Question-Open Heart Anesthesia??

You know this topic strikes me oddly. We are taking some of the sickest people in the community, placing invasive lines in every opening and creating plenty of new ones, putting them into a drug induced coma, splitting their chest wide open, cooling them to 27 degrees or so, stopping their hearts and building new plumbing for it, then we restart their hearts, wean them off bypass and close them up. On top of that we are not happy when they take longer than 3 - 4 hours to come off the vent? I'm not saying it isn't a goal but really, might some of the fast-tracking be unreasonable? Who benifits, the bean counters sure do. It reminds me of the people who believe that any goverment operation has excess baggage to cut. At some point there may be nothing else to cut/do to make things more efficient. We could just inject a bit of local and hold em down on the table with duct tape;)

Fast tracking post op hearts takes cooperation of EVERYONE involved....patients, surgeons, anesthesia providers, preop nurses, OR nurses, CVICU nurses, and the floor nurses. I intentionally put patients first. They need to know the expected course of recovery. No, they may not be 'out' for the entire day or overnight. Patient selection is also crucial. Not everyone is a candidate. The 78 year old with a 86 pack year history of smoking probably ain't gonna fly too quick postop. The trick is to balance. In this case, long term ventilation also increases postop morbidity. Anyway, to truly institute an early extubation protocol it takes EVERYONE to get involved.

PG

I agree that fast tracking is not for everyone, especially with the increasing incidence of octagenarians and sicker patients having surgery. However, our CNS and surgeons are promoting it when possible. We do have a lot of people in our unit that agree with you,Wntrmute2 :). My feeling is if the patient is stable, why not? There have beens studies done showing the safety and efficacy of it in certain patients, as well as cost-effectiveness (which does seem to be the driving force...). In our unit, we are currently shooting for the 4 hour mark if a list of criteria is met. As passin Gas metnioned, the patient is always first, if it does not look like they are going to fly on their own, we wait to extubate. The reason that I am asking the question is that monday we have a meeting with everyone: a few of the day/night nurses, RTs, our CNS, surgeons, anesthesia, and pulmonologists to look at the current protocol and make changes if necessary. I am trying to be as informed as I can be. Thank you both for your replies and comments. :)

i think it would be dangerous to expedite extubation beyond what we do around the country at this point... and the thought of switching to an even shorter acting narcotic or using benzodiazepine reversal is very scary.... 1) using a shorter acting narcotic increases the odds of poorly-controlled post-operative pain - which in turn can cause a lot of trouble in a cardiac patient with poor reserve 2) using a benzo reversal you are asking for trouble in patients who have a long history of chronic benzo use that you may NOT know anything about (a little valium before bed every night) - leads to seizures and a HUGE sympathetic output.... bottom line, surgeons know nothing about the appropriate time to extubate and neither do CNS - let the anesthesia provider or the ICU docs time the extubation to minimize aggravating a sick patient.... there truly is no rush, and no benefit from extubating a few hours earlier...

Tenesma:

Just curious, why do you come on this nursing forum and act as if you respect crna's and their skills? While on the student doctor forum you usually rip them a new a$$, especially whenever the crna vs MDA debate is the issue. I just read one of your comments today( on the anesthesia forum) about how you can teach a monkey to do any procedure referring to crna's and just how much smarter and greater MDA's are in every aspect of anesthesia care because your training is so much longer and better. While your training may be better it does not mean that ours is not good and that we are not capable of providing good anesthesia care. I would just appreciate that you make up your mind and stop being so hypocritical in regards to acting as if you think crna's are good providers when you want to come on this nursing forum and give your expert advice and then when you are with your peers you have nothing good to say about crna's. This is not a personal attack, but I have seen you do so many times, on the student doctor forum, that I just felt I had to call you on it.

We use a lot of fentanyl for pt during procedures. Then about 1/2 to 3/4 of the way, we initiate propofol, titrating upward as we wean the fentanyl down or completely off, depending on assessment. The goal would be that the pt would be only on propofol post procedure but always keeping in mind pt safety and comfort.

open heart recovery nurse here-

I think a lot of the fast track hype between hospitals is kind of like dudes at a bar bragging about how many inches they have. Using a fast track protocol is great when the staff is competent at using it...very much like the dudes. Sure you can say 95% of your open heart patients are extubated within four hours...but how many are oobtc the next day with all of their lines and ct's d/ced? How many are on the stepdown unit the next day? How many have a new need for dialysis? How many are reintubated at hour 5? A lot of different outcomes. I agree with everyones comments...especially those centered on collaboration, and screening.

As far as drugs...I have a basic understanding of ICU pharmacology, but loose the versed man! I think it is overrated for short term sedation (like the low risk open heart population). I think propofol is underated, and I think there is a lot of unecessary anxiety and assumptions of new nurses (I am not picking on anyone, if anything I am admitting a mistake) to hammer fresh hearts with fentanyl. The ubiquitous dose on my unit seems to be 50mcg on arrival...this can tack on an hour for the lil ol lady with liver dz.

I don't know, just my novice opinion.

The only reason I wouldn't use strictly propofol is because it's so darn expensive. One bottle costs around 200 dollars or so, I think, and if you're using 30cc/hr, that's going to cost a lot. Compare that to, say, Lorazepam 40mg/250cc, which I think costs about 80 bux. I forgot how much fentanyl costs.

This was the protocol in one facility

Sufentanil .5-1mcg/kg

Versed between 2-5 mg

half mac isoflurane.

Front loaded narcotic with extra, smaller dose prior to coming off pump (if on pump)

a couple of mg versed up front as well as another mg or two when coming off pump.

Basically the only difference between the fast track patients and the ventilate post-op patients was the dosage of narcotic and benzo. Reversal of the bezo was not standard, but if the patient was not breathing spontaneoulsy post-op it was considered as a cause.

I believe the standard around the country is less than four hours to extubation with a large proportion of facilites extubating within an hour.

It does require input from every department involved, it is certainly not just an anesthesia issue.

We use precedex in our facility, it is an alpha-2 agonist and can decrease the amount of analgesics needed. You do not have to d/c the drip prior to extubation. I think it is a great drug, but you have to closely monitor B/P as it can cause hypotension.