Want to Discuss Hearts?

hrtprncss · Jul 24, 2006

Same here, pretty much gtt's u see often with these pt's are ntg/neo/dob, we also tend to use albumin more than hespan. Some surgeons really push you to fast track the patients to extubate, though some won't mind if you keep them tubed overnight. A few sneer at you if you pass the 4 to 6 hour timeframe, and the patient is tubed. One hospital I worked at nurses and anesthesiology residents and resp therapy work together for extubation. Some places use weaning parameters, some just wing it and not get NIF's and things like that. At another hospital it's the np/pa who pretty much controls the vents. Of course pretty much no extubation after 10pm. I've worked at places where the surgeons would leave as soon as they get to sit down for the first ten minutes, some stay for about an hour or so, and some you just wish they would leave the bedside already. Some surgeons basically just call about an hour later and do a phone round, some don't even bother calling anymore, they just expect the patient to be up in the chair the next morning, sitting and smiling, so they could write for the tubes to be d'cd.

When it comes to dealing with families, I tend to encourage them to go home, especially if you kinda have a feeling that either the patient will be intubated the whole night, or the patient would be stable so the family can get much needed rest. If the patient seems a little labile then I encourage them to wait in the waiting room, until the patient stabilizes. You don't want to be sending them home and then they'd have to come back in, if something happens.

How many times have you seen the chaos of having to crack a chest open at the bedside? How did that go, I'd like to hear everyone's experiences. Out of ten years, there was only two times where a patient has had to be cracked open at the bedside. Those times I'd never forget, and remember forever. Share your stories please, maybe we can learn from each other, so IF it ever happens again, we maybe could be better prepared for it.

TennRN2004 · Jul 24, 2006

Our nurses and respiratory therapy manage vent wean to extubation. If post op ABGs look okay, we'll get an order to wean for extubation. Generally our goal is 6 hours also, but you have some who are slow to wake up or wake up freaking out and not pulling enough tidal volumes for us to be comfortable pulling the tube, or if the patient has bad sleep apnea we'll leave a few of those on overnight and let them extubate in the am when MDs are present. We don't have residents where I work, so the only doc in house are the ER MDs and the hospitalists, or our intensivists who we call in if they're needed for an emergency.

We used to use albumisol exclusively, but with the nationwide shortage of albumin, our MDs all agreed to use hespan as the first volume expander, then if we need more, albumin. But, if they've been oozy in the OR, on plavix with elevated coags, then we'll use albumisol on those pts.

I have never seen the open heart kit used at the bedside where I work. From what I've heard it's only been necessary once or twice and it's been a long time ago. I have been there on a night when we thought we were going to use it, had it open and ready, surgeon was prepping the sternum to open the patient up. That was not a fun experience.

The patient woke up on the vent going crazy, versed, precedex, and morphine wouldn't calm her down, bp shot up, nurse had surgeon on the phone for something else ativan or haldol, hung up, went to the bedside and saw 500cc had dumped in the chest tube in 2 minutes. Patient had blown a graft, we get him back on the phone, she starts crashing hard. We had nitro and epi back and forth, classic tamponade her ci dropped out, pa/cvp shot up, we ran for blood stat hanging all the fluids we have to keep her tanked up because she continued to put out massive amounts from the CT.

House sup was called to get the CV team in stat, so she calls, surgeon is there, first assist, everybody except anesthesia. Surgeon is yelling wanting us to page first gas man on call tell him to hurry up, and the supervisor gets this awful look on her face. She forgot to page anesthesia to come in. I thought the surgeon was gonna blow his head off he was so pissed, that's when he yelled for the open heart kit and starts prepping the sternum, wants to know if any of use can hook her up to the vent in the OR.

Luckily, anesthesia happened to be close by he calls right back tells the surgeon he'll be there in a minute, so we're running her over to the OR as he's running in the door. We also put her on vasopressin gtt to help constrict and slow the bleeding and gave calcium bolus, but it didn't seem to help much. She ended up getting I think 6 units red cells, plus platelets, FFP, the whole works. She came back though doing fine, we had strict orders to keep her completely knocked out until in the am. She stayed for I think about a week, then went out to the floor and did fine. It sure stresses the heck out of everybody when you've got one like that.

hrtprncss · Jul 24, 2006

Wow, amazing the patient did fine. The first time it happened to me, I was sitting down in front of the patient, and the patient was labile, and u just know something will happen. CT output was pretty high the last two hours, transfusing blood, maxing out the drips, then the patient dumped, as in dumped huge amounts, I call the surgeon and he said he's gonna take the patient back to the OR and he'll be there in 15 minutes. I hang up the phone look up the patient went into vfib right before my eyes as I was looking at the monitor. Called a code, defib the patient, nothing happening, the cv fellow comes and tried everything, then he says, ''get the kit, get the kit''. Opened up the pt, suctioned about 2 liters out, the surgeon calls ''bring her in the OR now" CV fellow jumps on the bed started internal compressions with his hands while he was on top of the bed, about 8 people pushing the bed to the OR with the CV fellow compressing...Finally got back to the room, it looked like a tornado touched down, couldn't chart, couldn't do anything, soooooo exhausted...unfortunately the patient never made out of the OR. Second time it happened, the patient was awake but looked real real real crappy, then just crashed, this time there was no chest tube, CV fellow says "he's tamponading, tamponading we need to open up" same thing happened, opened up, we had about 3 saline bags on pressure bag, called to have O negs be sent up, was taking forever, and just pushed as much hespan and albumin we could, finally patient was taken back to the OR, came back, stabilized, and was able to go home about a month later. IF these things happens a lot, I prolly would be burnt out after the first year, luckily most of the time it's smooth sailing.

JustMe · Jul 30, 2006

Oh you guys!! Surgery isn't the only way to treat a heart! Give me a good ol' MI, CHF, pulm edema, crappy valve any day!:roll

I've noticed when I float to the Surgical ICU, where our CABG pts go, that they (ahem) ignore their monitors! I LOVE watching the rhythms! Electrophysiology is SOOOO interesting! Nothing I love more than a sick heart that goes into VT! (I know--it sounds sick:p ).

When you have a sick heart the rest of the body goes next--full lungs, no U.O., bloated gut, neuro signs--we've got it ALL in our CICU!

heartICU · Jul 30, 2006

So, where do you guys want to start? I'll give you a run down of how it is where I work. Six surgeon cardiac thoracic team, do an average of 3-4 CABs daily, lots of thoracic cases also, a few AAAs, usually 1 0r 2 IABPs weekly, only gets VADS about every other year. Our goal is to have our hearts extubated, off all gtts, pull the Swan, and have them sitting up in a chair first day post op, hopefully transfer to the floor in 24 hours. Here lately though, they seem to be sicker and sicker, lots of redos, chronic renal issues, CHFers with crappy pumps (EFs in the 20-30 % range), so we're keeping a lot of them in the unit longer. How is it where you guys work?

When I worked in the CTICU, we did 20-25 hearts/thoracic cases a day (we have five CTICUs, one medical CICU, and one medical Heart Failure ICU). Balloon pumps maybe once a week, VADs about 1-2 times a month. PAtients with normal EFs typically were out of the unit in 24-48 hours, failure patients usually a little longer, and patients with the 10-20% EFs were usually there about a week. We pull all lines except pacer wires - they would go to stepdown with them in, and get them pulled 24 hours before discharge. Each nurse gets two patients, unless they were a VAD, ECMO, transplant, or came from the OR with an open chest. They were always 1:1 unless we had the staffing to put 2 nurses on it.

Every patient came up with nipride, nitro, levo, epi, amicar, and insulin made up and in the pump - sometimes they were running, sometimes not. Occasionally milrinone and aprotinin if they were more than a second time redo or a VAD explant. Occasionally Natrecor, and once in a while, with a really sick one, nitric oxide. Have only seen an open heart patient on a neo drip once - previous experience with levo sent him into a variety of malignant ventricular rhythms. Rarely vaso/dopa/dobut. Not that we don't use them, they just rarely came from the OR with them.

Most patients have a swan unless they were young, otherwise healthy, normal EF. In that case they usually just had a large MAC catheter. CTs were pulled POD#1 after drainage had been minimal for two hours. Unit RNs pulled them.

Staff rounds once about an hour after the patient arrives in the unit, then either goes into the OR again for their next case or goes home. The fellows manage the cases overnight. Same with anesthesia.

Very interesting to hear how other hospitals work!

TennRN2004 · Jul 30, 2006

Oh you guys!! Surgery isn't the only way to treat a heart! Give me a good ol' MI, CHF, pulm edema, crappy valve any day!:roll
I've noticed when I float to the Surgical ICU, where our CABG pts go, that they (ahem) ignore their monitors! I LOVE watching the rhythms! Electrophysiology is SOOOO interesting! Nothing I love more than a sick heart that goes into VT! (I know--it sounds sick:p ).
When you have a sick heart the rest of the body goes next--full lungs, no U.O., bloated gut, neuro signs--we've got it ALL in our CICU!

Not sure what you mean exactly by "ignore the monitors" but I can tell there are cases where you keep one eye on the monitor and one eye not that worried about what you see. For example, had a pt that was emergent, had a huge MI, went into arrest in cath lab, the whole works, he came back from OR with runs of PVCs, all MDs aware, it was assumed it was reperfusion arrythmia since the pt would go back into NSR after maybe 6 or 8 beats, and elytes were perfect. Also, we've had pts with ST elevation post op, not that we don't pick up on it, but if pt has pericarditis (which alot of them do since there's inflammation around the pericardium) they will have ST elevation on the EKG/tele and we don't worry about it. If they have ST elevation not attributed to pericarditis, we still just watch it. You know why they have the STE, but they've been to surgery to fix it, so what are you going to do about it? I wouldn't say that I ignore my monitor, I know what is going on at all times, but my response to what I see differs than if I was in our CCU next door with a rule out MI with new onset STE that may need a trip to cath lab, in active CP, with cardiac enzymes trending up.

And I don't think anyone is saying surgery is the only way to treat a heart, or that nurses who do cardiac in any other type of ICU do not have just as important a job. But, once you do the post op hearts, there's just something about them, if it's your thing, you love it. For me, it's not that I feel super smart doing the hearts or rub it in to other nurses who don't (a common misconception where I work, and some of the heart nurses probably do have a snobby tude b/c they work with hearts). What I love is the intensity of them, they come back totally out of it, usually awake within a coupla hours, getting extubated, getting lines out, putting the pieces together with what you see from cath report-EF, rt vs lt sided MI, valve insufficiency, etc. I feel very rewarded when I end my shift that I accomplished so much, a different feeling from the chronic medical pts I used to work with. Not that there's anything wrong with that, I love being an ICU nurse and enjoy my job where ever I work, but the hearts are my favorite hands down.

TennRN2004 · Jul 30, 2006

Wow, amazing the patient did fine. The first time it happened to me, I was sitting down in front of the patient, and the patient was labile, and u just know something will happen. CT output was pretty high the last two hours, transfusing blood, maxing out the drips, then the patient dumped, as in dumped huge amounts, I call the surgeon and he said he's gonna take the patient back to the OR and he'll be there in 15 minutes. I hang up the phone look up the patient went into vfib right before my eyes as I was looking at the monitor. Called a code, defib the patient, nothing happening, the cv fellow comes and tried everything, then he says, ''get the kit, get the kit''. Opened up the pt, suctioned about 2 liters out, the surgeon calls ''bring her in the OR now" CV fellow jumps on the bed started internal compressions with his hands while he was on top of the bed, about 8 people pushing the bed to the OR with the CV fellow compressing...Finally got back to the room, it looked like a tornado touched down, couldn't chart, couldn't do anything, soooooo exhausted...unfortunately the patient never made out of the OR. Second time it happened, the patient was awake but looked real real real crappy, then just crashed, this time there was no chest tube, CV fellow says "he's tamponading, tamponading we need to open up" same thing happened, opened up, we had about 3 saline bags on pressure bag, called to have O negs be sent up, was taking forever, and just pushed as much hespan and albumin we could, finally patient was taken back to the OR, came back, stabilized, and was able to go home about a month later. IF these things happens a lot, I prolly would be burnt out after the first year, luckily most of the time it's smooth sailing.

Ouch, don't you just feel helpless in those situations? You need to do 20 things at once, and you can't get any of them done fast enough. It never fails to amaze me that in spite of all the trauma we put some of these pts hearts through they end up surviving.

I think it's an advantage to have the fellows around. We don't have any interns of any type at my hospital, so they always have to drive in, and it's a long wait even if it's only 10-15 minutes when one is going bad.

hrtprncss · Jul 30, 2006

That's what I heard about community hospitals that don't have fellows or interns, they pretty MUCH are more autonomous because they don't have residents that would be there in a minute, so I heard typically the RN's from community hospitals would have to be pretty fast, and can function well alone.

chaosRN, ASN, RN · Jul 31, 2006

When I worked in the CTICU, we did 20-25 hearts/thoracic cases a day (we have five CTICUs, one medical CICU, and one medical Heart Failure ICU). Balloon pumps maybe once a week, VADs about 1-2 times a month. PAtients with normal EFs typically were out of the unit in 24-48 hours, failure patients usually a little longer, and patients with the 10-20% EFs were usually there about a week. We pull all lines except pacer wires - they would go to stepdown with them in, and get them pulled 24 hours before discharge. Each nurse gets two patients, unless they were a VAD, ECMO, transplant, or came from the OR with an open chest. They were always 1:1 unless we had the staffing to put 2 nurses on it.
Every patient came up with nipride, nitro, levo, epi, amicar, and insulin made up and in the pump - sometimes they were running, sometimes not. Occasionally milrinone and aprotinin if they were more than a second time redo or a VAD explant. Occasionally Natrecor, and once in a while, with a really sick one, nitric oxide. Have only seen an open heart patient on a neo drip once - previous experience with levo sent him into a variety of malignant ventricular rhythms. Rarely vaso/dopa/dobut. Not that we don't use them, they just rarely came from the OR with them.
Most patients have a swan unless they were young, otherwise healthy, normal EF. In that case they usually just had a large MAC catheter. CTs were pulled POD#1 after drainage had been minimal for two hours. Unit RNs pulled them.
Staff rounds once about an hour after the patient arrives in the unit, then either goes into the OR again for their next case or goes home. The fellows manage the cases overnight. Same with anesthesia.
Very interesting to hear how other hospitals work!

I really need to work there!!! I love fresh hearts & especially VADS. I don't get the fresh hearts often because I precept new nurses.

I haven't seen a fresh heart opened up at the bedside. It's only happened once since I've been in CV & I wasn't there that day :sniff:

I have seen a chest opened at the bedside...the pt was a post op cabg real sick...he was post op weeks...anyway, had a bad sternal infection, we were using a wound vac on him, cleaning many many times a day, the surgeon decided to open him up & clean him out from the inside. He opened him up with the chest cracker box, and pressure washed his insides. It was so gross & really exciting at the same time.

I'm waiting for a emergent tamponade, my patient or not, I'd like to see the MD open a chest at the bedside. Am I wrong for that?

We don't get many Swans anymore unless they are really sick or have a really bad heart. We (RN's) pull Swans, alines 1st pod. chest tubes are pulled 1st or 2nd pod depending on drainage. The MD pulls the temp pacer wires before the pt goes home. We usually send the pt to stepdown 2nd pod. 1st pod if they are walking & doing great.

In our CVICU, we get 2 patients. Sometimes 3 depending on staff. We are only 1:1 with a VAD or CVVHD. They try to make our fresh hearts 1:1 at first, but it doesn't always happen like that. If you have another pt, they are very stable have stepdown orders. Our IABP are almost never 1:1.

I agree with heartICU - it's very interesting to hear how other unit work & manage the heart pts.

Trauma · Aug 7, 2006

We are a 30 bed CV Recovery/CVICU. Our 10 bed recovery bay is dedicated to all fresh surgical patients. We average 100 pump cases a month including CABG,Valve replacements/repair, AAA, Thorocoabdominal Aneurysm repair, TMR, and MAZE. Our pump cases are 1:1 for the first 4 hours and then if the patient is stable the ratio is 1:2. We have a extubation goal of 6 hrs post op that is achieved by RT/RN collaboration. Four hours after extubation, the patient, if stable, is assisted to a chair(lines and all). Chest tubes are pulled usually the 2nd day post op if CT output is less than 80ml during the last 8 hrs. Common drips include Dopamine, Dobutamine, Milrinone, Nipride, Cardene, NTG, Amiodarone, Epinephrine, Norepinephrine and Insulin. 99% come back with Swan, A-line, CT, Epicardial pacinf wires, foley, etc. Once the sun goes down. its just he nurses and the patients, no residents.

I have been involved in about 25-30 emergent bedside sternotomies. I don't get the adrenaline rush anymore. After 9 yrs of seeing it, I am a lot more chilled and relaxed now. But I do remember the days! My attitude has changed over the last 5-6 years in that I would much rather take care of one of our chronics in the ICU than admit a fresh pump. Reason being for me is,recovery became routine. Writing down numbers every 15 mins. Extubate them and then its Morphine and Ice. I enjoy the multisystem complications that keep you on your toes in the ICU. Yes when a CABG goes bad, its a great learning experience, but there are more standard cases than unusual ones.

For volume...give me isotonic normal saline. My rationale is that if I need volume for a dehydrated, hemoconcentrated patient, the last thing I want to do is give large protein molecules to further dehydrate the cells as colloid osmotic pressure pulls volume intravascularly. When they get normovolemic, I'll check a HCT to where I am now that the pressures are good. And Saline is way cheaper than Albumin or Hespan. Albumin has its place but I prefer Saline to start.

It definately is interesting to see how other place run their units.

SorenDrake · Aug 12, 2006

I work in a 24-bed general critical care unit. We have 2 CV surgeons, do 4-12cases a week. ONly certain nurses who've done specialized training recover them, and they're 1:1 for first two shifts post-op, longer if the pt's really doing poorly.

We have about 8 pages of pre-printed post CVOH orders the docs sign, including sedation and ventilator weaning orders. It took me a while to get used to it, but the docs trust and expect us to order a Hct or K+ whenever we feel it prudent. As far as the weaning goes, the nurse's work with RT, which I find frustrting most of the time. I realize the RT's are busy, but I can't be going to find them for every step, especially when it's the exact same steps all the time! Recently I had a pt down to the last step, was 10min away from PFTs (we do MIP and FVC and STV), and I discover the RT went on lunch break!:angryfire And the person watching for her typically works peds and had no idea how to get an ABG from an art line, and also couldn't do the PFTs. (she said she couldn't find the equipment, and it was 45min before she found it) Needless to say, the pt was severely fatigued and in pain by the time the regular RT came back, and the pt failed. I had such a hard time refraining from chewing RT out. I just made sure she knew how frustrated I was.

One doc prefers albumin, the other hespan. Of course, the pt usually comes up from the OR with a few extra bags of saline or LR's up, and if needed can be "used." Typical meds are dop, dobut, NTG or Nipride, diprivan for sedation. We also use toradol in scheduled doses once extubated and if creatinine is ok, and no HX of kidney problems. It seems to control majority of pain for most pts.

I think the worst pt I've had so far was the mother of one of our infectious disease docs. I was so nervous because he's one of those docs that is a pain in the but (we have computer charting, use the computer for everything including lab results, xrays, etc. He demands that everything be printed out every AM and put on chart before he gets there. Heaven forbid your other pt is crashing and you don't have time--he'll throw a fit until someone does it) Anyway, a little old lady with bad osteo, was supposed to have an AVR and CABG*2, but they had problems. Had a weird art line situation-one radial they said wouldn't work so they put in a femoral and "piggybacked" it into the radial, had never seen that before. They had trouble placing the cordis and swan, so she only had 2 cordis's and a CVP on one of them. No CO or CI, no SvO2...ANd of course, I'm relatively new off heart orientation, and there are no other heart nurses there for help/support. RT is blocking me from all of my lines, is very rude when I tell them to move, charge nurse is trying to help me organize these lines, pt was HTN one minute, then no BP the next! The charge nurse and I think the art lines messing up, there's still a rhythm, we try to troubleshoot the lines, no change. crap. i think i said that several times. I start feeling for a pulse, none. she starts, then i listen for heart sounds...none. well my word changed to shiot, code starts, and practically the whole unit is down there, the doc returns...pt finally comes back after much fluid and epi gtts...rollar coasters the entire rest of the shift. Amazingly, doctor-son is wonderful, just gives me his cell and home numbers, says he knows we're busy working, and leaves! After much thought and analyzation with my educator, we decide she was probably hypotensive in elevator, (anesthesia is notorious for giving a little bolus of something there and not telling) problly got some epi IVP, hence the HTN when I got her, then the fluid status caught up with her, and since I didn't have the usual lines (no SvO2 to suddenly drop), there was no warning. The pt ended up in step-down 2 days later. I don't think I slept very much that night. Thankfully, I've not had one like that since. I will be using all this experience when I become a CRNA, and trust me that I won't be giving little boluses and then ahanding them off without a word...