repositioning oscillator pts question

[Zookeeper3]

Can you all share with me what your current practice is with oscillator patients and repositioning? We are running quite a few of these vents with the "season" in full swing. As long as respiratory has a full "wiggle" if you will, and peak airway pressures recover quickly, why not turn these patients with pillow propping to the left and right?

Simply put, my patient is on 100% fio2 on an oscillator, we're maxed.... yes he does desaturate to 86% with movement, but recovers in 30 minutes... why go through all this and have the pt. die from massive pressure wounds if you can prevent them with turning, even Q4 hrs.

Like prone positioning, the patient desats initially but recovers and benefits from the turning therapy. I believe we cause patients to become intolerant to turning based upon lack of turning.

So if we still have a full "wiggle" and quickly resolving mean airway pressure, why not turn these guys? Our pulmonologist wrote a specific order not to turn my patient, so what gives? If my patient recovers in a safe amount of time, why set him up to die from preventable wounds?

Now I know how complex this is and I am really dumbing it down, but it really IS that simple. Please share your current practice as I'm having a hard time finding evidenced based practice as to what policy or practice is occurring in other facilities. When I polled my peers almost half said they would turn and half not, so we have to resolve this quickly. While each patient situation is at the discretion of the RN (we've all been there), surely, some of you have a policy in place that addresses immobility and skin protection protocols?

Lastly and thank you for your patience, medicaid/medicare does not reimburse therapy from hospital acquired wounds.... I'm hoping to use this as an additional incentive to just simply prop some pillows and tilt a patient which only improves lung recruitment and can benefit my patients overall recovery.

Final words, my pt. is hemodynamically stable, beautiful vs, just desats with the initial turn, we can't do anything else from an RT standpoint, maxed on 100%fio2, I can argue both sides. "don't dare turn, airway and o2 is the priority" but the decompensation is brief. Massive skin ulcers, which can result in a secondary morbidity and lack of compensation in pay is a huge concern as well.

How are you practicing? Lets keep this simple please, we all understand the complexity involved.

[oldiebutgoodie, RN]

Good for you, Zookeeper3! I am interested in the LEGITIMATE comments, as well. We had a patient recently on an oscillating vent, (I'm the wound care nurse), and all the epidermis was sheared off both buttocks. It was awful.

Oldiebutgoodie

[WindwardOahuRN, RN]

Good for you, Zookeeper3! I am interested in the LEGITIMATE comments, as well. We had a patient recently on an oscillating vent, (I'm the wound care nurse), and all the epidermis was sheared off both buttocks. It was awful.

Oldiebutgoodie

I've seen this too, more than once. I've also seen patients who are so terribly unstable that they code when you try to turn them, HFOV or not. We have had many patients on HFOV and yes, a few have developed decubiti. They lived. I am convinced that they would have died if we had done the "policy" thing of turning and positioning Q2h. Why am I convinced? Because they coded, repeatedly, while being turned.

The patients on HFOV often have extremely life-threatening co-morbidities in addition to their pulmonary issues. This question does not lend itself to a simple "what does the policy say," cut-and-dried black-and-white response. It may very well be an issue of horrendously labile blood pressures, arrhythmias, and absolute crash and burn results. Cytokine release, loss of baroceptor response, so many other factors play a part in whether a patient will tolerate being turned. Bariatric patients are a particularly difficult population.

Yes, we do document the consequences of turning these patients and our intensivists write the "DO NOT TURN" orders as needed.

Nobody wants to see the awful decubiti that sometimes result from these decisions but, in real life, we sometimes have to make tough choices. And if the choice is between a decubitus and a death, well, we choose the decub.

In over thirty years I've seen a lot of things that go against textbook policy but there has always been a reason, always been a rationale that involved balancing the chance for life over the very real possibility of death. It has not always been pretty but that's the way it is.

OldiebutGoodie, I have respect for your specialty but with all due respect you really haven't been in the field all that long and there is much that you have not been exposed to. Medicine and nursing is sometimes a very finely tuned ballet, complete with performances that we are not very proud of. We wish we could do better, make things more like the textbooks and policy manuals would like, but we just can't. This is where critical thinking and the art of nursing come into play. Staging decubiti and recommending treatment regimens are certainly valuable contributions to the care plan but compared to the minute-by-minute decisions we must make on a constant basis it's far less complicated. This is not meant as a derogatory comment and please don't interpret it as such but there simply is no way that you are as involved in the intricacies of the critical care patient to the extent that the ICU nurses are. And honestly, since you are not an ICU nurse, I would not expect you to understand fully the conditions that we are faced with.

Sometimes we end up with a patient who is never going to be what he was before he became so terribly ill. But he's alive and only through the massive efforts of the nurses who got him through his most desperate times. Tough choices but sometimes they're the only choices we have.

[oldiebutgoodie, RN]

OldiebutGoodie, I have respect for your specialty but with all due respect you really haven't been in the field all that long and there is much that you have not been exposed to. Medicine and nursing is sometimes a very finely tuned ballet, complete with performances that we are not very proud of. We wish we could do better, make things more like the textbooks and policy manuals would like, but we just can't. This is where critical thinking and the art of nursing come into play. Staging decubiti and recommending treatment regimens are certainly valuable contributions to the care plan but compared to the minute-by-minute decisions we must make on a constant basis it's far less complicated. This is not meant as a derogatory comment and please don't interpret it as such but there simply is no way that you are as involved in the intricacies of the critical care patient to the extent that the ICU nurses are. And honestly, since you are not an ICU nurse, I would not expect you to understand fully the conditions that we are faced with.

Actually, I HAVE been a critical care nurse, so I DO understand the "minute by minute decisions" you must make. I was NOT inferring that turning was required, I was addressing the rather flip answers some had made to the original poster, and was interested in what other units do. So please don't lecture me on critical thinking, etc. I am quite aware that my contribution is rather insignificant in the plan of care of the critcal care patient. However, I was curious if anyone had any constructive suggestions in a situation like this, since I am consulted on these issues.

Oldiebutgoodie

[WindwardOahuRN, RN]

Actually, I HAVE been a critical care nurse, so I DO understand the "minute by minute decisions" you must make. I was NOT inferring that turning was required, I was addressing the rather flip answers some had made to the original poster, and was interested in what other units do. So please don't lecture me on critical thinking, etc. I am quite aware that my contribution is rather insignificant in the plan of care of the critcal care patient. However, I was curious if anyone had any constructive suggestions in a situation like this, since I am consulted on these issues.

Oldiebutgoodie

According to your previous posts you were an "ICU nurse" for a very very short time. I applaud you for your venture into nursing late in your working career and truly do respect your chosen specialty. My opinion remains that you simply do not have the experience to realize the challenges we ICU nurses face on a constant basis.

My post was meant to be constructive and informative regarding what really goes on in the ICU, garnered from decades of experience as opposed to published nursing care plans and evidence-based practice statistic crappola.

This is what truly goes on in our critical care units. True life and death decisions, constantly weighing the pros and the cons, the benefits versus the consequences. The realities.

Flip answers are sometimes tossed to the masses out of frustration and a "Good Lord can you not SEE what we are dealing with here??" exasperation. The flip answers may be accompanied by a heaving sigh and rolling eyes but they do not detract from the fact that we have the very best interests of our patient at heart.

"Interested in what other units do"? Well, as a veteran of SICU, MICU, CCU, open-heart, solid organ transplant, and burn units, I've told you what we do.

Whatever the situation dictates at any given time, based on the status of the patient.

Simple as that, and eminently understandable by those who have been there, done that, saved a life or two, and returned to fight another day.

There simply are no pat answers here.

Summary? We do the best we can and we know what the best SHOULD be but the truth is we can't always meet the expectations of those who sit in offices and write the policy books.

[oldiebutgoodie, RN]

According to your previous posts you were an "ICU nurse" for...a year. Which speaks volumes. I applaud you for your venture into nursing late in your working career and truly do respect your chosen specialty. My opinion remains that you simply do not have the experience to realize the challenges we face on a constant basis. You don't. Period.

My post was meant to be constructive and informative regarding what really goes on in the ICU, garnered from decades of experience as opposed to published nursing care plans and evidence-based practice statistic crappola.

This is what truly goes on in our critical care units. True life and death decisions, constantly weighing the pros and the cons, the benefits versus the consequences.

Flip answers are sometimes tossed to the masses out of frustration and a "Good Lord can you not SEE what we are dealing with here??" exasperation. The flip answers may be accompanied by a heaving sigh and rolling eyes but they do not detract from the fact that we have the very best interests of our patient at heart.

Well, I'm certainly not going to debate you on who knows the most about the ICU. However, you can use your knowledge to teach (in a more positive way), or to dismiss. Nowhere in my posts did I infer the ICU nurses were naughty for not turning. I was asking a question. Furthermore, nowhere did I say I know more than a long time ICU nurse, so I don't quite understand your comments.

And in terms of my being in the ICU for a year "speaking volumes", well, my father was dying, then he died, and I had to take care of the estate, at which time I switched specialites. SO...

I'm signing off.

Oldiebutgoodie

[DUKEFAN13]

NO!!....do not turn patients on an oscillator....you loose the peep and pressure you've worked so hard for....why would you do that?.....Remember that the pateint will not be on an oscillator forever...theres usually two ways out of this.....if the patient makes it back to conventional ventilation then you go ahead and turn all you want. Better to have a living patient with a small pressure ulcer than a dead patient....

[dmc_rrt]

On this type of vent, the pt is receiving quite high alveolar pressures, so you want fairly even distribution of these pressure t/o the lung to prevent pneumos. This doesn't happen when a pt is on it's side. Also, the way gas exchange occurs during HFO also depends on trying to get equal gas exchange to both lungs. Again this doesn't occur when the pt. is on it's side. To assess proper oscillation or "wiggle" the pt. has to be supine, as the wiggle needs to be to mid thigh. Hope this helps.

[8jimi8ICURN]

We have most of our bad swine flu cases on the rotaprone beds. Pt's do initially desaturate, when turning but the recruitment of the posterior lung surface area allows us to keep our FiO2 much lower. I cannot recall having any of our ventilated patients higher than 40%. Now then... i'm not saying that everyone is surviving and the rotaprone has its own issues with pressure wounds, but i say turn your patient. We were proning our patient who were not hemodynamically stable. Getting septic from a pressure ulcer while recovering from h1n1 has not helped anyone.

[WindwardOahuRN, RN]

On this type of vent, the pt is receiving quite high alveolar pressures, so you want fairly even distribution of these pressure t/o the lung to prevent pneumos. This doesn't happen when a pt is on it's side. Also, the way gas exchange occurs during HFO also depends on trying to get equal gas exchange to both lungs. Again this doesn't occur when the pt. is on it's side. To assess proper oscillation or "wiggle" the pt. has to be supine, as the wiggle needs to be to mid thigh. Hope this helps.

The most we will turn these patients is what is basically a "shift" or "tipping"---propping the patient very slightly to take some of the pressure off of the bony prominences.

If the patient tolerates a turning bed we will try that with just a maximum of a 20% turn bilaterally and we stop immediately if we see any decompensation in either hemodynamics or pulmonary function. Way less than the 40% recommended for prevention of decubiti but we take what we can get.

A huge (no pun intended) problem arises when the patient is a bariatric patient. You just cannot prop these people without doing a full-on turn to the side---they crush the props and the attempts are a waste of time, resulting in a big lump of "prop" stuff that is sure cause skin issues. Bariatric patients also do not tolerate turning as a simple logistical consequence of their size. They crush themselves, literally, just as if they had been placed in a vise. We turn them fast and with as many people as we can muster. You can watch these patients turn purple within seconds (and then brady down---eeesh) and, decubiti be damned, they just can NOT be part of the "Turn Q2H" program.

I've seen the pneumos with the HFOV's and I've run for the chest tubes. One of the many possible adverse effects and complications of HFOV.

These patients are so very critically ill that we often must forego the lower priority issues for the highest priority concerns. Airway, breathing, circulation.

Butt flesh, though important, is waaaay down on the list. Yes, I know the relationship between decubiti, infection, sepsis, and death and I'm not dismissing it at all. But we have to make tough choices and sometimes it really sucks but we do the best we can.

And DMC? Great to see an RRT contributing here. I love the RT's where I work. Great bunch of people, wonderful resources. My go-to pulmonary pals. :loveya:

[porterwoman]

I don't take care of the HFOV pts yet, have been in our MICU for a little over a year--but, our policy is--no turn for first 24hrs on HFOV, across the board. Beyond that, we take it case by case. I'll look up the policy when I go back to work & tell you more.

RP in the Duke MICU

[Nurseboy1]

Ok so I work in the Duke MICU. We don't have a hard line policy with repositioning HFOV patients. During the first 24 hours we do no position changes. After that period we generally utilize continous lateral rotation and see how the patient's hemodynamics and oxygenation tolerate it. If they tolerate the rotation we will turn the patient.

All that aside it comes down to the individual patient. If we can't wean the oscillator and they are still on high FiO2 I don't turn them. I can treat a pressure ulcer, but it's hard to fix dead.