esie

It is standard practice here in Oz that 99% of ICU patients have an IJ, sub-clavian or femoral multi-lumen central line inserted, or a PICC line if they are a long term patient requiring fewer infusions. The central line would have either three or four lumens. The distal lumen is connected to CVP monitoring, and can be used for IV injections or as an extra line as required. Another lumen is devoted to inotropes. The final lumen (in a triple lumen) has a "traffic light" (multi port attachment) attached, into which the maintenance fluid, fentanyl, propofol, midazolam, precedex, potassium, insulin, frusemide, etc etc is infused. If I am lucky enough to have a quad lumen line, the fourth line will be for a drug that must generally run alone, such as TPN with insulin piggybacked), GTN, heparin, etc. Our bible is the Australian Injectable Drugs Handbook, which details all IV drugs available in Australia, with each drug entry detailing availability, generic/trade names, preparation, administration, stability, compatibility/incompatibility data, and special notes. If I am in doubt about compability, I consult the bible, and then juggle lumens as necessary (and if desperate, insert a peripheral IV).

Here is a link to the Qld Health current wages rates. To give you an idea, I am an RN, and I have been registered for four years, nearly into my 5th. So, to give you an idea, I am at a Gr 5 level, paypoint 5.

We generally run with a guideline of MAP >65mmHg, unless specifically indicated. When considering chatting to the docs about a fluid bolus, I consider the trends over the last 2-3 hours. What has the pt's urine output been, where is the MAP hovering, where is the CVP? What is the patient's condition, and what is the general aim of the day? What was their general baseline before becoming sick enough to be admitted to ICU? So, it's not a matter of waiting to treat a tending downward MAP, it's considering all of the trends.

Our fresh hearts, whether a simple CABG or valve replacement, or more complicated by IABP or nitro, are always 1:1.

In our unit, and the other units I have worked in, a chest X-Ray is ALWAYS performed to verify placement before use. Sure, air boluses and aspiration and litmus test have their place in initial verification, but with a CXR you know for sure the NGT/OGT is in the correct place. Your preceptor should have supported you more in this, and pushed for a CXR. In the end, it is your registration on the line, you must always act to protect this.

At the hospital I work at in Australia, pts on Bipap in Respiratory HDU are 2:1, but are watched very closely for a decline that will need ICU admission. We do have Bipap pts in ICU that are 1:1, but they generally have other issues going on.

I was recently *this close* in going to Alice Springs Hospital ICU for a secondment (couldn't go in the end as my hospital refused to allow any leave without pay, even though our unit is about 3FTE over). I think for a first time rural placement, it might be a great place to consider. Alice Springs is an established rural town, but with plenty of infrastructure in place. From there you could easily transfer out to rural and remote nursing, once you get a feel for the place.

In our unit, we use T-pieces to deliver humified oxygen to a long term ventilated patient who is being weaned from the ventilator. We generally do first day 1-2 hours t-piece, then 2 hrs ventilator, and continue that for the day as tolerated, and then back onto pressure support for the night. The second day, if tolerated, the patient will have longer turn abouts between the t-piece and the ventilator...and so on until the patient is fully weaned. They can go to the ward permamently on a t-piece. For turns, baths, transfers to radiology etc, we generally put the patient on a swedish nose for convenience, but then pop them back onto the t-piece as soon as practical.

If you have an emergent newly admitted patient going into septic shock, very hypotensive and trending downwards, the TPN is the least of your worries. As others have said, the course of action would be to cease the TPN (and aspirate and flush the lumen); administer the other orders; continue to monitor her BSL and if necessary hang a bag of dextrose. In septic shock, it is extremely important to get the antibiotics up ASAP. Your preceptor gave you the correct guidance.

In the ICU department I work in, all admitted patients, whether overnight post-op, short term, long term, on or off inotropes; everyone has an arterial line. Never ever interrupt your inotropes, except to wean them down, it's too risky for the patient. We always draw our blood for lab tests off the arterial line, unless it isn't aspirating. In this case, we draw off the central line or picc line if available, failing that, we do a peripheral stick.

Pre-extubation, we immediately use paracetemol 6 hourly and use either 2mg boluses of morphine, or 20 mcg boluses of fentanyl (depending on the pt's age, kidney function, allergies etc) PRN. Once extubated, the pt has a PCI that delivers either 0.5mg morphine every 5 mins, or fentanyl...unfortunately if the patient is in acute pain after a turn, the PCI is not particularly effective.

Hi Misscherie, as you have mentioned the Great Barrier Reef, this is a link for Qld Health payrates. In fact, take your tine browsing the whole Work For Us site, there is some great info in there. When doing your research about where to work, take into account that private hospitals pay less than Qld health, & generally have greater nurse to Patient ratios.

We use a bladder temperature line to the minitot for pts with an IDC with a temp attachment; naso-oesophageal temp line to the monitor on cardiac surg pts & pts without IDC temp attachment; and generally a themometer auxially or femorally otherwise.

I also went into a med surg ICU as a grad, but I had the experience of a paramedic background. Best piece of advice I can give is ask lots and lots of questions! Don't be afraid to ask your CN's, senior RN's, doctors, physiotherapists, speech therapists, and anyone else! Otherwise, take a deep breath, and don't panic :)

One of the current trials being conducted by ANZICS Clinical Trials Group in Australia & New Zealand is the CHEST study. The study is comparing the use of Hydroxy-Ethyl Starch (Voluven, Hespian) 0.9% Sodium Chloride, with 0.9% Sodium Chloride alone, in fluid resuscitation in critically I'll adults over a 90 day mortality period. Having spoken to a couple of the Intensivists at my old unit, which is enrolled in the trial, the expected outcome is that this trial will have a similar outcome to the SAFE trial.*In the units I have worked in, generally only saline or albumin are used, although OT sometimes used Plasmalyte.