clementinern

My best advice would be to NEVER NEVER NEVER be afraid to ask questions, even if you think it is a "stupid" question. Please, trust me when I say that most ICU nurses would much rather have you ask questions than do something that might be out of your comfort zone. If a seasoned nurse is teaching you something, even if you feel as though you already know, listen to what they have to say. You may take away one new pearl of wisdom that you didn't already have. Good luck!!

In our facility manual pressure is held for at least 20 minutes, and then a femostop is applied for 1-3 hrs in most circumstances.

You are correct that a pt with an open chest does bubble most of the time. It's precisely because the chest is open, so you pretty much always have a leak. Regarding Maevish's post about how there shouldn't be any leak in a mediastinal tube- while this is true, most of the time in open heart pts, they actually have a pleural tube in there as well. If they have just 2 tubes they're likely only mediastinal- if they have 3, the one on the pts left is a pleural tube to the left chest. If they have 4, they probably have 2 mediastinal and a pleural tube to each lung. So, you can see leaking because while it looks as though they are all mediastinal, really one or 2 are places in the lung. So, it's pretty tricky to have an airtight seal with an open chest cavity, so you'll pretty much always have a leak. Hope this helps.

Yes we use the Arctic Sun at my facility and I have seen no issues with skin integrity related to the pads.

Also i wonder why the docs would have you go up so high on Epi and add vasopressin without increasing Dopa or adding Levophed first? Vasopressin usually works in conjunction with Levo....seems like increasing the Dopa to alpha doses or adding Levo would have constricted you more.

Was the pt an AVR in addition to CABG? Sometimes those pts are used to really high SVR's pre-op and the suddenly competent valve can have a hard time adapting to the decreased afterload. I also find the addition of the IABP odd, even though it will help perfusion, yes, I'm not sure how it will help perfuse when the SVR is already SO low. Though your numbers did improve somewhat, so what do I know! :) Was the pt febrile? As I'm sure you know that can also cause vasodilation. A final thought, do you know if the pt had Tricuspid regurg and did you FICK the cardiac output at all? Sometimes CCO monitors can be inaccurate in a pt with MR and TR, but the numbers (CO) tend to be falsely low, not high. Do you measure SVO2, and if so, what was it?

My only thought is that you ran the albumin through the same line as propofol or something else that could drop bp and the sudden infusion of albumin gave them a little bolus. Otherwise, it just doesn't make any sense. If that is what happened- for the record- i always run my fluid line in front of my pressors or sedatives so that doesn't happen. If that is not what happened, and the albumin was running alone- I have no explanation for you!!

Definitely don't need to shut off the IABP during a code. Generally we put it in pressure mode, as others have said. The only possible rationale I can think of to leave it in EKG mode is that the newer IABP's switch between modes automatically; perhaps this is why?

We have free reign to give up to a liter of LR and a liter of Albumin, and then we are supposed to call; but the understood rule of thumb is that up to 3 liters is generally considered ok. Our docs tend to prefer more fluids vs more pressors though.

I don't actually recall running both together, but lidocaine is generally indicated for polymorphic VT over amio.

I've found versed to be the best, but you said your facility doesn't use it. That's too bad; it works great. Fentanyl typically works well too. Also, 250cg of Neo is over the max dose! Yikes! I'm also curious about why you said pt wasn't hypovolemic- what were their numbers?

Many years ago i had a pt who had a HCT of 9!! Yes, the HCT!!! He was a jehovah witness and was refusing blood products. I can't remember what happened to him or what the scenario was.

It depends on the doc, some docs will titrate drips to augmented BP and some will titrate to IABP mean. We document all of the #'s on our sheet, including peripheral A line BP's. The IABP #'s will be most accurate though and all hemodynamic calculations (ie SVR, PVR) should be calculated with those #'s. It's not so much that an IABP "messes" with your periperhal a-line numbers; technically, your peripheral a line SBP should be about the same as your Augmented BP on the IABP, because your periperal A line is measuring your highest possible BP # (which would therefore be the Augmented BP). That doesn't always seem to be the case in real life, but it's usually pretty close, within 10 points or so. That is why the mean reading on your IABP will be different than if you tried to figure out the IABP mean on paper; it takes augmented BP into account.

Well, I can't say specifically what drugs your unit will use- but I can take an educated guess based on what we use in our CVICU. Propofol Dopamine Lasix Neosynephrine Precedex Angiomax Calcium Gluconate Calcium Chloride Nitroglycerin Milrinone Dobutamine Levophed rarely, Vasopressin Sodium Bicarb Hope that helps. Good luck!

Also, I think the first person to respond to your post- CABG patch kid- maybe have been confusing augmented diastolic with assisted diastolic. You WERE correct that assisted diastole should be lower. Augmented pressure, however, should be higher.

I think the way you worded your question made it a little tricky to understand what you were asking. You didn't actually have a "negative afterload reduction", but you are correct in saying that you were making the pts heart work harder. You actually were increasing the pts afterload. Did you have a measurement of what their SVR was? The problem was most likely with the timing of the balloon. Do you have self timing IABP's? Even if you do, sometimes deflation needs to be adjusted. Most of the time, if your assisted diastole is higher than your unassisted diastole, you are deflating too late. Put the pt in 1:2 if they can tolerate it. Try moving the deflation a little earlier, and see what happens. Watch your numbers as you change the timing, and for another minute or so as long as they are stable in 1:2. If you see some but not enough change in the numbers, time it to deflate even earlier. If you start to lose your augmented pressure, you are deflating too early (not allowing the balloon to stay inflated long enough, which therefore decreases your augmented pressure. make sense)? Your goal is to have the lowest possible assisted numbers while at the same time maintaining your augmented diastolic pressure preferably at least 10 or so points higher than your systolic. Clearly you don't have much support with your IABP's, and the doctor should be ashamed of himself for not telling you to check the timing; until you are completely comfortable with timing, and that takes a while, bring a cheat sheet into the room that shows exactly what incorrect timing looks like and what the hemodynamic results will be with improper timing. Datascope makes a great handheld laminated cheat sheet. If you don't have one, go to the datascope website and print something up. IABP's are serious business and proper timing is essential!!! Good luck in the future! Do you have a critical care educator that can help you learn more about IABP timing?

the hypocalcemia you see with post op cardiac surgery pts is related to fluid shifting from the actual bypass pump and, as you mentioned, from blood products. also being cold can alter electrolytes. calcium works by increasing the "squeeze" and conduction, so it raises blood pressure and heart rate. chloride is more powerful than gluconate and usually has a bigger response- also in my experience tends to be more transient.

In my facility, we typically use Calcium Gluconate to replace a low ionized ca of

I always say, simply, "pt is resting quietly".

To be honest with you, I think I would have looked to treat the cause of the rate- despite the AFib, the pt had a lot of other potential reasons to be tachycardic and hypotensive. Was it anesthesia effect causing the low bp? Pain or fever causing the increased HR? At the beginning of your shift, when her pressure was in the 80's, I probably would have shut the cardizem off to see what happened. It doesn't sound like it was helping much anyway, and then maybe she would have been able to tolerate the beta blocker. When it comes to the lopressor- with a BP in the 80's I definitely would have held it- but if she sustained in the mid 90's I would have given it. It depends on other things- what were her lungs like? Was she in some CHF because of the NS at 100 for 2 days, plus the Afib on top of it? Maybe she needed lasix. Was she dry from being in the OR and needed MORE fluid? How was her urine output? o2 sats? I would need all of this info before I could make my decision. I think you have a lot of factors at play here and can't make a prudent decision based on BP and HR alone. That said, if her lungs sounded ok and her sat was good and she was making good urine, was pain free and afebrile, I really would have liked to have gotten that lopressor into her. Good job, though, it's never a black and white decision. :)