Join us as we talk through clinical cases in the ICU setting, illustrating important points of diagnosis, treatment, and management of the critically ill patient, all in a casual, "talk through" verbal scenario format.
Lightning rounds #32: Creating a POCUS system with Leon Chen
We chat with Leon Chen about his work setting up infrastructure for clinical POCUS at Memorial Sloan Kettering. Leon is an Adult/Gerontology Acute Care Nurse Practitioner in the ICU, Clinical Program Manager of Research and Simulated Learning, and an Associate Professor at Columbia University School of Nursing.
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* Leon’s recent paper: Point-of-care Ultrasound (POCUS) Program for Critical Care Nurse Practitioners and Physician Assistants in an Oncological Intensive Care Unit and Rapid Response Team
TIRBO #44: The things I carry
A brief discussion of the stuff in your pockets as you practice medicine.
Episode 65: Obstructive UTI with Ashley Winter
We discuss the nuts and bolts of urinary infection with an obstructing stone with Ashley Winter (@AshleyGWinter), board certified urologist with a fellowship in male and female sexual medicine, and chief medical officer of Odela Health.
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* A patient with UTI (or even just undifferentiated sepsis) and a non-trivial ureteral stone generally needs decompression of the affected kidney, whether or not there is significant hydronephrosis on imaging. Hydro is sensitive to other factors, such as dehydration, but its absence does not rule out sepsis secondary to urinary obstruction. CT is more sensitive here than ultrasound, which is mostly useful for ruling in hydronephrosis. (Such patients will usually need a stent, not a nephrostomy, as the latter is difficult when there is little hydronephrosis.) From a urology perspective, the size and position of the stone is probably more important than the hydronephrosis.
* That being said, be attuned to the possibility of a patient with another source of sepsis, and an incidental bacteriuria and kidney stone. Anesthesia and a urology procedure won’t help these people. A cleaner urinary sample (e.g. straight cath or Foley, if the initial sample was a “clean” catch) can sometimes help here.
* Consider also that a completely obstructing stone may be hiding pyelonephritis because the bacteria and leukocytes cannot pass the stone. This is not a very common scenario, but can lead to a “clean” urinalysis, so consider it in a patient with an obstructing stone and septic picture.
* Try to get a urine sample before giving antibiotics.
* Intra-renal stones will usually not cause obstruction, but occasionally in the setting of abnormal anatomy they may, such as a stone in a caliceal diverticulum causing a local/segmental hydronephrosis.
* Obstructing stone + UTI + unstable with sepsis = emergent decompression within hours. Overnight cases should generally be drained overnight. Stable patients can potentially wait longer.
* Option #1 for decompression is a ureteral stent, which stretches from the intra-renal pelvis to the bladder, traversing the area of the stone, and is deployed via cystoscopy. Urine drains around the stent, not necessarily through it. Stents can usually only be left for a maximum of 3 months and should be removed when no longer needed (i.e. when serial imaging shows passage of the stone, or a procedure has been performed to remove the stone). Long-term stent requirements involve serial stent replacements. They are placed in the OR under some level of sedation. Very distorted anatomy, such as in oncology cases, may make it difficult to find the ureteral orifice or to traverse the ureter.
* Option #2 is a percutaneous nephrostomy. These are placed by Interventional Radiology. The patient is proned (not possible in all patients), and imaging (usually ultrasound) is used to guide a needle to the renal pelvis, then a pigtail catheter using a Seldinger technique. This can often be done with local anesthesia only. Lack of significant pelvic dilation or large body habitus make these more difficult. The result is a nephrostomy tube and drainage bag, which can be aesthetically unappealing to many patients. Anticoagulation may be a contraindication since you’re puncturing the renal parenchyma. They are usually not intended to be permanent,
TIRBO #43: Lying to ourselves (the clinician’s perspective on end-of-life care)
From the Critical Concepts blog, thoughts on our personal biases and lack of humility when contemplating end-of-life decision making.
Lightning rounds #31: How to not get fired
Bryan and Brandon chat about holding down jobs, conflict resolution and interpersonal skills, and how to protect yourself as an employee.
TIRBO #42: The mobile locus of control
When are patient outcomes your fault?
Bedside Nurse Finds Value
As a bedside PCU/ICU RN, I find these episodes so informative, so relevant and applicable, and a great benefit to the nursing community! I recommend them to my friends to listen to. I find the perspective of both hosts to be so valuable to helping me understand so much of what is not communicated between the “MD” team and the “nursing team”. This podcast honestly pushes me to critically think while making my practice better!
Great resource for newbies!
I’m a new NP in thoracic and surgical critical care units and really enjoy these episodes! They are educational, informal and funny ! Will definitely be continue to listening them every week !
Great commuter education
I always love to listen whenever I’m driving to and from work. I’ve learnt a lot from this podcast. Thanks to you all.