propofol in his line. In about 30 seconds he just kinda wilted into a naked pile on the bed at which point in time he aquired a new hospital gown, 4 point restraints and a dose of geodon." 1. I hope that no one that reads this and thinks this is standard practice because it is not. You would not run up to a psych patient in crisis and push verced...... ....(bet THAT hurt the next time he had a trick!). 2. Way to make fun of and exploit your patient, that's super professional.

All of our ICU pts who are still intubated come directly to ICU. Something else to consider for some facilities is cost-sharing between departments, dont forget to think about the $$.

The whole hospital is tele :) You should come check us out, it's really great. Our "cardiac" tele unit nurse to pt ratio is a max of 4:1 sometimes without an assistant though. I'm the only Sarah in the critical care unit if u ever want to call, I'm definitely there on wednesdays and thursdays.

A “whip” is when any kind of invasive line either under or overestimates the actual sbp and underestimates the dbp because there is excessive catheter movement intra-vascularly (aka whip). “Whip” is artifact that under dampens your waveform and will have a steep upstroke on your waveform and sometimes an extra waveform after you flush. It is more often observed in PA catheters but can happen on A-lines as well. A “rose” is a small circular devise that you place between pt and system that attempts to equalize pressure.

At first I was bummed about the white, but I got use to it. Mayo is a great hospital to work for and the uniform is definitely not a reason to decline a position. Everyone always knows who the RN is :)

NO- It seems to be cyclical. Arizona is a state that hospitals are difficult to staff related to the significant population changes from summer to winter. I was a traveler for 2 years at mayo clinic and have since signed on as a permanent employee. I love my job there, we are always well staffed and the education is awesome. The floor nurses never have more than 4 pts (5 on their worst day), stepdown never has more than 2, and Icu usually assigned to 1 (2 if stepdown status or extremely stable) All resources are always available to you in a timely manner, especially in an emergency. The physical therapy dept is amazing and it really affects pt outcomes. Scheduling is great, the ICU is extremely accomodating. They pay double time for OT in the winter. I will always promote Mayo it's a great place to work.

We want a short half life so that we can turn it of to do "sedation vacations" and check pt's neuro status etc....... Also if your pt starts to dump their BP for any reason, you need to be able to lighten their sedation. Propofol can decrease cardiac output. Usually pts will have trach placed after a few weeks.

UMMM.... you are not crazy! Propofol decreases cardiac output among other cardiac effects, they should definitely be on monitor....alll monitors! We would never use propofol for concious sedation.....they would not be conscious :) Only on vented pts. Follow your instincts. You can never be to prudent, pt trust us with their lives!

I always check for corelation, if the values are significantly different then I take cuff pressures on other extremities. If my a-line is different then all of these, then I trust cuff. The reason why I check different cuff pressures is because it is fairly common for pts to have left subclavian stenosis that will give you a false low SBP. You can also try a "rose" on your aline if there is a "whip" in the reading. Sometimes that will help.