HyperTension

I just can't help myself on this... ::sorry people:: ACLS has successfully recovered this post... Granted, pupils are F&D, no gag, no blink, maxed pressors, and just started epi... "just because".. OH, and the floor just called... the found the missing DNR paperwork.. :)

Leaning towards just bad timing IMO. With regards to the variance between pausing the pacer vs. slow decrease in rate to see what the underlying rhythm, I have seen a difference in the hearts being "more able to tolerate" a gradual transition vs. abrupt (with pause). Having the time... well, thats a whole different ball of wax. Sounds like there was a lot of issues just below the surface that lead towards the compromise of this patient. Acidosis, O2 comsumption (both myocardial and systemic), grafted RCA.... Heck, the increased irritability of the pacemaker site alone with an RCA bypass alone ups the ante for bad events to happen. Pt. probably has a poor EF / cardiomeg, add stunned vent just with the surgery alone. Pts with a high grade AS are fluky until they get their CVP up as a general rule, but it's a fine line between maintaining a functional CVP vs. fluid overload (Starlings Law), add multiple inotropes, electrolye imbalance, H&H... metabolic acidosis refractory to poor organ perfusion... ohhh such fun. Thats one of the biggest reasons why I like OHS pts. It's the thinking behind your actions.... :)

Where to begin... Ethically, I'm not sure. From a personal standpoint, you need to make it very clear to him that this behavior needs to stop. There is no excuse / justification for stealing a patients medications. If one needs to be on something, then he/she needs to be evaluated by their PMD for a script. If there is a a sentinal / near-sentinal event, and that nurse is impaired, and you knew that the individual was consuming.... ??? What happens when they urine screen or gas spec. his hair and test positive for substances that have not been prescribed then link that back to the missing medications? He is not the first to "get around the safeguards". It's not fool-proof, it never will be be as long as a human is involved in the loop of administering medications. I can't imagine us not being liable on some level. Sooner or later it will catch up if this really is occuring. Is his / their license worth it? One can absolutly appear "not impaired"... look at functioning drunks.... and still "do the job" in their view.... all the way to the accident. Is it worth the patients life, personal respect, the very license that he worked very hard for? If he needs something for anxiety / sleep, see your doc, It really is OK. What stigma is worse, the one where you swallow your pride and say you need help for a legitimate issue, or where you are questioned by state police (theft / consumption of a non-RX controlled substance is a felony), evaluated by multiple therapists, restricted license (at best) by the state board, going through random tox. screening for 6 months to 2+ years... Really, is it really worth it? Our profession will attempt to work with an individual through their addiction, there are avenues to to get / stay clean, as well as anon. reporting lines one can call if he/she feels that they are working with an impaired nurse. Now that your no longer with that institution, your probably in the clear, but from an emotional / personal standard viewpoint are you really?

No.. And no... You have an air leak. (Give myself the Captain Obvious award for that statement alone). Causes for such are many, compounded with the fact your patient has an open chest (retracted open, or just not sutured?). Is this leak related to a communication through the dressing placed in the OR, secondary to lung injury (trauma, surgical, cancer, COPD bleb......) Chest tubes placed into the mediastinum are done to drain blood postoperatively and to prevent cardiac tamponade. Any time you have an air leak that was not noted in the OR at time of placement, you essentially start from the patient and work back. Make sure your dressings are secure, tube connections valid, no possibility of this communication of air is occuring outside the patient. To be honest, it doesn't suprise me that a patient with an open chest has an air leak from the adjacent mediastinum being open. Everything that keeps their chest enclosed has been interrupted (either surgically and / or due to and now "patched" closed. It may not be "air tight". You may have a communication from the pleural cavity, I don't know given the level of information given with this post. A good link to review / research: Go with the flow of chest tube therapy . I apologize that this reply is not as linear as I'd like it to be, please post / PM if more information requested.

Chuckles and shudders at the thought of a stool transplant.......

certificate

I'd have to echo organophosphates, or some sub-component of the bug spray. More often than not people don't read the directions on the bottle, and have the philosphy of "if one is good, 4 is better". Pesticide.... isn't that what they sprayed in the house???? :) However that does not mean that this individual didn't get access to something a bit stronger and decided to try that tatic as well. With regards to BP/HR.... Esmolol and Nipride. If your going to go for the most "pounce for the ounce", that will do it. Obviously your going to use a sedative (Diprivan being the most ideal for the high potiential of >72hr intubation time) I guess you could go with a labatolol drip.. it is cheaper... but esmo has a shorter HL, and I'm a pharmo control freak.

Absolutly... As their primary RN, I am ultimately responsible and accountable for events that happen to the patient. By no means do I desire this next statement to be negative / degrading.... Techs do not have a need to be accessing arterial lines (granted I'm a bit more open to those with the VAMP, but still my premise stands). If something goes wrong, it falls onto the nurse. A critical patient whose art line has clotted off / gone bad while on multiple pressors / lab draws can really make for a rather interesting time. I'm not keen on a line that has not been capped properly and the patient has now bleed all over the place, or the pressure bag that was replaced and nobody bleed the air..... Don't get me wrong, a good tech / secretary will completely make your evening, but like anything in medicine there is a limit.

I absolutely echo previous the responses regarding etiology of the hypotension at hand. As a general statement, sedation is not a "one size fits all" type of therapy (not much is in critical care, minus celestial transfer). Lately I'm finding that with patients that don't evolve well with either precedex or diprivan have done better with combination of both. If the goal is vent. weaning I have a tendency to go heavier with the precedex (our hospital / anesthesia protocol allows for up to 1mcg/kg/hr and suppliement with diprivan, vs. more of a generalized sedation where the roles may be better reversed (heavier on diprivan with precedex as a suppliment). Also bear in mind that precedex has a tendency to potientiate co-administered central nervous system depressants. I've read various studies / drug-rep's that have stated by a factor of 1.5 - 2X. Not sure if there is a solid number to state, but It's something I am aware of while medicating my patient. Now add narcotic / opioid therapy. Fentanyl may be ideal due to it's lower incidence of induced hypotension / decreased histamine release vs. morphine / dilaudid, and shorter half-life, but it's far more expensive vs. the other 2 mentioned. Add any hepatic / renal impairement to murky up the waters as well. Ativan / valium (old school) are also a valid option but they have a far greater half-life / clearence, especially with long term usage. I personally prefer to use them as PRN suppliments, but will absolutly advocate for a ativan drip if events / needs dictate. Now lets talk about your stated dosing of dopamine / Neo. If your not getting the effect you want (or need), it's time to advocate for different flavor (similar to sedation no?). Your maxed on dopamine, and very maxed out on the traditional dosing of Neo. It's time to add Levophed and possibly look at the usage of vasopressin (last on, first off). However, a lot needs to be considered with this, ie: etiology of the hypotension (septic, post bypass pump, etc, etc, etc). Whats your heart-rate at, especially considereing your at 20mcg/kg/min of dopamine, volume (you stated that volume was not an issue, but I'm mentioning it as a general consideration). I'd say it's time to try a few different flavors to get your BP in line (inferred), then worry about sedation. (I'd would have advocated of precedex and suppliment with diprivan / fentanyl) And this is just over the few minutes I have left on my break to answer.

Here is a pretty detailed explanation of these... http://en.wikipedia.org/wiki/Receptors,_adrenergic,_alpha The problem you will run into is there really isn't a "simple explantion". Well.. there is, but it's really not worth it especially if your giving medications that activitate / antagonize said receptor.

I'll start it with this... Oh, Oh, Oh, To Touch And Feel...... First year ED residents are good for something.. :) On a different note... thats what keeps me involved in medicine and nursing (focal to Critical Care / ED for me). There is always something to learn, and it's constantly evolving, and you have a chance to make a difference "almost" every day you work. Nobody knows everything, despite certain individuals most sincere desire to appear so. Smart nurses (and others) know this, and use it as a strength. Noooooo... SaraO beat me to it.... :)

My opinion only..... Use common sense. If your discussing something rather graphic / unusual, be very aware of the environment around you, and to who you are talking too. Heck, just do that anyways'. It has a tendency to keep things much simpler-er-er for all those involved. You can present anything and be fairly descriptive.... However making it "personal" (with regards to that patient / family, or anything that can lead back to the patient) is a no-no. I'm sure others can get far more specific with regards to HIPAA, and I'll leave that to people far more tolerant to that stuff than I.

Another trendy subject is early initiation of antidepressive therapy on patients in the ICU. This is something that is all to frequently missed for both providers and nurses alike to address. Intra Abd. HTN is another nice subject gaining attention. Personally, VAP is a good topic, but it's a pay for performance topic, and probably (hopefully) been brought up quite a bit. Goal directed therapy regarding Sepsis is a pretty decent topic, and you have access to A LOT of research / papers on that subject, same with tight glycemic control in the ICU setting. I have to mirror what ICUnurse1977 stated regarding your experience and type of facility your at. That will have a pretty good impact on the topic / presentation needed.

Curious: Whats your / unit's definition of "hypotensive". I know that seems like a short-bus question, but you would be amazed at the variety of answers given. If this is something new / change in trends, I absolutely would say get a manual BP to confirm what the machine says. Do I think that this would be something focal to a generation of machines..... probably not. There is nothing wrong with obtaining an old-fashioned BP if you don't trust / like the readings given in relation to what your patient is doing. Bear in mind that your NIBP monitors are more sensitive to pressure changes (A-fib, cuff size, muscle mass, tissue between the cuff and the artery, muscle tremors, elevation of extremity over heart and so forth) vs. stethoscope / manual cuff pressure. I have a tendency to even get a Q2 / Q4 NIBP reading even with a pt. having an A-Line for trends (what happens when your line goes bad, and you have a significant change with an NIBP reading?). Not sure if this help, this is more a global answer to your monitor specific question.

Couple of things that are really important... especially with rotating from ICU #1) The ability to adapt / change gears in a very, very short time (like walking from one room to another) You can literally have an infant with an URI / getting nebs and performing a ped. respiratory assessment, to the 87 y/o male who takes Oxycontin for pain, and has not pooped in 6 hours, and is urgently requesting a enema (or two, with a side of digital disimpaction), to the homeless fellow who is at his baseline of ETOH (>.03), and somebody took off his shoes, around the corner to the pelvic setup for the PID shuffle, with an Cat. 1 trauma that is "enroute", and EMS is giveing you report as they are hauling fanny into the ambulance bay. Any thats in your first hour........ #2) Don't take things personally. Trust me, you are NOT going to be seeing / treating the top 10% of the population by general standards (inter-city is a whole different universe). Tempers can be short, patients (and family's) are stressed out, intoxicated, off their meds, or its just their general disposition... It's not you... just let it go and move on. #3) Stop thinking like an ICU nurse. You don't have the time. Focused assessments, isolate the issues at hand, treat them as best you can, and move them on (Upstairs / Admission, Out the door / discharge with orders to follow up with their PMD, or downstairs / celestial transfer) You are NOT going to be able to fix everything, much less make a global impact (but it's really nice when you do). The motto for the ER is "Treat 'em and street 'em". ** Disclaimer** Thats not to say that ICU won't help you.. It will, especially with the more complex patients, but it's a whole different pace and mentality that takes time to evolve into. My opinion only.... If you can balance ICU with a solid ER (including peds) background, you can walk into any situation and be a profound asset to the patient, family, and participating staff. Just remember, its a learning experience, and it will take 1-2 years to become proficient (variable based on the person, drive, orientation process, staff, and the institution). Keep a degree of humility, an open mind, and a caffinated beverage and off you go. Good luck!