richard1980

Take graduate level courses and get A's in them. From what I've heard, it's 'what have you done lately'. Admissions committees may overlook a low GPA from a decade ago if you've take multiple years of graduate level science work and have a 4.0. Do other things to make yourself stand out: get involved in committees at the hospital, become an ACLS instructor, maybe try to move to a CVICU or SICU to get more experience with hemodynamic manipulation, volunteer in the medical tents of a local marathon. Basically, go above and beyond in everything you do. While 9 years experience in the MICU is impressive, you may find motivation to improve in re-learning and learning new things if you switched to a different ICU with different patient populations.

The question I have is how could you possibly be ready for anesthesia school if you're a new grad and have one year of nursing experience? You probably don't even take care of the sickest patients in your own unit yet. Get more experience and the whole transition will be easier. Just saying....

What a dumba**! Good for you for standing your ground and trying to go above him. All you can do at that point is document what you did and what he said. Kudos to you!

It's useful if it's started in surgery and used as a bridge to extubation, its usually not started correctly. The patient needs to be kept in a dim quiet room without a lot of stimulation and usually helps if they're on a benzo and/or narcotic because it's potentiates the effects. I think it's only FDA approved for 24 hours but some docs will use it for days and days...

Absolutely levophed is the first drug of choice but if she's further decompensating perhaps its cardiogenic and epi and perhaps a swan would be indicated. We uses swans every day in my unit. Vigileos are, imo, garbage. The pt can't be tachy or afib and according to Edwards all their test subjects were intubated, sedated and paralyzed in NSR. Of course you have to look at everything, and no, i don't automatically jump to, lets swan them. But a swan is indicated in severe shock which she clearly is in. The criteria for a swan, which I'm sure you're familiar with are as follows: Diagnosis of shock states - check Differentiation of high- versus low-pressure pulmonary edema Diagnosis of idiopathic pulmonary hypertension Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE) possible check Monitoring and management of complicated AMI Assessing hemodynamic response to therapies - check Management of multiorgan system failure and/or severe burns - possible check Management of hemodynamic instability after cardiac surgery Assessment of response to treatment in patients with idiopathic pulmonary hypertension In my facility, depending on the intensivist working, she would probably get a swan. I really think the whole idea of not using swans has gone too far. We used to swan everyone. Now it's fallen out of favor, wouldn't surprise me to see it fall back in favor, kinda like how levophed was out of favor for quite a while...now its very popular

I disagree, I think a swan would be indicated as she appears to be in severely decomponsated shock of some sort and doesn't appear to be responding to the treatment they were giving her, a continuous SvO2 monitor would be nice to see as well. (SvO2 monitoring is, IMO, one of the most important numbers in situations like this) While they did not do enough to correct her acidosis, a PA cath definitely would help guide her treatment plan, studies have shown that even the most seasoned health care professional accurately guesses the correct filling pressures as little as 30% of the time. While, I agree with you that we do not have enough information to accurately guide care I disagree on your take that Epi wouldn't help. If it's a pump failure due to acidosis, I highly doubt that thats the only problem, Epi would improve contractility. If she's giving birth she's young enough to tolerate a pH of 7.19 without having complete circulatory collapse. Something else is going on here, sounds like a possible embolism and dying tissue. As I said earlier, I don't think her volume status was optimized and if you're to the point where you're running wide open norepi, there are other options to consider, such a swan and other vasopressive/inotropic agents.... I'd also maybe try an amp of Calcium Chloride as well.

Addendum: In 6 plus years of taking care of heart patients I have never had or seen a negative outcome from keeping the tubes patent...only from letting them occlude by not being aggressive enough.

I will continue to strip chest tubes as needed as I have been instructed by my surgeon and are written into our post op heart orders. I think if theres any question, ask the surgeon what he or she wants.

....Weird.........

It's our facilities policy that we cannot bolus propofol in a syringe but we can use the bolus feature on a pump and give them a few ml's at a rapid rate. I guess the highest rates of propofol I've seen is around 100 mcg/kg/min or so but usually we'll add a fentanyl gtt and precedex or versed or ativan if the patient is requiring high levels of diprivan. I think you did fine sedating your patient. IMO intubated patients, as long as they're comfortable/cooperative should be kept at a MRS of 3 a vast majority of the time. No reason to keep them wide awake with an ETT but no reason to snow them either unless it's medically necessary or they're interfering with their lines.

You got punked by a lazy nurse....

Me too... yikes... In a couple words.. ABSOLUTELY NOT ARE YOU OUT OF YOUR FREAKING MIND???!!

"A class at Stanford" eh? When did they become the authority on CT management...? Just kidding. :-P All sarcasm aside, the competent nurse should use his or her judgement on the selection of gentle "milking" or aggressive "stripping." There is a place for both practices in the care of post cardiothoracic surgical patients. I've seen a surgeon cut the CT and stick a sterile yaunker with full suction into someones chest to suck out clots. Thats a hell of a lot more negative pressure (considering he pinched the sides of the chest tube wall) than I could generate stripping a tube.... I'm not encouraging reckless stripping of tubes but faced with the outcome of a tamponade you do what you have to do to generate the best end-outcome for the patient.

If she was that sick she needed a swan... and from the sounds of it tons and tons and tons of volume. How much volume is tons? Give it on pressure bags or with a Level one rapid infuser/warmer until you get to the downward trend of the starling curve. I'm guessing her hgb was ok? Remember....always optimize volume status before using vasopressors and inotropic agents. A pH of 7.19, while very low, isn't ridiculously low and the levo should've done SOMETHING. She probably should've had about 4 amps of bicarb and a gtt or if that didn't work, (as someone already suggested) tham. What's a PMA and why would they tell you to run levo wide open without trying something else like epinephrine or neosynephrine?

You get a good sick open chest with a BiVad and DIC and it can be a long night...

Haha... Good times... We don't really let residents in patients rooms that are that sick. Hopefully their "pocket cheat sheets" were laminated...

Just wondering... I'd say probably around 30+ for me but I'm curious if someone has a ridiculous story to share.

As long as we're on the subject.... whats the most output you've seen in the shortest period of time out of a mediastinal chest tube? Couple years ago I had a guy come up and dump 3+L in the first hour and a half before going back to surgery.

Depends if they are bleeding or not. I always strip my chest tubes on CT surgery pts. Sometimes its only a couple times the first shift they come up from the OR...other times you're stripping until you hands feel like they're gonna fall off. You really can't get clots out from the insertion site just by "milking." You have to strip the hell out of the tube sometimes. Other times its not necessary. I've only stripped a pleural tube at the request of the surgeon....anastomotic leak from esophagogastrectomy and the chest tube was putting out pure nastiness. As far as the AACN procedure manual goes, I don't know...never checked what they have to say about "stripping." But they also say you shouldn't have your sxn for ETT suctioning turned up very high. If your ETT is clogging because theres so much crap coming out of it you do what you gotta do.... Best practice doesn't fit every patient every time.

Levophed does increase heart rate some as it's a potent alpha AND beta adrenergic inotropic-vasopressor. Every patient will respond differently, but there is a breaking point where the chronotropic beta effect will kick in and you'll start to see an increase in their heart rate. Maybe that will happen at only 5mcg or maybe it's 50mcg. But none the less, it's important to recognize that some patient's heart rates will not tolerate levophed at higher doses.

I've had a ETOH patient on a Ativan drip at 20mg/hr with them still moving around, although intubated. I think he drank something like a 1.75 of vodka a day. As far as Ativan pushes? I've given about 14 mg an hour for a few hours to get someone under control. Just push it in almost as fast as you draw it up to get their DT's under control before the MD decides we should have a drip.

You'd be fine to hook up the pressure line. The doc will flush it with a hell of a lot more than the mL of 0.9 you'll be giving the patient by hooking up their line. You'll be able to tell right away if you're in the right spot by the waveform.

We have a locked unit so I don't have to deal with people coming in when I'm not expecting, etc. If we don't want company we simply say "not right now." They really don't have a choice. There's a lot of talk about "family oriented ICU care." I too understand the need for families to see their loved ones when they're sick and vice versa. But if someone is critical and sedated there's no reason for someone to insist on staying while you try to navigate around them. It usually works well to inform families, like you talked about above, that their loved one is very sick right now and needs to rest. I tell them that short visits are ok, but there's a reason they're in the ICU and not the floor. Good luck to you!

I think they've changed it within the last year. I took it about 2 months ago.

First open chest huh? Yeah it's pretty fun. If someone's having sternal dehiscence, no matter the reason, in my facility, it's standard procedure to place a vac over it. There's no negative effects on hemodynamics or respiratory mechanics. W. Vacs rock. It's fun when they just have a little hole and cough and blood/fluid squirts out all over the place. Welcome to SICU. Keep some extra scrubs handy. :-)