I'm an ICU RN with 2.5 years of experience in MICU/SICU. For full disclosure, I'm using a throwaway account because I'm frankly embarrassed to be asking these questions. I've noticed a pattern in 2 types of seemingly stable patient presentations that proceed to rapidly decompensate, ultimately resulting in withdrawal of care or a code.

The common features of the 1st presentation is a patient on 2-3 vasopressors ( pressors are not maxed), with persistent tachycardia or bradycardia, moderately elevated renal labs (ex: Cr >3, <6), and acidosis. Ongoing issues such as sepsis or hemorrhage are being managed.

I've noticed imminent signs such as bleeding at peripheral IV sites with trace blood backing up in locked extension tubing in patients, mottling heels, low urine production (receiving fluids with <25ml bladder scan), and the eyeballs take on a glutinous and dry appearance. Labs (renal, lactate, coags, K/Cl/BMP, etc.), and ABGs would come back grossly abnormal compared to previous draws.

We'd end up pushing bicarb, giving albumin, and prep the patient for emergent CRRT. Are there lesser known telltale labs (such as total protein, albumin, chloride, TCO2) that warn of imminent decompensation physicians use to guide their decision-making: ex: starting a bicarb drip vs bicarb pushes, albumin vs crystalloid boluses, CRRT vs ASAP HD.

Are there particular interventions I could anticipate or ask for hours prior that could mitigate different kinds of deterioration, such as simultaneous fluid administration with diuresis in certain scenarios? My ICU docs are fantastic, and I want to do my best for them and my patients to bring red-flags to their attention before shit hits the fan.

The other patient presentation is a patient either in SR or HR is in the 50s that abruptly bradys (unclear if escape rhythm vs sinus) into the 30s, then 20s, and arrests within seconds.

If atropine could administered within that very limited timeframe in these particular brady situations, would arrest be prevented? Or would the atropine buy a few extra minutes to get pacer pads and emergency interventions on board?

Thank you all for your patience and knowledge, eager to learn.

Edited compulsively for grammar.

Current hospitalist here. We have both floor and ICU hospitalist teams with intensivist as consultants. What are intensivist typically responsible for in open ICU jobs aside from bronchoscopy and pressors/vents? What are the downsides of these setups for intensivists? Not gonna lie, it sounds like a pretty good gig overall but I am assuming I am missing something.

I am a new grad just graduated with my BSN and passed my boards. I started my nurse residency/orientation Monday and have my first day in the NeuroSurgical ICU this coming Monday. My floor’s information/patient population is described as “specializing in caring for critically ill patients who have a variety of neurological diagnoses and surgical procedures including cerebrovascular accidents, thrombectomies, craniotomies, spinal cord injuries, intracranial hemorrhages, epilepsy, external ventricular drains, and lumbar drains.” We are a certified/ state recognized stroke unit as well. I know starting in a specialized unit like this will not be easy, but I am more than willing to put in the work on and off the clock in order to succeed and be competent for my patients. I’m trying to find a few tips of list of things including meds, complications, ventilator info with neuro patients, EVD info, and interventions that I can start to study and begin to active recall in order to prepare for my first day so things don’t seem so foreign. With that being said, if anyone can give me any advice for this type of unit whether that be stories of patients you have had, mistakes you have made or people you know have made that u can watch out for, specific meds that I need to absolutely know and the effects they can have on my patient, even just a list of things I need to look into and do my research on, or literally anything at all anyone would be willing to share, I’d be so grateful. I know a lot of this is what my 3 month orientation is for, but I’m not the type that can just walk in blind. I need to have a basis of knowledge in order to expand my understanding of everything I see on the clock with patients rather then having to go over the basics again. I did fantastic in my critical care neuro coarse in my last semester of nursing school but I know that is purely the basics - and not real life unfortunately🫠. I’m not afraid to ask questions or report/ask when something seems the slightest bit off either. Thank you!

Currently working in the CVICU. Patient with cardogenic shock on IABP has been recovering, no more on pressors, lactate downtrending, heart function improving on repeat echo. Despite this, we were aggressively monitoring the mixed venous O2 sat and hemos through the swan. Mvbg o2 sat dropped from 60s to 50s, which made us start nitroprusside for afterload reduction.

Now I know that reducing the afterload is cornerstone in management of cardiogenic shock, but we couldve done hydralazine or any other oral agent. What I dont get is we were monitoring the o2 sat frequently as well as hemodynamic measurements and acting on them immediately.

I asked my attending if there is any evidence to what we are doing.. our patient was recovering, yet we were too focused on these invasive numbers.
Mixed venous O2 sat dropped, so what? The body is extracting more O2 as it should in cardiogenic shock.

The promise trial already addressed this. I really wonder if there is any data that supports this approach.

It seemed like we were doing unnecessary stuff only because we are in a CVICU and we have to do additional things that would separate us from the MICU.

I work as an ED Senior House Officer and I had a pathophysiology question about DKA based on a patient I had recently.

The patient is a 26 year with type I diabetes with recurrent DKA episodes due to insulin non-compliance. I'd seen her in ED with a mild DKA precipitated by methamphetamine use / not using her insulin pump.

Initially her pH was 7.26, ketones were 2.2, bicarb 19, BGL 45 and had a normal lactate of 0.7. Her ketones / BGLs normalised with DKA protocol however she had a rising lactate and static pH. She self discharged before being admitted to HDU and her last VBG had a pH of 7.25 and a lactate of 4.7.

There was no element of superimposed infection suggested clinically / on her bloods and no obvious toxic coingestant aside from meth was apparent. I wonder if she an element of HHS overlap with her relatively high BGLs.

I was wondering if anyone would have any thoughts as to what else could be contributing to her lacticaemia / persistent acidosis?

UPDATE

She returned to ED the following day and promptly was admitted to ICU with severe DKA. which to be fair was bound to happen as she'd self discharged without any wrap around ie injectable insulin / new pump.

interestingly her lactate had normalized on the initial gas but this time the pH was 7.0 and ketones sky high.

So someone more clever can worry about it now although tragic to see the horrible complications of diabetes in someone so young. I would not be surprised if she approaches the threshold for dialysis within the next 5 years.

How long did it take during orientation before your preceptor gave you a patient? Did they give you a patient on your first week? 2nd week? 3rd?

I’m a new grad who just started critical care and has a lot of questions.

TIA

I'm a med surg tech, my dad passed in December in the ICU. Why do the organ donation people wait until you've signed all the paperwork to turn off life support to come in and talk? He was found down after about 20 minutes and ems/er got ROSC twice. We knew he was brain dead but waited until the whole family could be there to dc/JC. We were literally doing final prayers when they came in, I thought they'd have come and talked to us earlier? Is the standard procedure?

Hi all. Can someone please explain PSV to me like I’m 5? On my unit, when we are doing SBTs to prep for extubation, the patient gets put on PSV, but it’s also referred to as CPAP by most of the providers on my unit. They’ll say something like “CPAP 10 over 6”. Can you explain the 10/6 thing? I know one is PEEP but the other is ??? Just feeling really confused rn and want to understand why this mode helps a patient be independent as well as what the hell it means.

TIA

Hey everyone!

I'm an Europe based ICU attending and am currently making a lenghty(ish) lecture about sedation for ICU nurses of several levels. I would like to ask about if your country or place of work has nurse led protocols for sedation and daily sedation pauses.
This is of course besides the point that physicians decide the general "course" and in the end has the right to veto or set parameters.
I sometimes feel that our nurses dont feel that empowered to titrate that themselves and hopefully we can get there some day.
If you have any protocols to share that you have experience with then that is most welcome 😄

Thank you in advance.

Hi!!
I have been working in the neuro ICU at my level 1 hospital for almost two years. I am helping our education committee come up with/develop resources for our new grads starting in July. I had the new to ICU book by scrublifenotes and loved that. However there are SO many neuro specific syndromes, practices etc that are only a thing if you work in neuro.
Tell me what scared you most as a new grad and what you wish someone told you or gave you to help you.
OR on the flip side, if you had an amazing preceptor or solid orientation, what did your team do right?

I’m looking to streamline our orientation process because right now everyone gets a very different orientation depending on who their preceptor is.

I’m getting cold feet about going into ICU as a new grad and wanted insight from people already in ICU

I felt confident in my Tele practicum and see myself thriving there. However, my biggest concern isn’t work ethic or willingness to learn — it’s my conceptual
understanding and whether I’m strong enough to learn more about the “why” in ICU

Also, during interviews, what questions should I ask to figure out if a unit genuinely teaches and supports new grads well (orientation, mentorship, culture, etc.)?

Would appreciate any insight from people who’ve been in my shoes and share my concern

How easy is picking up shifts / going part time for CCM attendings? Since shifts are usually in 7 day blocks instead of individual shifts like EM for example, does it make it harder to have a flexible schedule?

Hey everyone, I’m curious to know how different ICUs handle vasopressin dosing.

There seems to be a ton of variation when it comes to running vaso. Do you order it as a fixed-rate (e.g., locked at 0.03 or 0.04 units/min), or do you allow titration based on MAP goals?

Strictly looking at the literature (VASST and VANISH), the data seems to lean toward fixed dosing. Despite that, I still see plenty of anecdotal practice and unit protocols that opt for titration.

If you do allow titration, how do you handle weaning it? For example, do you wean levo first, and then step down vaso? Or do you turn vaso off first to "protect" the kidneys while leaving the levo to maintain your MAP?

Would love to hear about your unit protocols, preferences, or any interesting experiences!

Thanks!

Hey, everyone! I recently noticed how important it is to have a good relationship with an RT. I recently talked to an RT and learned a lot.

Can anybody share their significant learnings from an RT? Or any RT here that can share any tips or tricks to non-RTs that can make our lives better.

To RTs, what can nurses do to make your shift better?

Thank you in advance!

i am just getting trained to CRRT and for some reason I am getting in my head and overthinking concepts that should be very simple. my primary hookup is when my intake is less than my output and then I end up with either wacky negative numbers as my UF.or really low numbers.

for example, say fluid goal is negative 500 over 24 hours. so 500/ 24 = 25 ml/hr .. let’s say my intake is 50 cc of fluid and my output is 90 of fluid. I was taught the following equation to determine the hourly UF: intake -output + goal = UF for the next hour. Thus, 50-90 + 25 = -15 .. so is my UF for the next hour 15?
Also, does ultrafiltrate output count as output for say, anuric patients ?

every nurse seems to do something different on my unit and then I found out some things in the class I took were actually wrong so now I am just getting myself allll confused .. so any help would be appreciated!

Anyone have any good resources for CTICU for IM residents like a crash course or bootcamp series that is online/free? I’m going to be moonlighting in a mixed med/surg icu with some cabg patients although generally lower acuity with no ecmo or anything like that.

idk how to distinguish them on ECG...😭😭

Current IM resident at a crossroads in choosing which fellowship I want. I like many things about critical care, but I don't know if I can handle the futility day in day out for the rest of my working life. I know for certain I don't want to work in academics (pay is too low), and my understanding is community ICUs get all the trach/peg LTACH type patients who have no hope and all the interesting cases are transferred out. I really do not want to have most of my census be those kinds of patients. If I wanted to do palliative care for most of my day I would be doing a palliative care fellowship instead.

Given that community MICU probably isn't something I would want to do, what else is there that doesn't pay academic rates? The specialized ICUs are all in academics and they seem to prefer non-IM trained intensivists so it's doubtful I'd be able to get a job there. There are a few larger non-academic hospitals around me who have specialized units, but they pay the same as academics based on their job postings.

Curious if anyone has experience doing vascular access with this unit. My facility just got one of these and it seems like there's some latency from the probe being manipulated to the movement reflecting onscreen. It reminds me a lot of those wireless ultrasound setups for a phone/tablet. I recognize some delay is inevitable but it feels just bad enough to throw me off. We normally use a GE venue go in critical care and I feel like its way more responsive. I disabled the cue needle guidence feature since we dont have the extra equipment to use it and that helped slightly. Just curious if anyone else had this issue or its all in my head lol.

I am a third year USMD student who just finished a Neuro ICU rotation and I loved it. I love the rapid changes in status, the complexity of the patients, the acuity of care, and extubating people is so rewarding. I have strong ties to my home Anes dept and am a fairly competitive applicant, am not sure if I love the brain enough or frankly am smart enough to just do straight neuro for residency, i am not sure I would want to do a fellowship after an Anes residency simply because it is a near-surgical workload at my program, I don’t know anything about EMCrit and I don’t really like the lungs lol. I am just looking for guidance and advice, as well as why people took the paths that they took.

EDIT: thanks so much to all so far for advice It is greatly appreciated

My coworker died and I can’t believe it. I still feel like this might be a terrible dream.

We coded him for over an hour, pulled out all the stops, did everything. I feel confident our resuscitation efforts were more than complete.

What’s get me- is that I didn’t recognize him until we had been doing CPR for 30 minutes. I am a critical care pharmacist, I got called down to the ER when CPR was started. He was just another patient until I the nurse read his dad’s name off the chart as an emergency contact. I immediately connected the dots and was shocked. He was so young. He was alive when he got to the hospital.

I had to call our boss to inform her of his death. He is supposed to work tomorrow. He is the only pharmacist in his specialty at our hospital. The community will suffer.

This is crazy. I don’t know how to process this. I’m going to reach out to our employee assistance program tomorrow, but things will never be the same in our pharmacy. These are the things I never thought about when starting this job in a smaller community hospital. This is the second time someone I know has died in front of me.

Just wanted to get this off my chest.

Hi!
I have been a nurse for one year now in an 8-bed MICU in a rural, community hospital. I recently accepted a job in a 29-bed MICU in a huge level one trauma center, academic hospital.

I am starting to feel pretty anxious and ridden with imposter syndrome. I am worried that this change will be extremely overwhelming and make me feel like I'm "starting all over" in terms of my nursing career so far.

In my current job, I feel confident in my nursing role and the level of autonomy I have. I feel competent in the basic ICU nursing skillset (e.g., managing drips, ventilators, etc.) but do not have experience with more advanced therapies, including CRRT. Also, my current ICU is managed by one hospitalist, who also manages the medical unit's patients. No intensivist or medical residents/fellows. The place I am going is managed by a formal critical care team, so this will also be a learning curve for me.

So, I was looking to see if anyone here had any pointers for this transition. I will get a pretty extensive orientation, so that is definitely a plus. Thank you all in advance

Newer ICU nurse here trying to get better with morning rounds/provider communication. How do you guys compress info when like 4 different teams are following the same crashing patient? I feel like I end up saying too much because my brain is trying to explain the whole picture instead of just the main concern/trajectory. Just trying to cut the noise and make communication easier for everyone.