nursingdude78

For some reason our hospital does not do Versed drips, just Ativan. I kind of assumed that Versed would act similarly to Ativan when combined with Fentanyl.

I had a patient that was dropping her pressure on propofol, switched her to ativan and fentanyl drips, and it was just as bad. She was on 20 mcg dopamine and 250 mcg of neosynephrine, definitely was not hypovolemic. Would you try ativan alone, or fentanyl alone, or something else? I know ativan and fentanyl work synergistically to create sedation, do they do the same to blood pressure when they are combined?

I liked a lot of what I saw when I interviewed at Case. It sounds like they accept a wide variety of people. I had never heard anything about them only accepting younger people until I read it on this forum. Hopefully that is not true. It was a tough decision for me deciding where to go. I agree that a "rinky dink" community hospital is not the way to go. I was comparing a level one trauma center (500 beds) where I now work to a Level one university based hospital where I used to work (1000 plus beds, nationally ranked). I feel like I am stretched a lot more where I currently work, I have not had the residents to use as a crutch. But this is coming from a relatively new nurse, I think a veteran nurse of 8 plus years would benefit more in a university based hospital because they will see the more unique complications etc, and can actually help out the residents who often dont know what to do.

Hopefully you get in to some other programs. I was the same way when I interviewed. I asked a ton of questions and basically interviewed them. I liked that Case Western starts their clinical training early and you get over 900 cases under your belt by the time you graduate. I did not like all the nursing theory classes and would not be excited about being 31 and the oldest one in the class. I have decided to attend another program. I will have 18 months ICU experience when I start, so I hope I feel comfortable and ready. I study a lot and feel pretty good about my ICU knowledge, but am far from an expert. I agree that the big teaching hospitals may not be the best, even though all the schools seem to think so. You want to be at a place big enough where all the sick patients get sent to you and don't get transported off to another hospital, but if it is big university hospital, then you always have residents and other people nearby to go to. At my hospital, you have to rely on yourself and other staff nurses, which I think is a good thing.

It is a bummer to wait so long for an answer. They are not breaking their admission rules though. You have to have 1 year ICU experience before the program starts, so someone who graduated in May can qualify to attend school in August of the following year. There are different opinions about the experience factor. I have talked to a lot of CRNA's and anesthesiologists who basically say that there is little correlation from ICU to Anesthesia and you should just get on with school and learn anesthesia. I have also talked to CRNA's who felt extensive ICU experience was critical to learning anesthesia well. I think a lot depends on the individual. I personally think 2 years is a great number. You become pretty comfortable in the ICU by that time, but not yet an expert. After 2 years, the law of diminishing returns kicks in big time.

I took stats 9 years ago, all the other programs I applied to are fine with that. All the MSN anesthesia programs have nursing theory, but the MS in Nurse Anesthesia programs do not have nursing theory, their didactic is more focused on the hard sciences. Look at the curriculums, they vary widely. Ultimately all programs give you the the ability to be a CRNA, it just depends on your preference. CCF will provide unmatched acutiy, but do you have to take a 2nd seat to MD Anesthesia residents? I have heard of some horror stories from some MSN programs (not Case Western) where they had to write a ton of papers and do all this BS that was in no way related to anesthesia. I got accepted to Mercer and am waiting to hear from USC and Kaiser. I like Mercer because it is a medical school with no anesthesia residents, so SRNA's = residents = great training. Plus they average 1200+ cases, more than anywhere else I have talked to. I also liked that the curriculum was mostly free of fluff classes. USC program looks strong. Have heard awesome things about Kaiser, but again they have a ton of fluff classes too. Congrats to everyone who was accepted, Case Western has a great name and I am sure you will be happy there.

Yea, same here. I thought we would have heard by mid January.

I got my letter last week. Have not decided yet if I will attend Case Western or go elsewhere. I have to take Stats again in order to attend Case :-( Also all the nursing theory classes do not excite me.

That could explain the bicarb drip possibly. I am not positive if dye/contrast was used.

She had initially been bradycardic and that was the reason to wean the dopamine last. She became acutely hypotensive I suppose because of the A-fib which started at a rate of 110-120 , but eventually got up to the 140's before I got the Amio started. She had a low EF to begin with and the rapid rate decreaded her preload. She was on bicarb because of no other reason than her respiratory acidosis from what I remember. Turning up the Neo and Levophed did not bring her pressure up much, so that is when I tried the Epi, which worked. Once the amio brought her HR down, the problem seemed to be fixed and the epi was turned off. I think Dobutamine may have been the best option looking back, but I did not have an order for it and was waiting for the Doc to call back.

I had a patient with cardiomyopathy and 2nd degree type 2 HB that went in for an elective PPM placement, during the procedure, she got a hemothorax and was brought to our unit. I had her that night. She was vented, on a bicarb drip, dopamine, neo and levo drips. An epi drip had just been weaned off about 2 hours earlier and was on standby. Paced rythm with stable BP at the time. I had orders to wean dopamine last. A couple hours later, she starts getting tachy, HR 110-120, A-fib. Her systolic BP drops to the 50-60's. I turned up the neo and levophed, but decreased the dopamine because I thought it might be contributing to the increased HR. The BP was still not rising, so I started the Epi drip thinking she could use an inotrope? I was worried that the Epi might make things worse since she was tachy already. The BP did come up and the doctor called back after all this and gave an order for an amio bolus and drip to be started. The heart rate came back down I got the epi turned off shortly after. She was not dumping much out from her chest tube, I did not have a CVP, but I think her volume status was ok. What do you guys think about this, was it the right call to turn back on the epi drip? Was I right in initially turning down the dopamine and increasing the levo and neo? Thanks, B

Thank you all for the great input. This was a new order at the time to keep the CVP above 12. The patient did have sepsis.

I recently had a patient who had orders to give a 250 ml NS bolus if her CVP dropped below 12. She was on a vent, and 10 mcg of levophed with systolic of 100-115. She had ascities with a lot of fluid in her abdomen. Can someone please explain the physiology behind this? I thought normal CVP was 5-10. Why would we want it above 12?

I may be mistaken, but I thought Perfusionists only made around $60k and on top of that they have a hard time finding jobs? Is this right?

Hello Everyone, I was recently let go from a critical care fellowship and totally blind-sided by it. My preceptor continually told me that I was doing great, but the management came up with some reasons to let me go (I charted wrong twice on some of the side rails/safety measures and some other minor issues). I think the real reason for them terminating me is that they are way over staffed right now, and I am the most expendable. My dilemma now is finding a job (preferably in critical care) in this horrible job market. Is it possible to work for free while you gain experience? I would gladly offer to work without pay while I was being precepted and oriented to a new unit and then get hired on with pay after a few months. Is this ever done? It seems like hospitals would like it because they don't have the financial cost of training someone. I am definitely able to relocate. Any hiring managers out there reading this?