Advice for a new ICU nurse, vasopressors, fluid status

[TitoG]

I transitioned from tele to Float Pool ICU at a teaching facility. It's my first week on my own and I'm just really nervous. I have a few questions that I've been thinking about and your input would be great. I've learned a lot and feel a little better after reading some of the threads on AN so thank you to everyone for sharing.

1. When do you ask for another vasopressor? One preceptors told me to ask for another once I'm titrating up and reach half of the max dose, another said once I reach my max dose. Can some of you walk me through your thinking process when it comes to this question. My inclination is not to wait until I'm maxed out since I probably want to have something else ready to go just in case.

2. Any assessment advice on deciding if a patient needs more fluid or not? I know CVPs are a coin toss and even the Flotrac is only accurate under certain conditions plus very few patients get this. I'm just wondering what numbers or assessment findings you guys use to decide that they need to ask for more fluids or question giving more fluids.

3. What have you learned that you wish someone had told you sooner? Any experiences/mistakes that thought you valuable lessons int he ICU that you can share?

[ptier_MNMurse, BSN, RN]

Hey TitoG! Welcome to ICU! It's a blast and a lot of work, and totally rewarding!

Answering your questions:

1. My facility has taught to ask for a second pressor once we reach a certain threshold. For example our norepi dosing is 0.03-0.4 mcg/kg/min. We are told to ask for another pressor once we reach 0.1 mcg/kg/min of norepi. See if there is a protocol, but it is wise to ask for a second pressor before you are maxed out, and I would imagine most ICU physicians would like to start a second pressor before maxing out on just one d/t mechanism/area of action (ie. vasopressin acts on mesenteric capillary beds and can cause bowel ischemia). They all have their different pharmacologic profile and potential complications, but as a rule of thumb, being maxed on one is not the best option.

2. You are listing legitimate assessments for fluid status. CVP, flotrac (a little more variable), a PCWP (if you have a swan), passive leg raise, trendelenberg position and assessing their response, looking at their hands/arms, legs/feet, face for edema, and listening to their lungs for pulmonary congestion are all good ways of assessing their fluid status and therefore responsiveness (Also check their I/O's in your chart to see how far up/down they are). You also have to look at the bigger picture as well. Getting to know your patient population is important! A young trauma patient may require and tolerate 2 liters of fluids wide open, while an elderly patient with cardiac disease may actually be tipped over the edge with a 500 ml bolus. Bottom line, read up and become an expert on your population!

3. Don't take it home with you, leave your worries at the door and build healthy coping habits! You will make mistakes, use them as learning experiences and move on. Always be open to learning, even when you think you know it all! Enjoy the ride!

Best of luck!