ShaunES

We cool for ~24 hours, then passive rewarm with space blanket aiming for 0.5 degree celcius/hour. We remove blankets and recommence cooling if they exceed this. We've had several successful cases, but we've also had several unsuccessful cases. Have to be careful with potassium shifts during the temperature shifts, make sure you're doing regular ABGs and slow their warming if they are becoming hyperkalemic.

If you're applying to ICUs why are you getting nervous about going into the cath lab? Just go, it sounds like a good job with a good orientation and it will certainly get you in the door.

Bottom is worst. Properly positioned esophageal probe (at the aortic arch) will give you the closest match and the fastest response to blood temperature changes.

cvp is useless to assess volume status and you should ignore it; better yet, put your vasoactive medications on the distal lumen and you have another free lumen. last or first it doesn't matter, there's going to be a good whack of medication in the actual catheter itself that you will bolus if you put anything on it. our standards are: vasoactive medication on its own lumen unless paired with other vasoactive medications. (does central venous pressure predict fluid responsiven... [chest. 2008] - pubmed - ncbi for my cvp claim; " the pooled area under the roc curve was 0.56 (95% ci, 0.51 to 0.61)"; may as well flip a coin.)

Seems much simpler to just use a bag and then you never have to stop it.

If the argument is that it's time consuming, then I agree, it can be time consuming. On the other hand, changing bags takes a minute or two at most, and fluid removal is simple. As for charting, I'm not sure how you guys do it, but it's pretty simple for us, just bang in the pressures and the fluid removed and you're done; when compared to the other hourly stuff you do it's not a big deal at all. Simply put if acuity is the reason you 1:1 these patients then I would reasonably expect ventilators to be 1:1.

That's why they're 1:1. What's the difference between an intubated patient and someone on CRRT? If you lose an airway that's a lot bigger deal than your circuit clotting. I don't understand.

CRUSADE is demonstrating that those treated with Morphine have double the mortality rate than those not given morphine. If one were to use opiates/opioids, I would suggest fentanyl - faster, nicer and an all around better drug.

I work in a large ICU in Australia. We're 1:1, and work 12 hour shifts. We get a 20 min morning tea, 30 min lunch, 20 min afternoon tea, 30 min dinner. We do break with our neighbour; our bedspaces are separated by curtains and benches, and you can see all the important stuff from sitting in the middle; vent, monitor, pumps, patient. In our isolation rooms one of the two people on the floor (person running the pod of 9 patients, and the person assisting them) will do your break, or they will get a new patient person to do it, or the access nurse to do it. While doing breaks with two ventilated patients, we don't do anything; physios aren't permitted to treat out patients, we just watch and address alarms as needed. While on our breaks, you can do whatever you damn well want.

I've walked intubated patients around the unit with a transport ventilator, so no, using a bedside comode isn't that crazy an idea. Not every intubated is unstable, if you have the resources and time to do it safely, do it! (The procession for the walk was pretty funny, myself, two other nurses, two wardsmen, another wardsmen pushing an oxford recliner chair, and another with the oxygen) This is ICU mind you, down in emergency I wouldnt even dream of it :)

I just use the bolus feature in our pumps, saves me having to baby sit the pump, and I don't accidentally leave it infusing at 1200mL/hr.

Our hospital has occupational therapists who do all our splints/etc, they provide scrotal slings to assist with reducing pressure, seems to work.

Sounds like a problem with the system, not with you. In my ICU, all orders are entered onto our electronic system by the doctor requesting them, and show up instantly on our bedside computer. Similarly, lab tests are ordered the same way, but in addition our doctors go a step further and bring us the pathology request form, as well as verbally telling us what they're requesting, why, and if we need to do it now, or when we next draw bloods. Sounds like your system needs improving, and any fault is with it, not with you. I'm sure you did the absolute best you could, it sounds like it.

When you're sick!

http://www.srlf.org/data/Upload/Consensus/pdf/50.pdf This study has the patients in severe sepsis on an average of 0.45mcg/kg/min of noradrenaline, with a maximum of 1.06mcg/kg/min. While there is still a lot of mystery in when you should add more vasopressors, a limit of 20mcg/min seems to be less than evidence based. Showing good outcomes on 1mcg/kg/min is surprising, that's a lot of noradrenaline isn't it, like I said we like to add in vasopressin/adrenaline at 30-40.

Our septic patients start on noradrenaline (nor-epi/levophed), once they hit about 30-40mcg/min, we start vasopressin at 0.04units/min, and from there we can wean the noradrenaline down, but keep the vasopressin going. This way we use the optimal pressor (norad), until we get to doses that are getting to the point where we need to add more in (usually we cap at 40-50mcg/min), and from there add in vasopressin.

Any trauma like that should score an art-line anyway, so the noise of a trauma bay is irrelevant after that goes in (usually one of the first interventions).

Australian ICUs are 1:1 for ventilated patients, and 99% of patients are 1:1 anyway. Come on over!

I get six weeks a year of paid leave, or 12 at half pay, enough time to relax, dont have to use it all at once, or at all (so can have massive holidays every few years etc), it's nice.

Since we've covered the easy stuff, how about something way out of left field? Paroxysmal Nocturnal Hemoglobinuria!

An ECG takes 30 seconds, and pulling bloods takes 2 minutes. I don't understand why you would spend time trying to get the order changed when you could have done in the time you spent complaining!

Hey, I'm in ICU here in Australia, and I've noticed that you guys in the states seem to have 1:2, even with stuff like vents and CRRT. I'm just wondering about the practical aspects of this; what happens when one of your patients tries to rip something out? Are they all in four point restraints (I've seen a lady nearly self-extubate with a foot!)? Do you just keep them sedated? Are they right next to each other? In my unit, we have 1:1 for 99% of patients; even the people going to the ward usually are 1:1. Vents are 1:1, no negotation. CRRT 1:1, etc etc. We keep everything we need bedside, and aren't meant to leave the beside; for breaks we sit between two patients, during which time absolutely nothing can happen to either of them; no physio etc The only 1:2 is our post-op HDU, and even then we have enough staffing for at least two of them to turn into 1:1's. Just wondering what your thoughts are on 1:2, do you ever feel like your other patient could get into trouble without you watching? Anyway, if you have any questions as to how our ICU runs please let me know! (Also I understand some of you don't have 24/7 medical coverage? How the hell does that work?)

Vents are 1:1 here, CRRT is 1:1. 95% of our patients are 1:1, even the people waiting to go to the ward.

In our hospitals ICU it is policy that nurses do not reinsert airways (how often do you actually get to use it, and do you want to stuff it up and make further reinsertion more difficult?), nor do we keep trachys at the bedside (a lot of waste given all items at the bedspace are the patients, and when they leave it all gets chucked/taken with them). The intubation trolley has all the equipment needed, and the difficult airway cart has even more in the event it all goes pear shaped. These are ~15 seconds from every bed, and we have two medical staff covering every 8 beds, for a total of 8 medical staff, and a minimum of two senior registrars. I'm not sure all these instructions of "put it back in" is wise, given that every situation is different (surgical trachy vs perc, why are they trachied, etc)

We use ICIP, from Phillips. It's great, I haven't had a problem at all, and it integrates with everything so well.