What is the most complex clinical procedure you had to do in your career?

3 As a student in her final year, the most complex clinical procedure for me has to be cleaning and packing a wound. I did this numerous times during clinical. What about you?
Routine tracheostomy tube change (but at the request of my pulmonolgist who happened to be attending and the blessing of my CI) not just inner cannula. A full trach change.

I would have to say that it's the routine BID dressing changes of a severely burned patient. It can take 3+ hours with 2 RNs, a PCT and an RT to manage the vent. Another RN to give IV meds, plus the heat lamps and the extreme amounts of PPE. Burn ICU nursing is the most complicated type of nursing IMO. Some wound VACs or Coloplast dressings can also take hours with conscious sedation. Keep it real.

RN delivery of a macrosomic infant with a 2-minute shoulder.

Following certain phase 1 trial protocols where you're timing the drug infuion just so, getting pharmacokinetic levels, documenting side effects religiously, getting EKG's set times after the drug hits the patient (so you need to know how many ml's of saline are primed in the tubing) and God knows what else.

I had a patient with necrotizing fasciitis that started in her labial area who ended up with a surgical wound stretching down into her inner thighs, up through both labia, her abdomen, and all the way up the side of her ribs by the time the removal of affected tissue was done. That was a complicated dressing change just because of the size of the wound, and the fact that she was obese to begin with, so parts of the wound were five inches deep. I think I used at least ten rolls of saline-soaked kerlix to pack it and at least 7-8 abd pads to cover it up. It took several people to hold the fat back to keep the wound from collapsing into itself while the dressing change was being done.It was very memorable because I had her before surgery too, and the initial complaint she presented with was a black blister about the size of a silver dollar. I remember seeing it and knowing it was bad because of the obvious necrosis, but I never imagined the tissue damage was so extensive.

Big burn dressings - yeah, for all the reasons stated above plus placing the actual dressings isn't as intuitive as you would think. It's a bit like trying to piece together a jigsaw puzzle without being able to manipulate the puzzle pieces first if that makes sense.Throw in an unstable pt who is on CRRT and pressors, and you are turning this patient from side to side frequently...blegh.

Wound vacs can get complicated sometimes. My most complicated was a pt I had once who had an abdominal surgery and they nicked the bowel. Everything got infected and there were fistulas in several places. Her abdominal wound took up the majority of her abdomen under the ribs with large gaping crevices in a cross pattern. It leaked watery excrement and we had to pack it about 6 times a shift. It was the craziest thing. She was hospitalized for months.

Quote from calivianyaI had a patient with necrotizing fasciitis that started in her labial area who ended up with a surgical wound stretching down into her inner thighs, up through both labia, her abdomen, and all the way up the side of her ribs by the time the removal of affected tissue was done. That was a complicated dressing change just because of the size of the wound, and the fact that she was obese to begin with, so parts of the wound were five inches deep. I think I used at least ten rolls of saline-soaked kerlix to pack it and at least 7-8 abd pads to cover it up. It took several people to hold the fat back to keep the wound from collapsing into itself while the dressing change was being done.It was very memorable because I had her before surgery too, and the initial complaint she presented with was a black blister about the size of a silver dollar. I remember seeing it and knowing it was bad because of the obvious necrosis, but I never imagined the tissue damage was so extensive.

Quote from blondy2061hOmg, that's horrible. Do you know how she eventually did?

Managing an IABP- and ventilator-dependent patient with IICP drain --- back when everything was manual and slip-ups could have lethal conseuences. Continuously adjusting IABP timing, measuring critical parameters Q 15-30 min, including IICP pressure & drainage.... while titrating 2 pressor drugs, antiarrhythmic & fluids for optimal perfusion. GAH - absolutely exhausting, particularly for a 12 hour shift. Sooo glad that technology is much better now.

Waiting for the PICC Line nurses to chime in

Wound- Absolutely zero abdomen. No Muscle, no fascia, no omentum, just organs that needed to be delicately packed around. To make it worse, the patient had a hole in their stomach that continuously leaked the powerade that they drank all day long.Then there was the exposed (12 inches) of vertebrae.There was also a backside wound on a 500 lb man. Eight Kerlix and 10 ABDs.Trachs are nothing. Once had a floating jackson inside a three-inch diameter site that had to be packed around. Needed three people to turn the patient as one had to hold the trach the whole time.Hate PEG placements at bedside. So very brutal.How about pushing a prolapsed rectum back up inside someone?Then there was the 600 lb woman with a recessed urethra. Got a million of them.How about the first time you put an IV into a scalp vein?