Shyam Sunder Tipparaju, Gopinath Ramachandran, Ravinuthala Venkat Kumar, Muppiri Vijay Kumar. Pages PDF. It is often difficult to know for certain whether a particular patient needs to be nursed postoperatively in the intensive care unit (ICU), if one exists in your hospital. Intensive Care Unit. Guidelines for Clinical Management. (Developed for the Colonial War Memorial Hospital ICU). Compiled by: Dr Lisa Bennett, Consultant.
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MOH Pocket Manual in Critical Care. TABLE OF . Facilitate transfer to the operating room or ICU. . Most guidelines and clinical protocols recommend that. have ventured further and we are now proud to be able to present to you another 11 management protocols and 2 policies that will cover a diverse range of. Intensive Care Topics: common admissions and useful algorithms. UIH Clinical Care Guidelines These are some general rules/guidelines to follow.
Nursing Care of the Ventilated Patient. Some investigations may be ordered on a routine basis to facilitate the overall daily management of the unit. However CXR should be ordered following placement of central venous catheter, endotracheal tube, nasogastric tube, chest drains or when cardiorespiratory pathology is suspected. In, w,. However in an MRSA outbreak, there is strong evidence for active surveillance cultures.
Nasal swabs are taken from all ICU patients, wound swabs taken when applicable and nasal swabs from staff only if implicated in transmission.
In an vancomycin-resistant enterococci VRE outbreak, surveillance swabs should include rectal swabs from all ICU patients, wound swabs in applicable patients and rectal swabs from staff only if implicated intransmission. In the setting of a respiratory reservoir outbreak, tracheal aspirate culture should be sent from suspected patients. For this reason facilities that rarely e. Screen epidemiologically-linked patient contacts e. Consider point prevalence survey of affected unit. During an outbreak, screening cultures of contacts are also important.
Surveillance cultures for endotracheal aspirates may be done weekly to - identify MDR pathogens o predict susceptibility patterns o aid empiric antibiotic therapy Pn-gram An. Routine blood test ordering for patients in intensive care.
Anaesth Intensive Care Oct; 28 5: Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU. Chest ; Nasal swabs collected routinely to screen for colonization by methicillin-resistant Staphylococcus aureus in intensive care units are a sensitive screening test for the organism in clinical cultures. Surg Infect Larchmt Dec; 11 6: Baba, G. Nirnmo, AM Allworth et al. The role of surveillance cultures in the prediction of susceptibility patterns of Gram-negative bacilli in the intensive care unit.
European Journal of Clinical Microbiology 8: An audit for microbiological surveillance and antimicrobial susceptibility in the intensive care unit. Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: A role for routine endotracheal aspirate cultures. Chest , Depuydt, D Benoit, D Vogelaers et al. Systematic surveillance cultures as a tool to predict involvement of multidrug antibiotic resistant bacteria in ventilator-associated pneumonia.
Role of serial routine microbiologic culture results in the initial management of ventilator-associated pneumonia. Infec- tious disease: Multidrug-resistant Pseudomonas aeruginosa ventilator-associated pneumonia: The role of endotracheal aspirate surveillance cultures.
Ann Pharmacother January, Choosing appropriate goals for mechanical ventilation is more important than the mode. Low tidal volume ventilation should be instituted in all patients on mechanical venti- lation. If necessary, accept physiologic target outside normal range e. The optimal time to initiate Ventilatory rescue therapies in high potential recruiters is within 96 hours of onset of Acute Respiratory Distress Syndrome ARDS when alveolar recruitment potential is the greatest.
The choice of rescue therapy should be based on equipment availability and clinician expertise. If the therapy does not result in improved oxygenation, it should be aban- doned. In PCV, Pplat is equivalent to peak airway pressure. If VCV is used, the Pplat needs to be mea- sured regularly e. Use the lowest FiO2 to achieve adequate oxygenation. Infusion of intravenous NaHCO3 8. Contraindi- cations to permissive hypercapnia include intracranial hyperterwion, concomitant metabolic acidosis, acute coronary syndrome, right heart failure and worsening pulmonary hypertension.
If conventional ventilation fails i. High potential recruit- ers are those who at the end of the trial demonstrate all of the following: Do not perform further recruitment manoeuvres in non-recruiters. Consider non-Ventilatory strategies to improve PaO2.
The following steps are to be performed only in recruiters: Perform recruitment manoeuvre. Additional sedation, paralysis or both may be required during manoeuvre. Monitor for hypotension and desaturation. Different lung recruitment manoeuvres that may be performed are: Re-recruit the lung at the optimal PEEP level.
Reassess in recruiters. Non-Ventilatory rescue strategies to improve oxygenation: Possible complications include pressure ulcers, unplanned extubation, dislodge- ment of catheters, increased use of sedatives. A regime using methylprednisolone for 28 days is as follows: If extubated between D1 - D14, proceed to D15 of therapy. Other non-Ventilatory strategies to improve oxygenation: Exercise caution in patients who are hypovolemic.
Severe hypoxemic respiratory failure. Part 1: Part 2: Nonventilatory strategies. Recommendations for the diagnosis and man- agement of corticosteroid insufficiency in critically ill adult patients: Crit Care Med. Methylprednisolone infusion in early severe ARDS: Chest Lung recruitment in patients with the acute respiratory distress syndrome.
N Engl] Med. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am] RespirCrit Care Med ; A randomized, controlled trial of furosernide with or without albumin in hypoproteinemic patients with acute lung injury. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
N Engl J Med. The process is uneventful in most patients, but may take up half the time on a ventilator in problem- atic patients. Most patients require a period of rest after intubation, but consideration of the wean- ing process should begin very soon after intubation.
Delay in clinical judgment that weaning may be possible and delay in assessment of readiness to wean is a common cause of delayed weaning. The patient must be awake, cooperative, haemodynamically stable and able to cough and protect airway before extubation.
It is important to minimize or discontinue sedation for daytime breathing trials. Unless there is evidence for clearly irreversible disease e. Resolution of acute phase of disease for which patient was intubated - Adequate cough Absence of excessive tracheobronchial secretions Pmjgmm 1nl: IIl au.
Respiratory criteria 1. Adequate oxygenation: Neurological criteria i. None of these measurements, when used in isolation, can predict with certainty which patients are ready to breathe spontaneously independently.
Once the patient is deemed ready to wean, proceed with spontaneous breathing trial. It is important to communicate with the patient that attempt at discontinuation of ventilation is about to begin. Spontaneous breathing trial SBT The SBT can be conducted while the patient is still connected to the ventilator circuit or the patient can be removed from the ventilator and allowed to breathe through an independent source of oxygen via a T-shaped breathing circuit known as the T-piece.
SBT through the ventilator: The advantage is patient safety as patient is not disconnected from ventilator and back-up ventilation can be provided if the patient is apnoeic. In addition, tidal volume and respiratory rate can be monitored. SBT through a T-piece: The advantage is the reduced work of breathing with the T-shaped circuit.
Protocol for SBT 1.
Allow 30 to minutes for the initial trial of spontaneous breathing. SBT is considered a failure when patient develops respiratory, cardiovascular or neu- rological instability. Criteria for passing spontaneous breathing trial: In, s,.
Refer to appendix 1 for explanation of cuff leak test. If a patient fails a SBT: Pn-gram An. NIV can be used as an alternative weaning technique in patients who have failed con- ventional weaning or failed to meet standard extubation criteria. Role of Tracheostomg o Must be considered: Weaning from Mechanical Ventilation in the Intensive Care Unit Protocol to mean a tracheostomised patient with prolonged wean or prolonged meclaanical ventilation Principle is to utilize daily SBTS of progressively increasing duration after a certain level of ventilatory support reduction has occurred.
Firstly, reduce level of PS gradually by 2 cml-I20 q 24h. Once a PS of 10 - 12 cmH2O is reached, perform assessment for readiness to wean.
A stepwise approach
If deemed ready to wean, perform SBT using a trachymask for eg 2h. Eventual goal is to reach 24h without ventilator support and therefore be completely liberated from ventilator. Appendix 1 Cuff Leak Test 1. Qualitative assessment 2. Measure the difference between inspired and expired tidal volumes. To improve prediction of post-extubation stridor, perform simultaneous assessment of cough and cuff leak: Absence of both audible cough and cuff leak indicates patient is 10 times more likely to develop post-extubation stridor.
Program Ana-sh-siolngi 1. Igv, aan K: Cardiac i. Ischaemic heart disease dysfunction ii. Valvular heart disease iii. Systolic or diastolic dysfunction iv. Increased metabolic demand of weaning imposing an increased cardiac workload v. Respiratory 1. Reduced pulmonary compliance dysfunction i. Pneumonia primary admission diagnosis or ventilator-associated. Cardiogenicornon-cardiogenic pulmonary oedema 11 iv.
Pulmonary haemorrhage v. Reduced chest wall compliance eg kyphocoliosis vi. Splinting eg abdominal distension, obesity and ascites II. Obstructive problems i. Bronchoconstriction Tube obstruction Kinked tube iv. Inappropriate ventilator settings resulting in increased work of breathing v. Post-extubation - glottic oedema, increased airway secretions, sputum retention 3.
N euromuscular I. Depressed Central drive i. Encephalitis ii. Metabolic alkalosis II. Peripheral nervous system dysfunction i.
Guillain-Barre syndrome, myasthenia gravis usually apparent before weaning ii. Critical illness neuromuscular abnormalities important cause! Nutrition i. Obesity Malnutrition Overfeeding 5. Unresolved systemic disease - sepsis 6.
Table of contents
Neuropsychological i. Delirium ii. Depression iii. Anxiety 7. Metabolic i. Hypokalaemia, hypomagnesemia, hypophosphatemia Steroids and hyperglycaemia - controversial 8. Anaemia Controversial P: Weaning Assessment of readiness to wean - is the patient ready for a spontaneous breathing trial SBT? Able to protect airway?
Continue mechanical ventilation. Weaning of Mechanical Ventilation. Weaning from mechanical ventilation. European Respiratory Journal ; What is the optimal approach to weaning and liberation from mechanical ventilation? A randomized, controlled trial of the role of weaning predictors in clinical decision making. Critical Care Medicine ; Epstein SK.
Weaning from ventilator support. Maclntyre NR, et al. Management of patients requiring prolonged mechanical ventila- tion. Chest ; 2 6. Scheinhorn D], Chao DC, et al. Outcomes in post-ICU mechanical ventilation: A therapist-implemented weaning protocol.
Kollef M, Isakow W editors. Extubation management. Identify type of shock whether it is obstructive, distributive, hypovolemic, cardiogenic or mixed. Before the use of inotropic and Vasopressor support, it is important to: Correct hypovolemia ii. Exclude causes of obstructive shock eg. The selection of the drugs is determined by the cause of shock and the desired thera- peutic activity targeting the underlying pathophysiology.
The dose of inotropes and vasopressors need to be titrated to targeted goals. The route of administration of inotropes and vasopressors is via central venous catheter. Blood pressure shall be monitored continuously via arterial line. Advanced hemodynamic studies e.
Do not delay resuscitation pending ICU admission. Commence IV noradrenaline infusion Dose 0. Adrenaline may worsen acidosis and increase lactate. Dopamine may cause cardiac arrhythmias and should be used in patients with low risk of dysrhythmias. Consider adding IV hydrocortisone 50 mg q6h or mg q8h in refractory shock Pmjgmm. In low cardiac output state, vasopressin may further decrease cardiac output.
Therefore, invasive or non-invasive measurement of cardiac output is recommended. Decreased cardiac output CO and evidence of tissue hypoxia despite adequate intravascular volume are hallmark of the condition. Correct hypovolemia and hypotension with judicious fluid replacement, unless pulmonary edema is present. Ensure MAP 2 65 mmHg. Early cardiology consult is recommended if cardiogenic shock is due to acute myocar- dial infarction in view of rescue revascularization.
Use of intra-aortic balloon pump may be considered. Inotropic and Vasopressor Support in Intensive Care b. N oradrenaline 0 Use to restore coronary perfusion - Recommended as first line therapy in the presence of severe hypotension 0 Usual dose range 0.
Dopamine causes cardiac arrhythmias and higher risk ofdeath in cardiogenic shock d. Phosphodiesterase inhibitor e. The PLR test consists of measuring hemodynamic effects of leg elevation up to 45 degree. Simple way to perform the test is to transfer patient from semi-recumbent posture to PLR position by using automatic motion of the bed. Pn-grain An.
Ip, t-Inmal Pm. N oradrenaline 2. MAP — Mean arterial pressure 2. SVV — Stroke volume variation es 1 Y 3. PPV — Pulse pressure variation 4. HCT — Hematocrit 5. PDEI — Phosphodiesterase inhibitor 4. DJ De Backer D et al. Dopamine versus norepinephrine in the treatment of septic shock. Crit Care Med ; 40; 3; Polito, A et al. Vasopressin for treatment of vasodilatory shock: Intensive Care Med Norepinehrine or dopamine for septic shock: A systematic review of randomized clinical trials.
Vasopressin in septic shock. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl] Med ; ; Annane D et. Norepinephrine plus dobutamine versus epinephrine alone for man- agement of septic shock: Lancet ; Vasopressor support in septic shock.
Chest ; ; Dellinger RP et al. Surviving Sepsis Campaign: International guidelines for manage- ment of severe sepsis and septic shock: Crit Care Med ; 36; 1 ; Dickstein K et al. ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure Interaction of vasopressin infusion, corticosteroid treatment, and mor- tality of septic shock. Crit Care Med ; 37; 3; Monnet X et al. Passive leg raising predicts fluid responsiveness in critically ill.
Crit Care Med ; 34; 5; Preau S, et al. Relation between mean arterial pressure and renal function in the early phase of shock: Critical Care , R Pierrakos C et al. Can changes in arterial pressure be used to detect changes in cardiac index during fluidchallenge in patients with septic shock? The goals are to provide adequate calories and protein to keep up with ongoing losses, prevent or correct nutrient defi- ciencies and promote wound healing and immune function.
Enteral feeding should be commenced as soon as possible. Enteral nutrition EN is preferred over parenteral nutrition PN in the critically ill. Parenteral nutrition PN is not without risks and to be started when clearly indi- cated. Overfeeding should be avoided. Patients at risk of refeeding syndrome should be identified before initiation of nutritional therapy. Enteral Nutrition EN 1.
Commence enteral feeding within h of ICU admission if the gastrointestinal tract is functioning and the patients have been adequately resuscitated. For patients who have undergone recent bowel anastomosis, prior discussion between the surgeon and ICU specialist may be required before commencement of enteral feed- ing.
Enteral feeding will be carried out using a nasogastric or orogastric tube. Use 12FG in adults. Confirm the correct position of the tube by any two of the following methods i aspirating for gastric contents ii injecting ml of air down the tube and auscultat- ing the epigastric area and iii radiography.
Confirm that the feeding tube is in the correct position before each feed by checking the external length of the tube and by auscultating the epigastric area. Use any of the 3 methods to administer enteral feeding: Aspirate the feeding tube q4h. Exclude bowel obstruction. If there is no clinical evidence of bowel obstruction, administer prokinetic agents.
If aspirate continues to exceed mls, consider small bowel feeding and elemental formulas. Aspirate just prior to the next cycle. Severe Community-Acquired Pneumonia. Ventilator-Associated Pneumonia. Pleural Diseases. Sleep-Disordered Breathing. Oxygen Therapy. Surinder K. Jindal, Ashutosh Nath Aggarwal. Pulse Oximetry and Capnography. Hemodynamic Monitoring. Divatia, Ramesh Venkatraman.
Fluid Therapy, Vasopressors, and Inotropes. Cardiorespiratory Arrest. Sheila Nainan Myatra, Amol T. Kothekar, Jigeeshu V. Cardiogenic Shock. Acute Heart Failure. Cardiac Arrhythmias. Shyam Sunder Tipparaju, Gopinath Ramachandran. Acute Coronary Syndromes. Hypertensive Urgencies and Emergencies. Aortic Dissection. Cerebrovascular Accident. Dedeepiya Devaprasad, Nagarajan Ramakrishnan. Subarachnoid Hemorrhage. Status Epilepticus.
Acute Flaccid Paralysis. Intracranial Pressure Monitoring and Management. Rajagopal Senthilkumar, Nagarajan Ramakrishnan. Acute Febrile Encephalopathy. Sedation and Analgesia. Brain Death.Evidence Based Practice Guidelines: Dose requirements need to be titrated to individual patient needs and clinical effect.
ICU Protocols A stepwise approach. A randomized, controlled trial of furosernide with or without albumin in hypoproteinemic patients with acute lung injury. A sedation goal should be established and regularly redefined for each patient.
Norepinehrine or dopamine for septic shock: New England Journal of Medicine ;
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