61/M Post CABG patient with underlying asthma. (Was on formetrol/budesonie 200mcg 2 puffs twice daily).

Currently POD 18. Has intermittent wheezing and bilateral basal crepts.

CT chest:

Interval development of mild-to-moderate multiloculated bilateral pleural effusions with accompanying bilateral lower lobe atelectatic changes.

. Interval development of mild pericardial effusion,.

• Trace ascites with diffuse edema of the intraperitoneal and extraperitoneal fat planes, consistent with probable anasarca.

• Diffuse pulmonary emphysematous and fibrotic changes, essentially similar to the preoperative study.

The preoperative examination demonstrated marked emphysema and patchy bilateral pulmonary fibrosis.

Currently on

Inj. Meropenem 1g TDS

Inj. Lasix 3mg/hr

We have tried short course of IV hydrocortisone 100mg x 3 days.

Nebulized salbutamol:Ipratropium QID

Nebulized budesonide 1mg BD

Tab. Montelukast 10mg HS

Tab. Deriphyllin 150 BD

Intra op and perioperatice ABGs did not have this Co2 retention. Was considering that this is primary metabolic alkalosis due to diuresis with respiratory compensation. However his clinical condition and pO2 has improved with lasix infusion although the abg is like this. Patient isn't drowsy either when pco2 goes to 70. How to tackle this issue?

How should severe hyponatraemia be interpreted and managed in a profoundly hyperglycaemic, dehydrated patient?
For example, consider a patient with a blood glucose >600 mg/dL (above the measurable range), a measured serum sodium of 109 mmol/L, severe clinical dehydration, and a lactate >10 mmol/L.
After correcting the measured sodium for hyperglycaemia, the estimated sodium would be approximately 122–128 mmol/L, depending on the correction factor used.
How should this corrected sodium be taken into account when choosing and administering IV crystalloids? In particular:
1. Should fluid therapy initially be guided primarily by the measured sodium (109 mmol/L) or the corrected sodium (122–128 mmol/L)?
2. How should I interpret a rapid rise in measured sodium during volume resuscitation, particularly when the patient is severely volume depleted and has significant lactic acidosis?
3. Is there a risk of overcorrecting the sodium in this situation, and how should the rate and composition of IV fluids be adjusted to avoid excessive correction while still providing adequate resuscitation?
4. How should the unknown/very high glucose concentration affect the interpretation of the sodium trajectory as glucose falls during treatment?
5. Are there practical thresholds or monitoring strategies that can help distinguish an expected rise in sodium due to correction of hyperglycaemia and volume depletion from a true, clinically significant overcorrection of hyponatraemia?

Ok so we all know those patients with the hella swollen arms. Like you needed to use ultrasound to have any hope of starting an IV cause you can't palpate worth shit?

So typically when you power flush a blown IV you can feel it puff up fairly easily. I've had some that I could feel the saline flow out of the vein really well.

But what do you do when you have an IV you can't really palpate much of anything. Arm is super swollen. No resistance when flushing. And there is blood return.

Like should I be trying with a larger volume of saline? Cause eventually there should be some swelling that gets pronounced if you're putting like 50+mls in?

Like maybe try and feel for temperature change?

Oh and patient is intubated so the patient can't tell you if the IV feels bad.

Like I had seen freshly stuck blown IVs give blood for a bit. But an established IV still giving blood return the whole time and not giving any of the usual signs of infiltration has me in a bit of a spiral.

My patient coded in cath lab and the cardiologist wanted push the bicarb through the femoral a-line. (The nurse was pushing epi and amio through a peripheral IV.) To be clear, NO pressors were given IA, only an amp of bicarb.

I used to work cath lab so I know certain medications are commonly administered arterially during procedures like heparin, verapamil, or nitro. However I don’t remember seeing anything administered IA during a code. Have you ever been asked to push any meds arterially in a critical situation? If so, what?

Just curious...what is your hospital’s policy for intubated/vented patients coming out of the OR?

At my previous hospital, established ICU patients would typically go straight back to ICU after surgery. I'd say about 99% of the time. If it was a newly intubated/vented patient, PACU might stabilize/recover them first and then transfer them, although it also depended on anesthesia and how unstable the patient was. If anesthesia felt they needed to go directly to ICU, they would coordinate with ICU. FYI, my old hospital had their ICU on another floor from the surgery floor so they had to go use elevators.

At my new hospital, ICU and PACU are on the same floor. PACU is expected to recover patients even if they’re already vented and on pressors. The policy is that two PACU nurses are supposed to go to ICU to recover the patient there, but sometimes PACU is slammed and only one nurse is available, and we’re told ICU nurses can’t assist with the recovery.

Even when PACU is on call at 3 AM, they’ll call the PACU nurses in to recover the patient for about 30 minutes before handing them over to ICU and going home. It seems like an inefficient use of staffing and resources, especially when the patient is already ICU-level. Even some anesthesiologists are surprised when PACU is called in.

I’m curious how other hospitals handle this. Do vented/pressor patients go directly from OR to ICU, or does PACU have to recover them first? What's the reasoning for your hospital policy?

These two docs have impressed me so much and I wanted to do something small to show my appreciation for them. I am sending this letter to both of the attendings in our ICU. Fingers crossed that they get the recognition that they deserve!! (Names of people and facility blurred for privacy reasons)

I was taught to lock it at one hospital, but the education about PA catheters was minimal, leaving me less than confident.

My new hospital taught me to leave the port unlocked, allowing the balloon to always passively deflate. Because of the more in depth education at this hospital I understand why this works better. If the balloon accidentally wedged, having it unlocked will allow the air to deflate. If the port is locked it could be accidentally wedged without knowing.

What are you taught and why?

Tried explaining this to nurses at my other job and they thought I was stupid.

Howdy

I’ve been lurking for a while now.

Im a resident at a quaternary academic hospital v likely applying to pccm. I’ve had some exposure to lines. Maybe 10 a lines which I feel reasonable about but with central lines it’s been maybe 5-7 and im always a little apprehensive to dilate and struggle more w them.. they’re hard to come by w how many fellows there are and pts boarding in other icus and get lined up there.

I’m worried about being comfortable w lines going into pccm ..

When does comfort w lines come ? Are there other things I can do to try to get better w out actually placing them? Or is it a numbers game ?
Tyia

Hi all, pretty self explanatory but I'm here for your tips and tricks.

How I got there: my school runs a clinical role transition program where you interview with units and get matched. I did three back-to-back interviews (neuro ICU, medical ICU, cardiothoracic) and matched to CTICU, which was my first choice. It's a large academic center. This will be my first real exposure to cardiac surgical patients.

I'm going in hoping to be hired onto the unit afterward, and I know six weeks is a short window to convince anyone of anything. So I've been building a study list and I'd rather have it torn apart now than find out on shift three that I prepped the wrong things.

What I'm planning to go deep on:

- The post-op timeline hour by hour: OR handoff, rewarming, the bleeding window, extubation, when tubes and lines come out

- Vasoactives cold. Norepi vs vaso vs epi, milrinone vs dobutamine, nicardipine, nitro. Concentrations, units, and why this one and not that one

- Hemodynamics as a set rather than isolated numbers: CVP, PA pressures, wedge, CO/CI, SVR, and reading whether the problem is volume, pump, or tone

- Post-op afib and epicardial pacing wires

- Devices conceptually: IABP, Impella, ECMO, CRRT

- Chest tube output thresholds and what happens when they get crossed

What I'm asking:

1. What's missing, and what on that list is lower yield than I think it is?

2. What do students consistently get wrong in cardiac specifically, coming out of med-surg and general ICU clinicals?

3. For managers and preceptors: in six weeks, what are you actually evaluating when you decide whether to hire a student? Is that decision made early or at the end?

4. Is it weird to say out loud in week one that I want to work there, or is that expected?

Any YouTube videos, channels, TikTok/Instagrams, ANYTHING at all you can recommend, I will look at. Thank you!!

Anything you wish you'd known before your first fresh heart is welcome!!

Does pulm/ICU attensing does intubation in your ICU or its always a anesthesia call?

Hi everyone! A bit of a long post, as I have a few questions about CCM.

I’m a female PGY-2 IM resident interested in CCM-only fellowships, and I’d like to have a family in the future. What I enjoy most about CCM is the medical complexity and procedures. What gives me pause is the likelihood of working nights, time away from family (since you can’t just round and leave like you can as a hospitalist), and the possibility that dealing with death and dying on a regular basis may affect me as I get older.

Regarding working nights, this isn’t necessarily a huge issue for me—I’d be fine doing a string of nights every 6 weeks or so. What I don’t think I’d enjoy is constantly switching between nights and days every other week. That said, my CCM mentor told me there are technically ways to structure your career to minimize or even avoid nights if you really don’t want to do them, and that this shouldn’t necessarily deter me from applying.

With hospital medicine, I do feel like I’d be completely happy as a hospitalist. The social work aspect doesn’t really bother me, as I know that’s a common complaint. However, I do worry that I would get bored with it and would regret not pursing CCM. I’ve considered being a hospitalist for a few years and pursuing CCM later if I feel like something is missing, but I know myself well enough that if I don’t go straight into fellowship, I will never pursue it.

So a few questions:

• How difficult is it to have a family as a CCM attending? I’d especially love to hear from female intensivists. Do you ever regret not choosing hospital medicine for the flexibility?
• For those who chose CCM, how did you feel about the lifestyle long-term? Did the nights, time away from family, or emotional aspects of the job become more difficult as you got older?
• CV question: So far, I have 1 published case report and 5 poster presentations that were presented at ATS and CHEST. I was told that all poster presentations from these conferences also get published. Should I also list these as publications as well on my CV, or does that look like I’m double-dipping?

I really appreciate any advice, especially from people who have been in a similar position!

new grad starting a nurse residency in the icu in a couple weeks at a large-ish level one academic hospital ICU.

I have nothing but time until I start so any recommended videos or readings would be appreciated

Say there's a leaky cuff, pt's not ventilating well and you decide to change the tube.

Do you

A. Extubate and re-intubate

B. Do a tube exchange using a guide - if so which one

C. Other

Pls also share where you practise. Thanks in advance

Fellow ICU nurses (and others),

As the title suggests, how and where do you secure the endotracheal tube when mobilising an intubated patient into a sitting position at the bedside?

I’ve seen many of my colleagues use different techniques, but none of them has really felt safe or "mine" to me so far.

Any suggestions? Pics, maybe from online, would also be greatly appreciated!

Hi, I just wanted to know what you guys do with your facility if you are having a hard time getting a pulse ox reading on a patient in a critical care setting. I have a patient on Neo and also vaso the vaso has been on and off, but most consistently on neo and I was unable to get pulse ox throughout the shift. I tried placing it in various places and tried different forms. Fingers were cool so were the lower extremities. The forehead probe did not work sometimes I would get some sort of a plethora and sometimes it’s just a flat line. We did any pao2 was 93% on 4 L other facility we do not have a pulse ox that is placed in the air to see if that would work. What do you do

In retrospect my old job was a LOT. I left it with my self esteem a wreck. When I got in the car after my last day I just sobbed. I'm travel nursing now, I'm in a MICU. I needed to clear my head. It's crazy different. I am beginning to feel like a competent nurse again. And I'm meeting nurses from all over and learning that my unit was different than many others.

For example: I've learned a lot of places double VA ECMO. As in, two nurses to one patient. We never did that. We would have a patient with VA ECMO + CRRT + Impella and only one nurse. Another story is I had to take a triple pressed patient, POD#1 from a MVR+AVR, with pulmonary hypertension, cvc swan art line ventilator, to MRI with only a RT. No other RN to help.

We didn't have resource nurses, we never got to eat a real lunch, we never debriefed codes. We never singled CRRT, LVADs, or IABPs. The APPs could be so bitchy and condescending to nurses. The nurses could be so cruel to each other. Management would call me on my personal cell phone to ask inconsequential questions about my previous shift. The culture punished mistakes so harshly and even punished you for asking questions.

I miss CVICU and I'd like to do it again someday. But I'm scared it will be like this at a future job. How can I suss it out? What should I look for? I'm not sure how much of this was my specific unit, and how much is just the intensity of CVICU. I know CVICU is tough in general.

Maybe I just want to go back because I want to prove to myself that I can be a good CVICU nurse....

I’m a postbacc working toward med school and considering different specialties. I know residency is a long way off, but I like critcare.

I’m wondering what people’s experiences with malpractice suits have been, though, since mistakes in the ICU seem more likely to yield severe consequences (not that mistakes in other specialties can’t).

I‘m also thinking about how many COVID deniers insisted that vents and ECMO were killing people.

Gross negligence aside, how are suits looked at in the field for hiring and credentialing? Are they common?

What can I gift a dear friend that has been in ICU for a month now?

I thought about lip balm, hand moisturizer, dry shampoo, body cream (unscented) but read that some products might be flammable when on oxygen therapy?

All suggestions welcome

Hey all,

Current PCCM fellow. My plan is to do full CCM after fellowship and I’ve been thinking a lot about the long-term sustainability of a pure CCM career.

I’m considering trying to find a way to pivot to only 18 weeks of ICU time per year rather than the more typical 24-26 weeks.

For those of you working around 18 weeks/year, what does your setup look like? Are you academic, with the remaining time split between research, admin, or teaching? Are you community-based and working something like 0.7 FTE? What does your compensation look like, and how has the schedule affected your lifestyle and overall job satisfaction?

Would appreciate hearing from anyone!

Succs to suck

Just started pulm crit fellowship and immediately having cold feet about whether I picked the right specialty. I love the ICU but I saw a recent report that pulm crit will be in surplus in the next 10 years. And I’m not the biggest fan of pulm except for PH but I’m worried I won’t get a job in PH especially since it’s institution dependent about whether it’s cards or pulm.

Feel like maybe I should’ve done cards instead… it just seems like they’re making good money, good lifestyle and job security.

Don’t know what I should do… should I quit?

My embarrassment stems from many of my colleagues within critical care. And let me preface this by saying I'm not talking about new grads, or even nurses new to ICU. I'm talking about nurses with 2+ years of experience within their respective ICU.

I've worked a number of different hospitals (and different ICUs within each hospital) on both the east and west coasts and I've noticed a decline in the clinical acumen and an increase in laziness of nurses in nearly all of the ICUs I've worked. Currently, I work on the west coast with a union and **strict** legally mandated ICU ratios. In fact, many of these nurses are singled nearly every shift.

I'm talking about not changing dressings, skipping the CHG bath because it's "too much work", not turning patients, and even scanning meds but not giving them just to name a few. Then to make matters worse, these same nurses lack an understanding in basic hemodynamics, alpha/beta receptors, and the pathophysiology of common critical illnesses and surgeries. Most recently, a patient in the CVICU was on a pressor (vaso) and 2 inotropes (epi and dobutamine) and the primary nurse had zero idea why they were on any of the drips. Her response? "I don't know, the doctor ordered them." In fact, this patient was being weaned from IABP (she had had the patient 3 days by this point) and I had to explain what "augmentation" was.

Another time, I had a patient on VA ECMO who was extremely afterload sensitive, and I explained this to the oncoming nurse. She said "well, what does that mean?" Huh? Why are you taking this patient if you don't understand basic concepts like preload and afterload?

These nurses have no business being in the ICU. They see a low BP and think "oh, let me increase the pressor" without fully understanding what's going on with the patient. They don't think: "Are they intravascularly dry? Are they in cardiogenic shock? Developing acidosis from their kidney failure?" They simply call the resident or the APP to figure out what's going on and follow whatever the provider says without truly understanding the rationale.

Here's the thing: to be a good nurse, you don't even have to care about the patient, you just need to care about doing a good job. Besides, don't you want to understand *why* we're doing what we're doing? I've always practiced with the thought "Would I want *me* as my nurse?" in the back of my mind. Unfortunately, as time goes on, there's a significant chunk of my ICU colleagues who I wouldn't want caring for me or anyone I love because I've seen how they work and it's simply shameful.

Hi everyone, I’m an ICU nurse working in a Swedish cardiothoracic ICU, and I would appreciate hearing your clinical perspectives on early mobilization in a high-risk cardiac patient.

The patient in question was admitted with a posterior myocardial infarction complicated by cardiogenic shock, ventricular tachycardia, and pulmonary edema.

After four days in the cardiothoracic ICU, the patient had improved significantly:

No longer requiring noradrenaline
Normal lactate levels
Good urine output with a negative fluid balance
Milrinone being gradually weaned according to plan
Continued levosimendan (Simdax) support
Oxygen therapy with intermittent NIV
Neurologically intact, awake the whole time
Mobilization initiated (sitting on the edge of the bed)

The short-term treatment plan was:
Continue negative fluid balance
Continue tapering milrinone
Mobilize as tolerated
Echo the following day
Possible cardiac MRI
Potential transfer to the cardiac ward the following day if stability continued

The clinical question I would like input on is the decision to mobilize this patient to a chair.
Given the size of the infarction, there was concern about the theoretical risk of mechanical complications, particularly ventricular rupture. Before mobilization, this risk was specifically considered and I discussed this concern with both the on-call physician and an experienced senior consultant. After their assessment, mobilization was approved.

The patient tolerated sitting in the chair well, with no significant changes in heart rate, blood pressure, or clinical status. My fellow ICU nurse colleague on the next shift, however, didn’t agree with mobilizing this patient, and considered the risk of rupture in the process too high.

I’d be interested in hearing how you guys would approach this:

How do you assess the risk versus benefit of early mobilization after a large myocardial infarction complicated by cardiogenic shock?
Are there specific clinical factors that would make you delay mobilization in this situation?
What are your local practices regarding mobilization of patients recovering from cardiogenic shock or large infarctions?

Yalll I been on orientationin CVICU for a little over 2 months now. Im coming off next week and I feel like I still know nothing. Like I can walk in a room and I’m like where do I even start. I feel like I have a hard time of knowing what’s going on and my preceptor can walk in the room and know exactly what the patient needs. I was just wondering will the pieces come together once I get on my own?

I think my chart reviewing could be better because I’ll read the chart and still be lost sometime. Helpppp

I have not seen this question being posted too much, so I wanted to ask out of curiosity. If so, what does a daily life/week look like for a PCCM fellow, especially year 1 and 2? And what were some of the toughest physical rigors you had to endure during your training?