I recently had a patient with suspected heyde’s syndrome prior to an AVR + aortic root replacement. VWB panel still pending. What is the correlation between aortic stenosis, the GI bleeding, and acquired VWB factor decrease? I tried doing some research, I guess there’s still some unknowns and I understand sheer force with the stenosis valve can cause proteolysis of VWBf but how does this ultimately correlate with specifically GI bleeds?

I’ve recently had a couple of instances of triggering momentary SVTs while selingering the guide line in, whilst placing a central venous line. The thing is, I wasn’t even halfway in- technically, nowhere deep enough to be triggering these? Could anyone explain why and how this is happening- and how I can avoid it?

sigh feeling so incompetent after my shift. been a nurse for two years and six months in a high acuity medical icu. i’m fine at taking care of the regular two icu paired patients but just feel so stupid when things start to get more critical. i know most of it comes with time but i find myself comparing myself to the other nurses who are able to just jump in. i feel like a lot of icu nurses get excited for these more critical situations but i don’t. anyone else ever feel like this?

I know the usual argument that it doesn’t matter because they’re pulseless, but is there any physiologic contraindication to doing a synchronized shock at the usual shock dosage for pulseless VT? And on the other hand, is there any data supporting synchronized shocks for Pulseless VT?

It costs nothing to synchronize, but in my anecdotal experience this is not done.

Hey, I'm running into an issue lately at work. New policy for pressors states that they must be ultrasound guided. The minimum catheter length in the forearm is 1.75 inches, and the upper arm (no AC) must be 2.5 inches. US access has become available to most of the facility. I have become fairly skilled and embraced placing USGIVs.

Our more senior ICU nurses are flat-out refusing to learn to use ultrasound. They talk trash about people using ultrasound, and claim they are not skilled at placing standard PIVs. Of course after their pt has been stuck 6+ times they want an ultrasound IV. They are attempting to place regular PIVs in deeper vessels which inevitably end up infiltrating. There are relatively few ICU nurses trained to place USGIVs, but we are always more than happy to help with lines when asked.

I think the biggest misconception that they have is that USGIVs are not just for difficult IV access pts (DIVA). It is also to be able to place extended caths that are confirmed to be fully in a vein.

Last shift central access was not able to be obtained by medical residents on a post-code pt on multiple high dose pressors. Pt just had one working 20g that was very sluggish. They were a previous IVDU, was very edematous, and had been in LTACH for a long time. Pt had fistulas in both arms, and I cannulated the arm with the failed fistula after visualizing that site and confirming that the fistula did not exist anymore. Basilic vein was patent and I cannulated it with an 18g 2.5 inch cath without much trouble. RN was obviously not happy about having to ask me to place USGIV.

Has anyone encountered similar issues with hesitancy to use ultrasound? Or a flat-out refusal to learn?

Is the placement of a temp HD catheter / apheresis catheter a core competency as defined by the ACGME for PCCM? ACGME guidelines are a bit light on details. What type of temp central line placement, if any, would not be placed by PCCM docs? Are the above catheters generally placed by intensivists or are they more often placed by other specialties like nephrology?

I recently had an encounter with a patient who was started on a 24-hour hydrocortisone infusion. When I asked my intensivist the rationale as it was my first time having a patient with this, he told me because of a recent study done.

Background on this patient: late 90s male, PMHx of COPD, HTN, DM2, PVD, and neuropathy. Came in because wife found him down and couldn't wake him up. EMS intubated in the field because apparently, GCS was 3. Came up to my floor on 60% FiO2. Long story short, after a family meeting they decided hospice for the patient. I've seen patients with similar presentations and not given this infusion.

Couple questions about this. What would be the reason for starting this patient on this infusion? Would it be because of age? Which study is being referenced? Lastly, do you guys do this commonly on your floors? Thanks!

Hey everyone

I am ICU PGY-4 , i have elective rotation and i am considering doing it in Echo.

I am looking for a center in Europe that can offer an elective rotation in this matter for 4 weeks, for international/visiting residents

I have sent plenty of emails and got no responses

Any help and suggestions would be greatly appreciated

Thank you!

CVICU nurse here. I work in a pretty high acuity ICU (ECMO, transplant, all the devices), and I’ve noticed some of our providers are very reluctant to give albumin for elevated lactic in our post-op patients (POD 0-1) even after 4-5L of fluid have been given or more. Can anyone provide insight on this?

Can someone explain utilizing mixed venous gases to aid in evaluating the patient’s response to weaning inotropes?

what’s the worst aortic dissection you have seen? I recently cared for someone with type A aortic root dissection that extended through the subclavians into the carotids all the way to the iliacs.

Hi everybody, I’m about to be a new grad nurse this spring and currently have an interview lined up for a critical care nurse residency, and I was wondering if you guys had any advice such as what kind of questions to expect, good things to highlight, good questions to ask them, what to avoid talking about, etc.

I currently work at the hospital I’m interviewing at as an SNA. I’m in the float pool and have floated to my hospital’s SICU and MICU as well as their PCU unit a couple times so I’m hoping that might give me an edge but I would really appreciate any advice you guys could give!

At the ICU there are guidelines that request visitors leave 6:30-8:30 am and pm. 1 overnight family member allowed. This is also GA and in March the no patient left alone bill was signed which provided clarification and has some distinction of essential caregiver versus visitor.

This two hour period twice a day is for shift change. It also is a terrible time if you have to work and happen to have someone in the hospital. What are y'all's thoughts as medical professionals? Do you care if a caregiver is a fly on the wall during shift changes?

Does it make a difference if the patient is on a ventilator or not?

We’re putting soy sauce down the OGT/NGT instead of 3%. The soy sauce packets come from the cafeteria, no nutrition facts, no mls. They don’t show up in the MAR and are just getting put in as a nursing communication order. So a soy allergy won’t flag and if you don’t put in that verbal or the provider forgets to order it…

New grad RN here. I’m feeling pretty confident by myself after 8 months (not complacent, I’m just happy with where I’m at and still continuing to learn), but then sometimes I feel like I don’t even know the basics like the question I’m asking lol.

If my patient is desynchronous with the vent, I tend to bolus them with fent and titrate up. If we’re looking to extubate, I titrate the propofol down because I know you can’t extubate on prop. Outside of that really I just base my titrations off of the CPOT/RASS orders. I’d like to have more knowledge on the hemodynamic differences between both and when you would choose one over the other. Thanks!

I would like to know how many nurses should realistically be hired working a daily night 12 hour shift in a small icu set up of 8 beds?

Hi! I’m not a native English speaker, so i apologise for any spelling mistakes. But I’m curious if any of your hospitals have protocols of how to prevent and treat delirium? We’re currently working on it and I wanna know how you all prevent and treat ICU-delirium. I’m also searching for personal experiences on what treatment you think works best! It would also be helpful to know in which country you work!

per policy most drips are changed every 96hrs. i recently learned that amiodarone is changed every 24hrs. why?

does the filter lose efficacy? does amiodarone change something in the tubing?

SIMV sets a mandatory rate and allows patients to take unsupported spontaneous breaths between those mandatory breaths. AC allows for mandatory breaths with spontaneous breaths assisted with pressure support to achieve similar tidal volumes compared to the mandatory breaths.

In reading about how SIMV was invented for weaning, but the lack of assist on the spontaneous breaths meant that it fell out of favour, a few sources have mentioned that SIMV now comes with pressure support.

How is SIMV with pressure support difference from AC ventilation? Is it not the case that both are mandatory forms of ventilation with the opportunity for patient-triggered breaths and those triggered breaths are supported with additional pressure?

Edit: Is it just the fact that SIMV allows for synched mandatory breaths and AC doesn't? Other than that are they the same?

Hello all!

For your ARDS patients, has anyone had experience with the automated proning beds like Rotoprone or the newer Pronova that is supposedly better for the skin?

Automation seems nice and more efficient but I know most facilities have had plenty of experience with manually proning by now.

Thanks in advance for any and all feedback...

EDIT: love all the feedback.

I agree manual proning has its advantages. However, if the patient is over 300 lbs, unstable due to trauma, and just particularly not an easy flip, I do think an automated bed would be advantageous. It's a pain getting them in the bed, but once you do, the bed does the rest.

Also, there is a new prone bed called the Pronova we just trialed. It's a lot better when it comes to protecting the patient's skin, which was my biggest issue with the Rotoprone...

I’m a new nurse in a level 1 trauma hospital in their regional burn center. We had a patient with 95% TBSA come in and family chose to withdraw care. My preceptor said that we do not fill out the death survey because burn patients cannot be organ donors, another nurse said the burn center she worked on in Texas did organ donation all of the time. I know if the patient dies from MODS due to hypovolemia that would make them ineligible for certain organ donations, but if the patient were to die from respiratory failure wouldn’t that make them eligible for organs other than lungs? I’m looking for more insight on one or the other if anyone can share their knowledge on the subject.

I’m curious to get the critical care community’s input on surgeons with egos that may negatively impact patient care. I had an experience with a cardiac surgeon who delayed/withheld critical interventions seemingly to protect his stats. While it wasn’t openly said, it was clear to those of us involved, including the intensivist and the surgeon’s own NP. She said, when I stressed the dire need for CRRT, “I have to treat Dr. X too,” which felt like she was afraid to advocate for the patient.

We had a post-CABG patient who urgently needed CRRT and reintubation, but the surgeon refused to allow us to reintubate. We had to max out the BiPAP settings, to the point where we were concerned about the patient becoming distended. Only after a drawn-out debate did the surgeon allow us to place access, but only on the condition we also placed a Swan for “his heart,” as he put it.

Unfortunately, the patient didn’t survive. Has anyone else faced situations where a surgeon’s ego overshadowed patient care? How do you approach advocating for patients in these circumstances? Would appreciate hearing others’ experiences.

Hey guys, I am curious if AI and more specifically Machine learning is already a thing in your unit? Do you get any kind of assistance based on predictions in your EHR or CIS? I do not mean the regular scoring stuff like APACHE. More like a real time alerting for certain risks, suggestions for therapy e.g. personalized dosing for sedation, vasoactive substances, etc. If so, does it provide a real benefit and what's your experience in terms of reliability of the predictions?

I read a lot of papers with great results but my impression is, it's still not arrived at day to day work. Please proof me wrong.

I used to be an ICU nurse in the past and the prediction capabilities of our CIS were to provide a pop up saying: hypotension, tachycardia, fever > could be Sepsis. Not so useful.

Good afternoon!

I’m curious if anyone here has a gig attending in a VICU, and more specifically what that day-to-day actually looks like, schedule, compensation, etc. Also would like to know if it’s your primary gig or in addition to another position?

Thanks in advance!

What's the lowest number of urea/BUN you've seen with manifested UE. Personally I've intubated a patient with a Urea of 145 (BUN 68) with manifested UE before who had a drastic improvement after hemodialysis, but everyone was skeptical before that because most people can tolerate ureas of >200 with no manifestations. What is your experience with this, is this really very rare?

Hi everyone, I’m on the panel of interviewers for our new night ICU supervisor. Which questions should I be asking?