mtwedt

All our patients have Swans at our center. Volume resuscitation is determined by a patients individual hemodynamic needs and is nurse driven as to how much is given and when initially post-op, up to 5 units of Albumin 5%. It is highly patient specific, depending on LV function, preload dependence, LV compliance, etc. We have total fluid limits, including IV gtts of 40 to 60ml per hour that no one pays any atttention to because it can be impractical. There are 24 hour fluid limits of anywhere from 1500 to 2400 ml that we devide up into thirds and target for an 8 hour shift using NS to meet the target over an 8 hour period, again including gtts but not albumin, which is tracked separately on a blood balance sheet with chest drainage and other blood products that may need to be given. What turns out to be excessive volume the next day after surgery is from very active third spacing by post CPB pts for 8-12 hours post-op et volume must be maintained to optimize filling and preload and hemodynamic performance. Off pump pts have far less endothelial leak than on-pump and therefore will generally need less volume resusitation. Giving Lasix to patients is common if they do not adequately mobilize their third space fluid or are fluid long from blood products for post-op bleeding or simply required a larger preload initially post-op. The concentration of IV drips and the amount of NS given is, again, nurse driven. Given the pronounced tendency for the post CPB patient to have endothelial leak and many patients need to have adequate preload intitally post-op to allow for dialling in their blood pressure to desired limits with Nipride, it is not at all uncommon to need to give Lasix the following day when the leak has stopped and things have stabilized. It is by no means an error if your patient needs Lasix to divest themselves of third space fluid the next day.

I agree with the other posters. The primary concern in using Dopamine, or other positive inotropes, in the setting of chest pain, is that of increasing myocardial O2 demand in an ischemic heart, thereby increasing ischemia and potential for arrythmias. In the most acute cases of ischemia and chest pain accompanied by significant hypotension unresponsive to fluids, ie.. cardiogenic shock or evolving cardiogenic shock, the treatment is IABP and a very quick trip to the cath lab for intervention and/or possible emergent cardiac surgery.

I think you are referring to the Argyle plastic tubing that connects the drain to the suction source, correct?. If you need to transport a patient, you have three options: Remove the suction tubing from the drain and transport the patient on water seal, something that may not be a good idea in a patient with large airleaks (ie.. lung reductions), transport with the suction tubing and connect to suction at your destination, or transport connected to portable suction (which I've never done). The determining factor is whether or not the patient can transport without unacceptable air accumulation off suction. Drainage of fluid from the thorax via chest tubes is first and foremost a gravity issue rather than one of suction.

Most new grad positions are for nights. You can, at least, earn a bit more money to pay off school loans! I have found the clinical management of the patient at night often more discreet on the day of surgery, doing the final dialing in of the patient to optimize hemodynamics and such based on an individual patient's cardiac function. While fresh admits have there own set of challenges, it is often not the best learning environment for the new practitioner to learn in. It moves very quickly and the new practitioner will find themselves being reactive rather than being proactive. We've recently had a few in our unit and I am not overly impressed with the result. They seem to manage by rote and not by knowledge. Oddly enough, despite the fact the the Day shift does the bulk of precepting a new person, I have not found that they are particularly good at following up with good clinical teaching that the Night shift is so good at. The care is the same except for no scheduled admits and no weaning of patients on longer term ventilation being managed by Pulmonary. We continue our regular extubation protocol 24 hours a day. There is far less opportunity for collaborative interdisciplinary stuff with the docs and some other disciplines as this goes on in the daytime and interaction with the family will often be less as, hopefully, they feel comfortable enough to go home. This does provide an environment that allows the new practitioner more space to learn from experienced colleagues. After 28 years of Cardiac Surgery, most of which has been on Nights by choice, I can tell you that a top flight RN on Night shift is worth its weight in gold to an intelligent Cardiac Surgeon and the good ones know it.

I went straight to Critical Care nearly 30 years ago when the training/orientation was much less and I never regretted it. Your concerns and doubts are natural and healthy, they will motivate you to learn as much as possible and to always keep learning. Nurses who lose that underlying drive to learn as much as possible for the welfare of their patients, who become complacent in their knowledge base, are not good, they're dangerous. The initial stress level of practicing in Critical Care does diminish over time as your experience base increases along with your practical and applied knowledge. I have work with many nurses "new" to Critical Care over the years and have found it is the motivation and effort that the individual puts into to the job that makes the difference. It is sometimes easier to work with new grads who don't have to unlearn or re-adapt patterns of thinking and intervention that nurses from other areas have to do. It is also quite stressful for an experienced nurse to come to Critical Care and be thrust into an environment that she/he cannot function in as competently and effectively as they did in their previous one. It rocks their professional self-confidence pretty hard and can be an even greater stressor than starting from the ground up as you are contemplating. Godd luck as to you as you start your career.

I have 1,000,000/3,000,000 attached to my homeowner's insurance. It was cheaper. I have State Farm. My agent brought it up many years ago. My understanding of lawsuits against nurses is that they are directed at the hospital, under the premise of respondeat superior ( let the master answer). It is easier to sue an anomalous institution than an individual and institutions have deeper pockets. I thought it was illegal to discover potential financial assets of a defendant in litigation.

Our institution has no policy regarding this situation, but I agree with the other respondents. The issue is the bleeding at a rate of 100ml/hr. beyond the first few hours. A coagulopathy work up is indicated. Turning facilitates drainage and therefore reduces potential tamponade. We have an early extubation protocol and most of us "rock and roll" the patient from side to side to get them off their surgical linen and evaluate drainage. Did they just dump or are they going to keep it up? We also generally don't remove chest tubes until the patient has been up in the chair in uncomplicated recovery. Again, an opportunity to dump. I have never heard of, nor would I countenance, turning as the "cause" of someone's bleeding. An agitated, intubated patient who is bucking the vent and dancing all over the bed, certainly could increase their rate of bleeding by jacking their BP all over the place. I prefer to take my bleeding patients to an SBP of 100 and keep them sedated and intubated until I have the matter sorted out either with or without return to CVOR.

It's interesting to read everyone else's experiences. For the Home Health RN who reactivated the thread, I would think that whatever protocol you have in place for home Dobutamine would be acceptable for home Milrinone. Proper discharge teaching for the patient and family would be critical here. A collaborative protocol between yourselves and the discharging cardiologists should be established. My concerns would be for various forms of hypotension: hypovolemic, orthostatic etc. You could run into problems if the patient has big increase in his diuretic dose or becomes ill and dehydrated. Again, patient teaching and a collaborative protocol would be key here. I use Milrinone only in the acute setting, immediately post OHS, and it is employed only when the patient fails to separate from CPB with more standard cocktails led by Dobutamine. It's general purpose in this setting is to kick up CO but it is also an excellent vasodialator, especially in the pulmonary beds. Since it is not our first line inotrope and the patient has now been on CPB for an extended amount of time, Milrinone's vasodialating properties can become problematic and require a pressor in the form of Neo or Vaso to support SVR and therefore BP. This vasodialating impact becomes less and less as the patient moves farther away from a long pump run and the CPB induced levels of vasodialating mediators begins to fall off. The key difference between Milrinone and Dobutamine is that while both are inotropes, Milrinone is a non-catecholamine. Being a phosphodiesterase inhibitor, it directly increases available cyclic AMP to the myocardium and does not utilize the beta andrenergics as Dobutamine does. Since beta andrenergic receptors are finite in the heart, although with dysfunction based changes in distribution and density, Dobutamine has an ultimate end point of effect. Once all beta andrenergic receptors have been recruited, that is that. Higher doses of Dobutamine will not help and, unknown to many, can have an alpha pressor effect in high doses (>10mcg/kg). Milrinone's effect is not limited by beta andrenergic availability and therefore may be preferred by some cardiologists who feel their patients might already be at maximum levels of beta andrenergic recruitment, hence Milrinone seems to "work better". Both drugs are inotropes, Dobutamine is a superior chronotrope, in my opinion, and the lusitropic ( diastolic relaxation) effect of these drugs as compared to one another is debated in the literature. I have read that chronic Dobutamine for end stage CHF will certainly improve quality of life, but shorten it as well. I do not know if the same holds true for Milrinone.