Saturday, April 24, 2010

ICU tip: Watching Trends

If there is one thing I could tell people about staying prepared for anything in the ICU it would have to be to always, without a doubt, watch your trends. I am nerotic about checking the trends on my charting. Heart rate, blood pressure, cardiac output, fluid balance are all things that I like to pay attention to in terms of where they are heading.

Example: The other day I was taking care of my second open heart patient. I was still on orientaiton, but since we were short staffed and they had no one to precept me, I was placed on my own for the last four hours of my shift. When I received the patient around 1:00pm his heart rate was somewhere in the 80's. Normal Sinus Rhythm, no ectopy at all really.

By 4:00pm he was somewhere along the lines of 99-103 in his heart rate. I brought it up with my charge nurse and my preceptor. "Did you check his lytes? What's his potassium and mag. levels at?" "How much fluid has he gotten? What's his CVP? (central venous pressure) His pressures look fine."

"I know his pressures look fine and his lytes are fine...all replaced and on top of that his CVP is 12, right where we want it. But his heart rate is in the 100's now."

The respone I get from everyone: "He's probably fine, he's not really that tachy so I wouldn't worry." Even the doctors said they wouldn't be concerned until he reached over 120.

So here is where the trends come in. If the patient's heart rate was in the 80's upon arrival and has increased by 20 beats per minute in the past 3 hours...where do you think he will be by 7:00pm? (this btw, is conveniently the time when our incredibly intimadting CT surg. attending comes to do his me, the man is scary)
Yup, you guessed it...around 7:30pm the surgeon comes by and my patient is trekking along at a heart rate of 130. Definitely not a good thing for a fresh, post-op CABG patient. I also noticed he had started to shiver a bit, despite the fact that his temperature was completely normal.

My alarms are going off, meanwhile the ICU team (who is also scared to death by our CT surgeons)is trying to decide what to do and probably trying to stall until CT surgery arrives.

To make a long story short the outcome was fine. CT surgery came by and I explained to them the trend I had been noticing. The treatment was much different than expected though. Probably a mix of the patient coming off sedation from the OR and not being properly sedated in the ICU meant he was slightly waking up...while he was still intubated.
We increased his sedation, gave him demerol for the shivering and then ended up giving vecuronium (a paralytic)to help him relax and not tense up so much. This is why I love our scary but brilliant CT surgeons. It worked like a dream and my patient went back to normal. At least long enough for me to give report and get home...far away from the craziness that is the ICU.

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