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EASE YOUR WAY THROUGH FACILITATION Everything  your  preceptor   told  you... But  your  brain  was  too  full  to  remember!

Tuesday, September 18, 12


Neuro Know  the  signs  and  symptoms  of  a  stroke Pupils,  cough,  and  gag  reflexes  important   assessments  for  intubated/sedated  patients Check  blood  sugar  and  blood  pressure  if  noting   neurological  change Ask  a  peer  for  input!

Tuesday, September 18, 12


Ventilator Peak  Airway  Pressure Caused  by  anything  that  increases  pressure  in  the   chest ARDS,  Pneumothorax,  Tamponade,  Mucous   Plug,  Pneumonia Watch  the  trend Coughing  is  normal  cause  for  high  airway  pressure

Tuesday, September 18, 12


Ventilator Common  Modes  of  Ventilation PRVC-­‐Pressure  Regulated  Volume  Control Provides  a  lot  of  support Can  be  very  uncomfortable

SIMV-­‐Synchronized  Intermittent  Mandatory  Ventilation Provides  moderate  support Appropriate  mode  for  weaning

PS-­‐Pressure  Support Minimal  Support Weaning  mode Tuesday, September 18, 12


Ventilator Weaning  Parameters NIF Anything  less  than  -­‐20  is  good (ie  -­‐20  to  -­‐50) FVC Should  be  weight  in  kg  x10 RSBI Less  than  100  is  ok  but  closer  to  50  is  better

Tuesday, September 18, 12


Hemodynamics Know  the  normal  hemodynamic  parameters Watch  the  trends  for  your  patient  and  be  aware  of   aberrations  from  the  norms  for  that  patient Know  your  patient’s  Ejection  Fraction Ask  your  preceptor  or  other  seasoned  staff   member  questions  if  you  are  unsure.....it  is  a   matter  of  patient  safety

Tuesday, September 18, 12


SvO2 Venous  Oxygen  Saturation Association  between  oxygen  carried  to  tissues  and  the  oxygen  utilized

Factors  which  INCREASE  SvO2   and  DECREASE  demand  for  O2 Anesthesia/sedation

Factors    which  DECREASE   SvO2  and  INCREASE   demand  for  O2

Hypothermia

Cardiogenic/septic  shock

Increased  SaO2

Fever

Increased  Hgb

Decreased  SaO2

Increased  CO

Decreased  Hgb Decreased  CO Seizures/shivering

Tuesday, September 18, 12


SVO2 Hgb/Oxygenation/Cardiac  Output Drawing  Mixed  Venous/Recalibrate  CCO Must  draw  Hgb  with  each  calculation Press  draw  on  CCO-­‐-­‐draw  3ml  waste  and  1/2ml   specimen  from  PA  port  of  swan Specimen  should  be  drawn  at  rate  of  1ml  per   minute The  O2  sat  is  the  SVO2  on  a  venous  blood  gas

Tuesday, September 18, 12


Tamponade Tachycardia

Elevated  CVP

Low  blood  pressure

Distant  heart  tones

Narrowed  pulse   pressure

Decreased  urine   output

Low  cardiac  index

SOB

Low  SVO2

Low  SaO2

Tuesday, September 18, 12


Cardiac  Output CO=  HR  X  SV Not  as  simple  as  it   looks High  HR  decreases   SV  decreasing  CO Very  high  SV  will   decrease  HR Many  medications   will  have  positive   and  negative   influence

Tuesday, September 18, 12

Use  nursing   assessments  to   evaluate Urine  Output Mentation Capillary  refill Don’t  forget.... Assess  your  patient  and   don’t  rely  on  the  monitor!


Cardiac  Output Verify  value  using  Fick  equation For  most  accurate  value  obtain  fresh  mixed  venous  and   ABG 125(males)  or  120  (females)

13.4  X  Hgb  X  (SaO2-­‐SvO2) SaO2  and  SvO2  are  percentiles  (i.e.  .99-­‐.75)

Tuesday, September 18, 12


CVP CVP  with  a  swan  is  in  the  right  atrium  (more   accurate  measurement  than  with  a  regular   CVL) Measures  venous  return  to  heart  (pre-­‐load) Abnormal  values  (high)  can  indicate: Fluid  Overload

Right  Heart  Failure

Pulmonary  Hypertension

Tricuspid  Valve  Disease

Tamponade

Right  Ventricular  Infarct

Tuesday, September 18, 12


PA  Pressure PA  Systolic Measures  RV  systolic  ejection  (amount  of  pressure   needed  to  open  pulmonic  valve) Abnormal  values  (high)  can  indicate: Pulmonary  hypertension

Left  Heart  Failure

VSD

ARDS

Fluid  Overload

Tuesday, September 18, 12


PA  Pressure PA  Diastolic Measures  the  resistance  of  pulmonary  vascular  bed   with  pulmonic  valve  closed  and  tricuspid  valve   open  (close  estimate  to  wedge  pressure) Abnormal  values  (high)  can  indicate: Left  Heart  Failure Tamponade Mitral  Stenosis

Tuesday, September 18, 12

*Fluid  Overload  vs.  Pulmonary  HTN* PAS  will  be  high  in  both  but  in  pulmonary  HTN  wedge   pressure  (we  will  use  PAD)  should  be  close  to  normal   and  in  fluid  overload  the  PAS,  PAD,  and  CVP  should  all   be  elevated


SVR Measurement  of  afterload

SVR=  MAP-­‐CVP                  CO Force  the  heart  has  to  pump  against

High Hypothermia Hypovolemia Response  to  surgical   stress

SVR  has  a  direct  effect  on  CO Tuesday, September 18, 12

Low Hyperthermia Hypovolemia Inflammatory   Response Sepsis


Ionized  Calcium Ionized  Calcium  level  measures  the  physiologically   active  free  calcium Calcium  is  a  positive  inotrope  (increases  the  force  of   muscle  contraction) Banked  blood  has  citrate  to  prevent  it  from  clotting Citrate  binds  to  calcium  lowering  levels Ionized  Calcium  levels  should  be  checked  after  4units   of  RBC’s  

Tuesday, September 18, 12


Nitric  Oxide Vasodilator  inhaled  via  ETT  to  decrease  PA   pressures    and  increase  PaO2 Runs  in  PPM While  weaning,  monitor  CVP  and  PAP May  start  Viagra  prior  to  weaning

Tuesday, September 18, 12


pH  and  BP If  your  pt  is  acidotic,  your  vasoactive  drips  may   not  be  effective Try  checking  an  ABG  if  going  up  on  drips  and   BP  is  not  responding May  need  NaHCO3  to  correct  base  deficit Watch  Na  levels  when  giving  multiple  doses  of   NaHCO3  (may  need  Tham  drip  if  Na  is  high)

Tuesday, September 18, 12


Treating  High  K+ Regular  Insulin  IV  (10  units) D50  1amp  IV Calcium  Chloride  1amp  IV

Albuterol  10mg  Neb   Treatment

NaHCO3  1  amp  IV These  methods  force  K+  back  into  cells.    They  are  temporary   fixes  as  the  K+  will  eventually  leak  back  into  vascular  system Kay-­‐Exylate  30-­‐60  grams  PO/ NG/PR  (may  take  a  while  to   work)

Dialysis (Hemodialysis  or  CRRT)

These  methods  permanently  remove  K+  from  the  body

Tuesday, September 18, 12


Coagulation Platelets May  be  low  or  ineffective  due   to  meds

Protamine  (reversal  for   heparin)

Treat  with  platelets/DDAVP

FFP

PT/INR FFP  for  quick  reversal Vitamin  K  (6-­‐12hrs  to  work)

Fibrinogen Cryo

Tuesday, September 18, 12

PTT

Cryo  may  be  needed  if  Factor   VIII  low

Rule  of  Thumb: For  every  4  units  of   RBC’s....Give  one  unit  of   yellow  


Immunosuppression All  transplants  must  be  on  one  med  from  EACH  of  the   categories  below Steroid

Antiproliferative

Solumedrol  IV OR Prednisone  PO

Cellcept   OR Myfortic

Tuesday, September 18, 12

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Calcineurin   Inhibitor Prograf     OR   Thymo   OR   OKT3     OR Cyclosproine


Facilitation guide