Should OR RN's be ACLS/PALS certified?

shodobe · Jun 17, 2004

jwk, it seems to me you have a higher opinion of yourself than I do of myself. I am confident enough in my self to know what to do when it is necessary. This is not about what I know and don't know. It is about wether OR nurses need to be ACLS or PALS cert. My OPINION is, no. You obviously are more intelligent than I and keep up on all the drugs and changes. I, on the other hand, am just a grunt worker paid to do what he is told to do during a code, just like you're supposed to do. I think you might be confusing me with a previous post because it sounded like you thought I and my co-workers just stand around doing nothing. We have the same protocol as your hospital has and we still don't need PACU rescuing us because we all know are part of a code. As you can see your response has the hairs on the back of neck standing u. End of discussion.

stevierae · Jun 17, 2004

For those wondering about cross-allergy with PCN and cephalosporins - it is certainly not rare. It's on the order of 10-15%.
However, severe anaphylactic reactions are unusual. And not all cases get an ETT, so your anesthetist's assertion is somewhat ridiculous.
Finally - the latest recommendations for antibiotic usage in surgery recommend that the antibiotics be given not less than 30 minutes prior to skin incision. That's easy for drugs like PCN and Cephs, which can be given fairly rapidly after a test dose. Others like Vanco and Cipro need to be given much more slowly, so we try and start them 1 hr prior to going to the OR so that they will be fully infused by the time of the incision. The timing does make a difference in post-op infection rates.

Gosh, jwk, we are not rookies here! I think we all know about recommendations for when antibiotics should be given before surgery; as well as the fact that NaHCO3 is not given routinely any more (always based on blood gases) and we all know the infusion recommendations for Vanco; to avoid Red Man's Syndrome.

We also, even if one is not certified in ACLS, know that Bretylium has not been around for quite some time (check any code cart and you won't see it. I haven't seen it in probably a decade.)

And I do know that the cross sensitivity to both cephalosporins and PCN is reported to be around 10%. Never seen it quoted as high as 15%, but that could be true; not disputing you.

What I guess I meant to say is, regardless of the rate at which it is reported in the literature, one can go one's entire career and NEVER see a case of a cross sensitivity to BOTH cephalosporins and PCN. In fact, I have seen only ONE in almost 30 years of practice. In the '80s, you never saw an anesthesiologist even bother with a test does; cross sensitivity was thought to be so uncommon. Only in the '90s did I start seeing anesthesia providers give test doses, and that was by no means across the board. I have to say that CRNAs, as a rule, are more cautious, which is a good thing, then many anesthesiologists, who can get a little cavalier. I have seen an anesthesiologist delibeerately push Vanco to prove to a nursing student his theory that Red Man's syndrome doesn't always happen as reported in the literature. He literally said to her, "I don't believe in that one hour rule. Anesthesiologists push much more dangerous drugs than this. I push EVERYTHING. Watch." Well, it happened, and he treated it appropriately, but she left with a different impression of him than I am sure he would have liked her to have.

I really found your post to be quite condescending, even if you are an anesthesia provider. Many of us are very experienced operating room nurses; many of us (myself included) do other types of nursing and are nurse educators, as well. I am an IV nurse educator as well as a legal nurse consultant. I also keep up with the literature and, of course, with new evidence based practices, and modify my own practices accordingly.

Are you an anesthesia provider? I certainly hope you don't treat the OR nurses in your OR with the same condescending, contemptuous attituted with which you seem to view us.

And, as a matter of fact, I can mask a patient very well, whether pediatric or adult, as well as start both pediatric and adult IVs skillfully and efficiently. I can also put in an airway, and, during my years as a Vietnam era corpsman, have done a stab trach or two to save a life. Any OR RN who has worked with private practice anesthesiologists can mask and start IVs; in peds cases, it used to be just the circulator and the anesthesiologist; one would start the IV and one would mask; either could fulfill either chore equally well. if you didn't know how, you soon learned.

I cannot intubate, and wouldn't. Learning in ACLS on a fake patient is not the same as the practice anesthesia providers and EMTs and RTs get on human patients. I know my limits.

Also, FYI---as an LNC, I have sat in on more than one depo involving an OR death after an arrest. Never, NEVER, has the "code record" been asked for or entered into evidence. The anesthesia record tells its own story. That is all that has ever been asked for in a request for document production. It is more than sufficient for the medical examiner, as well, at least wherver I have practiced. I cannot speak for Georgia or the rest of the South. I have done cases in Florida, however, where it was not requested; again, all that was looked at as a record of events was the anesthesia record.

As a circulator, I, too, chart a brief description of what occurred; of course I make sure that what anesthesia documents and what I document are the same.

I'll say this again: most "codes" that occur in the OR are on a patient who already has a protected airway; hence, they are not the high drama people make them out to be. Also, they are often transient and not "codes" at all--more often PEA due to some transient problem (i.e., knocked of a bleb during intubation; tension pneumo results; stick an IV catheter in the intercostal space (think it's 4th or 5th; not sure) to relieve the tension pneumo; PEA reverts to NSR. Then, if need be, you can put in a chest tube and either continue with or cancel the surgery.

Or, it's a vasovagal reaction. Or, the pulse oximeter falls off or an EKG lead gets displaced and people freak out when alarms ring and the datascope looks like Vfib (but is really artifact.) The code cart is pulled in and everybody realizes: We didn't look at the patient, only at the monitors. Everybody looks sheepish and embarrassed. In any case, most "codes" in OR are over before one can "record" anything on a code record.

"Show's over! Nothin' to see here, people!"

shodobe · Jun 17, 2004

Well put, stevierae. I just have trouble putting into words on the computer what I think. I"ll be the first to admit I don't know everything about all drugs but know enough about the ones I might give in the OR to keep out of trouble. Luckily, the number of drugs we give in the OR is small and usually the same over and over. I still have to ask about some drugs that show up on patient's drug sheets. Some are completely over my head and I haven't a clue what they are. Doesn't make me a bad person. The worst thing about antibiotics being given before surgery is we get the patient from the floor and guess what- the little piggyback is sent with the patient and we end up giving it in the room. So the recommended one hour or so before surgery is null and void because the floor nurse forgot ot start it. We have been using alot of Cefotan and Rocephin(?) lately without any problem. If you had to try to remember everything that needed to be watched over then why would you need anesthesia or? If you have good, competent anesthesia then that is one less worry for you. I am still responsible for looking at all aspects of the patient's care but still rely on others to do certain things also. I don't think it is wise to worry about every detail. Leads to early retirement. Rambling, sorry got to go. Mike

squeek · Jun 18, 2004

ditto to shodobe and stevierae!

I did not mean literally ... I realise all do not have ETT, this was a bloody unlucky situation.

in Oz we do not start Abs prior to surgery {maybe we are a LITTLE behind}.!!! in litigation too happily.

I can manage ANY airway>>> 10 yrs of recovery ensured that... I can place an LMA if required; obviously a guedels or nasopharyngeal; I have placed ETT under anaesthesia supervision, but would not do so without .. it is not in my scope of practice in Oz. I will not lose my licence for such a reason ... bag and mask til they wake will work for me.

cheers Squeek

stevierae · Jun 18, 2004

in Oz we do not start Abs prior to surgery {maybe we are a LITTLE behind}.!!! in litigation too happily.

You know, that 30 minutes before incision rule is literally almost written in stone here--no more (unless, like Vanco, you need an hour) no less. In fact, I believe it is a CDC guideline; don't quote me, but the guidelines have been revised fairly recently because hospital aquired infections, (formerly called "nosocomial") especially post-op ones, have become so rampant.

Now, those of us who are OR nurses prefer to blame the floor nurses for poor hand washing practices--and indeed that is usually the case with MRSA and VRE--but there are others that have been looked at by infection control and the OR criticized for not getting the antibiotic in within that golden half-hour before the incision is made. rarely is it ever found to be due to an unsterile insturment or a break in technique, even after scrupulosulay examining flash autoclave graphs and pulling entire loads of autoclaved instrumetns ot make sure the sterile indicators have "turned." It usually boils down to the wrong choice of antibiotic (although in ortho, good ol' Kefzol still is standard of care, and it's cheap, and it WORKS) or an antibiotic not given in a timely fashin, when it isn't a patient with risk factors for infection (obesity , diabetes, immunocompromised.)

In fact, I am analyzing 2 med mal cases right now that are almost certainly because, in one, NO antibiotic was given pre-op (pretty much standard of care these days to give a pre-op antibiotic) and in the other because it was given well after the incision was made. There simply is no other logical explanation--these were ortho outpatients, so we can't blame the floor nurses, LOL!

squeek · Jun 18, 2004

hey I should have been a little more specific, we do give Abs before incision but not on ward pre-op. I wonder if else where in Oz they are following your trend [as we invariably will do, it is just a matter of time]

:) squeek

squeek · Jun 18, 2004

ps. not a standard of care here yet, many procedures are done without antibugs!

squeek

lifeisbeautiful · Nov 21, 2004

I do agree the more you know the more your going to be responsible for.

Isn't that the truth! My employer will 'push' extra classes and certifications onto people. Though it is wonderful to obtain the education, I often question the real motive behind it. Like you said, the more you know can often used as a way for the hospital to assign 'just one more assignment now that you know about----(fill in the blank)'

This is why I let my ACLS expire. Mike

Unfortunately, if I did that, I wouldn't be allowed to work in the PACU. ACLS/PALS is a requirement where I work for PACU nurses. Plus, if PACU Nurses weren't certified, who would help the Anesthesiologist and the Surgeon with the patients during a Code?

shodobe · Nov 21, 2004

Going way back to mt original post, I let my cert expire because we don't require it. If it was a required like alot of ORs do, I would certainly get it. Unlike the main OR, PACU is left alone with many problem patients and do not always have the luxury of anesthesia being there, so of course they are required to have ACLS/PALS. If you go through the older threads you will fine a few about CS and such and about if it iss a good idea to have all of these responsibilities in the OR, not PACU. There are many opinions on wether to have or not to have certs a requirement to work certain places. I am not by any means a drug wiz, but I know enough about them to get by and stay out of trouble. Mike

emcrn · Dec 13, 2004

Our hospital does not require ACLS/PALS for OR nurses. However, if you want to be able to administer conscious sedation then you must have ACLS. Personally I consider it a professional responsibility to keep up my certifications, even if the chances of my having to use any of my knowledge are (thank God) slim to none, because of the presence of MDAs and CRNAs in the rooms. Just because you "don't have to" do something doesn't mean you shouldn't do it anyway.

Ellen

nurselily3 · Jan 10, 2005

I think it would be a good idea. Having information to better care for your patient is never a bad thing. As an ACLS/PALS cert nurse (used to be in the ICU and now in the OR) I think it helps me keep up with what's going on. In fact, I think all acute care nurses should be ACLS certified.

stbernardclub · Jan 10, 2005

Oh my God....O.R. nurses that do not need A.C.L.S????????????????? NUTS!!! TOTALLY NUTS!!!!!!

Ok, remembering that I work PACU my question occurs because out hospital has determined that it is unecessary for the OR nurses to take ACLS etc, except for BLS(basic life support) since there is an anesthesiologist in the room. This is purely a cost cutting matter we believe. Whats up in your neck of the woods? We are a 290 bed acute care facility averaging 15 cases(give or take) a day.
Thanks,