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ICU PROTOCOLS. Dr V itul Manhas Dr R K Dogra Dr Yashwant Verma. SEQUENCE OF EVENTS FOR ANY CRITICALLY ILL PATIENT. Initial assessment Transportation and shifting Monitoring Investigations Infection control and treatment Ventilatory support Feeding and glycaemic control

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icu protocols

ICU PROTOCOLS

Dr VitulManhas

Dr R K Dogra

Dr YashwantVerma

sequence of events for any critically ill patient
SEQUENCE OF EVENTS FOR ANY CRITICALLY ILL PATIENT
  • Initial assessment
  • Transportation and shifting
  • Monitoring
  • Investigations
  • Infection control and treatment
  • Ventilatory support
  • Feeding and glycaemic control
  • Organ support
  • Supportive care
  • Progress of disease
  • Weaning
  • Discharge from ICU
outreach calling criteria
Outreach calling criteria
  • Respiratory rate >25 or < 8/ min
  • Oxygen saturation < 90 % on FiO2 > 0.35
  • Heart rate > 125 or < 50 beats/min
  • Systolic blood pressure < 90 or > 200 mmHg
  • Sustained alteration in conscious level
critical care level of dependency
Critical care level of dependency
  • Level 0 – require admission, monitoring < 4hrs
  • Level 1 – risk of condition deterioration, monitor > 4 hrs
  • Level 2 – require single organ monitoring
  • Level 3 – require advanced respiratory monitoring or support

HDU, CCU

ICU

Advanced respiratory monitoring or support

Support for two or more organ system

level 2
Level 2
  • Inotropic support for cardiovascular monitoring
  • Renal replacement therapy
  • Non – invasive ventilatory support
  • Patient with major uncorrected physiological abnormalities
  • ASA grade III and ASA grade IVfollowing 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 transfusion
patients who are generally not appropriate for icu admission
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 state
brain stem dead testing
Brain stem dead testing
  • Pupillary light reflex
  • Corneal reflex
  • Pain response
  • Vestibulo-ocular reflxes
  • Gag or cough reflexes
  • Apnoea test
monitoring in icu
Monitoring in ICU
  • Haemodynamic monitoring
  • Vital parameters,
  • Urine output
  • Neurological function
  • Peripheral circulation
  • Equipment functions and settings
  • Patient condition for progress or deterioration
ensuring accuracy
Ensuring Accuracy
  • Appropriate measurement equipment for the size or age of the patient, e.g. BP Cuff
  • Correct siting of line, cuff
  • Phlebostaticaxis 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 atmosphere
assessment patient monitoring equipment
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 lights
  • All alarms should be activated and assessed
assessment of progress of disease
Assessment of progress of disease

Critical care scoring system

  • Glasgow coma scale – used universally
  • APACHE – USA & UK
  • SAPS – mainland europe
  • TISS
  • SoPRA
  • SOFA score
  • MODS score
  • Trauma score
sofa score
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.
investigations and microbiological surveillance
INVESTIGATIONS AND MICROBIOLOGICAL SURVEILLANCE
  • 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
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 – 30o – 45o Head of Bed up (not just the head of patent as a sedated patient will slip down)
skin prep
Skin prep
  • 2% w/v chlorhexidine is better than 10% w/v povidone; chlorhexidinepovidoneand chlorhexodine sequential cleaning is even better as skin preparation for central line insertion.
  • Chlorhexidine1% 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
sepsis resuscitation bundle
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%
sepsis management bundle
Sepsis Management Bundle:
  • Low dose steroid administered for septic shock in accordance with a standardized ICU policy
  • Dotrecoginalfa (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
the antibiotic care bundle
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
what system of icu care is best
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

admissions to and discharges from the icu
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 .
all patients admitted to the icu must be seen by a consultant intensivist
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
  • Research
services outside the icu
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)
triage
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 life
discharge from the icu
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

FAST HUG

Basic Bundle for all ICU patients A checklist:

REMEMBER: FAST HUG

  • Feed
  • Analgesia
  • Sedation
  • Throboprophylaxis
  • Head of bed elevation
  • Ulcer prophylaxis
  • Glucose Control
continuous intravenous sedation
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 -2

slide33

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 + propofol

b. 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 / bdTab. 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 -6hourly
  • Age > 60 years: 2.5 -5 mg PRN / 6 hourly
slide35

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”
stress related mucosal disease prophylaxis in the intensive care unit
STRESS RELATED MUCOSAL DISEASE PROPHYLAXIS IN THE INTENSIVE CARE UNIT

Specific 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 failure
prophylactic therapy for srmd
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 sucralfatein 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 daily
discontinuing srmd prophylaxis
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 )
venous thromboembolism prophylaxis recommendations
VENOUS THROMBOEMBOLISM PROPHYLAXISRECOMMENDATIONS
  • On 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 monitoring
  • Early ambulation remains the most important non pharmacologic approach to prevention of VTE.
pharmacological modalities
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/min
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