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Propofol is a great drug for quick weaning. It has an extremely short half life. There is absolutely no reason to leave a patient on psv overnight when they are clearly failing. With a respiratory rate in the 40s tachycardia and hypertension you need to put them on a rate and sedate them. Also why point out that propofol is a respiratory depressant? If the pt is going to be on the vent overnight then make them comfortable. Benzos are associated with increased delirium and increased mortality in some recent studies. Precedex is nice bc no respiratory depression. But like propofol it causes hypotension. I think it is a jump to say they need a lasix drip. Good for weaning but hard on the beans.

This just came up in my unit recently. Its absurd. I guess next time I start norepi on a crashing patient I will start at 0.5mike and then wait 5 min to increase by another 0.5 ARRRRGGGG stop the madness Is JCAHO run by nursing theorists?

My belief system? The cascade of the dying process? Is this about nursing theory? Are any of you icu nurses?

This isn't a nursing book, but I liked it better than all the critical care books I read. It covers lots of physiology that's relevant to icu work. Clinical Anesthesiology by Morgan/Mikhail/Murray Also check out emcrit.org and lifeinthefastlane.com

Wow, I guess I should just start a morphine drip the next time I respond to an Rapid Response call on the floor for a DNR or Limited code patient. Or maybe just refuse to treat them and go back to the unit. And never give anyone 100% fio2 because it might kill them. Thanks for the help.

One patient was DNR but we were trying to keep him going until his family got there. The next was a meds only code. So in both cases I had an intensivist in the room and we were giving pressors and code drugs. I don't like it when really sick DNR patients are brought into the icu and we try to resuscitate them. I don't see the point in it either, but its relatively common at my unit. So I try and keep them alive, short of CPR and intubation. My point was that if someone is dying and you are trying to keep them alive, they need oxygen and there is no reason to resuscitate them on 40%.

This has happened to me twice recently. I have had some very sick patients on bipap (DNR) who were near death. When the patients desaturated, and I suggested to the respiratory therapist (both times already at the bedside with me) to turn the fio2 up to 100%, they balk and only go up to 50%. So I have to go over myself and push the buttons. Both patients died pretty soon after this despite some improvement in sat. I don't think the patients died because of hypoxemia. Anyway, it just seems crazy to me, if somebody is hypotensive, desaturating, and barely alive, why be stingy with the o2? Has anybody else had this issue?

I agree that more volume (dry?) and maybe blood (low hct?) might be good options when you are on multiple pressors. Steroids might help also. Lots of people think bicarb helps, but after reading lots of books I'm not sure its a good idea. I have given it to really sick people but I'm not sure if it helped as I was throwing all kinds of stuff at them. Calcium seems to help usually. Treating the underlying cause is always a good idea if you know what's wrong. I see patients in my unit on levophed and neosynephrine occasonally. I don't get it. Typically Levophed is the first-line pressor. It has some Beta but mostly Alpha activity. So why choose a pure Alpha agent (Neo) as the second pressor? All that does is increase afterload further. I mean if the patient is tachycardic and you have a good h/h and plenty of volume in, sure you don't want Beta stimulation. But why do you want 2 alpha agents? Thats why vasopressin makes sense once you max out on levophed, it acts via a different pathway. Maybe add epi or vasopressin as the 2nd/3rd ones.

I think you would need to know a lot about physiology to understand why a low pH kills patients. I don't understand it really, but from what I've read at some point your body cannot carry out the cellular functions necessary to sustain life once your pH gets to low. Supposedly acidosis depresses cardiac function as well. Also you will hear that pressors don't work once the pH gets really low. I think it makes lots of sense to think about scvo2 when you have a sick patient (and how to increase it). The rivers trial showed a lot of benefit with this approach in septic patients. look up "early goal directed therapy" and "rivers" also it will help if you understand how to interpret abg's.

Do the Pass CCRN practice questions like crazy and if you can do well on the practice test you're good to go for the real one.

wow i have never heard or read anywhere that levophed dilates the coronary arteries. it might increase coronary perfusion by increasing diastolic arterial pressure. maybe you are thinking of nitroglycerin? levophed has some effect on beta receptors but mostly works on alpha. So you get some beta 1 effects (increased heart rate and contractility - the opposite of lopressor) but mostly you get alpha (vasoconstriction). i always look up a drug in lexicomp if i'm not familiar with it, but as an icu nurse you need to know the basics like levophed. one good place to start is "pharmacology for the prehospital professional". its a free podcast by an icu doctor, covers lots of the meds we use in critical care.

yeah i agree don't bring a bunch of stuff into the room. if the patient is sick the last thing you want is a bunch of cleaning supplies getting in the way. you can get that stuff when you need it.. i don't like to wait until the patient is throwing up or getting intubated to find that none of the suctions work, so I set up and check at least 2 suctions with yankhauer catheters. get the ambu bag ready, set it up and hook it to 02. also make sure you have a couple oral airways. also its important to have all the monitoring ready like you described plus two pressure cables. etco2 is nice also.

I think experience is the best teacher but here are some good resources for learning outside of the icu: Pass CCRN (throw the book out but do the practice questions on the cd) Emergency Management of the Coding Patient (its going to happen sooner or later) Clinical Anesthesia by Morgan/Mikhail/Murray (lots of great information for the icu even though its about anesthesia) podcasts- emcrit, icu rounds, keeping up in em, ercast, gascast, lots of good free ones

I just want to recommend to everybody to check out some of the great resources on the internet, especially if you are relatively new to the icu. Some of the info is over my pay grade (c-spine clearance, PE risk stratification, etc.) but lots of it has been very useful to me at work, and its interesting stuff. EMCRIT.org - amazing, tons of great podcasts on er/icu topics. The most recent podcast goes over how to bag patients. I actually used the jaw thrust technique described in this video at work yesterday and it worked way better than what I used do. some other great podcasts are: emrap.tv , ercast , emergency medicine cases, icu rounds , pharmacology for the prehospital provider , embasic, keeping up in emergency medicine also check out resus.me and life in the fast lane blog.

I studied for several months before I took ccrn and passed. I read a lot of medical stuff on my own (especially relevant topics in Anesthesia books like physiology and meds). I watched the gasparis videos and they were ok but not that useful in my opinion. I also used the book Critical Care Nursing Certification by Ahrens (its ok not great), and the Pass CCRN book. I barely opened the Pass CCRN book (its just a bunch of lists) but the CD that comes with it is great. If you get really good at the practice tests and quizzes on the Pass CCRN CD you should be good to go.

i think the last couple posts are really useful. also you want to see the o2sat and the pao2. the sat on the abg and the spo2 on the monitor will be pretty close. you want the sat>90%. sat is the % of hgb saturated with 02. Cardiac output, arterial sat and hgb/hct are three important factors affecting o2 delivery. on the other end of it you can look at lactic acid or svo2 to see if the supply is meeting demand. if someone has a high lactate (metabolic acidosis) or low svo2 they need more o2 delivery. pao2 is the partial pressure of 02 is arterial blood (oxygen that's not bound to hemoglobin). pao2 on room air in a normal person is around 90. so if someone is on o2 and their pao2 is low you know they aren't oxygenating well. also if you see a pao2 of 300 you'll know you need to turn down the fio2. but for me the sat is the important part of the equation if you have an unstable patient.

PASS CCRN - the book comes with a cd of practice questions, if you can pass the practice test you should be fine on the ccrn. that's the best resource. i thought the other stuff mentioned was ok but not nearly as important. the internet has some great resources also- check out emcrit.org, ercast, emrap.tv, emergency medicine cases, icu rounds. they all have free podcasts/videos lots of icu stuff.

when i was brand new in icu i asked some more experienced (20-30+ years) nurses about the ccrn test and they told me i had no business studying for it. the test isn't that hard and studying for it will force you to learn some good stuff. i say start learning now. you can't sit for the test for a while, but the knowledge you gain will help you. its very empowering to learn.

I say study and pass the CCRN. The only resource I think you need is the Pass CCRN book (throw the book away and use the cd of computer questions its just like the test). Also check out these podcasts/blogs: emcrit.org, emrap.tv, ercast, icurounds, resus.me Study up on ACLS algorithms. My favorite book is Clinical Anesthesiology by Morgan/Mikhail/Murray (its anesthesia but lots of the meds and physiology apply to icu work). Also get an EKG book and learn rhythms.

i guess this isn't the point of your thread, but... there is some research which shows that morphine is not great for MI patients. http://www.dukehealth.org/health_library/news/8243

one thing i think is important that is not usually mentioned: after you get a flashback, you actually need to advance a few more millimeters and then stop the needle and advance the catheter. once i started doing this my % of good starts improved a lot. most people will tell you to advance the catheter as soon as you see a flash, but in my experience it doesn't work. also its easier if you lower the arm off the side of the bed (gravity helps fill the veins), and if the patient is on propofol.

For what its worth- I worked at my first RN job in 2005 at Vanderbilt on 9North surgical stepdown. I think my base pay was $18/hr, night shift differential was a few dollars then there was also a weekend diff. I worked 12hr shifts with 36 hrs a week. Also, the staffing ratios were good, they didn't try to work you to death. To me that's as important as the pay scale.

why not just hook it up to a transducer and see what kind of waveform you get?

I need some help with assisting with line insertion. It seems like half the time i assist with this procedure the md gets ****** off because I screw something up. So I thought I would list the steps and if anybody feels like adding anything I would appreciate it. First I get a copy of our consent, make sure the md talks to the signee, and get it signed if the patient or family are able. Then I get the line cart which has most of the necessary supplies. Next I need to move the patient's ekg leads away from right IJ/SC insertion sites if that is where the line is going. Then grab some wrist restraints if the patient is confused, and maybe some versed/fentanyl as well. Put the patient flat. Wipe off the expected insertion site(s) with chlorhexidine. Get some transducer tubing ready to go with 500ns in a pressure bag. Where I work the RN is also supposed to wear a sterile gown, mask, gloves and hat. Then the md needs help putting on the sterile gown. Is it acceptable to just tie up the ties on the back of the gown? Sometimes the doctors hand me a card and then they turn around tie it themselves. Which is the correct way to do it?\ they also put on sterile gloves and then pretty much I just hand them the needed supplies as they ask for them. They drape the patient with sterile drapes. Then they get the line ready to go with flushes. Sometimes they ask for me to squirt some saline into a sterile bowl. Then they use lidocaine to numb the area. After the line is placed they usually ask me to flush the lines and then we get chest film to check placement. If anything here is incorrect or anything was omitted please mention it. thanks

I feel your pain. seriously, its a difficult job and it causes a lot of anxiety. its a painful learning process sometimes but i think it just takes time. My first couple years in icu were tough but I got more comfortable. besides gaining experience, it really helped me to try and learn outside of work. i read icu, ekg and anesthesia books and research new things online. also I studied for the ccrn this year. I still run into new problems that i don't know how to handle sometimes at work but knowledge helps.