SICU pearls

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cfdavid

cfdavid

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So, I did the search function, and still have some questions.

I'm starting SICU 8/1 and have a few questions that Marino perhaps doesn't answer. Forgive me if these seem rudimentary, but these questions are often not taught (and can be institutional) or written about (often because no clear consensus may exist and thus to publish would open the author up to criticism from all levels).

HOWEVER, I'm looking for generalities (I know there are exceptions which I'll handle) and little pearls. I know to take certain things with a grain of salt as, well, things vary......

Here they are:

First, other than Marino, are there any good SICU (or just CCM) pocket books out there which are worthy? I like Marino in that he explains things very well.

**Any resources on chest tube management? Marion says the chest tube need NOT be connected to a vacuum source. But, at what general "level" can you determine a tube may be removed??

**In the SICU (I had an MICU rotation MS4), which are the "go to" vent settings?? Also, I've noticed that semantics comes into play at different institutions (ex: PEEP with Pressure Support seems essentially like BIPAP only with an ET Tube and Vent). Is APRV (airway pressure release ventilation) becoming popular in ARDS cases?? Also, do ARDS cases in SICU go to MICU?? OR do the SICU folks manage them there.

**I've never been clear about blood cultures, frankly. If you get a blood Gram stain AND culture, shouldn't the Gram stain always (aside from fungal or Mycobacterial) come back ASAP?? Also, how many days can you wait until the blood cultures remain negative, to call them negative? (I will be reading Marino but if anyone has this at their fingertips, any general rules are appreciated). *****I know it takes different bugs different amounts of time to culture, but is there a general rule? I've always heard 48 hrs.

**Any key concepts one should brush up on prior to the rotation. I always like to hit the ground running, and any input is appreciated.


Thanks for the input, in advance. Again, I'll be reading Marino starting tonight or tomorrow.

cf
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If your SICU is run by Anesthesiology department - it will be much easier.
Ask if they have their manuals for the residents/interns. Ask specifically about respiratory/vent management as it is department-dependent. Find out which attending is an airway-respiratory guru and try to get the info from him/her.

If the SICU is run by surgery - then it still will have some subspecialization inside (different attendings have different interests).

There is also a big Murray out there (online included) - if your schedule permits - go through it.

Go also here http://www.pacep.org/
Even if PA catheter is not as widespread as it used to be - you will still learn a lot from that website.
 
cfdavid said:
So, I did the search function, and still have some questions.

I'm starting SICU 8/1 and have a few questions that Marino perhaps doesn't answer. Forgive me if these seem rudimentary, but these questions are often not taught (and can be institutional) or written about (often because no clear consensus may exist and thus to publish would open the author up to criticism from all levels).

HOWEVER, I'm looking for generalities (I know there are exceptions which I'll handle) and little pearls. I know to take certain things with a grain of salt as, well, things vary......

Here they are:

First, other than Marino, are there any good SICU (or just CCM) pocket books out there which are worthy? I like Marino in that he explains things very well.

**Any resources on chest tube management? Marion says the chest tube need NOT be connected to a vacuum source. But, at what general "level" can you determine a tube may be removed??

**In the SICU (I had an MICU rotation MS4), which are the "go to" vent settings?? Also, I've noticed that semantics comes into play at different institutions (ex: PEEP with Pressure Support seems essentially like BIPAP only with an ET Tube and Vent). Is APRV (airway pressure release ventilation) becoming popular in ARDS cases?? Also, do ARDS cases in SICU go to MICU?? OR do the SICU folks manage them there.

**I've never been clear about blood cultures, frankly. If you get a blood Gram stain AND culture, shouldn't the Gram stain always (aside from fungal or Mycobacterial) come back ASAP?? Also, how many days can you wait until the blood cultures remain negative, to call them negative? (I will be reading Marino but if anyone has this at their fingertips, any general rules are appreciated). *****I know it takes different bugs different amounts of time to culture, but is there a general rule? I've always heard 48 hrs.

**Any key concepts one should brush up on prior to the rotation. I always like to hit the ground running, and any input is appreciated.


Thanks for the input, in advance. Again, I'll be reading Marino starting tonight or tomorrow.

cf
Click to expand...

Had a big response all typed up but my browser crashed. In short, read your Marino, use West for basic pulm/vent phys.

Chest tubes are usually managed by the primary team, they scale down the care based on output or evidence of pneumo/hemothorax, go to water seal, pull the tube. there is a regimental nature to it.

ARDS is a big player obviously, most all people use low Vt models, although I used bilevel ventilation some my last time through. Id recommend reading about bilevel as it can be complicated but its impressive when you know it. Yes, you will manage complications of the surgical patient (including ARDS) in the SICU.

Cultures are not confirmed negative for five days usually. Gram stain can guide you but if nothing is growing after 48-60 hours, then its usually not pathogenic enough to cause sepsis (if your patient looks septic). When to start therapy is patient/unit/attending/hospital-specific.

Here are some seminal articles from the last ten years, stuff on steroids in spesis, glucose control, vent management, ARDS, fluid management, etc. Good stuff to know but I wouldnt try to get it all in in the next 4 days.

https://www.yousendit.com/download/T1VsSXQ2Zy9PSHhjR0E9PQ

Do case-specific reading in your down time and get through Marino.

There is a PACEP website that is good for pulmonary artery catheter education also (google pacep), since as you will see more often, its near impossible to manage a critically ill patient without one :rolleyes:

Good luck!
 
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Idiopathic said:
Had a big response all typed up but my browser crashed. In short, read your Marino, use West for basic pulm/vent phys.

Chest tubes are usually managed by the primary team, they scale down the care based on output or evidence of pneumo/hemothorax, go to water seal, pull the tube. there is a regimental nature to it.

ARDS is a big player obviously, most all people use low Vt models, although I used bilevel ventilation some my last time through. Id recommend reading about bilevel as it can be complicated but its impressive when you know it. Yes, you will manage complications of the surgical patient (including ARDS) in the SICU.

Cultures are not confirmed negative for five days usually. Gram stain can guide you but if nothing is growing after 48-60 hours, then its usually not pathogenic enough to cause sepsis (if your patient looks septic). When to start therapy is patient/unit/attending/hospital-specific.

Here are some seminal articles from the last ten years, stuff on steroids in spesis, glucose control, vent management, ARDS, fluid management, etc. Good stuff to know but I wouldnt try to get it all in in the next 4 days.

https://www.yousendit.com/download/T1VsSXQ2Zy9PSHhjR0E9PQ

Do case-specific reading in your down time and get through Marino.

There is a PACEP website that is good for pulmonary artery catheter education also (google pacep), since as you will see more often, its near impossible to manage a critically ill patient without one :rolleyes:

Good luck!
Click to expand...

Thanks Idiopathic.
 
cfdavid said:
**Any resources on chest tube management? Marion says the chest tube need NOT be connected to a vacuum source. But, at what general "level" can you determine a tube may be removed??

**In the SICU (I had an MICU rotation MS4), which are the "go to" vent settings?? Also, I've noticed that semantics comes into play at different institutions (ex: PEEP with Pressure Support seems essentially like BIPAP only with an ET Tube and Vent). Is APRV (airway pressure release ventilation) becoming popular in ARDS cases?? Also, do ARDS cases in SICU go to MICU?? OR do the SICU folks manage them there.

**I've never been clear about blood cultures, frankly. If you get a blood Gram stain AND culture, shouldn't the Gram stain always (aside from fungal or Mycobacterial) come back ASAP?? Also, how many days can you wait until the blood cultures remain negative, to call them negative? (I will be reading Marino but if anyone has this at their fingertips, any general rules are appreciated). *****I know it takes different bugs different amounts of time to culture, but is there a general rule? I've always heard 48 hrs.

**Any key concepts one should brush up on prior to the rotation. I always like to hit the ground running, and any input is appreciated.


cf
Click to expand...

cf, good for you thinking ahead.

i am not the expert on any of these subjects, but i'll tell you what i think you need to know as a minimum.

1) chest tubes. you do not have to put chest tubes on suction, BUT everybody and their mother does. Each surgery/ condition/ etc is associated with a certain underlying process that dictates at what output, or at what day you will convert from suction to water seal. Added to this, among a certain opperation each surgeon may have a different opinion on the subject. In general when output is low for 24 hours, most will put the CT on water seal (low is subjective and surgery based as stated before). After 12+ hrs on water seal and no reaccumulation, change in output, etc, many will remove them. Some chest tubes you would never want to put on suction. Dont be the fool that pust a bronchopleural fistula on suction. Its no big deal putting a ct on water seal, but i wouldnt remove one without making sure the surgeon is ok with it (they often think of it like a jp drain)

2) Go To vent settings: Guess what EVERYBODY has an oppinion on this one. Lemme give you a simple guide. If they are post surgical its easy...you wanna wean them. SIMV is an easy to use mode to wean somebody. Put them on SIMV Peep 5/ PS 5, Fio2 40% Rate 12, TV 600. Increase O2 and PEEP if pO2 is a problem. Increase PS and maybe rate if minute volume is low (high pco2).

If they are a trauma, typically simv. If they are severely head injured, I prefer AC, but, let me assure you, if you understand SIMV it doesnt matter which one you use. Respiratory arrest and need 'a break' again AC is a good mode. BUT surgeons tend to hate AC, so you can always add PS to your SIMV mode.

Dont put anyone on APRV until you understand it better. Outside of a few centers (to my knowledge) it is reserved for severe ARDS with refractory hypoxaemia on 'standard' modes. Some people think its the greatest thing since sliced bread. As a CA-1, dont go there on your own at night. If youve got hypoxia, call the attending.

3) Blood cultures. Surgical patients have fevers and white counts for all kinds of reasons. Head injured pts are a guarantee. This one you need to develop some clinical judgement that comes with experience. Very high fevers, especially without explanation should typically be cultured. After three days the culture is finalized (for most types of cultures) and is then considered negative.

4) If you wanna brush up on something, read about oxygen delivery and consumption over and over until it makes sense. Then pretty much everything you do in the SICU starts to make sense. You'll make bettter decisions, order fewer tests, and concentrate on the relevant issues. Also learn your vasoactive drips and choose among them intelegently, not just have your favourite because it makes the undulating little red line higher. And finally, please dont order troponins like you did when you were a medicine intern...
 
All excellent points. Three more:

1. Know everything there is to know about your patients... everything. Follow up labs like its your job, cuz it is.

2. Know ACLS COLD!!!

3. Carry some boom-boom sticks in you pocket. When on call, I always had a syringe or two of newly mixed pressors in my white-coat. Its not jcaho compliant, but as an anesthesia resident, you've used these drugs many times before and are comfortable with them... some of the other rotating residents likely won't be. It bought me some time in a sticky situation on more than one occasion.
 
cfdavid said:
First, other than Marino, are there any good SICU (or just CCM) pocket books out there which are worthy? I like Marino in that he explains things very well.

**Any resources on chest tube management? Marion says the chest tube need NOT be connected to a vacuum source. But, at what general "level" can you determine a tube may be removed??

**In the SICU (I had an MICU rotation MS4), which are the "go to" vent settings?? Also, I've noticed that semantics comes into play at different institutions (ex: PEEP with Pressure Support seems essentially like BIPAP only with an ET Tube and Vent). Is APRV (airway pressure release ventilation) becoming popular in ARDS cases?? Also, do ARDS cases in SICU go to MICU?? OR do the SICU folks manage them there.

**I've never been clear about blood cultures, frankly. If you get a blood Gram stain AND culture, shouldn't the Gram stain always (aside from fungal or Mycobacterial) come back ASAP?? Also, how many days can you wait until the blood cultures remain negative, to call them negative? (I will be reading Marino but if anyone has this at their fingertips, any general rules are appreciated). *****I know it takes different bugs different amounts of time to culture, but is there a general rule? I've always heard 48 hrs.

**Any key concepts one should brush up on prior to the rotation. I always like to hit the ground running, and any input is appreciated.

cf
Click to expand...

1) I like Tarascon's little Critical Care handbook. It's very basic in the sense that it's small, but it has lots of charts, graphs, differentials, and decision rules (e.g., I never remember all the metabolic alkaloses of Duke's criteria, etc)

2) Chest tubes can either be to suction or to waterseal (the waterseal is, literally, a seal made out of water, meant to keep the patient from being able to suck air back into the pleural space via the tube). When to remove them depends on the indication. PTX? theoretically as soon as the air stops coming out through the waterseal. Effusion or post-op cardiac surgery? When the output falls below whatever arbitrary limit your surgeon/institution is comfortable with (100-250/day).

3) I wouldn't say there's a go-to setting for all patients, although, despite decades of endeavor, there have only been two mode-disease combinations that have every been shown to improve outcome: lung-protective ventilation for ARDS and Spontaneous Breathing Trials for those ready to wean. All the rest are just hand-wringing (witness the recent SIMV trial in Chest). You are right about the semantics; if you know what you're doing, you can accomplish the same thing with a variety of settings. APRV/bilevel is intriguing and I've used it on a few patients with good success. The RTs I work with, who are generally very engaged and read a lot, like to fart around with bilevel and have some routines/weaning parameters they use that aren't super intuitive, but it seems to work.

4) It is unusual to see a positive gram stain in blood, I think primarily because the concentration in the blood is very low and you're unlike to actually se organisms. This is less true with urine and, especially, lung secretions. Your threshold for accepting a late positive culture as meaningful will depend on the patient. A recovering septic patient who improved on antibiotics who has staph epi grow out at 5 days might be less worrisome than your IV drug user with a murmur who previously grew out 1 of 2 staph epi, gets a negative TTE (so 2 Duke's minor criteria), and then has a follow-up staph epi at day 5 (now has 1 major and 2 minor, which puts him in a very different risk class).

In the end, you'll just need to do the rotation, ask lots of questions, take direction well, and accept that although some of what we do has some evidence behind it, most is sufficiently nebulous so as to allow substantial regional and local variation.
 
Frank Rizzo said:
3. Carry some boom-boom sticks in you pocket. When on call, I always had a syringe or two of newly mixed pressors in my white-coat. Its not jcaho compliant, but as an anesthesia resident, you've used these drugs many times before and are comfortable with them... some of the other rotating residents likely won't be. It bought me some time in a sticky situation on more than one occasion.
Click to expand...

Amen to that ... when it takes the nurse-pharmacy-nurse-2ndnursechecker loop 20 minutes to get a pressor infusion going, you'll be glad you had something with a purple sticker in your pocket.

Be discreet about it though. :) At one point, after an airway flail in which the nurses couldn't get into the Pyxis for drugs (I think succ was missing), I started keeping the equivalent of an anesthesia cart drug tray in a backpack. When the charge nurse caught me, it was ugly.
 
Excellent responses guys. Thanks so much. Read key chapters of Marino 5 months ago(once only) and did some reading last p.m. then today before work (cards month) today.

I agree that D02 and V02 (uptake) are excellent for understanding the parameters important in sepsis etc. Good stuff.

Will brush up on vents and pressors today.

cf
 
core0 said:
I'll add for ARDs look at the ARD NET protocols

http://www.ardsnet.org/

Especially the ventilator protocol on the right.

Also the Surviving Sepsis Campaign is pretty much required reading at my institution:
http://www.survivingsepsis.org/About_the_Campaign/Documents/Final 08 SSC Guidelines.pdf

David Carpenter, PA-C
Click to expand...

+1 on the SSC guidelines. It's a long document, but covers the recs and evidence base for sepsis, a lot of which can be generalized to other patients. You'll learn a lot from reading this.
 
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Awesome advice ! I start SICU on the same day as you CF, and I was going to start a thread asking for tips. Problem solved :)
 
aredoubleyou said:
What mode of ventilation would you choose for an unstable post-op or new trauma then?
Click to expand...

Well l would do spontaneous breathing trails. If patient isn't fit to go through SBT, then he/she isn't fit enough to be weaned anyway.
Would prepare patient prior to trying SBTs.
 
aredoubleyou said:
What mode of ventilation would you choose for an unstable post-op or new trauma then?
Click to expand...

For most post surgical patients, I think "weaning" is an unnecessary waste of time. Most patients without intrinsic or newly acquired pulmonary pathology can be liberated from mechanical ventilation rapidly.

I haven't found much reason to use anything but AC or pressure support. SIMV is fine too but not really needed. The fancy ventilation modes make the numbers better but really don't have a proven impact on any meaningful measure. Perhaps the most important thing is to use a lung protective strategy no matter what the mode.
 
aredoubleyou said:
What mode of ventilation would you choose for an unstable post-op or new trauma then?
Click to expand...

ICU is fun because it is a lot of the same basic framework as OR anesthesia but you have a much wider spectrum of processes to deal with and a longer timeframe to address them. You often have several hours to days to identify problems, organize a plan, carry it out, and modify it as needed. Like I said -- fun!

ID whatever's "unstable" about your patient and identify the processes keeping them on the vent: oxygenation, ventilation, hemodynamics, fluid overload, hosed mental status, tons of secretions d/t PNA, inadequate analgesia causing splinting, open belly, belly full of ascites.

As far as actually choosing a mode, it's seems like going to Volume A/C or Pressure A/C if that's your thing and then, when ready, a 30 to 60 minute SBT "wean" -> extubation is the way to go.
 
Intensivist said:
Well l would do spontaneous breathing trails. If patient isn't fit to go through SBT, then he/she isn't fit enough to be weaned anyway.
Would prepare patient prior to trying SBTs.
Click to expand...

I'm not trying to be a d!ck, but I thought I'd give you the benefit of the doubt...but now I notice your med student so let me break things down for you so when its your turn to man the ICU, you can have a leg up

When a patient comes to the icu on a ventilator from the OR they are there because they are an 1. unstable coagulopathic half dead train-wreck, 2. failed extubation in the OR, 3. Have residual muscle relaxant AND would be sent to the ICU anyways, 4. Actually there are a million reasons..lets move on. In all these case you do not want or CANNOT put them on a spontaneous breathing mode of ventilation. We could argue about patient 1, but your train wrecks - in practice - are not going to be extubated that night or the next morning, so stressing them with an SBT upon arival to the ICU doesnt make sense. It is almost always better to put them on at least pressure support while you correct their acute underlying issues.

SBT are good for long term vented patients, often with or reovering from lung injury (ARDS, etc), significant neurologic injury, or other reasons of prolonged ventilation (open abdomen, etc). Youre muscle relaxed post op who is here for monitoring and the anesthesiologist decided not to reverse or even better yet give them a stick of cis for the road (b/c theyre going to the icu anyway - make it someone elses problem) can be extubated emperically w/out an SBT. Same with the trauma the ED guy intubated for 'seizure' or 'combativeness.'

I think you can agree with me on this.

The subject I think youre confused on is how to wean the patient. Since youre often not going to perform an SBT on arrival to ICU, you have to choose some mode of ventilation in preperation for SBT. There are 2 common choices: SIMV and AC. In AC you have a rate and volume, and even if you take away the rate, the patient isnt working hardly much at all to ventilate b/c a set volume is delivered every time he makes a small effort. He can easily maintain his minute volume with minimal work.

In SIMV, you can vary rate, volume, and pressure support. This means that as you take away the rate, you can progressively take away the pressure support for spontaneous breaths so the patient increases his work to maintain the minute volume.

Eventually you will get the patient to some point where you think he might fly on his own. This is where the SBT comes into play. Instead of waiting until you think that he might be ready to fly, you perform a daily SBT when certain criteria are met (PEEP <8, p/f ratios, etc, etc...varies from place to place). By performing an SBT instead of applying your best judgement, pts (on average) will be extubated sooner.

So, my uber-long post, is simply to point out that when you get a new patient, SIMV, in my opinion, is the best and easiest method of weaning as opposed to AC. SBT is a different issue, its run in conjunction with your set mode of ventilation, and can be applied to both vent modes.
 
proman said:
For most post surgical patients, I think "weaning" is an unnecessary waste of time. Most patients without intrinsic or newly acquired pulmonary pathology can be liberated from mechanical ventilation rapidly.

I haven't found much reason to use anything but AC or pressure support. SIMV is fine too but not really needed. The fancy ventilation modes make the numbers better but really don't have a proven impact on any meaningful measure. Perhaps the most important thing is to use a lung protective strategy no matter what the mode.
Click to expand...

My initial SIMV settings for ARDS are simmilar to yours on AC I bet (added PS to the point each breath is meaningful). I kinda like the idea of taking away pressure support when weaning, but I think there is NOTHING wrong with getting them off a rate THEN taking away the PS. Its 6 of one, half dozen of the other.

I agree with the fancy vent modes comment. Bilevel often does raise po2 and sometimes decreases the plateaus a bit, but I dont think youre changing much.
 
cchoukal said:
1) I like Tarascon's little Critical Care handbook.
Click to expand...

Second that. Love that little book.

Since we're throwing out lil pearls, I like what somebody told me on rounds one day what is roughly normal for a swan tracing: nickel, quarter over nickel, quarter over dime, dime. As in: CVP 5ish, RV ~25/5, PA ~25/10, Wedge 10 ish.

Pretty routine if you are seeing Swans daily, but after going over a year in outpatient and in a small dump swanless hospital, it's easy to forget what those numbers are. But that admittingly overly simplistic way to remember the tracing brought it right back what I was looking for.
 
Narcotized said:
Second that. Love that little book.

Since we're throwing out lil pearls, I like what somebody told me on rounds one day what is roughly normal for a swan tracing: nickel, quarter over nickel, quarter over dime, dime. As in: CVP 5ish, RV ~25/5, PA ~25/10, Wedge 10 ish.

Pretty routine if you are seeing Swans daily, but after going over a year in outpatient and in a small dump swanless hospital, it's easy to forget what those numbers are. But that admittingly overly simplistic way to remember the tracing brought it right back what I was looking for.
Click to expand...

Nice Narc. Also, thanks for all the other great posts.

cf
 
This is a nice little read at 6:00am. after a long night of appy/OB trains.

There is a billion and one ways to do vent management in the ICU. APRV was en vogue when I was a resident.

Honestly though, aredoubleyou's post get's to the point. Nothing wrong with SIMV with PS. It's a good mode to get your patient off the vent. If they are paralyzed, narcotized, etc.. then maybe try something else. But for weaning purposes, SIMV with PS is a golden bridge to PEEP5/PS5---> extubation.

CF. Look into criteria for extubation. There are many to look at and you will be tested on it over and over again. And.. you can use them in the ICU everytime you look at a vented patient.
:sleep::sleep::sleep::sleep:
 
aredoubleyou said:
I'm not trying to be a d!ck, but I thought I'd give you the benefit of the doubt...but now I notice your med student so let me break things down for you so when its your turn to man the ICU, you can have a leg up

When a patient comes to the icu on a ventilator from the OR they are there because they are an 1. unstable coagulopathic half dead train-wreck, 2. failed extubation in the OR, 3. Have residual muscle relaxant AND would be sent to the ICU anyways, 4. Actually there are a million reasons..lets move on. In all these case you do not want or CANNOT put them on a spontaneous breathing mode of ventilation. We could argue about patient 1, but your train wrecks - in practice - are not going to be extubated that night or the next morning, so stressing them with an SBT upon arival to the ICU doesnt make sense. It is almost always better to put them on at least pressure support while you correct their acute underlying issues.

SBT are good for long term vented patients, often with or reovering from lung injury (ARDS, etc), significant neurologic injury, or other reasons of prolonged ventilation (open abdomen, etc). Youre muscle relaxed post op who is here for monitoring and the anesthesiologist decided not to reverse or even better yet give them a stick of cis for the road (b/c theyre going to the icu anyway - make it someone elses problem) can be extubated emperically w/out an SBT. Same with the trauma the ED guy intubated for 'seizure' or 'combativeness.'

I think you can agree with me on this.

The subject I think youre confused on is how to wean the patient. Since youre often not going to perform an SBT on arrival to ICU, you have to choose some mode of ventilation in preperation for SBT. There are 2 common choices: SIMV and AC. In AC you have a rate and volume, and even if you take away the rate, the patient isnt working hardly much at all to ventilate b/c a set volume is delivered every time he makes a small effort. He can easily maintain his minute volume with minimal work.

In SIMV, you can vary rate, volume, and pressure support. This means that as you take away the rate, you can progressively take away the pressure support for spontaneous breaths so the patient increases his work to maintain the minute volume.

Eventually you will get the patient to some point where you think he might fly on his own. This is where the SBT comes into play. Instead of waiting until you think that he might be ready to fly, you perform a daily SBT when certain criteria are met (PEEP <8, p/f ratios, etc, etc...varies from place to place). By performing an SBT instead of applying your best judgement, pts (on average) will be extubated sooner.

So, my uber-long post, is simply to point out that when you get a new patient, SIMV, in my opinion, is the best and easiest method of weaning as opposed to AC. SBT is a different issue, its run in conjunction with your set mode of ventilation, and can be applied to both vent modes.
Click to expand...

l think you misunderstand me here. I was refering to patient being stable to extubate, no matter what mode you have given him/her during their time on vent. l was saying that it's proven that switching from whatever mode to SIMV for weaning makes the whole process much longer, with less success rate.
Of course you're not going to do SBTs on new admission in ICU if pt is unstable to even plan extubation. But if this is SICU patient with most likelz short ICU stay, l would think it makes no difference which mode you give them, because usually lungs aren't the issue, but rather CNS, belly or whatever.
While in ICU, l played alot with with PS and PCV on MICU patients, but on SICU patients AC is mode to go l think, especially if patient is let' say head trauma that needs deep sedation for few days.
 
in reality, theres little difference between AC with a backup rate and SIMV so its silly to argue. i think the big issue is whether you want to pressure control or volume control your demand breaths.
 
cfdavid said:
So, I did the search function, and still have some questions.

I'm starting SICU 8/1 and have a few questions that Marino perhaps doesn't answer. Forgive me if these seem rudimentary, but these questions are often not taught (and can be institutional) or written about (often because no clear consensus may exist and thus to publish would open the author up to criticism from all levels).

HOWEVER, I'm looking for generalities (I know there are exceptions which I'll handle) and little pearls. I know to take certain things with a grain of salt as, well, things vary......

Here they are:

First, other than Marino, are there any good SICU (or just CCM) pocket books out there which are worthy? I like Marino in that he explains things very well.

**Any resources on chest tube management? Marion says the chest tube need NOT be connected to a vacuum source. But, at what general "level" can you determine a tube may be removed??

**In the SICU (I had an MICU rotation MS4), which are the "go to" vent settings?? Also, I've noticed that semantics comes into play at different institutions (ex: PEEP with Pressure Support seems essentially like BIPAP only with an ET Tube and Vent). Is APRV (airway pressure release ventilation) becoming popular in ARDS cases?? Also, do ARDS cases in SICU go to MICU?? OR do the SICU folks manage them there.

**I've never been clear about blood cultures, frankly. If you get a blood Gram stain AND culture, shouldn't the Gram stain always (aside from fungal or Mycobacterial) come back ASAP?? Also, how many days can you wait until the blood cultures remain negative, to call them negative? (I will be reading Marino but if anyone has this at their fingertips, any general rules are appreciated). *****I know it takes different bugs different amounts of time to culture, but is there a general rule? I've always heard 48 hrs.

**Any key concepts one should brush up on prior to the rotation. I always like to hit the ground running, and any input is appreciated.


Thanks for the input, in advance. Again, I'll be reading Marino starting tonight or tomorrow.

cf
Click to expand...

cool i am starting SICU tomorrow as well.. and I am on call in the CCU tonight :(

from my understanding you should read up on diets and electrolyte replacement, vents and when to ex-tube i.e. SBI and lung compliance calculations. as for vent settings there are really two basic modes, as i am sure you know volume controle and pressure control and everything else is a variation of the two. then i was told to know my pressors, and hypertension drugs, also how to manage DM i.e. how much of which insulin to use and when, and of course know the basic antibiotics for the common bugs. otherwise we got a copy of some pocket ICU book forget the name, but it's pretty concise without too many explinations, i'll post the name of it when i get home tomorrow. I also have a pdf copy of The ICU book, the big one that i'll hopefully have time to read a few chapters in. Otherwise, i don't feel that worried, i did 6 weeks of combined MICU/SICU/Neuro ICU during my 3rd and 4th year and overall feel comfortable in the ICU, you just have to be more observant and more detailed with those pts. I am sure you'll do fine. good luck to us both next month...

oh and at my hospital 3 days of no growth= negative Cx.
 
Intensivist said:
l think you misunderstand me here. I was refering to patient being stable to extubate, no matter what mode you have given him/her during their time on vent. l was saying that it's proven that switching from whatever mode to SIMV for weaning makes the whole process much longer, with less success rate.
Of course you're not going to do SBTs on new admission in ICU if pt is unstable to even plan extubation. But if this is SICU patient with most likelz short ICU stay, l would think it makes no difference which mode you give them, because usually lungs aren't the issue, but rather CNS, belly or whatever.
While in ICU, l played alot with with PS and PCV on MICU patients, but on SICU patients AC is mode to go l think, especially if patient is let' say head trauma that needs deep sedation for few days.
Click to expand...

Yea, i think we were understanding eachother in the wrong contexts....looks like we agree more than disagree
 
RussianJoo said:
ohh yeah and fluid management, like calculating maintances and fluid defecit really quickly.
Click to expand...

im just a new third year but i feel like if i had to do fluids on someone i would take too long and they would die. does anyone want to recommend a brief but comprehensive source on fluids (hopefully one that covers the very young and the very old as well)?
 
VoiceofReason said:
im just a new third year but i feel like if i had to do fluids on someone i would take too long and they would die. does anyone want to recommend a brief but comprehensive source on fluids (hopefully one that covers the very young and the very old as well)?
Click to expand...

During our peds rotation i was taught a very precise way of calculating fluids and which type to use i.e. calculating the electrolyte requirements based on the pt's BMP, but i forgot what they taught us. i just use the 4:2:1 rule. http://www.cc.nih.gov/ccc/pedweb/pedsstaff/ivf.html
 
Let's see if I remember this correctly. I'm on my EM month now and an attending told me that he calculates fluids for maintenance this way:

100 cc for the 1st 10 kg
50 cc for the 2nd 10 kg
20 cc per kg remaining
Divide by 24 and you get your hourly rate.

He had some other way of calculating deficit, though I'm not really certain how to use it. I think you have to correlate the physical exam and other signs.

If fluid loss is approx 15%, then replace 150 cc/kg; if 10% then replace 100cc/kg; if 5%, then 50 cc/kg.

Of course there is also the 4:2:1 rule to calculate maintenance at the hourly rate. Hope that helps.
 
it all gets you to the same answer

4 cc/kg/hour for the first 10 kg
2 cc/kg/hour for the next 10 kg
1 cc/kg/hour per remaining kg

or weight + 40 for all weights over 20
 
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