ICU PROTOCOLS Dr V itul - PowerPoint Presentation

Slide1

ICU PROTOCOLS

Dr Vitul ManhasDr R K DograDr Yashwant VermaSlide2

SEQUENCE OF EVENTS FOR ANY CRITICALLY ILL PATIENT

Initial assessmentTransportation and shiftingMonitoring Investigations Infection control and treatmentVentilatory supportFeeding and glycaemic controlOrgan support

Supportive care

Progress of disease

Weaning

Discharge from ICUSlide3

Outreach calling criteria

Respiratory rate >25 or < 8/ minOxygen saturation < 90 % on FiO2 > 0.35Heart rate > 125 or < 50 beats/minSystolic blood pressure < 90 or > 200 mmHgSustained alteration in conscious levelSlide4

Critical care level of dependency

Level 0 – require admission, monitoring < 4hrsLevel 1 – risk of condition deterioration, monitor > 4 hrsLevel 2 – require single organ monitoringLevel 3 – require advanced respiratory monitoring or support

HDU, CCU

ICU

Advanced respiratory monitoring or support

Support for two or more organ systemSlide5

Level 2

Inotropic support for cardiovascular monitoringRenal replacement therapyNon – invasive ventilatory supportPatient with major uncorrected physiological abnormalities

ASA grade III and ASA grade IV

following major or minor surgery

Patient requiring pre – operative optimisation but not post – operative ventilation

Patient requiring frequent tracheal suctioning from tracheostomy tube

For rapid blood transfusionSlide6

Patients who are generally not appropriate for ICU admission

Irreversible brain damage End stage cardiac, respiratory and liver disease with no options for transplant Metastatic cancer unresponsive to chemotherapy and/or radiotherapy

Brain dead non-organ donors

Patients with non-traumatic coma leading to a persistent vegetative stateSlide7

Brain stem dead testing

Pupillary light reflexCorneal reflexPain responseVestibulo-ocular reflxesGag or cough reflexesApnoea testSlide8

Transport of critically illSlide9

Transport preparation ( ACCEPT)

ASSESSMENTFull 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 PACKAGING

Prepare patient, equipment and staff

TRANSPORTATION

Transportation Slide10

Monitoring in ICU

Haemodynamic monitoringVital parameters,Urine outputNeurological functionPeripheral circulationEquipment functions and

settings

Patient condition for progress or deteriorationSlide11

Ensuring Accuracy

Appropriate measurement equipment for the size or age of the patient, e.g. BP CuffCorrect siting of line, cuffPhlebostatic 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

Therefore

importance of a spirit level

Calibration

or standardization –zeroing to atmosphereSlide12

Assessment Patient Monitoring Equipment

Evaluate alarm defaults and configurations Determine who is responsible Develop checklist to guide such assessment Presence of other equipment of importance; e.g. patient call lightsAll alarms should be activated and assessed Slide13

Assessment of progress of disease

Critical care scoring systemGlasgow coma scale – used universallyAPACHE – USA & UKSAPS – mainland europeTISSSoPRASOFA scoreMODS score

Trauma scoreSlide14

SOFA SCORE

APACHE & SAPS scoring systems are designed and validated for data obtained during first 24 hrs of intensive care admission.Sofa system has been used to prognosticate and to follow changes in patient status throughout there intensive care stay.Slide15

0

1

2

3

4

Respiratory

PaO2 :FiO2

(mmHg)

>400

<400

<300

<200

<100Renal 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

Or

Dobuta

any dose

Dopa

>5

Or

adr

<0.1

Dopa

> 15

Or

adr

>0.1

Haemato

logical

Platelet count(10

3

/mm

3

)

>150

<150

<100

<50

<20

Neuro

logical

GCS

15

13-14

10-12

6-9

<6Slide16

INVESTIGATIONS AND MICROBIOLOGICAL SURVEILLANCE

Basic investigations on admission Full blood count (includes haemoglobin, total white and differentialcounts, 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

ECGSlide17

Infection control

Hand Hygiene: Use 60 – 90% alcohol or 0.5-1.0% chlorhexidine (w/v) Airway - orotracheal Oral Hygiene – chlorhexidine 2% or

povidone

10% at least thrice a day

Ventilator Circuits – change if visibly contaminated

Suction - no difference between closed and open

Body Position – 30

o

– 45

o

Head of Bed up (not just the head of patent as a sedated patient will slip down) Slide18

Skin

prep2% 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.

Chlorhexidine

1%

v/v is equivalent to only 1/5 of w/v solution.

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 Slide19

Sepsis Resuscitation Bundle:

Serum lactate to be measured Blood cultures obtained prior to antibiotic administration From the time of presentation, broad-spectrum antibiotics administered within 3 hours for Emergency Department admissions and 1 hour for non-ED ICU admissions In the event of hypotension and/or lactate > 4

mmol

/L (36 mg/dl):

Deliver an initial minimum of 20ml / kg of crystalloid (or colloid equivalent). Slide20

Use vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg

In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl): Achieve central venous pressure of 8mm Hg Achieve central venous oxygen saturation of > 70% Slide21

Sepsis Management Bundle:

Low dose steroid administered for septic shock in accordance with a standardized ICU policy Dotrecogin alfa (activated) administered in accordance with a standardized ICU policy Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3

mmol

/L)

Inspiratory plateau pressure maintained < 30 cm H2O for mechanically ventilated patients Slide22

The Antibiotic

Care Bundle Clinical criteria for initiation of antimicrobial therapy Actively get specimens for microbiology Initial empiric antibiotic choice based on local policy

Remove infected source: foreign body, drain collections

Modify when microbiology results are available

Daily review of antibiotic choice and continuation.

Regular expert input Slide23

What system of ICU care is best?

Closed unit - consultant intensivist. Open ICU – primary consultant.Semi closed or Transitional unit.Slide24

RECOMMENDATIONS

DEFINING THE FUNCTIONS, ROLE AND RESPONSIBILITIES OF THE CONSULTANT INTENSIVIST Slide25

Admissions to and discharges from the ICU

The consultant intensivist is ideally placed to triage patients, prioritise admissions and maintain a waiting list. The presence of written protocols outlining how patient admissions will be prioritised is helpful .When discharging a patient from the ICU, the consultant intensivist should be satisfied that the patient is suitable for transfer out of the ICU

.Slide26

All patients admitted to the ICU must be seen by a consultant

intensivist. daily rounds on all ICU patients. Make a clear plan for the next 12-24 hours. Common ICU procedures should be performed by the consultant intensivist or by personnel designated by the consultant intensivist

under his / her supervision. Slide27

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

ResearchSlide28

Services outside the ICU

Management of patients in the high-dependency unit Medical Emergency Team: Emergency department, including the Trauma team CPR team Artificial airway management

Invasive procedures outside the ICU (e.g., Central Line, PICC lines, Lumbar puncture, Insertion of feeding tubes

etc

) Slide29

TRIAGE

Due to the limited number of ICU beds, triaging may be necessary. The following factors will be taken into consideration in triaging: Diagnosis Severity of illness

Age and functional status

Co-morbid disease

Physiological reserve

Prognosis

Availability of suitable treatment Response to treatment to date

Recent cardiopulmonary arrest Anticipated quality of lifeSlide30

Discharge from the ICU

Conscious Good airway, extubated and stable for several hours after 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.Slide31

Basic Bundle for all ICU

patients A checklist: REMEMBER: FAST HUG Feed Analgesia Sedation

Throboprophylaxis

Head

of bed

elevation

Ulcer prophylaxis

Glucose

Control

FAST HUGSlide32

CONTINUOUS INTRAVENOUS SEDATION

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. Titrate the sedative infusion rate with the aim of keeping the sedation score between

-1 to +1

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 -2Slide33

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 Fentanyl may be used instead of midazolam and morphine in the

following conditions

:

a. renal failure

b. hepatic failure

200mcg Fentanyl is diluted in up to 20mls normal saline.

The infusion rate is

between 2 - 5mls per hour (20 -50mcg/hour)

Postoperative cases that are for overnight ventilation may be put

on a. morphine + propofolb. dexmedetomidine (only for 24 hours)

Slide34

Consider daily interruption of continuous sedative infusion at a fixed time every morning

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. There may be a need to add further sedation For example: Tab. Lorazepam 1-2 mg ON /

bd

Tab

. Alprazolam 0.5mg

bd

/

tds

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:Age < 60 years: 5 -10mg PRN / 4 -6hourlyAge > 60 years: 2.5 -5 mg PRN / 6 hourlySlide35

If sedation score: -2, half the intravenous sedative infusion. Decrease

the sedative infusion every 4 hours until a score of -1 is achieved 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. Patients that are paralysed need not be scored and should be denoted with a capital “P”Slide36

Revised Riker Sedation Agitation Scale

ScoreDescription

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

remains calm

Awakens easily to verbal stimuli. Remains awake, 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 stimuliSlide37

STRESS RELATED MUCOSAL DISEASE

PROPHYLAXIS IN THE INTENSIVE CARE UNITSpecific risk factors include : mechanical ventilation ( more than 48 hours) coagulopathy shock states ( septic, haemorrhagic, cardiogenic, anaphylactic)

severe head injury and neurosurgical patients

severe burns ( more than 30%)

multiple organ failureSlide38

Prophylactic therapy for SRMD

Considering available evidence and cost-effectiveness of current pharmacological agents for prophylaxis, the following are recommended: IV Ranitidine 50 mg 8 hourly. Reduce dose to 50 mg 12 hourly in patients with renal failure.The

superior efficacy of intravenous H2 antagonists compared

with

sucralfate

in preventing SRMD has been

demonstrated

, and therefore,

H2 antagonists

are preferred.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.IV Omeprazole or IV Pantoprazole 40 mg dailySlide39

Discontinuing SRMD prophylaxis

Prophylactic therapy is discontinued once patient is on full feeds and none of the above risk factors are present. Consider changing to oral therapy as soon as tolerating orally. 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 )Slide40

VENOUS THROMBOEMBOLISM PROPHYLAXIS

RECOMMENDATIONSOn admission to the intensive care unit (ICU), all patients should be assessed for their risk of venous thromboembolism.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

.

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.Slide41

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.Routine screening of patients for asymptomatic deep vein thrombosis is not recommended since this strategy is neither effective nor cost-effective.

LMWH have a number of potential advantages over Low

Dose unfractionated

Heparin (LDUH) which

include

once daily

administration, greater

bioavailability, lower incidence of

heparin-induced thrombocytopenia and cost effective due to less laboratory

monitoringEarly ambulation remains the most important non pharmacologic approach to prevention of VTE.Slide42

Pharmacological modalities

Low Dose unfractionated heparin (LDUH) eg. Subcutaneous (s/c) Heparin 5,000 units 8 hourly (high risk) or 12 hourly (moderate risk)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/minSlide43

ABSOLUTE RISK FOR VTE

Patient categoryRecommendations

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 prophylaxisSlide44

Thankyou