Vikingnurse

In my unit we focus a lot on delirium. Primarily because we have a no sedation protocol for our ventilated patients. That protocol in itself is step to minimizing or prevent delirium. Sedation on top of severe sepsis and mechanical ventilation and the patient will for sure develop delirium. Our protocol focus on non pharmacological interventions such as mobilization, reorientation and of course the most important thing - treating the underlying causes. Pharmacologic treatment is olanzapin 5-10 mg in the evening, for more severe agitation we tend to start with 1-2 mg of midazolam. Our expirence is that those small doses are often enough. If the patient seems delucional and agitated with a RASS > +2 we can use haloperidol. Starting with 1 or 2 mg and double it with 20-30 min. intervals. 1-2-4-8 mg. If we don't have effect of 8 mg we use larger doses of midazolam or sedate the patient.

In our unit we also use scopoderm or atropin... the only consideration you need to have using either of these drugs, are their potential to cause delirium. They are two anticholinergic drugs, which might "tip the scale". I definatly need to find out more about the two other suggestions - glycopyrrolate and oral erytromycin. That sounds interessting.

Could someone please explain what A/C stands for? Perhaps we just call it something else in our little country? It sounds a bit like the MMV (Mandatory Minute Volume Ventilation) on the DrägerXL... If the preset ventilations in A/C mode is given with regular intervals without synchronisation with the patients inspiration, it would seem as if the patient is working against the ventilator. It could explain the different readings... The ventilator starts an inspiration, the patient isn't ready for it and works against the ventilator leading to a small tidalvolume. Next the patient takes a deep breath (I understand that spontaneous ventilation is possible in A/C mode) to compensate for the interupted inspiration.

How sedated are your patients and how often do you use restraints? We don't use restraints at all and we use little or no sedation (with a few exeptions). If we have a patient in risk of selfextubation or could do harm to him or herself in any other way, we use nurse- or medstudents who want to earn some ekstra money. They make sure that central lines, arteriallines and all the other things stay in place and of course the patient stays in bed. And they are are an extra hand when needed. Workes perfectly.

What is your preferred mode of ventilation? We have the Dräger Evita XL, what a machine! We start out with the BiPAP+ASB mode, and as soon as the sedation is reduced enough we switch to CPAP+ASB. We have no weaning protocol and so the weaning process is rather random. Some doctors are agressive some are carefull, many nurses adjust the ventilatorsettings themselves based on experience. We have an intensivist present 24 hours. But do any of you wean using the BiPAP+ASB mode by reducing the set resp.frequency and the Tinsp? that will allow for gradually more spontaneous ventilation. Maybe some of you with different ventilators than the Dräger would like to tell about how you manage weaning.

I need some more information in your nurse to pt ratio. We are ALWAYS 1:1 day, evening and night. But then again we deal with everything medicin, personal care, ventilator "things" (suction, ABG's etc.) Both day and evening shift we have what we call serviceassistents. They do the cleaning, help with mobilisation and some other helpful things. In the daytime we have 2 ekstra nurses that also help with whatever. If I understand it correctly you have respiratiory therapist and perhaps other similar proffessions around the patient. What I would like to hear is how many healthcare proffessionals are around the patient.

I need some more information in your nurse to pt ratio. We are ALWAYS 1:1 day, evening and night. But then again we deal with everything medicin, personal care, ventilator "things" (suction, ABG's etc.) Both day and evening shift we have what we call serviceassistents. They do the cleaning, help with mobilisation and some other helpful things. In the daytime we have 2 ekstra nurses that also help with whatever. If I understand it correctly you have respiratiory therapist and perhaps other similar proffessions around the patient. What I would like to hear is how many healthcare proffessionals are around the patient.

Hi everyone! We are a couple of nurses working on our suctioning procedure in our ICU. I am trying to find a "standard" description of tracheal secret. What we noticed is that nurses write things like "water like", "thick", "moderate amount" or "not much". Ofcourse it gives you a clue. But how much is "not much"? Does any of you use some sort of chart or scale that somehow classifies the secretion so that all nurses understands the same, when someone writes moderate amount.

We use the Prisma Flex machine in my unit. Our choise is usually CVVHDF which mean we run both pre- and post replacement fluids. Depending on what we use the dialysis fore we run the prereplacementfluids between 1000-2000 ml/hr sometimes even 3000 ml/hr. The postreplacement always run at 250 ml/hr. We have 5 liters bags. We also reuse our effluent bags. We have special drains installed in the wall, so whenever the bag needs to be drained, we connect the bag to the drain. Then gravity does the rest - takes about 2-3 minutes. Bags are changes every 24h. CRRT patients are staffed 1:1 - but then again, so are all of our patients. Plus 2 ekstra nurses for every 5 patient.

We brush the teeth on ventilated pts once a shift. One hour after brushing their teeth we coat the mouth with chlorhexidine gel. The reason we wait is because the chlorhexidine stops the effect of the flour in the toothpaste. A study made in several ICU's in Denmark showed an reduction of up to 50% in VAP following the introduction of chlorhexidine as a part of the rutine.

We have an intensivist present in our unit all day. They are not allowed to leave our ICU, unless they have someone else to cover for them. We have no problems in getting a doctor to see the patient.

I think 99 pct. of all hospitals in Denmark have 8 hours shifts, some hospitals have 12 hours shifts on weekends. In that way you dont have to work as many weekends (usually 3 out of 8, but with 12 hours shift it is 2 out of 8) In Norway the most common form is 8 hours in daytime and 10 hours on the nightshift. You work every third weekend. Vikingnurse

Based on the "nurse : patient ratio" thread I would like to know how much other nurses work? how many hours a week? And if you would like to share the information... for how much? Personally I have an average of 35,5 hours a week, and 2 or 3 extra shifts per month. That earns me about 51200 US dollars a year - 1 dollar = 6 Kroner, gives me 310000 kroner a year I dont know how much an average nurse salery is in the US, but I have heard you do a lot better than that...

Sorry i'm for your friend. My favorit is PiCCO. Allthough invasive, it is less invasive than Swan Ganz. Also PiCCO is said to have some more reliable values (for some parameteres) than Swan Ganz, because it uses flow rather than pressure. But i am not sure about that. In the nurse instructionmanual I have for PiCCO, it states that some values are aprox. 15 min delyed in Swan Ganz, but instant when using PiCCO. Yes..... I am a PiCCO nurse. Just too bad we don't use PiCCO here

I'm working in a MICU. I think most ICU's in Scandinavia uses perspiratio when calculating fluid balance, all of my colleages from Finland, Sweden, Germany and Australia are also used to it. After all we are talking about liters, not just a few ml. Especially if the patient sweats. Most places we just used an estimate, usually 1000 ml, adding a bit if the patient has fever and adding some more if the patient sweats. In that way we at least consider it.