Recovering post op patients in Critical Care

mattsmom81 · Sep 22, 2004

I've worked at 3 SICUs where thoracic surgery patients come straight from the OR, the surgeon and anesthesiologist hands the patient off to the nurse. They are still vented on vasoactives. My favorite policy is 1 to one til hemodynamically stable, anesthesia has worn off, and pt extubated, but other facilities have other policies..in one dedicated CVICU nurses routinely cared for a fresh heart plus a lst postop heart every shift. Busy but not unmanageable, staff were well trained and the surgeons were excellent. :)

As far as AACN guidelines, I am not sure..have y9ou checked their website?

begalli · Sep 22, 2004

Yes. Our 25 bed ICU was created back in the 70's specifically for recovering patients from anesthesia following thoracic (CABG/valves/thoracic aneurysms) and vascular surgery including heart, lung and heart/lung transplants. We also recover general surgery/trauma patients as overflow from the 24 bed med/surg/trauma ICU.

Like mattsmom81 stated, the patient is rolled into the ICU from the OR suite by the surgeons and anesthesia and handed off directly to us, the RNs. They bypass any recovery room associated with the OR.

Whether these patients are 1:1 depend on how their surgery went. 99% of our post-op patients come back intubated and still under the effects of anesthesia. If it was a complicated or lengthy case, or if they come back with a balloon pump, VAD, ECMO, or are bleeding they're defintely 1:1. Sometimes these patients can need 2-3 RNs (2 at the bedside and 1 charting) to stabalize them. It can get very hairy especially when they're bleeding.

We also do open chest on the unit when the patient is too unstable to safely move back to the OR. Occasionally there can be 5-6 people in the room with one very sick patient...RN's, an anesthesiologist, surgeon, and CNS (also an OR tech if we're opening). In the 4 years I've been in this ICU, I don't think I've ever seen a patient roll in with neuromuscular blockade agents running as a gtt, but we do use those drugs for other reasons..ARDS, etc.

If the case was a routine CABG or uncomplicated transplant or vascular, the RN receives the fresh post-op with another stable patient already assigned. This assignment is busy for the first couple of hours, but the skill level of the typical RN on this unit is amazing and we do it, and do it well, all the time.

At no time on our unit is one RN responsible for more than 2 patients, even on breaks. It's been like this forever not only due to the acuity of our patients, but because it's also the law. Our unit staffs for this by having 1-3 RN floats (depending on the unit's census) to cover breaks, and lend a hand where needed.

As far as when the post-op anesthesia period ends, I guess it depends on the individual patient and the preference of the individual attending physician. I guess the anesthesia period, for me, ends when I hear bowel sounds. :)

Many times we will keep patients sedated with propofol (and pain meds) or fentanyl/versed for an extended period of time. With routine, uncomplicated cases we have a standing order to extubate within 6-8 hours depending on how the patient wakes up from anesthesia. As a matter of fact, all of our fresh post-op orders are standardized with additional orders for the individual patient. We are very autonomous.

We've had some routine heart transplants awake, alert and talking after only a total of 7-8 hours, including the surgery itself! It's amazing!

I don't know what the AACN's guidelines are. I'm sure there's plenty of info out there if you do a search.

Pediatric Critical Care Columnist · Sep 22, 2004

We also routinely recover post-op CVs, and some neuro, ENT and general surgical patients as well. Most of our transplants come back to the unit directly from OR, but the occasional renal tx will go to recovery and come up extubated. As a rule, if we sent the kid to the OR, they come right back to us; if they were expected to come to us post-op then they usually come directly; only if we were consulted about a "back-up" bed will they spend any time in recovery. Our intensivist takes over care of the patient the minute they arrive and it is up to them to decide when we'll extubate, and so on.

Our assignments are almost exclusively one-to-one, except for break coverage. Some of our CVs, as previously posted, will need two, three or four nurses in the first several hours in the unit. Some of our kids bleed like crazy... one of our Fontans from Monday went back to the OR three times for bleeding (>350 mLs in 20 min for a 10 year old isn't taken lightly!), turns out they had nicked a tiny collateral and didn't notice... :imbar They had to cancel their second case. We also have a number of chests cracked in the unit most months, for excessive bleeding or for tamponade most often. We've also cannulated for ECMO at the bedside. We've done muscle biopsies, fasciotomies and a variety of other surgical procedures in the unit as well.

zambezi, BSN, RN · Sep 23, 2004

All of our CV surgery patients are recovered in the unit. The surgeon, RNFA, anes, and perfusionist bring the patient back to their room. Bedside report is given after first and second call. We have criteria that allows us to extubate the patient after all of the criteria is met (or the surgeon can check the box that says do not wean...)

In our ICU, they also get patients back from surgery and recover them in there...usually it is the sicker of the patient requiring vasoactives or if they remain unstable...If it is a surgery than requires the more intesive post op monitoring, they will recover them in PACU and extubate and they bring the patient up... (I don't know their routine as well because I don't work over there much....)I would say that on average, if the patient is going to ICU, they will recover in ICU...some are intubated and others are not.

gwenith, BSN, RN · Sep 23, 2004

WE recover in our unit too but it doubles as a HDU and we do get post-op "babysits". The ones that have a high risk of going pear shaped. I just lurve the anaesthetists who bring these pts back intubated because they are too lazy to reverse the anaestetic in OR. Grrrrrrrr WE have to dirty a vent just because they could not be bothered extubating!!!!! We are located right next door to the theatre. I have even heard them say - "I didn't bother pulling the tube - I will leave that for you guys later". (mutters naughty words under breath and wishes said perpetrator to have some sort of accident involving no pain but lots of loss of dignity).

gizelda196 · Sep 23, 2004

In my place , on off shifts and weekends, we are the PACU and the ICU. We recover them and send them out to the floor or if they are unit pts we keep them. They are 1:1 for 1 hour. The other nurse or (nurses if we are lucky) cover our other patient. We dislike this and if we are too busy we demand they bring in the on call PACU. They try not to bring them in. We try hard to encourage them to bring them in!

heart queen · Sep 23, 2004

I think the problem that occurs is that an immedate post op, with out pacu is a 1:1 for a minimal hour, assuming not all the complicated scenerios are present (hopefully the OR has notified us of the instability ahead of time and on call RN's can be called for the 2-3 on 1's).

If there is a stable patient assigned, another RN will monitor the second patient for that recovery period (who will have no assist duties in the recovery pt. room).

Now if your unit lacks on call or floating personale available to handle those expected and unexpected arriving train wrecks... you have a serious issue which needs to be addressed yesterday. You can't have all your staff tied up with an unstable, while other potentially unstables are left unmonitored.

The ICU is an excellent place to recover if the PACU is full, understaffed or the patient is going to you anyway. Why charge the patient extra for services that you should be able to provide, assuming you staffing is flexible to do so?

**This does bring up the important relationship with anesthesia, you can't have any of those sneaky folk that are seceretly pushing a syringe of epi during their report with you, only to run off after you've accepted the patient and report..and it takes several times of your patient crashing after they've left to learn to ask... "that isn't epi that you're pushing IS IT?" Whole other post.

mattsmom81 · Sep 23, 2004

**This does bring up the important relationship with anesthesia, you can't have any of those sneaky folk that are seceretly pushing a syringe of epi during their report with you, only to run off after you've accepted the patient and report..and it takes several times of your patient crashing after they've left to learn to ask... "that isn't epi that you're pushing IS IT?" Whole other post.

:uhoh21: I think we must work with the same dear anesthesiologist...AND his 'mystery syringes'. :uhoh3:

Celia M, ASN, RN · Sep 23, 2004

I manage an 8 bedded ICU/CCU in a small hospital and we do recover pts. Usually they are ventilated and we take them because our PACU nurses are not familiar with the vents. The patients are 1:1 RN as we do not routinely recover patients (Title 22 in CA allows PACU to be 2:1 RN.) The patient has to be released from recovery status back to ICU status by the surgeon or anethetist. This occurs after 1 hour or when they are stable enough to be 2:1. This is usually accomplished by a phone call. We also recover patients who have had bedside procedures eg EGD, bronchoscopy and the majority of those are on vents too.

ratchit · Sep 24, 2004

I have worked PACU and ICU in several states. Generally, patient ratios in ICU and PACU are both 2:1. Fresh hearts typically go right to the unit after (hopefully!) 2 warning calls. The patient's RN is waiting in the room, usually with someone assigned to "second" them. But anyone who can shows up to help.

I've never had a 1:1 assignment in ICU when I was recovering someone- I can have 2 as a PACU RN or an ICU RN so I don't see why a non-heart surg patient would need to be 1:1'd. PACU really tries to rotate admits so that you have one fresh one mixed with one settled- taking 2 from the OR within 15-20 minutes of each other was unusal unless the cases were VERY minor. So having a stable ICU patient and a recovery should be OK.

The best system I have seen was where patients who went from the ICU to the OR go back to the ICU, bypassing PACU. Patients that might just need a little time before going to stepdown or the floor went to PACU. ICU on nights would recover late night or weekend surgeries only if staffing allowed for it. The house supervisor would call in the PACU team at the same time as the OR team; if the PACU RN did not want to come in they would call the ICU and ask us (very nicely- LOL) if we could take the patient. If we could, we would. If there was ANY question about us having time, we would tell PACU they needed to come in.

The other nice thing about that hospital was that PACU RNs could recover patients in the ICU if we had a bed. They were responsible for the patient, but had other critical care nurses available if something went wrong. I always hated being alone in the PACU.

nurselily3 · Jan 12, 2005

Our hospital policy is that if they come from ICU they recover in ICU, for continuity of care. If there isn't any room or it would cause a hold up for PACU then (it seemed) pretty frequently we would recover patients in the unit. We also recover all Heart, Lung, Liver, Kidney/pancreas transplants, all CABGS and AVR's, and most of the Trauma patients. If the patient is going to be a sicky..they they usually come to the ICU to recover (aaa's etc) so it doesnt slow down PACU's ability to recover the less sick to send them home or to a floor bed.