MLB55

The guy was well over a 100kg...

We only do hypothermia protocol for pts post cardiac arrest. That is, we cool them down to 91.7 - if that's what hypothermia your talking about. Craniectomy within the first 24-48 hours is what our neurosurgery and neurology teams push for. Did the pt have an Evd or bolt? I would assume so with the aggressive care, seemed all measure were given. Paralytics, 3 percent, mannitol - I guess the next step would be pentobarb coma and lobectomy. Did the do a lobectomy? I hope the patient wasn't brought to mri with high icps, that could of pushed the patient over the edge...

The needle decompression. That's a great question. I'm guessing, since he was pusleless and kept losing his pulse? I just heard the attending say, he needs to be decompressed. And he had a central line placed emergently on that side.??

In our 23 bed neuro icu, we clamp the drain to transduce pressures, position changes, and when we transport the pt.

Pt is a 63yo male with a hx of a subarachnoid hemorrhage 30 yrs ago s/p clipping. Pt present early in June with a new Sah, from the same aneurysm. Pt was re clipped on the 16th, stayed intubated for a day or two and was successfully Extubated. Complicated by dvts s/p ivc filter and on prophylaxis heparin tid. Un able to be fully anticoagulated secondary to the Sah. Pt was aox3, MAE and sent to the floor on the 19th. During therapy on the next day, pt became unresponsive. 4-5 rounds of acls were given and rosc was achieved. Pt TX to icu and again became pusleless 3 more rounds of acls as well as dopa and norepi infusions regained rosc. Needle decompression of the right side was obtained, followed by chest tube placement. A swan was floated and artic sun was initiated, and nitric was added. Pt now on Vaso, norepi, dopa, milrinone and epi. A heparin gtt was initiated for presumed pe, and head ct was negative for bleed. Over night pt 'stabalized' and was weaned to 10 of norepi and Vaso. Vent settings are 28 by 650, . 40 percent with an abg showing 7.38, 40, 120. Pa pressures are mid 40s/20s. Co equals 3, Ci of about 1.5. Svo2 in the 50s I come on shift the next am, and they want to take him to ir for mechanical retrieval. A long discussion was had, and the decision was made to take him. No impressive saddle pe, and a not very imposed right upper and middle lobe pe was retrieved. Pa pressures didn't change and his oxygenation and ventilation actually go worse. As well as his hemodynamics. Pt now on 28/ 700 and 80 percent with a gas of 7.29, 42, 86. Also, on Vaso milrinone norepi and epi. Pa pressures and Ci. Co are the same, svo2 now in the low 40s. 1 unit of blood is given with no response to svo2. Urine out put is 20-30mls, cr is normal. Trop is normal, echo shows a kinetic right sided heart. Question is, why did we take him to ir when he was doing so much better?

No I meant 4.5 liters. Not uncommon and not the most I've seen. I've had a patient that required 90+units of products... But that's another story. Her urine out put increased after the lasix and then patient started auto diuresing the next day or so. Cr peaked and then down trended to baseline. She did well.

Pts cr peaked the next day at 1.44, she's auto diuresing and cr is back to baseline.

Lasix immediately help here urine output. 400 in about 2 hours. Great input... She was definitely +a few liters since the or and had pulmonary edema on chest xray.

We sent one. I don't remember, serum na was normal though.

Pt is 74 yo with a hx of a parotid tumor that mets to the spine, "kidney insufficiency" (as reported by the patient),baseline cr seemed to be 1.09 and htn. Had a two stage back surgery something like T10 to pelvis. The second stage was aborted X 2 due to a fib with rvr. She finally has her second stage after being on amio and metoprolol. Ebl is 4500, received 10 units prbcs plus some coags, a few liters of colloid etc... She was hypotensive to the 60 sbp in the or at times. Post op day 1 receives 2 prbcs, 2 cryo and was Extubated. Cr is 1.20. Makes the minimum of 30ml/hr all day. No hypotension overnight receives 2 more of prbcs plus some albumin. Cr post op day 2 is 1.39. Urine output dwindles overnight and makes 5-20ml/hr. My question is, I suggested lasix in the morning and was denied. Afternoon Chem is 1.39 and cvps are greater than 20. Urine out put remains 15ml an hour and then the attending rounds and said it's Ok to give lasix. Is lasix the right or wrong choice her? Do we let her be oliguric until her kidneys kick back in? Again I gave her two prbcs plus 500 of albumin with no pick up in urine output. Mike

I think everybody feels like this at first. Nobody is truly comfortable until at least there first year. Take this opportunity to provide good care and to be known for the care you can provide. Sick or not. I found in my earlier days the sickest patients I got were the ones that came in after I dc'd pts to the floor. You never know what train wreck rapid response or trauma might come for your open bed. I'm the type of nurse who wants the sickest patients on the unit. But it is nice to have those patients going to the floor as a break. Be patient :-)

They are hooking it up directly to that white/blue port where the slic or swan would go. We typically put in a tlic and transduce off the distal port. But out of the or, anesthesia transduces off the aforementioned port.

Not the big line of a cordis. The part where you put a triple lumen or a swan. The same place and a mac.

Have you guys seen when anesthesia hooks up the cvp to the port where you put a triple lumen or swan line through? I think this is a waste of a port and I sort of think not an accurate way to measure cvp. Not that the cvp is the end all be all. Just wondering what you guys think?

I was only asking about triple H therapy for vasospasm patients. I think we would have better cardiac outcome with the same neuro outcome if we used maps. A lot of times these patients require 5 pressors and inotropes to get the patients sbp to 200. Meanwhile there ef goes from normal to 20% fast.