JohnW

Thanks for the replies. I've always used Alaris pumps (and I know they are approved for blood). The hospital where my wife (she is also an RN) works uses Baxter pumps, they have blood tubing, but their policy is that blood can only be run through a pump if it's going through a PICC, otherwise it must run by gravity. I think it might be an outdated policy, enforced for no good reason.

Does anyone know of a resource that lists which major brands of IV pumps are OK to run blood products through? I searched on the Baxter site for a while and could not find anything. Thanks!

It really depends, most institutions have a Sliding Scale heparin order sets that tell you how much to go up or down the gtt based on the ptt. As the nurse, there is no set calculation that you need memorize.

RRTs by familes? I think that's absurd. If you don't trust the floor nurses/MS on the floor where your loved one is staying TRANSFER to another hosptial. If the family thinks the floor nurse (and supporting team) are so weak that they can't recognize and emergency so blatant that the family can see it, that family and the patient should go elsewhere.

We used this drug in my SICU the other day (per cardiology) for a paitent who had ended up in Afib/Afluuter. The paient, who was in his 20s, was given concentrated IVP neo (by mistake) in the OR. He dropped his HR down to 30 and was given atropine. He came out to Us (direct admit) in RAF. We gave him the Ibutilide and had a ton of ectopy while the med was infusion. He then flipped into sinus and all the ectopy stopped. We kept him for 10hrs or so checking his QTc (we were doing 1 hr EKGs for a while) and then dc'd him to home. Anyone very familiar with the drug? I'd love some feedback, tips, what to expect type information? Thanks!!

Of course, sitting someone straight up will help prevent apiration, but it's certainly not a cure all. Many people with MS changes are not safe to eat (or eat everything) and deserve a S&S consult. Don't forget lots of people are silent aspirators, use extreme caution feeding someone with a change in MS.

Wow, that is a big difference. You guys do a lot, but it seems weird to me that you guys pull pleurals, but they don't let you draw ABGs? Our NPs or PA pulll epicardial wires as well.

We don't insert A-lines, although I wish we did, as sometimes it's painful to watch Interns struggles to get one. RNs and RTs can draw AGBs. We dc Swans, but do not advance them. We maintain CVVH, but do start it. We do not place central lines, IV nurses places PICCs and the MDs place other CLs. Some of the nurses I work with pull Medialstinal CTs, but I don't and don't really have an desire since I'm not good at reading CXRs.

Not sure what you mean here? Are we talking about non-vented people? It's comon sense and comon knowledge that for any patient with trouble swallowing that you sit them straight up when you feed them. Or are we talking about people getting TFs? Or are we talking about vented patients and "micro" aspiration around the cuff (VAP bundle stuff)?

In my view, this is a very sick patient. As others have posted, you would need to check her code status ASAP, she is a hair away from being tubed and on pressors. It's a big problem that she is not on a monitor and probably a liability. It's not OK for someone to be hanging out with a BP in the 80s and a HR in the 120s, espically an elderly person with a bad heart with an unclear MS. Also, this poor person has PNA - this is bad stuff here. It's not accpetable to just let her hang out with those vitals. With that said, here's the other info we need: 1.) Some BL stuff: does she have a recent echo (i.e. how bad is her heart), do we know her baseline creat (i.e. does she have baseline renal insuff or has being deydrated in the NH beat up her kidneys). 1.6 isn't that bad, but it's signifcant. Home meds: she's probably in A-fib (also probably having PVC with that K), what does she take? 2.) Is she septic? What's her temp, what's her WBC, how bad are the infiltrates on her CXR . She was just admmitted so her sputum is probably not back, most hospitals have a criteria for a dx of PNA. She needs ABX, and she needs a central line. 3.) Does she have COPD, does she wear home ? If the answer is no, we need to fix that Sat ASAP - we are beating up her heart. Time for an ABG right away. Brace yourself for a very ugly gas. Send it wil lytes to, those labs could be "high dries" - look for her K to even lower. 4.) Do we want to consider cardiac enzymes? Probably not going to do much, but you can be sure with that BP and that HR, her heart is really being workedver. 5.) What is her fluid status? Given the Hx, we assume she is dry, but she could also be in failure as well(time for an echo or time to atleast draw a BNP). Maybe blood with lasix (espically if she takes it at home). 6.) We need to fix her HR. It could be just that she is dry, but it is more likely she is now in A-fib. We need a 12lead to see what's going on. She doesn't have the pressure to give BBs or CCBs. But, she is not tolerating the fast rate, she needs that atrial kick and she needs a slow rate to perfuse her coronary arteries. We need need to consider cardioverting her. Bottom line, it's unlikely that there will be a simple fix here (such as giving her a few liters of NS). What are going to do if here BP drops to 70 and her rate goes to 150? 7.) Don't forget saftey. This woman is a fall risk at baseline and now if she's hypoxic, things are going to get worse.

All of our hearts come out with Swans. We do not wedge, we use PADs. We seldom Swan our non-CT patients, surgical patients. When we do it's most often a septic paitient whose heart is failing. We are just starting to see the "Presept" triple lumens CLs that measure continouse SVO2 and can give CO/CIs, with these I expect to see even less swans.

Don't you guys do a re-back on verbals? That would have been time to clarify. In this case, you can be pretty sure the Doc meant 10ml/hr. Depending on the concentraion you guys are using, 10ml/hr often works about to about 30mcg/min, a nice place to start your ngt at. Personally, I think is a big mistake for places to go by mls an hr, but lots of hospitals do it.

We use PO cardene as part of our vasospasm protocol for strokes/coils etc, but I have not used it IV. Personally, I don't like using Calcium channel blockers as first line drugs to control hypertension, but that just might be my comfort level.

We were inserviced the other day on the "presep" triple lumen CLs that allow for cont. SVo2 monitoring. One hope is that if these lines are placed in the ED, the Docs will be more willing to really pour in the fluid, even with an "ok" BP, in light of a less than optimal mixed venous.

Perfect, thanks! I'm assuming the wedge is used as a differential versus CHF?

One of my friends recent grad school interviews began with the questions: explain ARDS? What is thought to cause it, how is it treated? They were looking for a short and to the point answer. How would you guys have responded?

What about people that are NPO?

We do regular (i.e. aggressive) compressions on our open hearts until the surgeons arrives. Does anyone know of anything is the literature re: coding open hearts? Does the red cross have a set of recs? Last time I took ACLS I didn't work with hearts, but I don't remember anything specific?

Lots of hosptial now have TLCL that have a port that allows for continous monitoring of the SVO2 - I would guess that in a few years this will be the standard, as it's not that expensive and could have huge benefits. Most instuations have a target CVP that you tank to (with a goal BP), but an SVO2 lets you know if tissue perfusion is really OK

Here in Boston, this stuff if huge news. The following article was on the front page of our major newspaper (The Boston Globe). Personally, I think it's crazy. Of course, the running joke is that the hosptials are preparing for the time there are no nurses and the families have to take care of the patient themselves :) Brigham to widen access to ICUs Family presence seen as aid to care in cardiac cases Globe Staff / January 2, 2008 When Brigham and Women's Hospital in Boston opens its new cardiovascular wing in May, all 136 rooms - even those for intensive-care patients - will include a family sleeping area. Among the amenities:a pull-out bed with bed linens and a flat-screen television. The rooms will be as big as 350 square feet - about double the size of the hospital's current rooms - andpatients will be ableto designate a relative or friend to stay with them each night, basically living alongside them in the room. Doctors and nurses will encourage family members to help provide basic care, such as bathing and changing bandages, and allow designated individuals to remain in the room for most procedures, including removal of chest tubes, insertion of intravenous lines, and even resuscitations. "Pediatric hospitals have embraced this for years; the family is not thought of as a visitor," said James Conway of the Institute for Healthcare Improvement, a nonprofit research organization in Cambridge that has pushed the opening of adult ICUs to families. Brigham officials say this is the only cardiovascular center in Boston designed to include a family member in the patient's room. The Brigham is one of a growing number of US hospitals experimenting with open access or nearly open access for families of adult ICU patients - an idea that has met with opposition from staff at every institution that has tried it, at least initially. Many Brigham nurses also were uncomfortable with the concept at first- and some still are -though the hospital already has a relatively liberal visiting policy in the ICUs; exceptions are often made to the official visiting hours of 1 to 9 p.m. They worried that families with their own demands and questions would distract nurses from caring for patients. Nurses also were concerned about having to clean up after them - or having totend to fainting or upset family members during graphic or emergency procedures. "People die in the ICU if you miss something," said nurse Karen St. Martin, who works in the eighth-floor cardiac ICU. "It has to be a controlled environment." But after St. Martin and other nurses helped develop ground rules spelling out nurses' roles and establishing boundaries for family members, most staffers are now happier about relatives being a near-constant presence. Some, likeMeteriver "Thelma" Kincaid, already spend day and night at the hospital.The 65-year-old Bostonian has been living nearly full-time in the cramped family waiting room on the Brigham's eighth floor since October. Her daughter, Lauren, 23, who is suffering from heart failure, has had four operations since June, the most recent on Oct. 2, to try to repair a leaky artery. Even without thewashing-machine-sized cardiac assist device next to Lauren's bed, there would be little space for Kincaid to sleep in her daughter's ICUroom. So each night between 11 and midnight, when most visitors have left the family room, she rolls out a fold-up cot, makes the bed amid the half-full coffee cups and soda cans, and closes the door so she can sleep. Lately, another female visitor she has gotten to know has slept in a cot next to her. But sometimes Kincaid shuts her eyes inches from a complete stranger The nurses know Kincaid and allow her generous visiting time with her daughter, but she said "the privacy [of in-room accommodations] would be nice." Dr. Donald Berwick, president of the influential Institute for Healthcare Improvement, several years ago challenged hospitals to open ICUs to families, to improve the quality of care and the hospital experience for both patients and families. He and other supporters pointed to a few hospitals where patients went home sooner and medical errors dropped after family members were let in to ICUs, partly because they noticed problems like missed medication. But the idea remains controversial among hospital workers around the country. Internet message boards devoted to healthcare are filled with debate about the subject. On an institute online discussion group, one ICU nurse said open access was a success at her Midwestern hospital, and to keep out family "may cause more pain and suffering to the patient." But another nurse complained, "It is total mayhem," and still another wrote,"You end up spending more time tending to the family members than caring for the patient." At Geisinger Health System in Danville, Pa., the hospital's initial attempt to open its ICUs 24 hours a day failed. The hospital limited visitors to two at a time and required themto leave during procedures. "It didn't work when we trialed it," said Angelo Venditti, operations manager and a nurseat Geisinger. "Nurses were afraid to ask families to leave. So they didn't give families a good reason to step out. Families didn't understand and got into debates about why they had to step out." The hospital rethought its plan. It trained nurses in communication skills, let doctors and nurses decide when families could stay for procedures, and set up a system of lights to signal when relatives could return to the room. Now, open access is working well, Venditti said. Brigham staff and executives acknowledge that having family members around more often will be an adjustmentfor all concerned. Loved ones may find they don't get much sleep in an ICU room, given that nurses check patient's vital signs constantly, and some may decide not to stay. In other cases, patients may not desire that much togetherness with their families. The nurses committee that drafted guidelines for the hospital's new Shapiro Cardiovascular Center sought to strike a balance. The group recommended developing a family handbook that explains the hospital's expectations for relatives staying overnight in a patient room, including that nurses will not make their beds and may ask them to leave for certain procedures. The hospital will train nurses how to communicate with families, and also promised nurses help from social workers and other staff. Family members, along with the patient, will be briefed on each day's treatment plan, but families won't be present when nurses exchange information about patients during shift changes, a rapid, highly technical conversation. Now, several nurses said, they feel more comfortable that the change will work. "Things are shifting," said Matthew Quin, nurse manager of the Brigham's eighth-floor cardiac units. "Families are becoming part of the care team. They're healers too."

I'm assuming the poster was referring to resp variation in the CVP waveform - not in the A-line tracing?

Is it common for you guys to use nipride for heads? Some of our neurosurgeons try to stay clear of it citing a risk of increased ICP. . The fact that the patient actually tolerated the lopressor gtt (per you, her HR dropped from the mid50 to mid40) I would actually think that this is a person who in not BB niaeve and probably needs some blockade. I would probably have grabbed some nitro, but with the idea that esmolol or labetlol would probably be needed once the lopressor wore off. I would probably (assuming you a NGT and there are no other issue) be looking to start some PO hypertensives asap, - then a drug like hydralzine can used for "breakthrough" hypertension. Also, in terms of the metrop gtt, that's a huge drug error and I hope you filled an incident report. These are the types of errors that kill people. Please watch out for your patients and make sure this series of errors can't happen again.

As an aside, probably not good practice to replete mg and k at same time. Always replete Mg first. Don't forget, the Na-K pump is Mg dependent!

Why didn't you ask her what value she was looking at and how it was indicator of the need for more fluid? It can be tough admitting that you don't know something, but it's a good way to learn. Do you remember what the ABG was? Was the bicarb really high or really low?

We always piggy back K, Mg, Abx, etc. I don't see any reason not to assuming you make sure they are compatible with the carrier. When you run then on a dedicated primary line, the patient does not get all the drug, as they miss out on whatever is the line - that and it's real PITB to have these goofy primary lines around.