Transcript ICU PROTOCOLS - Pheonix India

SEQUENCE OF EVENTS FOR ANY CRITICALLY ILL PATIENT
0 Initial assessment
0 Transportation and shifting
0 Monitoring
0 Investigations
0 Infection control and treatment
0 Ventilatory support
0 Feeding and glycaemic control
0 Organ support
0 Supportive care
0 Progress of disease
0 Weaning
0 Discharge from ICU
Outreach calling criteria
0 Respiratory rate >25 or < 8/ min
0 Oxygen saturation < 90 % on FiO2 > 0.35
0 Heart rate > 125 or < 50 beats/min
0 Systolic blood pressure < 90 or > 200 mmHg
0 Sustained alteration in conscious level
Critical care level of dependency
0 Level 0 – require admission, monitoring < 4hrs
0 Level 1 – risk of condition deterioration, monitor > 4 hrs
0 Level 2 – require single organ monitoring
HDU, CCU
0 Level 3 – require advanced respiratory monitoring or support
ICU
Advanced respiratory monitoring or support
Support for two or more organ system
Level 2
0 Inotropic support for cardiovascular monitoring
0 Renal replacement therapy
0 Non – invasive ventilatory support
0 Patient with major uncorrected physiological abnormalities
0 ASA grade III and ASA grade IV following major or minor
surgery
0 Patient requiring pre – operative optimisation but not post –
operative ventilation
0 Patient requiring frequent tracheal suctioning from
tracheostomy tube
0 For rapid blood transfusion
Patients who are generally not
appropriate for ICU admission
0 Irreversible brain damage
0 End stage cardiac, respiratory and liver disease with
no options for transplant
0 Metastatic cancer unresponsive to chemotherapy
and/or radiotherapy
0 Brain dead non-organ donors
0 Patients with non-traumatic coma leading to a
persistent vegetative state
Brain stem dead testing
0 Pupillary light reflex
0 Corneal reflex
0 Pain response
0 Vestibulo-ocular reflxes
0 Gag or cough reflexes
0 Apnoea test
Transport of critically ill
Transport preparation ( ACCEPT)
ASSESSMENT
Full patient history and current problem
CONTROL
Identify leader and allocate tasks
COMMUNICATION
All communication is clear. Source identified and involve staff
involved with patient dispatch and receipt.
EVALUATION
Assess risk and benefit of transport, equipment needed and
urgency
PREPARATION AND Prepare patient, equipment and staff
PACKAGING
TRANSPORTATION
Transportation
Monitoring in ICU
0 Haemodynamic monitoring
0 Vital parameters,
0 Urine output
0 Neurological function
0 Peripheral circulation
0 Equipment functions and settings
0 Patient condition for progress or deterioration
Ensuring Accuracy
0 Appropriate measurement equipment for the size or age of
the patient, e.g. BP Cuff
0 Correct siting of line, cuff
0 Phlebostatic axis or Zero point as reference point
–Correlate zero point of the patient with that of transducer
–Changing position of transducer with that of patient
0 Therefore importance of a spirit level
0 Calibration or standardization –zeroing to atmosphere
Assessment Patient Monitoring
Equipment
0 Evaluate alarm defaults and configurations
0 Determine who is responsible
0 Develop checklist to guide such assessment
0 Presence of other equipment of importance; e.g.
patient call lights
0 All alarms should be activated and assessed
Assessment of progress of
disease
Critical care scoring system
0 Glasgow coma scale – used universally
0 APACHE – USA & UK
0 SAPS – mainland europe
0 TISS
0 SoPRA
0 SOFA score
0 MODS score
0 Trauma score
SOFA SCORE
0 APACHE & SAPS scoring systems are designed and
validated for data obtained during first 24 hrs of
intensive care admission.
0 Sofa system has been used to prognosticate and to
follow changes in patient status throughout there
intensive care stay.
0
1
2
3
4
Respiratory
PaO2 :FiO2
(mmHg)
>400
<400
<300
<200
<100
Renal
Creatinine
(mg/dl)
U/O ( ml/d)
<1.2
1.2-1.9
2.0-3.4
3.4-4.9 or
<500 ml/d
>5.0 or
<200 ml/d
Hepatic
Bilirubin
(mg/dl)
<1.2
1.2-1.9
2.0-5.9
6.0-11.9
12.0
Cardiovascular
MAP(mmHg)
N
>70
Dopa <5mcg Dopa>5
Or Dobuta
Or adr<0.1
any dose
Dopa > 15
Or adr >0.1
Haematological
Platelet
count(103/mm3)
>150
<150
<100
<50
<20
Neurological
GCS
15
13-14
10-12
6-9
<6
INVESTIGATIONS AND
MICROBIOLOGICAL SURVEILLANCE
0
0
0
0
0
0
0
0
0
0
0
Basic investigations on admission
Full blood count (includes haemoglobin, total white and differential
counts, platelet count)
Serum creatinine, blood urea and electrolytes (including Na+, K+, Cl-,
Ca2+,Mg2+, Phosphate3-)
Liver function test
Arterial blood gas
Blood glucose level (hand held blood glucose analyser is acceptable)
Septic / microbiology screen as indicated
CXR (after placement of appropriate lines e.g. central venous line,
nasogastric tube)
Patients requiring post-operative ventilation for a few hours may not
require a routine CXR
ECG
Infection control
0 Hand Hygiene:
0 Use 60 – 90% alcohol or 0.5-1.0% chlorhexidine (w/v) Airway -
orotracheal
0 Oral Hygiene – chlorhexidine 2% or povidone 10% at least thrice
a day
0 Ventilator Circuits – change if visibly contaminated
0 Suction - no difference between closed and open
0 Body Position – 30o – 45o Head of Bed up (not just the head of
patent as a sedated patient will slip down)
Skin prep
0 2% w/v chlorhexidine is better than 10% w/v povidone;
chlorhexidine povidone and chlorhexodine sequential
cleaning is even better as skin preparation for central line
insertion.
0 Chlorhexidine 1% v/v is equivalent to only 1/5 of w/v
solution.
0 Chlorhexidine 2.5 % v/v is equivalent to only to a 0.5%
w/v solution – inadequate for skin preparation, but
adequate for hand hygiene
Sepsis Resuscitation Bundle:
0 Serum lactate to be measured
0 Blood cultures obtained prior to antibiotic administration
0 From the time of presentation, broad-spectrum antibiotics
administered within 3 hours for
0 Emergency Department admissions and 1 hour for nonED ICU admissions
0 In the event of hypotension and/or lactate > 4 mmol/L
(36 mg/dl):
0 Deliver an initial minimum of 20ml / kg of crystalloid (or
colloid equivalent).
0 Use vasopressors for hypotension not responding to
initial fluid resuscitation to maintain mean arterial
pressure (MAP) > 65 mm Hg
0 In the event of persistent hypotension despite fluid
resuscitation (septic shock) and/or lactate > 4
mmol/L (36 mg/dl):
0 Achieve central venous pressure of 8mm Hg
0 Achieve central venous oxygen saturation of > 70%
Sepsis Management Bundle:
0 Low dose steroid administered for septic shock in
accordance with a standardized ICU policy
0 Dotrecogin alfa (activated) administered in accordance
with a standardized ICU policy
0 Glucose control maintained > lower limit of normal, but
< 150 mg/dl (8.3 mmol/L)
0 Inspiratory plateau pressure maintained < 30 cm H2O
for mechanically ventilated patients
The Antibiotic Care Bundle
0 Clinical criteria for initiation of antimicrobial therapy
0 Actively get specimens for microbiology
0 Initial empiric antibiotic choice based on local policy
0 Remove infected source: foreign body, drain collections
0 Modify when microbiology results are available
0 Daily review of antibiotic choice and continuation.
0 Regular expert input
What system of ICU care is
best?
0 Closed unit - consultant intensivist.
0 Open ICU – primary consultant.
0 Semi closed or Transitional unit.
RECOMMENDATIONS
DEFINING THE FUNCTIONS,
ROLE AND RESPONSIBILITIES
OF THE CONSULTANT
INTENSIVIST
Admissions to and
discharges from the ICU
0 The consultant intensivist is ideally placed to triage
patients, prioritise admissions and maintain a waiting
list.
0 The presence of written protocols outlining how
patient admissions will be prioritised is helpful .
0 When discharging a patient from the ICU, the
consultant intensivist should be satisfied that the
patient is suitable for transfer out of the ICU .
All patients admitted to the ICU must be
seen by a consultant intensivist.
0 daily rounds on all ICU patients.
0 Make a clear plan for the next 12-24 hours.
0 Common ICU procedures should be performed by the
consultant intensivist or by personnel designated by
the consultant intensivist under his / her supervision.
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0
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0
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0
0
0
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Communication with patients and their families
End of life decisions
Time Commitment to the ICU
Privileges outside the ICU
Follow-up of patients outside the ICU
Maintaining standards of intensive care practice
Administration
Payments
Teaching
Research
Services outside the ICU
0 Management of patients in the high-dependency unit
0 Medical Emergency Team:
0 Emergency department, including the Trauma team
0 CPR team
0 Artificial airway management
0 Invasive procedures outside the ICU (e.g., Central
Line, PICC lines, Lumbar puncture, Insertion of
feeding tubes etc)
TRIAGE
Due to the limited number of ICU beds, triaging may be
necessary. The following factors will be taken into
consideration in triaging:
0 Diagnosis
0 Severity of illness
0 Age and functional status
0 Co-morbid disease
0 Physiological reserve
0 Prognosis
0 Availability of suitable treatment
0 Response to treatment to date
0 Recent cardiopulmonary arrest
0 Anticipated quality of life
Discharge from the ICU
0 Conscious
0 Good airway, extubated and stable for several hours after
0
0
0
0
0
0
extubation
Breathing comfortably
Stable blood pressure and urine output.
Haemoglobin >6 g/dl or blood transfusion in progress
Minimal nasogastric drainage and has bowel sounds,
abdomen not distended
Afebrile
Looks better, sitting up, not confused.
FAST HUG
Basic Bundle for all ICU patients A checklist:
REMEMBER: FAST HUG
0 Feed
0 Analgesia
0 Sedation
0 Throboprophylaxis
0 Head of bed elevation
0 Ulcer prophylaxis
0 Glucose Control
CONTINUOUS INTRAVENOUS
SEDATION
0 Patients are to be assessed for sedation and agitation based on
the revised Riker Sedation and Agitation scale every 4 hours.
The worst score within the last 4 hours is to be recorded.
0 Titrate the sedative infusion rate with the aim of keeping the
sedation score between -1 to +1
0 Exceptions to keeping the sedation score between -1 and +1:
a. head injured on cerebral protection: sedation score -3
b. severe sepsis on high inotropic support: sedation score of at
least -1
c. RDS on high ventilatory support: sedation score of at least -2
d. tetanus: sedation score of at least -2
0 The standard sedative infusion to be used in patients
admitted to ICU is midazolam and morphine. 30mg
midazolam and 30mg morphine is diluted in up to 30mls
normal saline. The infusion may be started between 2 –
3mls per hour
0 Fentanyl may be used instead of midazolam and morphine
in the following conditions:
a. renal failure
b. hepatic failure
0 200mcg Fentanyl is diluted in up to 20mls normal saline.
The infusion rate is between 2 - 5mls per hour (20 50mcg/hour)
0 Postoperative cases that are for overnight ventilation may
be put on
a. morphine + propofol
b. dexmedetomidine (only for 24 hours)
0
0 Consider daily interruption of continuous sedative infusion at a
fixed time every morning
0 If sedation score is +2, exclude other causes of agitation such as
pain, hypoxia etc. Calm patient down by communicating with
him. Increase the sedative infusion rate.
0 There may be a need to add further sedation For example: Tab.
Lorazepam 1-2 mg ON / bd Tab. Alprazolam 0.5mg bd / tds
0 If sedation score +3, exclude other causes of agitation. Bolus
midazolam/morphine and increase infusion rate except in non
ventilated patients. IV haloperidol will probably be indicated:
1. Age < 60 years: 5 -10mg PRN / 4 -6hourly
2. Age > 60 years: 2.5 -5 mg PRN / 6 hourly
0 If sedation score: -2, half the intravenous sedative
infusion. Decrease the sedative infusion every 4 hours
until a score of -1 is achieved
0 If sedation score: -3, off sedative infusion. Assess 4
hours later. Restart at half the infusion rate once a
score of -1 has been reached.
0 Patients that are paralysed need not be scored and
should be denoted with a capital “P”
Revised Riker Sedation Agitation Scale
Score Description
defination
+3
Agitated and restless
When awaken or otherwise, pulling at ETT, trying to
remove catheters or requires physical restraints
+2
Awake but mildly
agitated
Anxious but mildly agitated. Attempts to sit up but calms
down with verbal instructions
+1
Awake and calm
Awake, calm and easily follows commands
0
Aroused by voice and Awakens easily to verbal stimuli. Remains awake, calm
remains calm
and easily follows command
-1
Aroused by
movement
Awakens to loud verbal stimuli or gentle shaking. Has eye
contact for at least 10 seconds but drifts off to sleep
OR
Awakens to loud verbal stimuli or gentle shaking and
follows simple commands
-2
Aroused by painful
stimuli
Localising or flexion to pain. Does not communicate or
follow commands
-3
Unarousable
Extension, minimal or no response to painful stimuli
STRESS RELATED MUCOSAL DISEASE
PROPHYLAXIS IN THE INTENSIVE
CARE UNIT
Specific risk factors include :
0 mechanical ventilation ( more than 48 hours)
0 coagulopathy
0 shock states ( septic, haemorrhagic, cardiogenic,
anaphylactic)
0 severe head injury and neurosurgical patients
0 severe burns ( more than 30%)
0 multiple organ failure
Prophylactic therapy for SRMD
Considering available evidence and cost-effectiveness of
current pharmacological agents for prophylaxis, the following
are recommended:
0 IV Ranitidine 50 mg 8 hourly. Reduce dose to 50 mg 12
hourly in patients with renal failure.
0 The superior efficacy of intravenous H2 antagonists
compared with sucralfate in preventing SRMD has been
demonstrated, and therefore, H2 antagonists are preferred.
0 The use of proton pump inhibitors (PPI) as prophylaxis has
not been shown to be superior to H2 antagonists and should
probably be limited to those with history of recent UGIB or
recent endoscopically proven ulcer.
0 IV Omeprazole or IV Pantoprazole 40 mg daily
Discontinuing SRMD prophylaxis
0 Prophylactic therapy is discontinued once patient is on full
feeds and none of the above risk factors are present.
0 Consider changing to oral therapy as soon as tolerating
orally.
0 For those who develop clinically significant bleed in ICU,
PPIs are continued for at least 2 weeks (IV / oral
omeprazole or Pantoprazole 40 mg BD )
VENOUS THROMBOEMBOLISM PROPHYLAXIS
RECOMMENDATIONS
0 On admission to the intensive care unit (ICU), all patients
should be assessed for their risk of venous
thromboembolism.
0 Consider withholding the heparin product when there is a
significant decrease of platelet count (30 to 50% of initial
count) or decrease to less than 100,000 per micro liter of
blood or when INR > 1.5.
0 The prevention of VTE in neurosurgical has favoured
mechanical prophylaxis methods. However the use of
heparin products is considered to be safe after 48 to 72
hours.
0 The insertion and removal of epidural catheters should
coincide with the nadir of the anticoagulant effect. The last
dose of LMWH should be 12 hours prior to removal of
catheter and can be restarted 2 hours later.
0 Routine screening of patients for asymptomatic deep vein
thrombosis is not recommended since this strategy is
neither effective nor cost-effective.
0 LMWH have a number of potential advantages over Low
Dose unfractionated Heparin (LDUH) which include
1. once daily administration, greater bioavailability, lower
incidence of heparin-induced thrombocytopenia and cost
effective due to less laboratory monitoring
0 Early ambulation remains the most important non
pharmacologic approach to prevention of VTE.
Pharmacological modalities
0 Low Dose unfractionated heparin (LDUH) eg. Subcutaneous
(s/c) Heparin 5,000 units 8 hourly (high risk) or 12 hourly
(moderate risk)
0 Low molecular weight Heparin (LMWH) eg. S/C Enoxaparin
(Clexane) 40mg daily when creatinine clearance less than
30ml/min or 30mg daily when creatinine clearance greater
than 30ml/min
ABSOLUTE RISK FOR VTE
Patient category
Recommendations
Low risk
eg. medical patients, immobilization, use of
pharmacologic paralysis or sedation, heart failure
Mechanical prophylaxis
Moderate risk
eg. general surgery, major gynecologic surgery,
major urologic surgery, sepsis, vasopressor use,
active medical condition
LMWH or s/c Heparin 5000
units 12 hourly in combination
with mechanical prophylaxis
High risk
eg. stroke, neurosurgery, previous VTE
LMWH or s/c Heparin 5000
units 8 hourly in combination
with mechanical prophylaxis
Highest risk
eg. spinal cord injury, major trauma hip/knee
arthroplasty, hip fracture Surgery
LMWH in combination with
mechanical prophylaxis