Who does your IABPs

Specialties CCU

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I was suprised to hear that in some areas the respiratory therapists did the insertion and management of IABPs. At my facility, we have the perfusion department who set them up preop/intraop. As far as management, we have two different types. One is leveled to the patient by a fiberoptic catheter during insertion so it is never leveled or adjusted. The other has an auto mode that is set up by perfusion and according to the manufacturer the operator cannot get the machine to augment better than the automatic mode on the machine itself can do. Pretty big boast, but so far I've never seen it proved wrong. I know it is totally area dependend, we have some great RTs, but I could not imagine having them running the IABP on a heart.

Also, we are not allowed to touch the vents at my facility, even to titrate FIo2, which I think is silly b/c we titrate o2 in every other type patient, I don't know why that is different. I would never change the rate or mode of ventilation, but RT is very territorial about their vents, and we've had nurses get in big trouble even for going from just 40 to 50% for sagging sats until RT could get to the patient. We have a new nurse coming to work with us who did all of the weaning to extubate on the hearts where she used to work. How is the practice where everyone else works on things such as IABPs, vents, etc.

2 threads going on here...

#1. It is perfectly appropriate for the RN to make SIMPLE changes in the vent settings. ie FI02, rate, as long as she is familiar and checked out on the vent, and she immediately notifies the RT of the changes. Rt's are not just techs, they Do have specialized knowledge; and are often not called upon enough to share thier expertise. OTOH, I have heard RT's make some WILD statements about "what should be done", because they don't understand the complete pathophys about CHF, PE, ARDS, etc.

#2. For the above reasons, I would doubt that any RT has the training, skills and ability to interpret waveforms to be able to safely monitor a IABP.

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When you say you can't adjust vent settings is that on fresh cases? We can do anything we want to the vent for the first 24 hrs then its usually managed by RT. We have an average extubation time of 2.2 hrs so we only reach that limit on the chronics.

The new balloons are very close with the auto timing, but there have been instances when I got better augmentation by switching to semi-manual and adjusting it myself. Not often, bt just because the pump supposedly times itself doesn't mean it can't be off.

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No, we can't make any vent changes at any time, period. In order for us to wean on the fresh hearts, we call anesthesia and give them post op abgs, we then get an order to either change vent settings or wean to extubate per protocol. RT has a specific protocol for vent weaning that they use. RNs are not allowed to touch the vent ever, unless we're using 100% O2 for suctioning, otherwise, no change in fiO2 or anything else.

As far as RTs managing IABPs, I'm not sure what exactly they do, I have just heard people say in some places they are involved with the IABP. I am still not sure exactly what they do, if they make changes, watch waveforms, etc, so that's why I posted here to see what other people's experiences are with patients who have IABPs. I know where I work, only the RNs who are heart oriented/IABP certified take IABPs.

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No, we can't make any vent changes at any time, period. In order for us to wean on the fresh hearts, we call anesthesia and give them post op abgs, we then get an order to either change vent settings or wean to extubate per protocol. RT has a specific protocol for vent weaning that they use. RNs are not allowed to touch the vent ever, unless we're using 100% O2 for suctioning, otherwise, no change in fiO2 or anything else.

That sucks. We get gases, k, h/h w/ istat as soon as we get them, then start to wean. Call RT to run extubation gases, if they look good pull tube. I say it sucks because no matter how good of a RT they are often times busy and it would be a pain to wait for them to wean the fi02 and the rate.

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The hospital where I worked, the cardiologists inserted the IABP, and nurses were 1:1, after special classes and certification.

We used to do a lot of 'messing' with the vents, depending whether it was our pulmonologist or one of the surgeons managing the vent.

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That sucks. We get gases, k, h/h w/ istat as soon as we get them, then start to wean. Call RT to run extubation gases, if they look good pull tube. I say it sucks because no matter how good of a RT they are often times busy and it would be a pain to wait for them to wean the fi02 and the rate.

I know, we hate it. Sometimes you have a patient who is wide awake, we've turned their precedex down for quicker extubation, and you've got an RT who doesn't stay in the unit. Most of our RTs are good, but sometimes it is a pain b/c the patient has been ready for maybe an hour or more, and we have to wait on RT. Most of them do go ahead and start weaning fi02 if sats are holding before we get orders to wean. Our mean extubation time is 4-6 hours.

I would be a little worried to pull a tube after 2 hours though, alot of ours are just starting to wake up at this point. Plus, we get alot who come out with a PO2 that is low even on 100%, so we slowly wean and often end up on a venti anyway. How often do you have to reintubate topher? I guess I'm just thinking we would if we pulled our tubes that early b/c our patients aren't awake enough for spontaneous vent without vent support that early. That is an excellent wean time though, and I know getting patients up, doing CDB earlier helps them recover quicker.

As far as when pulmonary or surgeon manages vents, RN calls the MD, gets orders and RT makes changes. We've all said before it's kinda dumb b/c it would make more sense for RT to talk to them if they're gonna be the ones doing the vent. It really stunk as a new nurse b/c there was so much I didn't know, and when intensivist would ask q's about the vent-peak pressures, pt volumes, I didn't know anything other than the basics-rate,ps,peep. Luckily, I had a nice RT that night who talked to the MD and explained to me what we were doing and why, this was a real sick pt on APRV mode, so it was even more confusing than usual for a new nurse.

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