🎓‼ Earn CE Credits! Pre-order ICU Advantage Academy: 👉🏼 adv.icu/academy 💲 10% off Critical Care Academy (CCRN Review): 👉🏼adv.icu/cca (USE CODE "icuadv10") 💲 10% off EACH Month @ Nurisng Mastery membership: 👉🏼 adv.icu/mastery 📝 NOTES available to members! ► RUclips: adv.icu/ym | ► Patreon: adv.icu/pm Thank you guys so much for watching! Please leave us a like if you enjoyed the video. We truly do appreciate it! Also we love hearing your comments so feel free to tell us what you think of the video. We hope that after this lesson, you will have a better understanding how to manage your patient who is on vasopressors. We hope that we were able to give you some information and knowledge that you can use to help to build your own intuition when titrating these medications as well. Don't forget to check us out and give us a follow on Instagram as well! instagram.com/ICUAdvantage
Thank you for this! Titration is definitely hard for me to understand but if you have the chance to make a video about different case scenarios and how you should titrate the patient's medications according to their vital signs that would be awesome.
So cool! Welcome to the wonderful world of CVICU. Lots of very interesting patients and toys there. Wishing you all the best and glad to hear that my videos have been helpful for you.
I really appreciate your work, I have really high concerns on trendelemburg position contraindication. Can you better specified the context? Can you provide some references?
You are the preceptor no one at my new place knows I have and the reason I will succeed..I am a nurse fellow and everyone is so judgemental,Thank you so much!! And most importantly you speak so clearly without errmm and such. You are awesome🙌
Quite the world traveler!! Love it. Glad you liked the lesson. I do have a series on CRRT. I may cover hemodialysis on its own in the future, but I haven't done it yet as its not specifically a critical care intervention, which is what I try to focus on specifically with this channel. Thank you for the suggestion!
Interesting videos and important on hand information. It would be nice for people outside the US who watch the series if you could include photos of elements described (manifold, three way stopcock, etc ). Ever thought of having subtitles in other languages?
Glad you liked it. Good idea about some of the pictures to help. As for other languages, I don't really speak any others so I wouldn't be able to create subtitles. 😔
My dad was in icu for 20 months - it started with a dental abscess then went to multi organ failure - he lost his fight July 30 2023 and I got his records there are 12,000 pages of notes from icu. I followed his chart daily and have learned a lot. I have my suspicions on these drops so I’m here to learn more.
I am an ER nurse in a level 1 trauma center that has a critical care bay. If you're a new grad, you can't work in the CCB until you have been there for two years, and I will be able to train there this Summer hopefully! We have a lot of borders, even for the ICU sometimes, so definitely lots of drip management and whatnot. Have found your videos super interesting and helpful! A question about using a stopcock line or y-siting different meds. Wouldn't having the meds flow through the same tubing mess with the infusion rates of each individual medication? I've never fully understood how piggy-backing works (we rarely piggy back meds in our non-ICU section of the ED)
Yes, unfortunately these days, lots of ICU patients end up spending quite a bit more time in the ED. Good for you for expanding your knowledge base for when you care for those patients. As for your question about stopcocks, the rate of infusion for each medication is still the same, but the total volume of fluid infusing increases. Example with some fake numbers to help it make sense. Drip 1 = 1mg/hr = 10ml/hr Drip 2 = 2mg/hr = 5ml/hr Total infusion after the stopcock = 15ml/hr, but still contains 1mg of drip1 and 2mg of drip2. Same applies if its 4 things all going in there. This will only apply if you are using a stopcock or manifold. If using a Y-site connection, eventually this will be true, but any medication already in primary line from the y-site to the patient will be increased until it is all infused and the new "mix" of old and new drop works to the end. That probably sounds confusing but I hope that makes sense. As for piggy-backs, I still feel like its black magic in how it works haha. Basically the fluid will pull from the bag with the highest fluid first, hence why we hang the primary lower than the secondary (piggyback). That way the piggyback goes in first and once its empty, then it starts pulling from the lower primary fluid. I don't understand "how" that works but it does lol.
Thank you so much for all your video series, I just discovered your channel and am religiously watching all your videos. I'm a pediatric resident and in our facility we work along with nurses on titration as they are not allowed to change the rates on their own. The information you share is incredibly helpful especially that I am starting my PICU rotation soon! BTW we had an incident just a few days ago when a Norepi line was flushed and the patient became momentarily hypertensive, good thing it was very brief but we learned from it! thank you for pointing it out.
You are very welcome! So cool! So glad these videos are helpful for you. I've heard of some states/places where the RNs don't titrate without an order. 😳 Interesting to hear how different things can be. Yeah the HTN from flushing can be quite scary given some of the pressures I've seen with it! Glad all was ok. I wish you the best of luck in your PICU rotation. Hats of to you guys as I couldn't do kids. Glad you found the channel and welcome! 😊
Eddie, thanks man. I'm new to the ER and I definitely needed this and all ur lecture. It really helps me to stay educated on my critical care knowledge. Thanks. 👍
Truly my pleasure! And yes, so much of what I cover very much applies for you guys in the ED as well. Glad you found the videos and have found them to be helpful.
This is a good tool I can share to my preceptee . Especillay labeling lines ! I’m for this but most nurses I work with don’t , even the experienced Icu nurses . Labeling makes my work easier especially when time comes patient status crash! Great lesson to share with my co workers !
Oh wow, yeah where I'm at just about everyone does. It really makes it so quick and easy to find what you need. We have different colored tapes and we put tape on the pump and write what med it is, then we put another piece of the same color tape at the end of the line where it attaches and it takes any guessing out of what line you need to get to.
As always, top quality videos with great information! I use them for personal review, when I took by CEN and TCRN. As a former ICU nurse though, I winced when you said “old nurses”. Ouch! LOL! 😉
Awesome video. I never understood the thought process behind using a manifold for infusing multiple pressors versus piggybacking them all together via the Y sites! As an ICU new grad, this was an extremely useful tip! Thank you.
Thank you so much for these amazing videos! I am an Italian icu physician and I don't understand what "label the lines" means, and also I ask you what "Y-site" is. I thank you very much for helping. Elena
Hey there Elena! Let me clarify. "Label the lines" is when we take tape and attach it to the tubing to identify what medication is flowing in that line. "Y-site" is the port that is on the tubing that allows you to connect another line to join the infusions together. When combined they form a "Y" hence the name. Hope that clear it up and glad you like the videos. :)
This was great!!! You’re so right about some preceptors not knowing how to explain titration. I am a new grad in the CVICU still on orientation and I have asked my preceptor and a few others about this and they all paused...then said “it comes with experience.” Which isn’t very reassuring at all. Your explanation has really helped me understand it better. Can’t wait to put it into practice.
Yay! So glad the explanation was what you needed! Its true that it does come with experience, but what they fail to realize is that experience is often from under or over titrating then playing a game of ping pong with their BP until you get the hang of it. Fortunately for you you will get plenty of experience with drip titration in the CVICU, so I'm excited to hear how things go for you. Make sure and follow back up at some point in the future. 🙂
Excellent video! Can you explain at the beginning how you got the math for increasing up 1 from a dose of 5 is a 20% increase versus titrating 1 up from 20 is a 5% increase if the Levo range is 1-50? Thanks!
Thank you Kelly! And yeah, so the point I was making was how depending on the dose that you currently are at, the effect of a change of 1mcg is really dependent on where you started. If you were only running at 5, and you increase by 1 more, you made a 20% increase. BUT if you were running at 20 and increased it by 1, that is now only a 5% increase from where you were. The point was that if you are at 5 and increase by 1mcg, then you will likely see a bigger change in your patients BP than if you were at 20 and increased it by 1. Make sense?
ICU Advantage thanks a ton for responding! So I get the concept that you’re saying which is so key because I’ve never heard anyone describe it like that before....I think I just don’t get if you are increasing a gtt from 5mcq to 6mcq versus 20mcq to 21mcq how is it a 20% increase versus 5% increase if the range of the gtt is 1-50mcq?arent you still increasing the gtt the same interval of 1mcq? I just want to understand where you get that calculation of 20% versus 5%, otherwise the concept itself makes a lot of sense. Thanks!
@@kellykassimo3517 Ok I think I see what you are asking. So yes the same 1mcg is the same proportion of your max dose, so that doesn't change. Thing to remember is that every patient is different and each patient responds differently to the medication, based on their own physiological differences as well as the extent of their illness. The concept of the percentages is in comparison to the previous dose you were running at. Take the first example. Start at 5 and go up by 1 to 6. That was a 20% increase in the dose going from 5 to 6. Practical example, if you have a drop of your patients MAP to 50, but you're only on 5mcg of Levo, you probably only need to go up a few more mcgs to be back in a normal limit. On the other hand if the same situation happens and you are at 20 mcgs, you are going to have to increase your levo by a lot more mcgs than in the previous situation. If you only went up by 1 mcg, you'd go from 20 to 21, which is only a 5% increase, and hopefully you can see that it would be a lot less effective because of how much your patient is already requiring.
Doesn't make sense to me. It's an important part of troubleshooting your a-line and ensuring the numbers it gives are accurate. And it only takes a couple of seconds to do.
Yeah unfortunately that's not something thats possible at this point with the channel. Hopefully/maybe sometime in the future. Glad you liked the info.
Nope! Very much a good evaluation of fluid responsiveness. It will not, though, help in the sense of increasing BP, like the intended effect of trendelenburg.
You always can use a bolus of inotrope instead of waiting, but of course calculate the dose, it is more safe then the flush because if you flushed the line a part of it will be saline and will have disconnection in the inotropic support for a while. Just saying
Thank you thank you thank you for explaining the importance of labeling and manifolding the meds. Helps SOOOOOOOO much when the $?!T is hitting the fan.
Absolutely! The first moment I would have is the when I am getting that mess in order. The worst when they are crashing and you are tracing lines to figure out whats what.
Thank you so much for your videos! They are effective and to the point. Please continue to put out great content. Perhaps how to prime an arterial line and set up the monitor. Thank you!
Awesome! Really glad you like them! I really appreciate that feedback too. As for the priming, I do have a whole series on Arterial Lines and in one of the lessons I did talk about that. :)
Thank you so much Bob! I'll see if I can maybe get a better picture, but I did find one online that I think shows what I'm try to explain. This picture I think is a pre-made product, but the concept is the same. The 3 way stop cocks line up in a row like this here: www.google.com/url?sa=i&url=https%3A%2F%2Fwww.bbraunusa.com%2Fen%2Fproducts%2Fb%2Fhigh-flow-stopcocks.html&psig=AOvVaw3J1kFzdBHmUUY3tVgSCCO3&ust=1617485702689000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCMCn0PfB4O8CFQAAAAAdAAAAABAJ Then you run the flush line in the back and each med comes into its own port. In the example above you've have 3 meds coming in. Hope that clears it up some.
Really great videos, thank you for making such informative content. Question about Y-siting drips and having a TKO or KVO line for pressors - do you recommend having the TKO flush line connected closest to the patient and having the pressors y-sited to the TKO line? Or have the pressor connected closest to the patient with the TKO flush line behind? I have not seen manifolds or sequential stop-cocks used in my ICU (unless they come up from the OR with them) - in emergencies where we need to Y-site multiple lines together, do you follow the adage of fastest first (closest to the patient) and slowest second, even when you have up to 3+ compatible y-sites together until you can get more IV access?
Thank you so much a great questions! TKO line is really only needed when you don't have fast flowing drips and/or just 1 or 2. That said, if you are having to add more to that line, you can somewhat reduce the impact of added flow of a new drip if you have a TKO. That said, once you get enough or running fast enough, its kind of a moot point. As for Y-site, absolutely use those in the moment. I wouldn't switch over until things had stabilized and I had time to "clean" up my room. Once you get used to the stopcocks you can, if they are readily available in the room, have it ready to go almost as fast. And yeah, I'd always do the fastest drip first, then Y off that. I've tried to think through it logically in my head to think through if it really matters, but that seems to make sense for me. I think if you ever have to disconnect, and reorganize, you have less (or no) other drug in the slow moving line. Either way, Y-site as a long term solution just isn't ideal.
I am new to your channel and to working in ICU as a new grad RN. I was looking for this content and I am glad that I have found your channel. Thank you for explaining clearly what is what and covering most pertinent information. Excellent job!
Thank you so much Tetyana! I'm happy that you found the channel and really glad to hear that the information is useful and helpful for you. Wishing you the best in your new nursing career.
Hi Eddie, thank you so much for the video! I just want to clarify- when you say to never flushing the pressor line, does that mean that you cannot do a full assessment on the lumen that the pressors are infusing through? (i.e. momentarily disconnecting to check blood return, make sure it flushes, then quickly reconnect) Thanks in advance
Great question. So if you flush the lumen you will bolus the patient with a hefty dose of pressor which is not good. Unfortunately you won't always be able to properly assess that lumen. You always need to draw back blood to clear the line before you do, but some patients would not tolerate stopping the pressor to assess or it might not be wise to have the time needed for the pressor to refill the lumen before reaching the patient.
You only do this kind of assessment if you suspected a blockage . Like frequent alarms from the infusion pump or BP that wont respond to the inotropic support. Although its better to change the lumen at that case. And try to aspirate before flushing the blocked lumen
Hey man, I'd love to see a video or a post on your website about line management and how to use manifolds. At my hospital we don't use manifolds often. Usually when they come out of the OR. I would love to learn more. Thanks!
Modern evidence strongly advises against the Trendelenburg for acute hypotension and shock. First, it decreases the patients ability to breathe. Secondly, it may cause rebound hypotension as baroreceptors cause venous dilation because they believe that blood flow is increased. Lastly, it may increase ICP.
🎓‼ Earn CE Credits! Pre-order ICU Advantage Academy: 👉🏼 adv.icu/academy
💲 10% off Critical Care Academy (CCRN Review): 👉🏼adv.icu/cca (USE CODE "icuadv10")
💲 10% off EACH Month @ Nurisng Mastery membership: 👉🏼 adv.icu/mastery
📝 NOTES available to members! ► RUclips: adv.icu/ym | ► Patreon: adv.icu/pm
Thank you guys so much for watching! Please leave us a like if you enjoyed the video. We truly do appreciate it! Also we love hearing your comments so feel free to tell us what you think of the video. We hope that after this lesson, you will have a better understanding how to manage your patient who is on vasopressors. We hope that we were able to give you some information and knowledge that you can use to help to build your own intuition when titrating these medications as well.
Don't forget to check us out and give us a follow on Instagram as well! instagram.com/ICUAdvantage
Thank you itis very interested to me I am working in icu as dietican and I am curious to know every thing going on icu
قق
The “art of titration” ....
Pretty much
thank you , very helpful , may the Lord bless you.
Thank you Maria!
Great work, would like to work more on the dosing, available concentration, and suitability of each vasopressors to the different clinical scenarios
Thank you for this! Titration is definitely hard for me to understand but if you have the chance to make a video about different case scenarios and how you should titrate the patient's medications according to their vital signs that would be awesome.
I really wish I had known this as a new grad! Nothing happened in my shifts but still good to be a safe nurse. Great content! Will share ...
Thank you! Glad you liked it!
New grad in a CVICU residency and I love your channel! Thanks for all your help. Much appreciated.
So cool! Welcome to the wonderful world of CVICU. Lots of very interesting patients and toys there. Wishing you all the best and glad to hear that my videos have been helpful for you.
What state are you working in...I hope to get a new grad CVICU position as well.
I learned the hard way not to flush a line with quad Levo running through it
Its a scary few minutes! Lesson learned I'm sure!
Lol i did the same! Thankfully, i only got brief tachycardia. Lessons learned
I really appreciate your work,
I have really high concerns on trendelemburg position contraindication. Can you better specified the context? Can you provide some references?
I’m not a new nurse but I’m new to CVICU and I’m coming off orientation soon, so this is super helpful. Thanks
Hi. I really find your channel so beneficial, do you mind making videos about ECMO as well. Thanks.
So awesome to hear! And YES I actually am planning a series on ECMO as soon as I have time and can get around to it. Hopefully soon!
Can you make videos about EVD? Thank you.
Yes another good suggestion! Also on the todo list for a future video!
TYVM, I am in an icu residency scared to death about pressers and drips. Your tips helped.
Disappointing that did not discuss under which applications/scenarios to use various pressors.
You are the preceptor no one at my new place knows I have and the reason I will succeed..I am a nurse fellow and everyone is so judgemental,Thank you so much!! And most importantly you speak so clearly without errmm and such. You are awesome🙌
Really happy to know I have been able to help!
I’m a Brazilian nurse in Germany and I’m so glad to you! I’ve learned so much. Do you mind making videos about hemodialysis?
Quite the world traveler!! Love it. Glad you liked the lesson. I do have a series on CRRT. I may cover hemodialysis on its own in the future, but I haven't done it yet as its not specifically a critical care intervention, which is what I try to focus on specifically with this channel. Thank you for the suggestion!
@hemodialise_para_enfermeiros
Thank you for your videos. They are very inspirational . They are defined in 1 word “GOLDEN “! Love, Love Love them! Thank you all and thank you God!
Interesting videos and important on hand information. It would be nice for people outside the US who watch the series if you could include photos of elements described (manifold, three way stopcock, etc
). Ever thought of having subtitles in other languages?
Glad you liked it. Good idea about some of the pictures to help. As for other languages, I don't really speak any others so I wouldn't be able to create subtitles. 😔
My dad was in icu for 20 months - it started with a dental abscess then went to multi organ failure - he lost his fight July 30 2023 and I got his records there are 12,000 pages of notes from icu. I followed his chart daily and have learned a lot. I have my suspicions on these drops so I’m here to learn more.
Your channel is dope. I’m just curious if you have ever done a poll of where your watchers work? Or what level they work at?
Appreciate that! And no I haven't. Not sure of the best way to collect all that info.
I am an ER nurse in a level 1 trauma center that has a critical care bay. If you're a new grad, you can't work in the CCB until you have been there for two years, and I will be able to train there this Summer hopefully! We have a lot of borders, even for the ICU sometimes, so definitely lots of drip management and whatnot. Have found your videos super interesting and helpful!
A question about using a stopcock line or y-siting different meds. Wouldn't having the meds flow through the same tubing mess with the infusion rates of each individual medication? I've never fully understood how piggy-backing works (we rarely piggy back meds in our non-ICU section of the ED)
Yes, unfortunately these days, lots of ICU patients end up spending quite a bit more time in the ED. Good for you for expanding your knowledge base for when you care for those patients.
As for your question about stopcocks, the rate of infusion for each medication is still the same, but the total volume of fluid infusing increases. Example with some fake numbers to help it make sense.
Drip 1 = 1mg/hr = 10ml/hr
Drip 2 = 2mg/hr = 5ml/hr
Total infusion after the stopcock = 15ml/hr, but still contains 1mg of drip1 and 2mg of drip2. Same applies if its 4 things all going in there. This will only apply if you are using a stopcock or manifold. If using a Y-site connection, eventually this will be true, but any medication already in primary line from the y-site to the patient will be increased until it is all infused and the new "mix" of old and new drop works to the end. That probably sounds confusing but I hope that makes sense.
As for piggy-backs, I still feel like its black magic in how it works haha. Basically the fluid will pull from the bag with the highest fluid first, hence why we hang the primary lower than the secondary (piggyback). That way the piggyback goes in first and once its empty, then it starts pulling from the lower primary fluid. I don't understand "how" that works but it does lol.
Thank you so much for all your video series, I just discovered your channel and am religiously watching all your videos. I'm a pediatric resident and in our facility we work along with nurses on titration as they are not allowed to change the rates on their own. The information you share is incredibly helpful especially that I am starting my PICU rotation soon! BTW we had an incident just a few days ago when a Norepi line was flushed and the patient became momentarily hypertensive, good thing it was very brief but we learned from it! thank you for pointing it out.
You are very welcome! So cool! So glad these videos are helpful for you. I've heard of some states/places where the RNs don't titrate without an order. 😳 Interesting to hear how different things can be. Yeah the HTN from flushing can be quite scary given some of the pressures I've seen with it! Glad all was ok. I wish you the best of luck in your PICU rotation. Hats of to you guys as I couldn't do kids. Glad you found the channel and welcome! 😊
Eddie, thanks man. I'm new to the ER and I definitely needed this and all ur lecture. It really helps me to stay educated on my critical care knowledge. Thanks. 👍
Truly my pleasure! And yes, so much of what I cover very much applies for you guys in the ED as well. Glad you found the videos and have found them to be helpful.
great stuff! Thanks for the content!
Very welcome! Glad you liked it!
Great information " very helpful , much enjoy , from Ronald Jones RN .
Awesome to hear this! Thanks for the comment Ronald!
Can you help with Sbar reports and routine report during the day?
Yes I actually have something like that on the todo list. 🙂
Regarding trendelenburg, is this the same concept for passive leg raise? Because we're taught to use PLR at my Boston hospital
This is a good tool I can share to my preceptee . Especillay labeling lines ! I’m for this but most nurses I work with don’t , even the experienced Icu nurses . Labeling makes my work easier especially when time comes patient status crash! Great lesson to share with my co workers !
Oh wow, yeah where I'm at just about everyone does. It really makes it so quick and easy to find what you need. We have different colored tapes and we put tape on the pump and write what med it is, then we put another piece of the same color tape at the end of the line where it attaches and it takes any guessing out of what line you need to get to.
Didn't know about this Trendelenburg position.. good to know 👍🏼👍🏼
As always, top quality videos with great information! I use them for personal review, when I took by CEN and TCRN. As a former ICU nurse though, I winced when you said “old nurses”. Ouch! LOL! 😉
Haha glad you liked it. I didn't mean it as a put down though! We have all learned so much from those who came before us!
And from those who come after us. That’s why I love your videos to stay current. Thanks again! Keep up the amazing work!
Awesome video. I never understood the thought process behind using a manifold for infusing multiple pressors versus piggybacking them all together via the Y sites! As an ICU new grad, this was an extremely useful tip! Thank you.
Awesome! Not only is it better for mixing, but it so much better for organization too!
Thank you so much for these amazing videos! I am an Italian icu physician and I don't understand what "label the lines" means, and also I ask you what "Y-site" is. I thank you very much for helping.
Elena
Hey there Elena! Let me clarify.
"Label the lines" is when we take tape and attach it to the tubing to identify what medication is flowing in that line.
"Y-site" is the port that is on the tubing that allows you to connect another line to join the infusions together. When combined they form a "Y" hence the name.
Hope that clear it up and glad you like the videos. :)
We still use trendelenberg in the PACU. 😅. And fluids of course
Ive never heard the phrase "TKO line", is this the same as a KVO line?
Hey Kellen! Yup you got it! TKO/KVO, different terminology for the same thing. TKO is "to keep open" so different way of saying the same thing.
Well I've always heard it as TKVO
This was great!!! You’re so right about some preceptors not knowing how to explain titration. I am a new grad in the CVICU still on orientation and I have asked my preceptor and a few others about this and they all paused...then said “it comes with experience.” Which isn’t very reassuring at all. Your explanation has really helped me understand it better. Can’t wait to put it into practice.
Yay! So glad the explanation was what you needed! Its true that it does come with experience, but what they fail to realize is that experience is often from under or over titrating then playing a game of ping pong with their BP until you get the hang of it. Fortunately for you you will get plenty of experience with drip titration in the CVICU, so I'm excited to hear how things go for you. Make sure and follow back up at some point in the future. 🙂
ICU Advantage I certainly will 😊!
New grad RN here about to start in the ICU next month. This was so helpful! Thank you so much !
Awesome to hear Cass! Congrats on the new ICU position btw!
@@ICUAdvantage thank you !
Excellent video! Can you explain at the beginning how you got the math for increasing up 1 from a dose of 5 is a 20% increase versus titrating 1 up from 20 is a 5% increase if the Levo range is 1-50? Thanks!
Thank you Kelly!
And yeah, so the point I was making was how depending on the dose that you currently are at, the effect of a change of 1mcg is really dependent on where you started. If you were only running at 5, and you increase by 1 more, you made a 20% increase. BUT if you were running at 20 and increased it by 1, that is now only a 5% increase from where you were.
The point was that if you are at 5 and increase by 1mcg, then you will likely see a bigger change in your patients BP than if you were at 20 and increased it by 1. Make sense?
ICU Advantage thanks a ton for responding! So I get the concept that you’re saying which is so key because I’ve never heard anyone describe it like that before....I think I just don’t get if you are increasing a gtt from 5mcq to 6mcq versus 20mcq to 21mcq how is it a 20% increase versus 5% increase if the range of the gtt is 1-50mcq?arent you still increasing the gtt the same interval of 1mcq? I just want to understand where you get that calculation of 20% versus 5%, otherwise the concept itself makes a lot of sense. Thanks!
@@kellykassimo3517 Ok I think I see what you are asking. So yes the same 1mcg is the same proportion of your max dose, so that doesn't change.
Thing to remember is that every patient is different and each patient responds differently to the medication, based on their own physiological differences as well as the extent of their illness.
The concept of the percentages is in comparison to the previous dose you were running at. Take the first example. Start at 5 and go up by 1 to 6. That was a 20% increase in the dose going from 5 to 6. Practical example, if you have a drop of your patients MAP to 50, but you're only on 5mcg of Levo, you probably only need to go up a few more mcgs to be back in a normal limit.
On the other hand if the same situation happens and you are at 20 mcgs, you are going to have to increase your levo by a lot more mcgs than in the previous situation. If you only went up by 1 mcg, you'd go from 20 to 21, which is only a 5% increase, and hopefully you can see that it would be a lot less effective because of how much your patient is already requiring.
ICU Advantage how do calculate 5-6 is a 20% increase and 20-21 is a 5% increase. Sorry if I’m being stupid that’s the part I don’t get ;)
@@kellykassimo3517 6/5 = 1.2 and 21/20 = 1.05 :)
I was just informed on my ICU unit - level 1 teaching hospital - that they aren't teaching square wave test any longer. True?
Doesn't make sense to me. It's an important part of troubleshooting your a-line and ensuring the numbers it gives are accurate. And it only takes a couple of seconds to do.
Thanks alot please continue ♥️
Thank you and will do!
Hi! Thank so much for these videos, you're an Angel. New Grad here and about to start an ICU job! Keep making these videos please!!!!
Right on! Congrats on the the new ICU gig and glad you are finding the videos helpful for ya
Great information, I wish you had a way of showing visually...some people are better learners when they see it!
Yeah unfortunately that's not something thats possible at this point with the channel. Hopefully/maybe sometime in the future. Glad you liked the info.
This is exactly the type of information I am looking for here on your channel ! Ty so much
Thanks for valuable knowledge
Happy to help!
I love your videos. All are very informative 🙌🏻❤️😊👏🏻
Thank you so much Bin! I really appreciate the awesome comment and so glad you like them!
@@ICUAdvantage need to watch all of your videos coz i find it very helpful at work. 👍
I've got a lot out there already for you to watch! If you ever have any suggestions, let me know and I'll add them to the to-do list.
@@ICUAdvantage yeah sure. I will watch all of them. Hope u make videos about renal. Like CRRT. thank you
Yes, currently on the to-do list! 🙂
So if Trendelenburg is considered outdated, is the passive leg raise (PLR) also?
Nope! Very much a good evaluation of fluid responsiveness. It will not, though, help in the sense of increasing BP, like the intended effect of trendelenburg.
thanks for your presentation. I have a note, it will be better if your voice is followed by written presentation on the screen.
Thanks for the feedback. I used to kind of do that before, but it slowed things down and made the videos much longer.
The reason is that.....not the reason is because....
Ty Eddie for sharing your God-given talent
Wow, thank you so much Socorro! You are far too kind. I'm just happy to be able to help. Let me know if I can help in any way :)
Eddie definitely has a God given talent!
You always can use a bolus of inotrope instead of waiting, but of course calculate the dose, it is more safe then the flush because if you flushed the line a part of it will be saline and will have disconnection in the inotropic support for a while. Just saying
You could prime the lumen based on the volume as indicated on the lumen, but it gets tricky
Thank you thank you thank you for explaining the importance of labeling and manifolding the meds. Helps SOOOOOOOO much when the $?!T is hitting the fan.
Absolutely! The first moment I would have is the when I am getting that mess in order. The worst when they are crashing and you are tracing lines to figure out whats what.
Great videos! Clear, concise, and well paced.
Great to hear. Glad you liked it!
Thank you so much for your videos! They are effective and to the point. Please continue to put out great content. Perhaps how to prime an arterial line and set up the monitor. Thank you!
Awesome! Really glad you like them! I really appreciate that feedback too.
As for the priming, I do have a whole series on Arterial Lines and in one of the lessons I did talk about that. :)
Thank you for the information.can we also have a video on basic principles for icu for beginners or those who aspire to be CCRN
I mean, that covers A LOT of stuff there lol.
@@ICUAdvantage thank you.I mean assessment of a patient,infusion pumps ,handover takeover,abgs and so forth
Love your channel! Learning so much on it! Would it be possible to make a video where you show the manifold with stopcocks?
Thank you so much Bob! I'll see if I can maybe get a better picture, but I did find one online that I think shows what I'm try to explain. This picture I think is a pre-made product, but the concept is the same. The 3 way stop cocks line up in a row like this here:
www.google.com/url?sa=i&url=https%3A%2F%2Fwww.bbraunusa.com%2Fen%2Fproducts%2Fb%2Fhigh-flow-stopcocks.html&psig=AOvVaw3J1kFzdBHmUUY3tVgSCCO3&ust=1617485702689000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCMCn0PfB4O8CFQAAAAAdAAAAABAJ
Then you run the flush line in the back and each med comes into its own port. In the example above you've have 3 meds coming in. Hope that clears it up some.
Really great videos, thank you for making such informative content. Question about Y-siting drips and having a TKO or KVO line for pressors - do you recommend having the TKO flush line connected closest to the patient and having the pressors y-sited to the TKO line? Or have the pressor connected closest to the patient with the TKO flush line behind?
I have not seen manifolds or sequential stop-cocks used in my ICU (unless they come up from the OR with them) - in emergencies where we need to Y-site multiple lines together, do you follow the adage of fastest first (closest to the patient) and slowest second, even when you have up to 3+ compatible y-sites together until you can get more IV access?
Thank you so much a great questions!
TKO line is really only needed when you don't have fast flowing drips and/or just 1 or 2. That said, if you are having to add more to that line, you can somewhat reduce the impact of added flow of a new drip if you have a TKO. That said, once you get enough or running fast enough, its kind of a moot point.
As for Y-site, absolutely use those in the moment. I wouldn't switch over until things had stabilized and I had time to "clean" up my room. Once you get used to the stopcocks you can, if they are readily available in the room, have it ready to go almost as fast.
And yeah, I'd always do the fastest drip first, then Y off that. I've tried to think through it logically in my head to think through if it really matters, but that seems to make sense for me. I think if you ever have to disconnect, and reorganize, you have less (or no) other drug in the slow moving line. Either way, Y-site as a long term solution just isn't ideal.
I am new to your channel and to working in ICU as a new grad RN. I was looking for this content and I am glad that I have found your channel. Thank you for explaining clearly what is what and covering most pertinent information. Excellent job!
Thank you so much Tetyana! I'm happy that you found the channel and really glad to hear that the information is useful and helpful for you. Wishing you the best in your new nursing career.
If you don't have the manifold stopcocks, I've heard that people stack them and the little connectors, can you show us the setup?
You don't have 3-way stopcocks?
I'm not sure what you are describing for the alternate setup though...
ICU Advantage we do have three way, but then do you just stack those?
@@AngeeAy Ahh got ya. Yup, just stack them together to make a manifold. I draw it out and explain the idea at 9:47 😊
❤❤❤❤
Thanks Eddie!
Hi Eddie, thank you so much for the video! I just want to clarify- when you say to never flushing the pressor line, does that mean that you cannot do a full assessment on the lumen that the pressors are infusing through? (i.e. momentarily disconnecting to check blood return, make sure it flushes, then quickly reconnect) Thanks in advance
Great question. So if you flush the lumen you will bolus the patient with a hefty dose of pressor which is not good. Unfortunately you won't always be able to properly assess that lumen. You always need to draw back blood to clear the line before you do, but some patients would not tolerate stopping the pressor to assess or it might not be wise to have the time needed for the pressor to refill the lumen before reaching the patient.
You only do this kind of assessment if you suspected a blockage . Like frequent alarms from the infusion pump or BP that wont respond to the inotropic support. Although its better to change the lumen at that case. And try to aspirate before flushing the blocked lumen
hello, can you add lessons towards pediatric ICU ? thanks!
Thanks for the suggestion. Unfortunately I don't have any experience with peds and really would not be the best to teach about it. Sorry.
Thank you 😊
Great job, good information, and very useful.
Thank you very much Jefferson! I really appreciate that.
Hey man, I'd love to see a video or a post on your website about line management and how to use manifolds. At my hospital we don't use manifolds often. Usually when they come out of the OR. I would love to learn more. Thanks!
Let me stew on that and think if theres something I can do for that.
Some times we use trendelinburg position to keep up with Bp and tissue perfusion e.g pts with massive bleeding
I can't say I've never done it, but a lot of evidence points towards this being a bad practice and that it should be avoided.
Thought same then I took a sepsis review class that said keep legs above heart but don't trendelenburg
@@teresarr07 Yes there is benefit in PLR (passive leg raises), but trendelenburg itself is what is recommended not to use.
Modern evidence strongly advises against the Trendelenburg for acute hypotension and shock. First, it decreases the patients ability to breathe. Secondly, it may cause rebound hypotension as baroreceptors cause venous dilation because they believe that blood flow is increased. Lastly, it may increase ICP.
Great tips! Will definitely use a manifold when infusing multiple pressors.
Awesome! They truly make it so much easier to manage!
Sorry, this might seem like a dumb question, but is a manifold similar to a trifuse? I believe our facility does not have manifolds.
Ty!
Really great and on point
Appreciate that!
Thank you!
You’re welcome!
Thank you!
You're welcome Chris.
Preach the trendelenberg!
Yes!
Excellent!!!
Thank you!!
Thank you!
You're welcome
thank you so much
You are very welcome! 😊
Love your videos
Awesome! :) Glad you enjoy them!
I definitely am grateful this lesson gifted me with an "ICU Advantage." - PCU Travel RN =)
Wohoo!! Glad you found the channel! 😊