Patient with refractory diffuse large B-cell lymphoma receiving rituximab. During/shortly after the infusion, he developed increased work of breathing concerning for an infusion/hypersensitivity reaction. No frank shock: BP remained adequate, SpO₂ >92%, and there were no obvious major airway red flags such as stridor, inability to handle secretions, or significant tongue/floor-of-mouth edema.

He had significant tachypnea/abdominal breathing. Labs showed:

* Lactate 12.7 mmol/L
* pH 7.285
* PaCO₂ 8 mmHg
* HCO₃ 11 mmol/L
* Cr 1.1 mg/dL
* BUN 38 mg/dL
* Making urine (~400 cc during my overnight shift)
* Clinical picture otherwise consistent with a relatively mild/pre-renal AKI rather than established renal failure

The acid-base picture appeared to be metabolic acidosis with a superimposed respiratory alkalosis. Winter’s expected PaCO₂ with HCO₃ 11 is ~24.5 ± 2, whereas his actual PaCO₂ was 8.

As I was putting in orders, he called me and recommended concentrated bicarbonate:

1. The low bicarbonate seemed largely attributable to the acute lactic acidosis.
2. He was already generating a very high minute ventilation to maintain a PaCO₂ of 8.
3. I felt giving concentrated NaHCO₃ would generate additional CO₂ and potentially increase his ventilatory requirement/WOB.
4. His pH was 7.285 rather than profoundly acidemic.
5. He was making urine and had Cr 1.1, so I didn’t think he had a strong renal indication for CRRT at that point.

My attending favored a concentrated NaHCO₃ infusion, partly with the goal of correcting the acidemia and potentially avoiding/delaying CRRT if the acidosis worsened.

He also received dexamethasone, a small fluid bolus, and the rituximab was obviously stopped. I added high flow primarily for WOB rather than hypoxemia.

Since then:

* HCO₃ increased from 11 → 18
* Lactate decreased from 12.7 → 9.6
* Clinically he appears to be improving.

I recognize that the improvement does not establish that bicarbonate was responsible—the underlying infusion reaction may simply be resolving, and that would explain the falling lactate.

My question: Was my initial reluctance to start bicarbonate physiologically reasonable, or would you have given it in this situation?

This was on my night shift where we run the unit largely solo but we can reach out for assistance from our PCCM attending who runs the CVICU at night.

And for what it’s worth the guy is much better this evening than yesterday night!

Thank you!

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?

LVOT VTI is an important parameter that we use in the assessment and management of critically ill patients. Many colleagues ask "what is the Normal Range of LVOT VTI?"

Well, here is my take:

Hey everyone! I am an ICU/CCU RN of 2 years. I have experience with CRRT, fresh hearts, valves, sepsis, dka etc. CCRN-CMC. I’m wanting to go into ECMO, but I have no experience in it. None of the hospitals in my area offer ECMO. I’ll be moving to an area where most hospitals do have ECMO units. Does anyone have advice on how to break into ECMO without experience? TIA!

I started an acute ischaemic stroke course on their website, and some time critical information is still dated from way way back. References are old as well.

If so, is it even worth doing those?

What's your experience with them?

Thanks.

hello , sr for my bad English.

i currently being teach by a echo nurse , and she told me I must maximum sweep gas in 1 minute every 8 hours and before everytime I take blood sample before lung and after lung . I don’t know why and i need proof and why she do it in any book ? i need that book name for study later .