I often teach the a few core principles of what makes ICU decision making different from treating what appears to be similar problems on the med-surg floors. Here are a few principles I emphasize, in no particular order...🧵
1. Think pressors, not fluids.
💊On the floor, low BP ➡️ IVF bolus. But in ICU, patients, physiology, monitoring are all different. Short term peripheral pressors are generally safe, but repeated IVF can be harmful. If the pt already rec'd IVF, think pressors.
2. When using fluids, think bolus, not maintenance.
💊There are good indications for mIVF (a slow drip). But I rarely use it in ICU.
- I want to see the response to IVF - a bolus allows for that. We can watch to see the effect real-time. You can give small boluses too.
Also...
- maintenance IVF is not more gentle! If the patient needs fluid they need it, and you won't stress them with a single bolus adjusted for their weight. Meanwhile, mIVF can run for days unchecked, most of it is going to 3rd space and causing problems.
3. When dealing with agitation, think precedex, not PRNs.
💊tl;dr: antipsychotics may at best give you short term benefit and benzos do the same with potential harm. You may get through the tough period with family involvement, high touch care & a bit of dexmedetomidine.
I use Precedex for agitation also. I’m not that enamored with it though as a drug for vent sedation as the effect isn’t that predictable like propofol is
Yes, it doesn't work as a sedative almost at all. I tell the residents the lowest RASS you can get from it is -1, and if you're already below that, probably stop the precedex. But it is excellent for weaning.
Also as @pulmcrit.bsky.social notes, also good synergy for analgesia!
I remember about 15 years ago at an SCCM conference there was the word "Precedex" everywhere--on the tote bags, hotel keys, billboards on trucks going around the blocks, pens, and they must have funded 20 "research" posters. I wasn't an early adopter.
Seems to be rarely a good idea to be an early adopter in critical care, at least when it comes to medications and procedures- but probably more reasonable on the side of non invasive diagnostics 🤷🏾♂️
