1

Royal Adelaide Hospital

Intensive Care Unit

Medical Manual
2003 Edition
Website: http://health.adelaide.edu.au/icu

2 Foreword Welcome to Intensive Care. This manual has been written to facilitate the daily running of the RAH Intensive Care Unit. It is by no means the definitive answer to all Intensive Care protocols and procedures, nor is it designed to be a textbook. A standardised approach to management is desirable for optimal patient care and safety, improving communication and understanding between members of the ICU team and associated specialities. This approach provides a common platform for staff who come from different countries and training backgrounds. This manual outlines various Protocols, which represent a standard approach to practice within the Unit. These have been derived from the available literature, clinical experience and where appropriate, cost-effectiveness. Guidelines designed to assist in clinical management are included, however patient management will ultimately depend upon the clinical situation. Assistance is always available from the Duty Consultant and senior nursing staff. Use your time in the Unit to get the most out of the large clinical caseload. Ask questions about clinical problems, equipment and procedures with which you are unfamiliar. There are numerous textbooks, journals and references available in the Unit. This manual has undergone numerous changes, with contributions from many of the ICU staff and from other specialty services within the hospital.

Dr Peter Toby Thomas Director January 2003 7th Edition

CONTENTS
Contents............................................................................................................................ 3 Royal Adelaide Hospital Intensive Care Unit .................................................................. 5 Administration.................................................................................................................. 6 A. Staffing.................................................................................................................. 6 B. Rostering and job descriptions .............................................................................. 9 C. Orientation .......................................................................................................... 10 D. Weekly programme............................................................................................. 11 E. Admission and discharge policies ....................................................................... 12 F. Clinical duties in the intensive care unit ............................................................. 13 G. Documentation.................................................................................................... 16 H. ICU Ward round ................................................................................................. 19 I. Clinical duties outside the Intensive Care Unit ................................................... 21 J. Emergency consultation and retrieval ................................................................. 26 K. Hospital Emergencies ......................................................................................... 29 L. Research in ICU.................................................................................................. 31 M. Information Technology in ICU.......................................................................... 32 Clinical Procedures ........................................................................................................ 33 A. Introduction......................................................................................................... 33 B. Procedures........................................................................................................... 33 C. Peripheral IV catheters........................................................................................ 34 D. Arterial Cannulae ................................................................................................ 35 E. Central venous catheters ..................................................................................... 36 F. Urinary catheters ................................................................................................. 38 G. Epidural catheters................................................................................................ 39 H. Pulmonary artery catheters.................................................................................. 39 I. Pleural drainage .................................................................................................. 43 J. Endotracheal intubation ...................................................................................... 45 K. Emergency Surgical Airway Access ................................................................... 50 L. Fibreoptic bronchoscopy..................................................................................... 51 M. Tracheostomy...................................................................................................... 53 N. Minitracheostomy ............................................................................................... 56 O. Pericardiocentesis ............................................................................................... 58 P. Jugular bulb oximetry ......................................................................................... 59 Q. Intra-aortic balloon counterpulsation .................................................................. 61 R. Cardiac pacing .................................................................................................... 64 S. Oesophageal tamponade tubes ............................................................................ 66 Drugs and Infusions ....................................................................................................... 67 A. Policy .................................................................................................................. 67 B. Principles of drug prescription in Intensive Care................................................ 67 C. Cardiovascular Drugs.......................................................................................... 68 D. Respiratory drugs ................................................................................................ 78

4 E. Sedation, analgesia and muscle relaxants............................................................ 80 F. Anticoagulation ................................................................................................... 86 H. Renal drugs.......................................................................................................... 95 I. Gastrointestinal drugs.......................................................................................... 97 J. Antibiotics ........................................................................................................... 99 Fluids And Electrolytes ................................................................................................ 106 A. Principles of fluid management in Intensive Care............................................. 106 B. Nutrition ............................................................................................................ 108 C. Haemotherapy ................................................................................................... 112 D. Guidelines for management of electrolytes ....................................................... 118 Clinical Management.................................................................................................... 129 A. Cardiopulmonary Resuscitation ........................................................................ 130 B. Failed intubation drill ........................................................................................ 133 C. Respiratory therapy ........................................................................................... 134 D. Management of Cardiothoracic Patients............................................................ 156 E. Renal failure ...................................................................................................... 159 F. Neurosurgical protocols..................................................................................... 167 G. Microbiology protocols ..................................................................................... 176 H. Drug overdose ................................................................................................... 184 I. Withdrawal of treatment.................................................................................... 192 J. Brain Death and Organ Donation ...................................................................... 192

ROYAL ADELAIDE HOSPITAL INTENSIVE CARE UNIT

The Royal Adelaide Hospital is a 700 bed teaching hospital affiliated with the University of Adelaide. The Intensive Care Unit is a division of the academic Department of Anaesthesia and Intensive Care and was commissioned in 1969. The existing ICU is a multidisciplinary unit with a complement of 20 intensive care and 8 high dependency beds, while a new unit is due for completion mid-2003 with 24 ICU and 10 HDU beds. There are approximately 1200 Intensive Care and 1400 High Dependency admissions per year. The casemix is equally split between medical and surgical patients. Traditionally, the unit has had a large trauma load (approx. 20% of admissions) and is the major tertiary referral centre for all surgical and medical specialities including neurosurgery, cardiothoracic surgery, burns, spinal injuries, surgical and medical oncology and hyperbaric medicine. Services not provided by the hospital include obstetrics, paediatrics and neonatology, and solid organ transplantation. As a major referral centre and due to the geographic nature of South Australia, a highly developed retrieval service has evolved which is based from the Intensive Care Unit. The service currently performs about 500 retrievals per year. Two private ICUs are staffed by the RAH ICU consultant staff. Rotation by registrars through these units is possible: 1. Wakefield Hospital Intensive Care Unit is a 12 bed multidisciplinary level 3 private Intensive Care Unit that predominantly manages post-cardiac surgical patients. There are 6 intensive care and 6 high dependency beds. This Unit manages approximately 450 patients per year and is accredited for Advanced Training (C6) by the Joint Faculty of Intensive Care Medicine. St Andrews Hospital Critical Care Unit is a 12 bed unit which is a combined private level 3 intensive/high dependency unit. The casemix is predominantly post-surgical with a vascular predominance and the unit manages approximately 250 patients per year.

2.

ADMINISTRATION
A. 1. Staffing Consultant Medical Staff

Department of Anaesthesia and Intensive Care Professor and Head Royal Adelaide Hospital ICU Director Consultants Dr P D Thomas Dr D R Catt Dr M J Chapman Dr D G Clayton Dr N. Edwards Dr M E Finnis Dr W M Griggs Dr P Sharley Dr M G White Dr R J Young Prof W B Runciman

Wakefield Hospital ICU Director St Andrews Hospital ICU Director Retrieval and Resuscitation Acting Director Dr P Sharley Dr M G White Dr D R Catt

7 2. Senior Nursing Staff Ms M Cattonar Ms A Jones Mr I L Blight Ms R Acott

Royal Adelaide Hospital ICU Nursing Director: Nurse Manager: Clinical Nurse Consultant: Clinical Nurse: (Equipment/retrieval) Wakefield Hospital ICU Clinical Manager St Andrews Hospital ICU Clinical Nurse Consultants

Ms A Rischbieth

Ms S Cantor Ms S Reay

3.

Registrars a) b) A Chief Registrar is appointed each year as the registrar spokesperson and is responsible for rosters. Two levels of registrars are rostered in the Unit: i) Senior registrars: Usually advanced vocational trainees who have completed anaesthetic and/or physician training, who are rostered according to seniority and experience. ii) Junior registrars: vocational trainees or experience registrars. Portfolios are determined by experience and rostering requirements. All registrars rotate through both the Intensive Care and High Dependency Units. Participation in the retrieval service is a requirement for suitably experienced registrars working in ICU. Leave is in accordance with the State industrial award (5 weeks annual and 1 week study leave) and registrars are required to forward a signed copy of leave requests to the Senior Registrar for rostering purposes. Training positions at Royal Adelaide Hospital: i) Intensive Care Positions a) The Joint Faculty of Intensive Care Medicine, (ANZCA & RACP) has accredited the RAH as a C24 Unit for training for the Fellowship in Intensive Care (FJFICM). Registered trainees with the Faculty may spend up to 24 months continuous (core and/or elective) training in the Unit.

c) d) e) f) g)

8 Registrars not enrolled in the above training scheme but wishing to gain further postgraduate experience in Intensive Care may apply for these positions. Applications including a current c.v. should be forwarded to Dr R. Young. c) Trainees enrolled in formal training programs are given priority of appointment. ii) Positions for non-Intensive Care Trainees a) Rotations of registrars in these positions are made from the respective specialty based training programs at Royal Adelaide Hospital. b) Anaesthetic trainees: 2 positions (accredited by the Australian and New Zealand College of Anaesthetists for training towards the Fellowship in Anaesthesia (FANZCA)) for 3-6 month terms. c) Physician trainees: 1 position for a 3 or 6-month term. d) Surgical trainees: 1 position for a 3-month term. (1) e) Emergency Medicine trainees: one position for 3 or 6-month term. iii) Supervisors of Training at Royal Adelaide Hospital: a) Intensive Care: Dr R J Young b) Medicine: Dr S M Guha c) Anaesthesia: Drs G Christie-Taylor d) Surgery: Mr P G Devitt e) Emergency Medicine: Dr R Skalicky f) Wakefield Intensive Care Unit: (1) Accredited as C6 Unit, ie. for 6-month elective ICU training, however is currently unavailable for training purposes. g) St Andrews Hospital Critical Care Unit (1) Four career medical officer positions are available, administered by St Andrews Hospital. (2) This Unit is not accredited for advanced Intensive Care training. (3) Director of ICU: Dr M.G. White. b)

9 B. Rostering and job descriptions 0800 - 1900 Consultant 1 Registrar 1 Registrar 2 ICU Team 2 Beds 12-20 ICU Team 3 Consultant 2 Registrar 3 Consultant 3 Registrar 4 Consultant Registrar Consultant Registrar Consultant 1 Manages Q4 A & B. Coordinates ward consults. Beds 1-6. Emergency pager & MET Calls. Beds 7-11. Consults pager. Manages Q4 C & D Beds 12-20. Manages HDU, Ward TPN. HDU beds 1-8. Backup to Registrar 3. Wakefield Intensive Care, High Dependency & Coronary Care Units St Andrews Intensive Care & High Dependency Units

Monday - Friday ICU Team 1 Beds 1-11

Wakefield ICU St Andrews ICU Monday - Friday ICU Team

1830 - 0830, Weekends, Public holidays.

Manages ICU and HDU. Coordinates retrievals, consults. Consultant 2 Backup to Consultant 1 and Private ICUs. TPN on weekends. Night Registrar 1 Q4 A, B. Ward consults* Night Registrar 2 Q4 C, D. Backup registrar 1. Night Registrar 3 HDU Backup registrars 1&2. Senior Registrar Weekend days: Registrar 1 duties. NB: *The night registrar carrying the Arrest Pager also attends MET Calls. Wakefield ICU St Andrews ICU Consultant Registrar Consultant Registrar Wakefield Intensive Care, High Dependency & Coronary Care Units St Andrews Intensive Care & High Dependency Units

NB: Migration to the new ICU is due to commence mid 2003 and while specific ward/bed designations may change, the unit will continue to be run as 3 teams (2 ICU and 1 HDU) with the same allocation of duties as above.

10 Retrievals Consultant

Mon-Fri 08:00-18:00 Mon-Fri 18:00-08:00 Weekends & P-Hol.

Dedicated Retrieval Consultant available to coordinate and/or perform retrievals. Duty ICU Consultant coordinates retrievals. Rostered to perform retrievals & assist in ward activities 1st On-Call for retrievals Rostered to perform retrievals & assist in ward activities 2nd On-Call for retrievals 1st On-Call for retrievals/ 2nd On-Call for retrievals

Registrar

Mon-Tue 12:00-22:00 Mon-Tue 22:00-08:00 Sat & Sun 08:00-17:00 Sat & Sun 17:00-08:00

Volunteers

All times not covered above

NB: Volunteers may be registrars, consultants or VMOs from the RAH or other hospitals within the Adelaide area.

C.

Orientation

1) Registrars commencing duty within the unit at the major RMO changeover dates will undergo a half-day orientation program 2) This will include sessions from: a) The Director of ICU b) The Director of Retrievals c) The Chief Registrar d) Infectious Diseases / Clinical Microbiology e) The Acute Pain Service

11 D. Weekly programme Daily 0800 1100 1200 1700 1830 Monday 0730 1200 1330 1500 Tuesday 1230 1500 Thursday 1600 1630 Handover Ward Round Main Ward Round: Conference room Fluid and clinical round Consultant Handover Registrar Handover Departmental meeting: Sando Room Surgical Grand Round: Lecture Theatre 1 ICU Consultants meeting ICU Audit: Conference Room Medical Grand Round: Robson Theatre Journal Club: Conference Room Registrar teaching session Anaesthesia Audit: Theatre ICU/HDU Teams All Staff ICU/HDU Teams ICU/HDU Teams ICU/HDU Teams All Staff All Staff Consultants All Staff All Staff All Staff Registrars All Staff

12 E. 1. Admission and discharge policies Admission Policy a) b) The patient is managed by the ICU staff during their stay in ICU and/or HDU. All admissions to ICU and HDU must be approved by the Duty Consultant. i) Resuscitation or admission must not be delayed where the presenting condition is imminently life threatening, (eg profound shock or hypoxia), unless specific advanced directives exist and are clearly documented. ii) Such admissions should be discussed with the Duty Consultant ASAP. Admission is reserved for patients with actual or potential vital organ system failures, which appear reversible with the provision of ICU support. Patients are admitted under the bed-card of the original clinic or taking unit while in the ICU. Clinics requesting elective postoperative surgical beds must confirm bed availability on the day of surgery, prior to the operation commencing. Admission disputes must be referred to the duty ICU consultant.

c) d) e) f) 2.

Discharge Policy: a) All discharges must be: i) Approved by the duty ICU consultant. ii) Discussed with the parent clinic prior to patient transfer, including any potential or continuing problems. Patients discharged on TPN must entered in the TPN folder in Q4A. Notify the Acute Pain Service of patients discharged under their care. Treatment limitation/non-escalation directives must be discussed with the patient or patients family, the parent clinic and clearly documented prior to discharge. A discharge summary must be completed and a copy included with the patient casenotes.

b) c) d) e) 3.

Deaths Policy: a) b) The duty ICU consultant must be informed of all deaths. The duty ICU registrar must ensure: i) a death certificate is completed ii) that the parent clinic or duty intern is notified iii) referring doctors (ie GPs, other specialists / hospitals) are notified. Where indicated, consent for a post-mortem should be obtained from relatives as soon as possible. The Coroner must be notified in all cases where: i) Death is due to violence a) Trauma deaths: vehicle, home, industrial b) Homicide / suicide ii) Death results from non-natural causes within 24 hours of admission. iii) The cause of death is unknown or uncertain.

c) d)

13 iv) No medical practitioner in attendance who can issue a death certificate v) Death is peri-operative (ie within 24 hours of an operation) vi) Death occurs in a psychiatric institution, or in a RAH inpatient from one of these institutions vii) Death occurs while in jail or in custody viii) Death occurs after admission for fractured neck of femur ix) The patient is certified Dead on arrival. Withdrawal or limitation of therapy is a consultant responsibility.

e) F. 1.

Clinical duties in the intensive care unit Infection Control in ICU a) b) c) Prevention and containment of nosocomial infection is a fundamental principle of effective medical practice. The critically ill patient is highly vulnerable to nosocomial infection, which results in significant morbidity, prolonged length of hospital stay, increased cost and attributable mortality. It is the responsibility of every member of the health care team to ensure compliance with Hospital and Unit infection control policies. This may include reminding senior colleagues or visiting teams to conform to basic issues such as hand-washing or barrier nursing measures. If you are reminded by a colleague to conform to these policies (eg hand-washing after examining a patient), then this should not be regarded as a criticism, but rather as responsible practice. Hand-washing remains the only established method of effective infection control and must be assiduously performed by all members of the health care team: i) Compulsory before and after entering a patients cubicle for: a) Physical examination of the patient b) Manipulation of patients environment including respiratory equipment, infusion pumps, dressings, drains, linen or bedding. c) Inspection or handling of the patient chart, casenotes or overway when these are placed inside the cubicle (ie Q4C). d) Following all procedures, even if aseptic techniques are used. ii) This may be performed by either: a) Washing for a minimum of 1 minute using Microshield hand cleanser (at the basin closest to, or within the patients cubicle), or b) Thorough application of Aqium Alcohol Gel c) In the MRSA area (Unit D) Triclosan cleanser is preferred. Gloves i) Disposable gloves must be worn for all contact with patients bodily fluids, dressings and wounds. ii) The use of gloves does not preclude hand-washing before and after patient contact. iii) Gloves must be disposed of within the patient cubicle on leaving.

d) e)

f)

14 g) Barrier nursing measures : i) The following patients are regarded as infective risks requiring barrier nursing: a) Infection or colonisation with: (1) Methicillin Resistant Staph. Aureus (2) Vancomycin Resistant Enterococcus (3) Multiresistant gram negatives (4) Clostridium difficile b) Burns c) Febrile neutropenia d) High risk immunosuppressed patients as directed by Infection Control ii) HDU patients who are infective risks must be managed in Q4IC. iii) An Additional precautions sign is placed outside cubicles of patients identified as infective risks. iv) New disposable gowns and gloves must be used for each person entering the cubicle and disposed of within the cubicle upon leaving. v) Attending nurses may use one gown per shift, provided it is kept within the cubicle. vi) Consumable stock within the cubicle should be kept to a minimum. vii) Notify appropriate staff if patients are transported to theatre, for diagnostic procedures, or for ambulance transport. viii) Once the patient has been transferred or discharged, the area should remain vacant until terminally cleaned in accordance with policy. ix) Environmental swabbing in Intensive Care is conducted as required by Infection Control staff. Aseptic technique i) Aseptic technique is to be used for all patients undergoing major invasive procdures (refer to procedures section). ii) This includes: a) Hand disinfection: surgical scrub with chlorhexidine for >1 minute b) Sterile barrier: full gown, mask, hat, gloves and sterile drapes. c) Skin prep with chlorhexidine 1% in 75% alcohol: let the skin dry. Sharps disposal i) The person performing the procedure is responsible for disposal of all sharps (needles, blades) using the sharp disposal containers. ii) Nursing staff are not responsible for cleaning-up sharps after a medical procedure. Traffic control i) Movement of people through the Unit should be kept to a minimum. This applies equally to visiting clinics and large numbers of relatives. ii) All visitors are expected to conform to the above infection control measures and should be tactfully reminded or instructed about these issues.

h)

i)

j)

15 k) Quarantine policy i) Beds 19 and 20 in Q4IC are nominated as isolation/quarantine rooms for highly contagious infections such as haemorrhagic fevers. ii) These rooms are sealed with independent airconditioning units.

2.

Guidelines for admission of a new patient to ICU a) b) Handover from the referring doctor. Obtain as much information as possible. Primary survey: i) Ensure adequate airway, breathing and place patient on highest FiO2 (1.0) until a blood gas is done. ii) Check circulation and venous access. c) Secondary survey: fully examine patient. d) Document essential orders: i) Ventilation ii) Sedation / analgesia iii) Drugs, infusions iv) Fluids e) Outline plan to nursing staff. f) Secure appropriate basic monitoring/procedures: i) SpO2 ii) ECG iii) Arterial line iv) IDC, nasogastric tube v) CVC for the majority g) Basic investigations: i) Routine biochemistry, blood picture and coagulation studies. ii) Septic screen/microbiology as indicated. iii) Arterial blood gas iv) CXR (after placement of appropriate lines) v) ECG h) Notify the duty consultant. i) Advanced investigations: CT, angiography, MRI, etc j) Advanced monitoring where indicated: eg PA catheter, ICP, SjO2. k) Document in case notes. (See below) l) Notify the parent clinics of patients admitted directly to ICU NB: this applies particularly to patients who have been retrieved. m) Clinic Interns and RMOs should clerk hospital admissions direct to ICU. n) Inform and counsel relatives.

16 3. Daily management in ICU/HDU. a) Daily investigations: i) Routine blood tests (biochemistry and haematology) are ordered on the daily flow chart and signed for on the 1100 am fluid round. Drug levels or other tests are requested as required and may also be requested on the daily flow chart. ii) The night duty nurses have kindly agreed to take the bloods at 0600 and complete the request form, which must be signed by the night registrar. iii) Registars are responsible for taking blood specimens: a) When nursing staff request assistance. b) For blood transfusion (1) The requesting registrar must ensure that the labelling of the request form and the specimen matches the patients wristband. iv) Chest x-rays are ordered before 0800 and signed request forms are handed to the duty radiographer. Handover ward rounds are at 0800 and 1830. These are brief business rounds to handover essential information to the next team (either day or night) and are attended by the duty consultant, team registrars and nursing coordinator. A full teaching ward round is held at 1100 daily, followed by a bedside fluid and clinical round. Liaison with parent clinics is essential to ensure continuity of management. Clinics must be informed of significant changes in a patients condition or the requirement for specialist investigations or interventions. Complex investigations (eg CT, MRI scans) and procedures must be authorised by the duty ICU consultant and discussed with the parent clinic where appropriate.

b) c) d) e)

G. Documentation The following guidelines are designed to facilitate the recording of clear, relevant information that is essential for continuity of care, audit and medicolegal review. Entries should establish a balance, being concise but still accurately recording all relevant information and events. 1. Documentation by ICU registrars includes: a) Admission note for all patients admitted to ICU and HDU b) Daily entry in case notes during admission c) Discharge summary d) Death certificates.

17 2. ICU Admission Note: a) All patients admitted to the ICU must have an admission summary. b) The admitting clinic must be notified and invited to record an admission summary for patients admitted directly to ICU. This is to ensure that admitting clinics are aware that a patient has been admitted under their bedcard. c) The admission note should incorporate all relevant aspects of the patients medical history, clinical examination and results of appropriate investigations. HDU admission summary a) Complicated non-ventilated HDU patients require the same level of detail as ICU patients. b) Routine postoperative short stay patients do not need detailed admission notes. In these patients record: i) Relevant operative/anaesthetic details ii) Significant comorbidities and history iii) Anticipated problems iv) Procedures eg epidural, invasive monitoring, TPN Daily entry in ICU a) A daily entry must be made in the case notes. i) Notes are most efficiently recorded after the 1100 ward round so that current results and management plans are recorded ii) On weekdays, these may be dictated and handed to the secretary who will type and place these notes in the case notes. iii) On weekends/public holidays these must be written in the case notes. b) Additional notes must be made for the following: i) Significant changes in physical condition necessitating changes in management, eg renal failure requiring dialysis. ii) Major procedures, eg laparotomy, tracheostomy, PA catheter iii) Results of specific investigations or tests, eg CT scans, endocrine tests iv) Changes in policy, eg non-escalation of treatment, advance directives. Discharge Summaries a) All patients transferred from ICU require a Medical Transfer Summary (MR 42) form completed. This includes deaths and patients transferred to HDU. b) This is a single page document outlining all relevant transfer information. c) The reverse side of the form is a nursing transfer summary, which will be completed by the attending nurse. The original should be filed in the case notes and a photocopy placed in the box in the communications room for filing by the secretary. d) The duty registrar on day of transfer is responsible for completing the form. Incomplete or missing summaries will be forwarded to the responsible registrar for completion. e) Short term HDU patients do not require detailed discharge summaries: only pertinent information relating to the stay in HDU is necessary.

3.

4.

5.

18

6.

Consent in ICU a) Competent patients: i) All competent patients undergoing invasive procedures in ICU or HDU should have a standard Royal Adelaide Hospital consent form (MR: 60.16) completed and signed by the patient. b) Incompetent patients (sedation, coma or encephalopathy) i) Third party consent is not necessary for routine ICU procedures; these include: a) endotracheal intubation b) arterial lines c) central venous lines d) pulmonary artery catheters e) transvenous pacing wires f) underwater seal drains g) jugular bulb catheters h) intra-aortic balloon counterpulsation i) oesophageal tamponade tubes j) bronchoscopy ii) However, relatives should be informed prior to the procedure if present and the indications, conduct and complications of the procedure should be clearly documented in the casenotes. iii) Major invasive procedures such as percutaneous tracheostomy, coronary angiography, permanent pacemaker insertion or acute surgical procedures require completion of a consent form: a) Emergency procedures signed by two doctors b) Non-urgent procedures by third party consent (next-of-kin). iv) Ultimate responsibility for consent lies with the operator performing the procedure, however ICU registrars should ensure appropriate consent is obtained. v) A person, not necessarily next-of-kin, who has been nominated by the patient as a medical power of attorney may sign or refuse consent on behalf of the patient. vi) Relatives must always be informed of any procedures and the consent issue explained, irrespective of the presence or absence of a medical or legal power of attorney.

19 H. ICU Ward round 1. The daily ICU 1100 am ward round is an integral feature of the running of the Unit. It is the forum to openly discuss management issues and is a useful teaching forum. All current X-rays are displayed on a multi-viewer and current results are displayed via computer projection. Registrars are expected to present their allocated patients at this round and to actively participate in the discussion. Presentations at this round should be of a standard suitable for a fellowship examination. The ward round is attended by: a) b) c) d) e) f) g) h) i) 4. Team 1/2/3 ICU consultants and registrars A radiologist An infectious diseases consultant Senior nursing staff Physiotherapists A pharmacist A dietician Invited clinics when appropriate Medical students

2.

3.

Presentation at ward round a) b) Presentation should take no more than 5-10 minutes. Emphasise the relevant and pertinent issues only: i) Patient details and demographics. ii) State day of ICU admission (eg Day 6 ICU). iii) Diagnosis or major problems. iv) Relevant pre-morbid history pertinent to this admission. v) Relevant progress and events in ICU (deterioration/improvement, procedures, investigations). vi) Current clinical status (system by system). vii) Outline features on daily pathology and radiology. viii) Current plan of management: a) Medications b) Further investigations / procedures c) Discharge / Prognosis

20 5. Bedside fluid round a) b) c) d) e) f) Team consultants and registrars review each patients condition. Flowcharts are re-written daily and include orders for ventilation, procedures, medications, infusions and fluid therapy. Printed stickers should be used for routine medications and infusions. All orders must be signed by a doctor. Requests for routine blood tests are made on the chart. Patients transferred to HDU or to the wards must have the hospital blue folder completed. As a general rule, all medication orders are re-written and fluid or nutrition orders for the next 24 hours are prescribed. Patients started on TPN should have their details entered in the TPN folder kept in Unit A. Similarly, HDU patients have their charts reviewed, however all medications and fluids are recorded on the hospital blue treatment folders.

g) 6.

Laboratory results a) b) c) d) Biochemistry, haematology and coagulation results for the 1100 ward round are projected from a PC in the conference room. Instructions for use of this PC are located on the adjacent wall. Other results must be obtained by the registrar, either by phone or via the computer terminals in each nursing station. The ward clerks will demonstrate how to access the pathology mainframe. Each registrar will need to obtain a code and allocate a password (see ward clerks).

21 I. 1. Clinical duties outside the Intensive Care Unit Policy regarding outside consults: a) b) NB: The Unit must not be left unattended at any time to attend outside calls. (ie. at least one registrar must remain on the floor) The consults and cardiac arrest/trauma/MET pagers are allocated as follows: i) Day (0800-1830): a) Team 1 & 2 registrars as required ii) Night (1830-0800): a) Q4IC night registrar - consults pager b) Resuscitation registrar - cardiac arrest/MET pager iii) These roles may be delegated according to the workload in ICU by the duty ICU consultant. All consults should be addressed as soon as possible. MET calls should be attended immediately. All consults/MET calls potentially requiring admission to ICU must be discussed with the Duty Consultant. If the ICU workload is heavy, refer ward consults to the duty ICU consultant who will delegate appropriately. Notify the senior nurse and fellow registrar when leaving the floor. The following duties accompany the Consults pager (pager no #89 1122*): i) Ward consults ii) Requests for vascular access (CVC insertion) iii) Requests for Total Parenteral Nutrition (refer to Team 3) iv) Requests for retrieval (refer to Retrieval or Duty Consultant) The following duties accompany the Emergency pager (#33) i) Cardiac arrest calls ii) MET calls iii) Trauma (P1) resuscitation a) Trauma pages are subdivided into levels b) Attendance by the ICU registrar is only required for Level 1 calls.

c) d) e) f) g) h)

i)

22 2. Ward Calls a) b) c) d) Consults regarding potential admissions from the general wards, theatre, A&E and ESS. Pre-operative consults for potential or booked surgical patients. Advice regarding fluid and electrolyte management, oxygen therapy, sedation and analgesia. Review as requested: i) Admissions to the Spinal Injuries Unit with potential respiratory failure. ii) Admissions to the Burns Unit for airway / breathing assessment, venous access and resuscitation. Requests for central venous access: i) Requests must come from registrar level or above. ii) ICU staff are responsible for obtaining consent for insertion. The risks and benefits must be discussed with the home team and the patient. iii) Most CVCs are elective and can be placed during working hours. iv) CVCs inserted for emergencies are performed as indicated. v) Consider insertion of a PICC line (via radiology) for appropriate patients. Haematology patients: i) Elective CVC lines are inserted under radiological guidance, not by ICU. ii) Blind CVC lines should only be placed by senior staff, ie. Senior Registrars or Consultants, following specific discussion and agreement. iii) Lines for resuscitation should be inserted as clinically indicated. Requests for TPN. Requests for peripheral IV access must come from registrar level or above after reasonable attempts have been made to obtain IV access.

e)

f)

g) h) 3.

Total Parenteral Nutrition (TPN) a) b) c) ICU provides a TPN service for the hospital. Requests for TPN are essentially elective (ie Mon to Fri: 0800-1800) and should be made according to recommended indications. Requests are made to the Senior Registrar via the consults pager. The Team 3 Consultant is available for assistance and will delegate responsibility for: i) Initial consultation with the requesting clinic. ii) Recording TPN patients in the TPN Folder in Q4A. iii) Insertion of a central venous catheter. iv) Daily: a) Review of electrolytes and fluid balance, b) Review of the central venous catheter, c) Prescription of TPN orders vitamins / trace elements, d) Issue a request form for serum electrolytes. The second on-call ICU consultant is responsible for TPN on the weekends. Refer to the section on nutrition in the clinical protocols for indications & complications.

d) e)

23 4. Cardiac Arrest & MET Calls a) 33 is the Royal Adelaide Hospital emergency code. This is the emergency number dialled (33#) to switchboard for general medical emergencies. These include: i) In-hospital cardiac arrest ii) Out of hospital arrest admitted to ED iii) Emergencies in theatre, general and ESS recoveries, radiology, outpatients and CCU. iv) Collapse of unknown aetiology in the hospital environs. v) MET team calls. The following people are automatically paged: i) ICU registrar or resuscitation registrar ii) ICU equipment nurse iii) Medical registrar All medical emergency calls (33# calls) must be responded to promptly. When a 33 is displayed on the pager, phone 33#. Switchboard will state the location of the arrest. Clearly state who you are (ie ICU registrar) and go to the location. Ensure that the ICU staff know where you are going and that the Unit is not left unattended. At the emergency: i) This hospital follows the Australian Resuscitation Council guidelines for cardiopulmonary resuscitation (refer to flowcharts for basic and advanced life support in the clinical protocols) ii) The ICU/resuscitation registrar is responsible for initial assessment, securing the airway and establishing effective ventilation. iii) Basic life support is done by attending nursing and medical staff and may be directed by either ICU or medical registrar. iv) Advanced life support is directed by the more senior registrar present. This is usually the ICU registrar. v) Depending on the outcome of the arrest, the patient may be admitted to ICU, HDU or CCU according to standard admission policies. vi) As a general rule, it is better to admit a patient if previous details are not immediately available than to prematurely abandon resuscitation. vii) Document your involvement with the resuscitation in the casenotes.

b)

c) d) e) f)

24 5. Trauma Calls a) b) c) As in cardiac arrest, a 33# call is activated for trauma patients who meet specified trauma criteria. (Refer to trauma directives.) Trauma pages will appear as 2 Levels: i) Level 1: major trauma requiring immediate attendance / airway support ii) Level 2: trauma requiring full assessment in P1. The following people are paged and the level response detailed on the pager: i) ICU/resuscitation registrar ii) Trauma Service registrar iii) Accident and emergency registrar On receiving a Level 1 call the ICU registrar should proceed directly to P1 in the Emergency Surgical Suite (ESS). Ensure that ICU staff know where you are going and that the Unit is not left unattended. At the trauma resuscitation: i) This hospital follows the guidelines of the Early Management of Severe Trauma System, Royal Australasian College of Surgeons. ii) The team leader is designated by the current Trauma Service Directive (found on the wall in P1 in ESS). iii) Role of the ICU / resuscitation registrar: a) Primarily as a backup for acute life threatening situations in the event that sufficiently experienced personnel are not available in P1. b) If anaesthetic staff are present in P1, there is no requirement for ICU registrars to attend the resuscitation unless specifically requested by these personnel or the Trauma Director. c) If anaesthetic staff are not immediately available, the following role is indicated until appropriate personnel arrive: (1) Initial airway management: ie assessment and intervention as appropriate. (2) Establishing effective ventilation (3) Assistance with vascular access and restoration of circulation. (4) Other acute interventions (eg. UWSD) as required d) Once anaesthetic & trauma team members are present and the situation is under control, return to ICU: do not leave ICU unattended for lengthy periods of time. If prolonged resuscitation is anticipated, call in the ICU or Trauma Consultant and/or delegate to the anaesthetic/resuscitation registrars if necessary. e) Transportation of trauma patients to CT scan, angiography etc are the responsibility of the ESS anaesthetic staff. f) ICU registrars must not do prolonged intrahospital transports for trauma patients without approval by the duty ICU consultant.

d) e) f)

25 iv) General principles: a) Document your involvement with the resuscitation in the casenotes b) Once the primary survey is completed, proceed to the secondary survey and order the appropriate investigations - generally all patients need lateral C-spine, chest and pelvis X-rays, group and cross-match. This is coordinated by the Trauma team leader. c) In critically ill patients, ensure that a suitably qualified person (in terms of resuscitative skills) remains with the patient at all times. This is mandatory if the patient is transported from ESS (eg to radiology, ICU, theatre). d) Notify ICU staff of pending admissions. e) Demarcation disputes are referred to the duty Trauma Consultant. 6. MET Calls a) b) c) d) e) The RAH will introduce a MET team early in 2003 as a part of the active intervention arm of a national multi-centre collaborative study, coordinated by the ANZICS Clinical Trials Group. The registrar carrying the Emergency pager will also attend MET calls. MET calls can be initiated by any staff member of the hospital and are to be attended immediately that is providing the ICU is adequately covered. The night Medical Registrar will also receive these calls but cannot be relied upon to be able to attend, therefore the ICU registrar will assume prime responsibility. Further details regarding MET calls will be found in the study documentation held in the ICU communications room.

26 J. 1. Emergency consultation and retrieval Retrieval Service policy documents a) b) A complete list of policy documents for the retrieval service is available in the communications room table-top folder. These policies include: i) 01-2002 Mental Health Patients ii) 02-2002 Mediflight Australia iii) 03-2002 Rapid Response Or Standby For Retrieval iv) 04-2002 Retrieval Requests And Activation v) 05-2002 Minimum Dress Requirements For Helicopter Operations vi) 06-2002 Helipad Protocols vii) 07-2002 Stretcher Patients On Qantas viii) 08-2002 Retrieval Diversion ix) 09-2002 Retrieval Medical Staffing Policy x) 10-2002 Retrieval Blood Protocol xi) 11-2002 Retrieval Nurse Staffing Policy xii) 12-2002 Observer/Student Ride-Along Program Staff participating in retrieval activities should familiarise themselves with the contents of these documents.

c) 2.

Retrieval familiarisation and competency policy a) b) c) d) This is coordinated by Dr Peter Sharley A/Director of Retrieval and Resuscitation. Adequate familiarisation and orientation with communications, geography, helipad access, aircraft and medical equipment is mandatory prior for any registrar wishing to perform retrievals. Adequate airway, vascular access and trauma resuscitation skills are essential. Aeromedical retrieval is an obligatory activity for suitably qualified ICU and anaesthetic registrars and represents an important and unique part of ICU training. However, registrars with serious apprehensions about flying are not compelled to do retrievals. All RAH retrieval teams are fully covered by the South Australian Health Commission with respect to life and medicolegal insurance.

e) 3.

Rapid Response Or Standby For Retrieval a) b) The SA Ambulance Service may advise the RAH Retrieval Service to either be on standby or request that there is rapid activation of a retrieval team. Whilst every effort must be made to respond to a rapid response request at no stage may the ICU be left unattended. This may result in an inability to respond or a delay in response.

27 c) Rapid Response criteria may include; i) an entrapped patient with apparent severe injuries and or deterioration. ii) multiple patients iii) extrication time and transit time that exceeds the likely time for delivery of a team to the site. Standby implies that; i) The relevant ICU Consultant is notified. ii) The medical and nursing personnel are activated and dressed in retrieval uniform.This means that after hours, the team doctor, if not on site is to move towards the hospital. (callback payment is approved if doctor departs his/her place of residence) iii) Blood supply is confirmed from the retrieval blood fridge. If the Standby request is confirmed team mobilisation occurs without further consultant authorisation, who can be subsequently notified that the mission is underway. If the mission is cancelled, Stand-down procedure includes notification of team members and the relevant ICU Consultant. If activated, transportation to the crash site is usually by helicopter or road and is usually confined to 150 kms radius of Adelaide. Ensure that the local hospital in closest proximity and their Medical Officer are notified. If the local MO is likely to be able to attend the scene prior to that of the retrieval team then he/she should be invited to attend.

d)

e) f) g) h)

4. a)

Retrieval Requests And Activation

The log book located in the communications room is for the essential documentation of all incoming retrieval and all other emergency calls. Calls are to be logged whether a team has been mobilised, or a rural MO or other health professional is merely asking for advice. Tact and understanding of the difficult role of doctors and nursing staff in isolated locations is vital. b) Requests for consultation may originate from a number of sources. Namely, c) the direct emergency number (8222 4222) d) ambulance radio both located in the communications room e) other ICU telephones f) ICU registrar pager g) other clinics who have been consulted by outside medical officers. h) Vital data to be recorded is indicated by prompts on the log page. This includes date and time, callers name, location, return phone number and brief synopsis of the problem. Advice on urgent resuscitation if indicated. This data is essential information for staff on later shifts, audit and subsequent medico-legal investigation. i) The Duty ICU Consultant after hours and the Retrieval Consultant during working hours Mon-Fri must be notified of all calls received. ALL RETRIEVALS MUST BE AUTHORISED BY THE DUTY ICU CONSULTANT OR RETRIEVAL CONSULTANT.

28 j) k) l) Other disciplines may be included in the consultation as relevant. A neurosurgeon for example may be required to be a part of the retrieval team to perform surgery at the distal site and thus would require early consultation. Initiation of transport arrangements with the Ambulance Service is via telephone 8204 3540. All conversations with the Ambulance Service are recorded. The mode of transport is usually determined by the Ambulance Service. The retrieval team from the RAH always involves a doctor and a critical care nurse. The Pilot has autonomy regarding the suitability of the usage of an aircraft and the number of staff able to be carried. Extra retrieval personnel must be approved by the pilot at the time of booking. Retrieval team usually assembles and travels to the airport by taxi for fixed wing missions. The RAH helipad is usual for helicopter departure unless inclement weather dictates an alternate departure site. If a retrieval is activated, notify the caller with arrival time and offer further resuscitation advice if required until the team arrives. Frequent communication is encouraged if the patient is unstable. Notify return destination tertiary hospital and destination site within that hospital. This must include confirmation of an available bed and notification to the relevant clinic. All RAH trauma must be admitted direct to the ED trauma resuscitation area. The retrieval team is expected to communicate with the ICU prior to departure from the distal site. This may be essential to plan a surgeon, an available theatre, an ICU bed, suitable protective precautions etc. With returning helicopter missions an additional radio contact from the team to the ICU is required at least 20 minutes prior to arrival to permit Helicopter Landing Officer and Crane lowering protocols to be activated. Verbal and written hand-over is essential to the receiving team. Retrieval data form and retrieval clinical note duplicates are to be returned to the box in the ICU communications room. Intrahospital transportation of Intensive Care patients a) b) c) d) e) f) g) All transports must be authorised by the duty consultant. The transport/investigation must be considered in the best interests of the patient. All ventilated and potentially unstable transports need a medical escort. Patients who are not ventilated and are stable may be transported by an ICU nurse; if there is any concern expressed by the nursing staff, then a medical escort must accompany the patient. At no stage must the Unit be left uncovered. If the Unit is busy, or transports clash with ward rounds, other personnel may be deployed to do the transport. This is coordinated by the duty ICU consultant. As a general rule, ICU staff are responsible for transportation of ICU patients. Anaesthesia is responsible for transport of the following ICU patients: i) Trauma resuscitation patients (P1) ii) Patients to and from theatre iii) Patients to and from hyperbaric medicine. iv) After hours transports (as part of duties of the resuscitation registrar)

m) n) o) p) q) r)

5.

29 h) i) Prolonged investigations/treatments: eg MRI, angiographic embolisation, invasive radiological procedures (eg TIPS). The transport of these patients should be discussed with the duty ICU consultant and Duty Anaesthetist. Guidelines i) Registrars must familiarise themselves with transport monitors, portable ventilators and infusion pumps. ii) Inform and discuss the transport with the nursing staff as soon as possible. iii) Patients must be appropriately monitored during the transport and observations recorded on the flow chart. iv) Document any problems which may occur during transport. v) Ensure that the results of investigations performed (ie CT scans etc) are recorded in the case notes by the appropriate person.

K. Hospital Emergencies 1. 2. The emergency number is 33# : state nature and location of emergency Fire a) A copy of the hospital emergency procedures (fire, smoke, bomb-threat) is kept in the Q4A and Q4D nursing stations. b) The chief fire and emergency officer is the overall controller during a fire or smoke emergency (code red). c) Become familiar with the location of fire exits, extinguishers and blankets in the Unit. i) Unless a fire is small and easily contained do not attempt to fight the fire yourself. ii) Remove yourself from the immediate vicinity of the fire, alerting other staff members as indicated, and position yourself behind the automatic fire doors. iii) The MFS has a 3 minute response time to the RAH. Wait for the arrival of the Fire Chief and assist in any patient movement/evacuation only as indicated by the Fire Chief. d) Role of medical staff i) There is no place for heroic action. Ensure your own safety first. ii) Wait for the arrival of the MFS. iii) Assist in patient assessment/management under the coordination of the Fire Chief. iv) In the event of a significant fire / smoke hazard, staff will only re-enter the danger zone in the immediate company of a MFS fire-fighter, with appropriate breathing apparatus.

30 3. Counter Disaster procedures a) b) A copy of the counter disaster plan is displayed in the communications room. Cards outline the responsibilities of key personnel located in ICU during the alert and activation phases: i) Directors of ICU, Trauma and Retrievals ii) ICU medical staff (consultant or registrar after hours) iii) Nursing staff iv) HERNIA (radio network) operator The duties of the ICU medical staff are listed on Card 12d Key points, i) The ICU medical officer becomes the temporary controller, until this duty is transferred to the duty medical administrator, during both alert and activation phases. ii) In this situation follow the Controllers card (card 33d) iii) Approve dispatch of medical team(s) to disaster site only if this does not compromise on-site staffing. iv) Liaise with the senior consultant, nursing staff and Director of ICU to decide whether to proceed to full activation.

c) d)

31 L. Research in ICU

1) Personnel: a) Coordinator of Research Dr Marianne Chapman b) Clinical Trials Coordinator Stephanie Creed (Ext 24624) c) Research nurses Sandra Andrenacci, Leesa Stanley, Justine Rivett d) Statistical and computing advise Dr Mark Finnis e) Intensive Care Unit Research Committee. As above and: i) Dr PD. Thomas ii) Dr RJ. Young iii) Mr I. Blight CNC. 2) Members of the medical and nursing staff are encouraged to become involved in research during their stay in the Unit. Registrars are expected at least to obtain consent for ongoing studies as part of their responsibility within the unit. Knowledge of these studies can be obtained from either the coordinator of research or the clinical trials coordinator. Further involvement is encouraged and there are supports within the unit to facilitate research to occur. 3) There are broadly 3 types of research project undertaken in the unit: a) Drug company sponsored projects b) Locally initiated projects (supported by funding from a) c) Studies performed with the ANZICS Clinical Trials Group (see below). 4) Staff are encouraged to present completed research at either local or interstate scientific meetings. Some funding is available for both nurses and medical staff who present work at any meeting. a) Applications should be made to the Coordinator of Research. b) Eligible meetings include, but are not limited to: i) ANZICS Annual Scientific Meeting (http://www.anzics.com.au/asm) (1) Abstracts must be sent by July. (2) Free papers/posters (3) Prizes are awarded for: (a) Best medical and nursing free papers (b) Best medical and nursing reviews (c) Best poster (d) Best paper by a JFICM trainee (Matt Spence Medal). ii) ANZCA ASM (ICU Section): free papers. Annual - May. iii) Thoracic Society of Australia and New Zealand: Annual - March. c) Further details can be obtained from the Coordinator of Research. 5) Most projects must obtain approval from the Royal Adelaide Hospital Research Ethics Committee prior to commencement. a) Dates for submission and forms may be obtained from the Clinical Trials Coordinator. b) If the study involves drugs then it must first go to the Investigational Drugs Subcommittee. c) A copy of the ethical approval letter and protocol must be given to the clinical trials coordinator. The clinical trials coordinator will also keep details of progress of research projects.

32 6) The intensive care research committee meets once per month to: a) discuss ongoing issues regarding research in the unit b) assess proposed studies for ethical and scientific validity c) act as a resource for protocol planning d) manage funding of research in the unit. 7) Further information: a) Facilities are available in the Adelaide University Department of Anaesthesia and Intensive Care for laboratory research work. There is an animal laboratory performing predominantly pharmacokinetic/pharmacodynamic studies. Resource personnel: Prof WB Runciman, or Dr Richard Upton. b) ICU database. We have a database extending back many years containing data on all intensive care patients (not HDU). This includes demographics, illness severity scores and outcomes. We also have access to a national database. We also collect other data locally. Resource person: Dr Mark Finnis. c) Australian Incident Monitoring Study. Resource person: Prof WB Runciman. d) ANZICS Clinical Trials Group. There is a national clinical trials group to facilitate multicenter trials in Australia. The group is open to all interested parties and proposals for multicentre trials can be presented for consideration. Meetings twice per year April and October. Resource person: Dr Marianne Chapman. M. Information Technology in ICU a) b) All consultant and both registrar offices are equipped with IBM-PCs, which are connected to the RAH local area network (LAN). Facilities available through the LAN include: i) Internet e-mail accounts ii) WWW browsing facilities (available on application). iii) Intranet resources, which are being continuously expanded: a) A copy of this manual. b) Internal phone directory c) Australian business directory d) Medline via OVID e) Poisons Index (via Emergency Services) iv) On application registrars will be allocated a username, which will carry with it an Internet e-mail account for the duration of their stay. In addition, many of the consultants have direct access to the internet via accounts with the University of Adelaide, plus access to the University Library resources (Medline - Silverplatter, Toxicology databases, etc) The Unit has a Web presence at http://www.health.adelaide.edu.au/icu.

c) d)

33

CLINICAL PROCEDURES
A. 1. 2. 3. 4. 5. 6. Introduction Registrars are encouraged to become proficient in all Intensive Care procedures. Invasive procedures should be authorised by a senior registrar or the Duty ICU consultant. Adequate familiarisation and supervision with unfamiliar procedures is essential: there is always someone available to help. The relative risk vs benefit of all procedures must be carefully considered. Do not persist if you are having difficulty with the procedure: call for help Consent for procedures: *refer to Administration / Consent a) Competent patients undergoing invasive procedures should have a standard RAH Consent Form (MR:60.16) completed and signed by the patient b) Third party consent is not necessary for incompetent patients undergoing routine ICU procedures. c) Major ICU procedures such as percutaneous tracheostomy or enterogastrostomy require third party, or two-doctor consent. Indications, conduct and any complications of the procedure should be clearly documented in the casenotes in addition to a consent form if this is completed. Discuss the planned procedure with the attending ICU nursing staff and allow sufficient time for setting up of trays and equipment. Remember: the nursing staff have extensive experience with these procedures. It is the responsibility of the operator to discard all sharps used in the procedure and to ensure that they are placed in a sharps disposal container. Procedures

7. 8. 9.

B.

1. Registrars are expected to become proficient in all routine procedures. 2. Specialised procedures are done either by the Duty Consultant or strictly under consultant supervision. 3. Protocols for the undermentioned routine and specialised procedures are outlined in the following sections

34 Routine ICU procedures 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Endotracheal intubation Peripheral venous catheterisation Central venous catheterisation Arterial cannulation Pulmonary artery catheterisation Urinary catheterisation Lumbar puncture Epidural catheterisation Underwater seal drain insertion Pleurocentesis Peritoneocentesis Nasogastric tube insertion

Specialised ICU procedures 1. 2. 3. 4. 5. 6. 7. C. 1. 2. Percutaneous tracheostomy Fibreoptic bronchoscopy Jugular bulb oximetry Transvenous pacing Pericardiocentesis Oesophageal tamponade tube insertion Intra-aortic balloon counterpulsation Peripheral IV catheters Indications: a) First line IV access for resuscitation including blood transfusion b) Stable ICU/HDU patients where a CVC is no longer necessary Management protocol: a) Remove all resuscitation lines inserted in unsterile conditions as soon as possible. b) Generally avoid peripheral IV use in ICU patients and remove if not in use. c) Local Anaesthesia in awake patients. d) Aseptic technique: i) handwash with MiniPREP (chlorhexidine/alcohol) + gloves ii) skin prep. with Persist Plus (chlorhexidine 1% / 75% alcohol) e) Dressing: adhesive occlusive (Opsite or equivalent) f) Change / remove all peripheral lines after 48 hours. Complications a) Infection b) Thrombosis c) Extravasation in tissues

3.

35 D. 1. Arterial Cannulae Indications: a) Routine measurement of systemic blood pressure in ICU b) Multiple blood gas and laboratory analysis c) Measurement of BP during transport of patients in hostile environments (eg during retrieval) Management protocol: a) Remove and replace lines inserted in unsterile conditions as soon as possible. b) Brachial and femoral arterial lines must be changed as soon as radial or dorsalis pedis arteries are available. c) Aseptic technique: i) clinical handwash with MiniPREP (chlorhexidine/alcohol) + gloves. ii) skin prep. with Persist Plus (chlorhexidine 1% / 75% alcohol) d) Local anaesthesia in awake patients. e) Cannulae: i) Arrow (Seldinger technique): radial or femoral kits. ii) 20G Insyte. iii) Single lumen 18G CVC for femoral arterial lines. f) Sites: (order of preference): radial, dorsalis pedis, ulnar, brachial, femoral. g) The femoral artery may be the sole option in the acutely shocked patient. h) Dressing: occlusive Opsite + sutured i) There is no optimal time for an arterial line to be removed or changed. j) IA cannulae are changed/removed only in the following settings: i) Distal ischaemia ii) Mechanical failure (overdamped waveform, inability to aspirate blood) iii) Evidence of unexplained systemic or local infection (cf CVC lines) iv) Invasive pressure measurement or frequent blood sampling is no longer necessary. k) Measurement of pressure: i) Transducers should be zeroed to the mid-axillary line. l) Maintenance of lumen patency i) Continuous pressurised (Intraflo) heparinised saline flush (1u/ml) at 3ml/hr. Complications a) Infection b) Thrombosis c) Digital ischaemia d) Vessel damage / aneurysm e) HITS (secondary to heparin infusion)

2.

3.

36 E. Central venous catheters

NB: Registrars should be familiar with the interpretation and limitations of haemodynamic variables derived from central catheters (CVC and PAC) in critically ill patients. 1. Indications: a) Standard IV access in ICU patients: i) Fluid administration (including elective transfusion) ii) TPN, hypertonic solutions (amiodarone, nimodipine, etc.) iii) Vasoactive infusions b) Monitoring of right atrial pressure (CVP) c) Venous access for: i) Pulmonary artery catheterisation (PAC) ii) Continuous renal replacement therapy (CVVHDF), plasmapheresis. iii) Jugular bulb oximetry. iv) Transvenous pacing. d) Resuscitation i) Standard 3-lumen CVCs are not appropriate for acute volume resuscitation (consider a PAC sheath) Management protocol: (applies to all types of CVC): a) Types: i) The standard CVC for all ICU patients at the RAH is a Cook antimicrobial impregnated (rifampicin/minocycline) 20cm triple lumen catheter. ii) Non-impregnated catheters inserted outside the ICU should be changed to a impregnated catheter according to clinical indication. iii) Vascath catheters are used for CVVHDF and plasmapheresis iv) Pulmonary artery catheter sheath (part of the PAC kit) b) Sites: i) Subclavian is the preferred site for routine stable patients, followed by internal jugular. ii) Femoral access is preferable where: a) Limited IV access (burns, multiple previous CVCs), b) Thoracic approach is considered hazardous: (1) Severe respiratory failure from any cause (PaO2/FiO2 < 150) (2) Hyperexpanded lung fields (severe asthma, bullous lung disease) (3) Coagulopathy (see below) c) Inexperienced staff requiring urgent access, where supervision is not immediately available.

2.

37 c) Coagulopathic patients: i) INR > 2.0 or APTT > 50s correct with FFP ii) Platelets < 50,000 transfuse 1 pack (5u) platelets iii) Failure to increment platelet count after transfusion avoid subclavian iv) Uncontrolled coagulopathy use femoral approach or PICC Technique policy i) Local anaesthesia in awake patients. ii) Strict aseptic technique at insertion: a) Hand disinfection: surgical scrub with chlorhexidine for >1 minute b) Sterile barrier: gown, glove, cap and mask and sterile drapes. c) Skin prep: Persist Plus (chlorhexidine 1% / 75% alcohol) iii) Seldinger technique only. iv) Suture all lines v) Dressing: non occlusive dressing vi) Flush all lumens with heparinised saline vii) Check CXR prior to use. Maintenance i) Routine IV administration set change at 5 days. ii) Daily inspection of the insertion site and clinical examination for infection irrespective of duration of insertion. iii) Catheters are left in place as long as clinically indicated and changed when: a) Evidence of systemic infection (1) New, unexplained fever (2) Unexplained rise in WCC (3) Deterioration in organ function (4) Positive blood culture by venipuncture with likely organisms (S. epidermidis, candida spp.), and/or b) Evidence of local infection - inflammation or pus at the insertion site. iv) Guidewire exchanges are actively discouraged. They may be indicated in the following situations, after discussion with a Consultant: a) Mechanical problems in a new catheter (leaks or kinks) b) Difficult or limited central access (eg burns). v) Maintenance of lumen patency a) Central venous catheters (pre-printed on the patient flowsheet) (1) Flush unused lumens with 1ml heparinised saline (1u/ml) 8 hourly b) Vascath: into each lumen 8 hourly, (printed sticker) (1) Withdraw 2ml and discard. (2) Flush with 2ml normal saline. (3) Flush 1.5ml solution (5000U heparin/2ml).

d)

e)

38 3. Complications: a) At insertion i) Arterial puncture a) Haematoma with mass effect b) Arterial thrombosis/embolism ii) Pneumothorax, haemothorax, chylothorax iii) Neural injury (phrenic, brachial plexus, femoral nn.) b) Passage of wire/catheter i) Arrhythmias ii) Perforation of SVC, RA; tamponade c) Presence of catheter i) Catheter infection: rates increase under the following conditions: a) Size of catheter - thicker catheters (pulmonary artery catheters, Vascaths) b) Site of catheter - femoral > internal jugular > subclavian sites c) Number of lumens d) Nature of fluid through catheters - TPN or dextrose solutions ii) Thrombosis iii) Catheter/Air embolism iv) Knotting of catheters (esp PAC) v) Pulmonary infarct / arterial rupture (PAC) vi) HITS secondary to heparin.

NB: Where insertion of a CVC presents significant risk in a non-urgent situation, consider insertion of a PICC line as an alternative. F. 1. 2. Urinary catheters Standard in all ICU patients Management protocol: a) Aseptic technique at insertion. i) Hand disinfection: surgical scrub with chlorhexidine for >1 minute ii) Sterile barrier: gloves and sterile drapes. iii) Skin prep: chlorhexidene 1% b) Local anaesthesia gel in all patients. c) Foley catheters for 7 days and change to silastic thereafter if prolonged catheterisation is anticipated. (ie > 14 days) d) Remove catheters in anuric patients and perform intermittent catheterisation weekly, or as indicated.

39 G. Epidural catheters 1. Indications a) Post operative pain relief (usually placed in theatre) b) Analgesia in chest trauma. Management protocol: a) Notify the Acute Pain Service of any epidural placed in ICU/HDU b) Epidural cocktails should follow the Acute Pain Service protocols c) Strict aseptic technique at insertion. d) Daily inspection of the insertion site. The catheter should not be routinely redressed, except under the advice of the APS. e) Leave in for a maximum of 5 days and then remove. f) Remove if not in use for > 24 hours or clinical evidence of unexplained sepsis or positive blood culture by venipuncture with likely organisms (S. epidermidis, candida). g) Heparin/Warfarin Protocol Complications a) Hypotension from sympathetic blockade / relative hypovolaemia i) This usually responds to adequate intravascular volume replacement b) Pruritis, nausea & vomiting, or urinary retention (opioid effects) c) Post-dural puncture headache d) Infection: epidural abscess e) Pneumothorax (rarely) NB: Further guidelines for the management of epidural catheters can be obtained from The Acute Pain Service Guidelines for Anaesthetists (revised 11/1/2000)

2.

3.

4.

H. Pulmonary artery catheters 1. Policy: a) Insertion of PA catheters must be authorised by the Duty Consultant. b) Become familiar with the theory of insertion, indications, interpretation and complications of PACs c) Insertion of PA catheters must never delay resuscitation of shocked patients. d) Allow sufficient time for nursing staff to set up insertion trays and transducer manifolds. e) Remove catheters once they are not being routinely used.

40 2. Indications: a) Haemodynamic measurement (cardiac output, stroke volume, SVR) i) Diagnostic assessment of shock states (cardiogenic, hyperdynamic, hypovolaemic) ii) Assessment of response to treatment in the above b) Measurement of right heart pressures (RAP, PAP): i) Acute pulmonary hypertension ii) Pulmonary embolism iii) Cardiac tamponade c) Estimation of preload / left heart filling (PAOP) i) Intravascular volume status ii) LVF iii) Response to fluid loading d) Measurement of intracardiac shunt: (Acute VSD) e) Derivation of oxygen variables (VO2, DO2): not routinely done in this Unit. Management protocol: a) Insertion protocol as per CVC b) Specific features of PACs i) Insertion protocol a) Sheath introducer (8.5 Fr) with side port, haemostatic valve and plastic contamination shield. b) Shared transducer for RAP (proximal) and PAP (distal) lumens c) Check competence of balloon and concentric position d) Ensure all lumens are flushed with hep saline prior to insertion. e) Ensure adequately zeroed system and appropriate scale (0-40mmHg) on monitor prior to insertion. f) Insert catheter using changing waveforms (RA RV PA) on monitor with balloon inflated and locked until catheter displays pulmonary artery occlusion tracing: usually 50cm on catheter in most patients using subclavian and left IJ approach; right IJ 40 cm. g) Deflate balloon and ensure adequate PAP trace. Adjust catheter depth until a PAOP trace appears with 1 - 1.5ml air in balloon. h) Suture introducer and attach contamination shield to the hub of the introducer. i) Apply a non-occlusive dressing. ii) Ensure an adequate PA tracing is on the monitor at all times: wedged tracings must be corrected as soon as possible: a) Flush distal lumen with 2ml N.Saline b) Withdraw the catheter until a PA trace is visible iii) Measurement of pressures: a) Reference pressures to the mid axillary line b) Measure at end-expiration of the respiratory cycle c) Do not disconnect ventilated patients to measure pressures.

3.

41 Measurement of PAOP: (1) End expiration: lowest point in ventilated patients, highest point in spontaneously ventilating patients (2) Use the electronic cursor on Marquette monitors after 2-3 respiratory cycles. iv) Haemodynamic measurements a) These are routinely performed by the nursing staff, however registrars should become familiar with the procedure. b) Record all measurements in the flow chart in the results folder. (1) Cardiac outputs: (a) Injectate: 10 ml 5% dextrose @ room temperature (b) Inject throughout the respiratory cycle (c) > 3 measurements and ignore values > 10% from average. (2) Derived variables: (a) CO/CI and SVR are routinely recorded (8 hly or as indicated ) on the ICU chart. (b) Other variables including PVR(I), SV(I), L(R)VSWI are recorded in the haemodynamics flowsheet. (c) Oxygen delivery variables are not routinely measured due to limited clinical utility: if they are measured oxygen saturation should be directly measured with co-oximetry. (d) Table of derived haemodynamic variables (see table) d) 4. Complications a) Related to CVC cannulation (see CVC section) b) Related to insertion/use of a PAC i) Tachyarrhythmias ii) RBBB iii) Cardiac perforation iv) Thromboembolism v) Pulmonary infarction (2 persistent wedging) ~ 0-1.4% vi) Pulmonary artery rupture ~ 0.06-0.2% (mortality 50%) vii) Catheter related sepsis viii) Endocarditis ix) Pulmonary valve insufficiency x) Catheter knotting xi) Balloon fragmentation/embolism

42

Standard Haemodynamic Variables

Variable
Cardiac index Systemic vascular resistance Systemic vascular resistance index Pulmonary vascular resistance index Stroke volume index Left ventricular stroke work index Right ventricular stroke work index Arterial oxygen content Venous oxygen content Oxygen delivery index Oxygen consumption index Oxygen extraction ratio

Formula CI = CO/BSA
SVR = MAP RAP 79.9 CO

Normal range
2.5-5 l/min/m2 750-1500 dyn.sec/cm5/m2 1400-2400 dyn.sec/cm5/m2 150-250 dyn.sec/cm5/m2 33- 47 ml/beat/m2

SVRI =
PVR =

MAP RAP 79.9 BSA CO

MAP RAP 79.9 CI

SVI =

CI HR

LVSWI = ( MAP PAOP) SVI 0.0136

50-120 g/m2 / beat

RVSWI = ( MAP RAP) SVI 0.0136

CaO 2 = ( Hb 134 . SaO 2 ) + ( PaO 2 0.003)

25-55 g/m2 / beat 17-20 ml/100ml 12-15 ml/100ml 550-750 ml/min/m2

CvO 2 = Hb 1.34 SvO 2 + PvO 2 0.003

) (

DO 2 I = CI CaO 2 10 VO 2 I = CI CaO 2 CvO 2 10 O 2 ER = VO 2 I DO 2 I

115-160 ml/min/m2 0.24-0.4

Shunt equation End capillary oxygen content Alveolar gas equation

Qs (CcO 2 CaO 2 ) = 100 Qt CcO 2 CvO 2

5-15% 80-100 ml/100ml 100-650 mmHg

CcO 2 = (Hb 1.34 1.0 ) + (PAO 2 0.003)

PAO 2 = FiO 2 ( 760 47) ( PaCO 2 1.25)

43 I. Pleural drainage

1) Indications: a) Pneumothorax b) Tension pneumothorax may require urgent needle thoracostomy c) Haemothorax d) Large symptomatic pleural effusion 2) Management protocol: a) Needle thoracostomy (tension pneumothorax): i) 16G cannula placed in mid clavicular line, 2nd intercostal space ii) Always place an UWSD following this procedure b) Pleurocentesis: (pleural effusion) i) Local anaesthesia and sterile technique ii) Cannula technique: (1) 3 way tap attached to 12 - 14 G IV cannula, syringe and rubber hose (closed system) (2) Remove needle from cannula and aspirate pleural effusion until dry. iii) Seldinger technique (1) Pigtail pericardial catheter (preferred) or single lumen CVC kit. (2) Insert guidewire through needle into pleural space (3) Insert catheter into pleural space over wire (4) Aspirate intermittently with closed system or attach to an underwaterseal drainage system. iv) Record volume removed and send for MC&S, cytology & biochemistry. v) Check CXR post-procedure. c) Underwater seal drainage: i) Local Anaesthesia in awake patients. ii) Strict aseptic technique at insertion: ie full gown/glove/mask & cap; chlorhexidine skin preparation iii) Site: mid axillary line, 3 - 4 intercostal space iv) ICU patients need large drains: 28F catheter or larger v) Remove trochar from catheter: do not use trochar for insertion of tube. vi) 2-3 cm skin incision parallel to the ribs (#10 or #15 scalpel) vii) Blunt dissection to and through intercostal space with index finger or Howard Kelly forceps until within pleural space. viii) Insert finger into pleural space to enlarge hole and insert tube directly into pleural space or with forceps. ix) Connect to underwater seal apparatus x) Insert 2 purse string sutures: 1 to fasten the tube, and 1 (untied) to close the incision on removal. xi) Dressing: occlusive dressing (Hypafix) xii) Check CXR.

44 xiii) Maintenance (1) Remove or replace drains inserted in unsterile conditions as soon as possible. (2) Leave drain in situ until radiological resolution, no further bubbling, or drainage (<150 ml/24 hours). (3) In ventilated patients, drains should be clamped for 4 hours and removed if none of the above are present. (4) Surgically placed drains (ie intraoperative placement) are the responsibility of the surgeon xiv) Streptokinase (STK) Instillation (1) Only following discussion with the Duty Consultant. (2) This may be done to improve drainage where blockage has occurred due to the presence of blood (3) 250,000U of STK is reconstituted into 50 ml N.Saline (4) Instill using aseptic technique (5) Clear UWSD tubes should be clamped for 2 hours. Pigtail catheters should be left open. (6) Patients should be positioned side-to-side each half hour for 2 hours. (7) The drain should then be unclamped and drainage volumes notes. 3) Complications: (minimised using the blunt technique) a) Incorrect placement (extrapleural, intrapulmonary, subdiaphragmatic) b) Pulmonary laceration (haemorrhage, fistula) c) Pneumothorax d) Bleeding i) local incision, intercostal vessels ii) lung iii) IMA (with anterior placement) iv) Great vessels (rare) e) Infection: empyema. f) Mechanical (kinking, luminal obstruction)

45 J. 1. Endotracheal intubation Policy: a) Endotracheal intubation in ICU patients is a high risk but vital procedure: i) Usually an emergency procedure, with limited time. ii) Usually indicated for acute respiratory failure, or associated with limited respiratory reserve iii) Patients may have cardiovascular instability and significant comorbidities iv) Patients may have cervical spine or oropharyngeal trauma/surgery v) Patients are at risk of vomiting and aspirating vi) Positioning is difficult. b) Familiarisation with the intubation trolleys, equipment and drugs is essential. c) Intubation should ideally not be done as a sole operator procedure. Skilled assistance should always be sought. d) If you are alone (ie after hours): call for help! Expertise in intubation is always available. Remember ESS anaesthesia staff. e) The majority of ICU patients mandate rapid sequence induction. Indications a) Institution of mechanical ventilation b) To maintain an airway i) Upper airway obstruction a) Potential eg early burns b) Real eg epiglottitis, trauma ii) Patient transportation c) To protect an airway i) Patients at risk of aspiration ii) Altered conscious state iii) Loss of glottic reflexes d) Tracheal toilet Techniques a) Orotracheal intubation is the standard method of intubation in this unit. b) Nasotracheal intubation may be indicated where: i) Patients require short-term ventilation and are intolerant of oral ET tubes. ii) Fibreoptic intubation is indicated: a) Following head and neck surgery b) Inability to open the mouth: e.g. intermaxillary fixation, TMJ trauma, rheumatoid arthritis. c) Upper airway obstruction iii) Contraindicated in base of skull & LeForte facial fractures c) Methods: i) Direct visualisation under rapid sequence induction ii) Fibreoptic bronchoscopic awake intubation iii) Intubating laryngeal mask LMA (Fastrac)

2.

3.

46 4. Endotracheal Tubes a) Standard tube: low pressure, high volume PVC oral tube. i) Males 8-9 mm: secure at 21-23cm to incisors ii) Females 7-8 mm: secure at 19-21cm to incisors iii) Do not cut tubes to less than 26 cm long. b) Double lumen tubes: *rarely indicated in ICU: i) Unilateral lung isolation for bronchopulmonary fistula, abscess or haemorrhage ii) These tubes should be inserted as a temporary manoeuvre prior to a definitive procedure iii) Allow differential lung ventilation c) Intubated patients from theatre may have the following tubes that are not recommended for prolonged intubation. These tubes must be changed if intubation anticipated > 48 hours if safe and feasible. i) Plain PVC tubes: change to standard EVAC translaryngeal tube ii) Armoured tubes: problems: a) High pressure, low volume cuff b) Once kinked, remain kinked: beware in patients who bite tubes. iii) RAE tubes: problems a) Difficulty in suction due to bend b) Fixed length from bend: frequently advance down right main bronchus c) High pressure, low volume cuff Protocol for endotracheal intubation in ICU a) Personnel: Intubation is a 4 person procedure; skilled assistance is mandatory: i) Top end intubator who coordinates the intubation ii) One person to administer drugs iii) One person to apply cricoid pressure once induction commences: a) This is recommended as a routine for emergency intubations b) The intubator should direct the person who is applying cricoid pressure so that pressure is correctly applied and removed if distortion of the larynx or difficulty in intubation occurs as a result. c) CP is considered safe in the presence of suspected spinal injury. iv) One person to provide in line cervical spine immobilisation (trauma and spinal patients only). Consider the use of Fastrac LMA for spinal patients to minimize neck movements. b) Secure adequate IV access c) Equipment (kept in intubation trolleys in Q4A, B, C & D). Ensure the following equipment is available and functional: i) Adequate light ii) Oropharyngeal airways iii) Working suction with a rigid (Yankauer) sucker iv) Self inflating hand ventilating assembly and mask v) 100% oxygen, ie working flowmeter at 15 l/min vi) 2 working laryngoscopes vii) Magill forceps

5.

47 viii) Malleable introducer and gum elastic bougie ix) 2 Endotracheal tubes a) Normal size + 1 size smaller b) Check cuff competence x) Access to difficult intubation equipment. a) Be aware of Failed Intubation Drill. b) Cricothyroidotomy equipment (#15 scalpel / #6.0 cuffed ETT) Monitoring (on all patients) : i) Pulse oximetry ii) Capnography iii) Arterial blood pressure (place an arterial line before intubation in most patients) iv) Electrocardiography Drugs i) Induction agent (thiopentone, fentanyl, ketamine, midazolam) ii) Suxamethonium (1-2 mg/kg) is the muscle relaxant of choice. a) Contraindicated in: (1) Burns > 3 days (2) Chronic spinal injuries (ie spastic plegia) (3) Chronic neuromuscular disease (eg Guillain Barre, motor neurone disease) (4) Hyperkalaemic states. (K+ > 5.5) b) Consider Rocuronium (1-2 mg/kg) if Sux. contraindicated iii) Atropine (0.6 - 1.2 mg) iv) Adrenaline (10 ml 1:10000 solution) Procedure: Rapid sequence induction and orotracheal intubation i) Pre oxygenate with 100% oxygen for 3-4 minutes. ii) Preload with 250-500ml colloid intravenously iii) Induction agent + suxamethonium iv) Cricoid pressure applied v) Direct visualisation of vocal cords and tracheal intubation vi) Inflation of cuff until sealed vii) Confirmation of end-tidal CO2 and chest auscultation with manual ventilation viii) Cricoid pressure released ix) Secure tube at correct length x) Connect patient to ventilator (see default ventilator parameters) xi) Ensure adequate sedation muscle relaxant xii) Consider insertion of a naso/oro-gastric tube. Required by the majority of ICU patients and insertion will avoid repeating the CXR. xiii) Chest X-ray xiv) Confirm blood gas analysis and adjust FIO2 accordingly.

d)

e)

f)

48 g) Sedation post intubation: i) None if comatose or haemodynamically unstable ii) Morphine midazolam, propofol, fentanyl, diazepam as indicated by the clinical scenario.

6.

Maintenance of endotracheal tubes a) Tapes i) Secure tubes with white tape after insertion. ii) Ensure that loop of tape is snug around back of neck but not too tight to occlude venous drainage. Should allow 2 fingers under tape. iii) Retape with adhesive tape once X-Ray check done. b) Cuff checks i) Volumetric (sufficient air to obtain a seal + 1 ml) tests are done following insertion and whenever a leak is detected with a manual hyperinflation once per nursing shift. ii) Seal is assessed by auscultation over trachea during normal ventilation. iii) Manometric tests are inaccurate and do not correlate with mucosal pressure. These are an adjunct only if cuff malfunction is suspected. c) Persistent cuff leaks i) Tubes requiring more than 5ml of air to obtain a seal or if there is a persistent cuff leak must be examined by direct laryngoscopy as soon as possible even if the tube appears to be taped at the correct distance at the teeth. ii) Ensure that: a) The cuff has not herniated above the cords b) Tube has not ballooned inside the oral cavity and pulled the cuff above the cords. iii) High risk patients for cuff leaks: a) Inappropriately cut tubes: do not cut tubes < 26 cm b) Facial swelling (burns, facial trauma) c) Patients requiring high airway pressures during ventilation d) Aspirate EVAC tubes 2 hourly, or more frequently (hourly) if > 10 ml supraglottic secretion per hour Endotracheal tube change protocol a) Ensure adequate skilled assistance, equipment, drugs and monitoring as for de novo intubation. b) Procedure i) Set the FIO2 = 1.0 and change SV modes to SIMV. ii) Ensure sufficient anaesthesia and muscle relaxation (fentanyl / propofol + neuromuscular blockade) iii) Perform laryngoscopy and carefully identify patency of upper airway after suction, anatomy of larynx, degree of laryngeal exposure and swelling. iv) Clear view of larynx and no or minimal laryngeal swelling:

7.

49 Application of cricoid pressure by assistant and careful, graded extubation under direct laryngoscopic vision. b) Maintain laryngoscopy and replace tube under direct vision. v) Impaired visualisation of larynx: a) Use gum elastic or ventilating bougie b) Place bougie through tube under direct vision and insert to a length that would be just distal to the end of the ETT (approximately 30cm from end of tube) c) Have an assistant control the bougie so that it does not move during movement of the endotracheal tube d) Application of cricoid pressure by assistant and careful, graded extubation e) Maintain laryngoscopy and ensure bougie is through the cords on extubation f) Replace tube over bougie and guide through larynx under available vision. vi) Inflate cuff, check end tidal capnography, auscultation, expired tidal volume and then release cricoid pressure. vii) Secure tube with tape. a) 8. Extubation protocol a) Ensure equipment, monitoring and adequate assistance as for intubation b) Preferentially done during daylight hours and is a medical responsibility c) Extubation criteria: i) Return of adequate conscious state to maintain adequate protective laryngeal reflexes and secretion clearance. ii) Adequate pulmonary reserve a) Resp rate: < 30 bpm b) FVC: > 15 ml/kg c) PaO2/FiO2: > 200 iii) In patients with upper airway surgery or swelling the demonstration of an adequate air leak around the deflated endotracheal tube cuff iv) Plastic surgical and ENT patients require consultation with the Parent Clinic. Those patients with intermaxillary fixation and wiring must have a person from the Parent Clinic familiar with the placement of the wires and a wire cutter present during extubation. d) All patients should receive supplemental oxygen post extubation.

50 K. Emergency Surgical Airway Access 1. Policy a) Cricothyroidotomy and jet ventilation are recommended procedures for urgent surgical airway access and emergency oxygenation. b) Call for help & skilled assistance then proceed without delay. c) Percutaneous tracheostomy is not an emergency procedure. Indications: a) Refer to the failed intubation drill in the clinical protocols section. b) Inability to maintain an airway despite basic manoeuvres - ie jaw thrust, chin lift + oral / nasal airways + inability to hand ventilate. Cricothyroidotomy a) Surgical technique i) Equipment a) Size 15 scalpel + handle b) Size 6.0 cuffed endotracheal tube c) Oxygen delivery circuit: Laerdal bag ii) Procedure a) Palpate cricothyroid membrane. b) 2cm horizontal incision through skin and membrane c) Insert blade handle into wound and turn vertically to enlarge wound d) Insert endotracheal tube directly into trachea e) Connect oxygen circuit f) Confirm correct placement with end-tidal CO2, auscultation and check CXR g) Perform catheter suction as soon as possible after adequate oxygenation h) Cricothyroidotomy is a temporary airway: arrange a definitive surgical airway (ENT surgeons) as soon as possible. b) Percutaneous technique i) Equipment a) Cook Melker Emergency Cricothyrotomy Catheter kit ii) Procedure a) Palpate cricothyroid membrane with well extended neck b) 1cm horizontal incision through skin c) Locate tracheal air column with fluid filled syringe & needle/cannulae d) Insert wire through cannulae & thread cannulae off wire. e) Thread dilator over wire & dilate puncture site. f) Feed introduce & tube over wire g) Remove wire & introducer

2.

3.

51 4. Jet Ventilation a) Equipment i) Cook Jet Ventilation Kit (Enk Oxygen Flow Modulator Set) ii) Oxygen flow meter set to highest flow rate b) Procedure i) Palpate cricoid membrane with well extended neck ii) Locate tracheal air column with fluid filled syringe & needle/cannulae. iii) Feed cannula off needle down the trachea. iv) Attach oxygen delivery tubing from flowmeter to cannula. v) Occlude lumens in tubing to produce the jet of oxygen. vi) Jet ventilation is a temporary airway: arrange a definitive surgical airway (ENT surgeons) as soon as possible.

L. 1.

Fibreoptic bronchoscopy Policy: a) This is only to be used by skilled personnel and authorised by the duty consultant. b) c) Under no circumstances may the bronchoscope be loaned to other clinics. Expertise with bronchoscopy takes time: registrars are recommended to approach the Department of Thoracic Medicine to attend bronchoscopy clinics to become familiar with the anatomy of the tracheobronchial tree and use of the flexible fibrescope.

2.

Indications: a) Difficult intubation (trained staff only): not used as aid to failed intubation b) Persistent lobar collapse that is refractory to physiotherapy c) Foreign bodies d) Diagnostic bronchoalveolar lavage (BAL)

52 3. Protocol for fibreoptic intubation a) Indication as per endotracheal intubation b) Procedure i) All equipment, drugs and monitoring as for any intubation ii) Supplemental oxygen must be given via a mask and may also be given via the suction channel of the bronchoscope. iii) Usually performed nasally: preparation of the nasal mucosa with topical 10% lignocaine or 2% amethocaine spray. iv) Anaesthetise pharynx with viscous lignocaine & larynx with transtracheal injection, direct application through the scope or nerve blockade. v) Check tube cuff vi) Place warmed appropriately sized tube (7-7.5 mm tube for either sex) into posterior nasal space. vii) Insert scope through tube under direct vision. viii) Advance the scope into trachea under vision ix) Advance tube over scope into trachea and then remove scope. x) Confirm ETT placement by ETCO2, auscultation and CXR. xi) NB: Suction at least 500ml water or saline through scope immediately following use and notify the equipment nurse that the scope has been used ASAP. Protocol for BAL a) Diagnosis of nosocomial pneumonia in selected patients i) Determination of colonisation vs infection in chronically ventilated patients. ii) These patients should ideally be off antibiotics for 24-48 hours. iii) Sufficient reserve to tolerate procedure: a) Ideally PaO2 > 70 and FiO2 < 0.7 b) BAL will commonly result in a 10% reduction in PaO2 for up to 24 hours after procedure b) Procedure i) Ensure sufficient sedation ii) Place patient on 100% oxygen iii) Select lobe to be lavaged from morning CXR iv) Local anaesthetic gel is contra-indicated (interferes with culture media) v) If possible, do not suction through scope prior to lavage (upper airway bacterial contamination) vi) Pass scope directly into the selected lobe vii) Wedge scope as far as possible - ideally to 3rd generation bronchi viii) Lavage with 4-6 x 20-40 ml aliquots of sterile normal saline ix) Aspirate between aliquots and label aliquots accordingly x) Send aspirates for quantitative culture and atypical pneumonia screen as directed.

4.

53 M. Tracheostomy 1. Policy: a) Percutaneous tracheostomy is the preferred method for tracheostomy in suitable critically ill patients. b) This procedure is only to be performed by experienced consultant staff or advanced vocational trainees under supervision. c) Patients must have the option of surgical tracheostomy cleared by the parent clinic (either medical or surgical). This is a basic courtesy. d) The decision to do a percutaneous tracheostomy is at the discretion of the Duty ICU consultant. e) Percutaneous tracheostomy is an elective procedure and has no place in urgent airway access. Indications : a) The indications for PCT are the same as surgical tracheostomy: b) Airway maintenance i) Prolonged intubation (> 7-10 days) ii) Prolonged upper airway obstruction (eg craniofacial #) iii) Laryngeal pathology iv) Subglottic stenosis c) Airway protection i) Delayed return of glottic reflexes ii) Tracheal toilet Contraindications to PCT a) Coagulopathy i) Platelets: < 100,000 ii) APTT: > 40 iii) INR: > 2.0 b) Previous neck surgery c) Difficult anatomy: ie short fat neck Procedure: a) Ensure consent has been obtained and documented. b) Equipment, monitoring and drugs as per endotracheal intubation available c) Coagulation screen prior to procedure. d) Bedside procedure light essential. e) General Anaesthesia: the person controlling the airway must be appropriately trained. f) Ventilate the patient on 100% oxygen.

2.

3.

4.

54 g) Tracheostomy equipment: i) A modified Cook Ciaglia kit using the Blue Rhino dilatational technique is standard for this Unit. ii) Tracheostomy tubes a) EVAC aspirating tubes are standard for all tracheostomies. b) This includes patients who have surgical tracheostomies: ensure that an EVAC tube goes with the patient to theatre. c) Patients who have non-aspirating tracheostomy tubes in place (ie from CTSU or other hospitals) must have these tubes changed to EVAC tubes as soon as safe and feasible. This is usually 4-5 days post tracheostomy. d) Other tubes: (1) Foam cuffed tubes: indicated in patients with tracheomalacia or persistent air leaks (2) Uncuffed tube (usually size 6.0) as part of weaning of tracheostomised patients to facilitate secretion clearance (3) Fenestrated tube: these are either cuffed or uncuffed tube with a fenestration that allow patients to talk. (4) Adjustable flange tubes: useful for patients with marked neck or soft tissue swelling. (5) Shiley long-term tubes: these tubes have a removable inner tube for tube changes. Insertion technique: i) Strict aseptic technique (goggles essential for operator and anaesthetist) ii) Local anaesthetic infiltration (2% lignocaine + 1:200000 adrenaline) over pretracheal rings. iii) Check the tube cuff, lubricate and insert the dilator into the tube. iv) 2cm horizontal incision over 1st or 2nd tracheal ring v) Pretracheal tissue dissection to fascia: look for anterior jugular vein and ligate if identified. vi) Insert a 14G IV cannula mounted on a syringe with saline into trachea and aspirate through saline/water to confirm intratracheal placement. vii) Reconfirm intratracheal placement by aspirating the IV cannula after removal of the stylet. viii) Insert the guide-wire through the IV cannula and remove the cannula. ix) Insert a small dilator over the wire into the trachea and make a hole large enough to accommodate the main dilating instrument. x) Blue Rhino graduated 1-step dilator: a) Place dilator and guide cannula (white) over the wire b) Slowly insert to required ETT size, ensuring the marker (black line) on the guide cannula remains at the distal end of the dilating tube. xi) Remove the dilator leaving the white guide cannula on the wire and insert tracheostomy tube & dilator over the wire/guide into the trachea xii) Remove the dilator and wire, inflate the cuff and suction the trachea xiii) Attach to a ventilator and confirm end tidal CO2

h)

55 xiv) Secure tracheostomy tube with tapes. xv) Obtain a CXR post procedure. xvi) Document the procedure in the case notes and complete separate operation note 5. Complications (of tracheostomy) a) Bleeding b) False passage c) Loss of the airway: immediately re-intubate the patient orally d) Pneumothorax e) Cricoid cartilage fracture f) Laryngeal dysfunction g) Tracheal stenosis h) Infection Prolonged care of tracheostomy a) Cuff checks i) Volumetric (sufficient air to obtain a seal) tests are done following insertion and whenever a leak is detected with a manual hyperinflation once per nursing shift. ii) Manometric tests are inaccurate and do not correlate with mucosal pressure. These are an adjunct only if cuff malfunction is suspected. b) Tube changes i) Routine change at 14 days. c) Aspirate EVAC tube 2 hourly or more frequently (hourly) if > 10 ml supraglottic secretion per hour.

6.

56 N. 1. Minitracheostomy Policy. a) b) This procedure must be authorised by the duty ICU consultant and performed by consultant staff or trainees under supervision. Minitracheostomy is not a definitive airway and should not be used as an alternative to endotracheal intubation or tracheostomy in patients that require definitive airway access.

2.

Indications a) Short term (< 72 hrs) upper airway access as an adjunct for secretion clearance in patients with reduced expiratory excursion: i) Exacerbations of CAL and purulent sputum ii) Post extubation for ventilator dependent respiratory failure or surgery iii) Quadriplegia with respiratory embarrassment iv) Acute or acute-on-chronic neuromuscular disorders eg Guillain Barre, myotonia dystrophica Incipient upper airway obstruction prior to definitive surgical airway access. May be used as an alternative to cricothyroidotomy for semi-urgent surgical access.

b) c) 3.

Contraindications a) b) c) Inadequate glottic reflexes : i) Mental obtundation (GCS<7) ii) Laryngeal dysfunction Coagulopathy (as for tracheostomy) Difficult local anatomy i) Previous neck surgery ii) Inability to palpate cricothyroid membrane iii) Burns or cellulitis of neck Respiratory failure requiring ventilation

d)

57 4. Procedure a) b) Aseptic technique. Technique: Minitrach II Seldinger kit i) Palpate cricothyroid membrane and midline. ii) Local skin infiltration with 2% lignocaine + 1:200000 adrenaline. iii) Insert 20G Insyte loaded on 5ml syringe filled with 3ml saline through cricothyroid membrane. iv) Confirm intratracheal placement by aspiration of air. v) Remove stylet and reconfirm aspiration of air prior to injection 5 ml 2% lignocaine into trachea. Warn patient that he/she will cough. Remove cannula. This will identify the depth required to access the cricothyroid membrane as well as provide a recurrent laryngeal block to facilitate cannulation. vi) Insert introducer needle loaded on 5ml syringe filled with 3ml saline through cricothyroid membrane with needle aperture directed caudad confirming intratracheal placement on aspiration of air. vii) Remove syringe and insert Seldinger wire through needle. The wire should move easily into the trachea. Any resistance implies a false passage or misplacement of the wire and the needle and wire should be removed immediately. viii) Remove introducing cannula over wire, ensuring that the wire remains in the trachea. ix) Incise skin adjacent to wire with enclosed short scalpel or #11 blade. x) Place short dilator over guidewire and insert into trachea through cricothyroid membrane. Similarly, this should pass smoothly with no resistance. Remove dilator ensuring that the wire remains in the trachea. xi) Insert minitrach loaded on long introducer over wire into trachea. Any resistance implies a false passage or misplacement of the cannula warranting removal of the introducer and cannula. xii) Suction cannula and close with attached cap. NB: the cannula is a size 4.0 tube and will only admit a size 10 suction catheter. xiii) Perform Chest Xray.

5.

Complications c) d) e) f) g) h) False passage Cricoid cartilage fracture Tracheal laceration Oesophageal laceration Pneumothorax Bleeding

58 O. Pericardiocentesis 1. Policy a) This procedure must be authorised by the duty ICU consultant and performed by consultant staff, trainees under supervision, or cardiology. b) Confirmation of pericardial effusion or tamponade must be made with echocardiography prior to procedure. Liaison with cardiology is essential. Indications a) Symptomatic pericardial effusion (tamponade). b) Although advocated in EMST, this procedure has limited utility in traumatic pericardial tamponade. Procedure a) Strict aseptic technique. b) Local anaesthetic infiltration if awake patient. c) This procedure is greatly facilitated using echocardiography guidance d) Technique: Seldinger technique and insertion of a pigtail catheter i) Small incision under xiphisternum ii) Insert needle on syringe at 45o from the horizontal axis and aim for tip of left shoulder iii) Advance slowly and aspirate until confirmation by aspirating blood or serous fluid iv) Insert catheter using Seldinger technique over guidewire. v) Confirm placement by aspiration and/or echocardiography vi) Check CXR (pneumothorax) vii) Suture and occlusive dressing if leaving for > 24 hours. Complications a) Arrhythmias b) Cardiac tamponade! c) Myocardial laceration d) Pneumothorax, pneumopericardium e) Liver laceration

2.

3.

4.

59 P. 1. Jugular bulb oximetry Policy: a) The decision to insert a jugular bulb catheter is made in conjunction with the parent neurosurgical consultant and authorised by the duty ICU consultant b) This procedure is only to be performed by consultant staff or advanced vocational trainees under supervision. c) Become familiar with the theory of insertion, indications, interpretation and complications of SjO2: this monitor is used in conjunction with the cerebral perfusion pressure (CPP) algorithm. (See neurotrauma protocols) Indication: The titration of CPP by maintaining SjO2 > 55% in moderate to severe head injury (i.e., GCS 8 where the injury 24 hrs old) where: i) Haemodynamic instability exists (eg extracranial trauma, hypovolaemic or cardiogenic shock), or ii) Haemodynamically stable, but requiring high dose catecholamines (>30 ml/hr) to achieve a CPP > 70 mmHg, despite euvolaemia and resultant catecholamine induced polyuria. Procedure: a) Site selection: i) Cannulate side of maximal parenchymal trauma on CT ii) If diffuse axonal injury, cannulate left IJ iii) The jugular compression test (compressing each jugular vein and cannulation of the side of maximal ICP) is unreliable and is not used. b) Insertion i) Full surgical scrub and drape ii) Perform a pre-insertion calibration of the SjO2 catheter to tests integrity of the optical system a) Open package but leave catheter attached to optical cuvette; connect to optic cable b) Press cal c) Press lid of reference cuvette until clicks (in catheter package) d) Select P for pre insertion calibration e) Wait until CAL OK message appears before inserting catheter f) Remove catheter from cuvette iii) Connect 3 way tap and flush catheter with heparinised saline

2.

3.

60 iv) Retrograde cannulation & insertion through the internal jugular v.: a) Use an 23G seeker needle to locate the IJV: b) Insert Cook needle in peel away kit adjacent to the seeker needle and remove the latter once the IJV is located with the Cook needle: note this needle is relatively blunt cf the seeker needle c) Insert the J-wire until moderate resistance is felt d) Insert the paediatric peel away sheath and introducer. e) Remove the wire and introducer, leaving the sheath f) Insert the catheter until level with the external auditory meatus (usually 15cm: indicated as the third marker on the catheter) v) Aspirate and flush the catheter. vi) Check the light intensity monitor. vii) Remove the peel-away sheath. viii) Secure with Tegaderm: do not suture, bend or coil the catheter ix) Do a lateral or AP cervical spine x-ray to confirm the tip of the catheter is at the level of C1 x) Continuous pressurised (Intraflo) heparinsed saline flush (1u/ml) at 3ml/hr In vivo calibration: to be done 12 hourly. i) Press cal ii) Select I for in vivo calibration iii) Aspirate blood in AGA syringe (the monitor will store the value) iv) Measured oxygen saturation from blood gas machine or lab. v) Adjust the stored value to the lab value using the or keys vi) Press OK when correct.

c)

4.

Troubleshooting a) Poor light intensity: i) Maintain head in neutral position ii) Flush or gently advance or withdraw catheter. b) Unstable baseline or sudden unexplained desaturation: i) Perform in vivo calibration.

61 Q. Intra-aortic balloon counterpulsation 1. Policy: a) The decision to insert an IABP is made in conjunction with the duty cardiologist and authorised by the duty ICU consultant. b) IABPs are the property of the cardiothoracic unit and Wakefield ICU. c) If they are inserted by ICU staff, it is only to be performed by consultant staff or advanced vocational trainees under supervision. d) Become familiar with the theory of insertion, indications, interpretation and complications of IABP. Indications : a) As a mechanical bridge prior to and following myocardial revascularisation or transplant: b) Ischaemic heart disease i) Low cardiac output states following cardiac surgery ii) Cardiogenic shock: in association with angiography and revascularisation (PTCA, stent or CAVG) iii) Acute mitral incompetence (papillary muscle rupture) or VSD following AMI pending operative repair. c) Myocardial disease i) Severe myocardial contusion ii) Severe myocarditis iii) Cardiomyopathy iv) Severe blocker overdose. Contra-indications: a) Aortic regurgitation b) Aortic dissection c) Severe peripheral vascular disease d) Tachyarrhythmias (relative) e) Coagulopathy (relative) Procedure protocol a) b) Strict aseptic technique Check IABP function prior to insertion: i) Adequate helium cylinder volume ii) Arterial pressure manifold: referenced to mid axillary line and correctly zeroed iii) Dedicated 5 lead ECG connected to IABP iv) Turn on and leave in standby mode

2.

3.

4.

62 Initial settings: a) ECG sense: 1:3 ratio b) Augmentation: minimum (pre-insertion only) c) Inflate and deflate times: zero Insertion procedure: i) Local anaesthesia in awake patients ii) Scrubbed assistant recommended iii) Select size (by patients height) a) < 165 cm: 34ml balloon b) > 165 cm: 40ml balloon iv) Femoral artery approach: Seldinger technique and insertion of a 12F introducer. v) The correct length for insertion should be checked prior to insertion using the angle of Louis (level of T4) as the surface landmark. Insert the balloon to the level of T4. The double black marker on the balloon catheter must be visible this indicates that the balloon has fully exited the sheath. vi) Connect to pressure transducer and pump, then press IAB fill button to fill the balloon. When balloon fill is complete, press assist/standby button to start the pump. Start on minimal augmentation and increase to maximum. NB: subsequent augmentation should not be set below 50% vii) Suture in place and cover with an occlusive dressing. viii) Set timing: a) Check balloon inflation against pressure wave: set to peak of dicrotic notch. b) Check balloon deflation against ECG: prior to QRS complex and observe decrease in end diastolic pressure. c) Check diastolic augmentation on pressure wave. d) Select augmentation ratio: *standard = 1:1 Maintenance i) Systemic heparinisation (APTT = 50-80s). ii) Check CXR post insertion: tip of IABP below T4 (carina) = below the origin of the left subclavian artery. iii) Neurovascular obs of insertion site, lower limbs and left arm hourly. iv) Nurse at < 30o elevation. v) Document pump timing (ratio) and adequacy of augmentation. vi) Assess haemodynamic response: CI, MAP, SVR, filling pressures, CXR. vii) Ensure clear balloon tubing is exposed, to monitor condensation (due to rapid helium shuttling) or blood in tubing (balloon rupture). v)

c)

d)

63 e) Timing during arrhythmias i) Ectopics: keep on ECG trigger, system will automatically deflate on ectopic ii) Tachycardia > 160/min : a) Reduce augmentation (equal to patient systole) b) Decrease ratio to 1:2 if reducing augmentation is not adequate iii) Atrial fibrillation: move deflate slide to extreme right to deflate on R wave. iv) VT or VF: defibrillate or cardiovert as required, the IABP is isolated v) Cardiac arrest (no output): start ECM: a) Effective output: set on pressure trigger to synchronise balloon inflation with ECM b) No output: set internal mode for a fixed rate of 40 bpm + 20ml augmentation Weaning: i) Commence when patients haemodynamics have improved. ii) IABP is generally removed within 72 hours. iii) Methods: a) Reducing ratio from 1:1 to 1:2 to 1:3 and / or b) Reduce augmentation. Note: minimum balloon inflation 50% Removal of catheter i) Notify cardiac / vascular surgeons ii) Cease heparin 3 hours prior to removal iii) Disconnect IABP tubing: do not aspirate the balloon iv) Use Fem-Stop local pressure device immediately on catheter removal: a) Inflate cuff to 50mmHg above systolic pressure for 20 minutes b) Reduce pressure to patients systolic for 20 minutes c) Reduce pressure by further 20 mmHg for 20 minutes d) Remove fem-stop and apply a firm dressing v) 10-20% may require surgical repair to the artery.

f)

g)

5.

Complications: a) Limb ischaemia - thrombotic or embolic b) Bleeding at the insertion site or systemically c) Infection d) Aortic dissection e) Occlusion of origins of aortic arch vessels if too high f) Occlusion of renal/splanchnic vessels if too low g) Thrombocytopaenia h) Balloon rupture: gas embolism

64 R. 1. Cardiac pacing Policy: a) The decision to use transvenous pacing (TVP) is made in conjunction with the duty cardiologist and authorised by the duty ICU consultant. b) If inserted by ICU staff, the procedure is only to be performed by consultant staff or advanced vocational trainees under supervision. c) Become familiar with the theory of insertion, indications, interpretation and complications of TVP. Indications: a) Medical pacing with adrenaline or transthoracic pacing may be adequate to treat many symptomatic bradycardias. Note: this is particularly relevant for retrievals and has obviated the need for prophylactic pacing in some high-risk patients. b) Any sustained symptomatic bradycardia which does not respond to medical treatment, or predisposes to a malignant ventricular arrhythmia. Note: pacing is indicated by the haemodynamic consequences of the rhythm, not the arrhythmia per se. c) Ventricular tachycardias (especially polyphasic) may respond to overdrive suppression pacing. d) Following cardiac surgery in high-risk patients (epicardial leads): i) Valve replacement / repair: especially mitral. ii) VSD repair / papillary muscle rupture. iii) Acute myocardial infarction. Types: a) Bipolar pacing lead (VVI): insert under image intensification (standard TVP at RAH) b) Balloon flotation leads: may be inserted under ECG or pressure guidance c) Paceport PA catheters: these have little utility. d) Epicardial leads: i) Placed during cardiac surgery in high risk patients ii) Usually unipolar ventricular, but may be bipolar, atrial or ventricular: check the operative note and liaise with the surgeon.

2.

3.

65 4. Procedure protocol: (VVI lead) a) Strict aseptic technique b) Image intensification c) Local anaesthesia where appropriate d) Insertion protocol: i) 6F peel away sheath or PAC introducer ii) Right IJ vein is the preferred route, then left subclavian. NB: if permanent pacing is likely then avoid subclavian placement. iii) Under I-I control, feed the wire through the RA until the tip just stops on the right ventricular wall iv) Connect to the control box (switched off) v) Set output and sense to their minimum value, and rate 20bpm faster than the patient's own rate (or 70bpm, whichever is greater). vi) Turn the generator on and gradually increase the output while watching the ECG for capture. vii) If there is no capture or a high output is required: a) Place on demand mode b) Turn output right down, advance or reposition the wire slightly c) Try to capture again. An ideal capture setting is ~ 2 mA d) Ensure wires are not exposed and tape both sides viii) Suture the wire and apply an occlusive dressing ix) Arrange a post-insertion CXR. e) Daily check: i) Battery strength ii) Capture: set the output 2x higher than threshold for safety. Floatation Catheter Insertion a) These may be inserted either blind, under ECG guidance (standard recommendation), or via pressure guidance for catheters having an infusion lumen (cf. PA catheter insertion). b) Aseptic technique & local anaesthesia where appropriate c) Insertion protocol: i) 6F peel away sheath, do not use a PAC introducer as these will leak ii) Attach V5 lead of an ECG to the distal electrode of catheter & monitor iii) Note P then QRS wave-form changes as the catheter advances to the RV iv) Advance catheter another 2cm, deflate the balloon & advance 1cm v) Connect to the pulse generator (switched off) vi) Set output and sense to their minimum value, and rate 20 bpm faster than the patient's own rate. vii) Turn the generator on and gradually increase output while watching the ECG for capture. viii) If there is no capture or a high output is required - see (4.d.vii) above ix) Suture the wire and apply an occlusive dressing x) Arrange a post-insertion CXR.

5.

66 S. 1. Oesophageal tamponade tubes Policy: a) All patients with tamponade tubes should be intubated prior to insertion and managed in Intensive Care. b) As a result, ICU staff may be requested to insert oesophageal tamponade tubes for acute upper GI bleeding. c) The decision to insert a tube is made in conjunction with the gastroenterologist. There are a number of tamponade tubes available: ensure that the operation, balloon inflations are discussed with the gastroenterologist. d) Become familiar with the theory of insertion, indications, and complications of these tubes. Indications : a) Variceal haemorrhage: i) Where endoscopy cannot be done due to bleeding ii) Failure of sclerotherapy, banding and/or octreotide. Types of tubes: a) Minnesota: b) Sengstaken: c) Linton: oesophageal and gastric balloons and aspirating ports oesophageal and gastric balloons and gastric aspirating port gastric balloon and aspirating port

2.

3.

4.

Procedure: a) Prior to insertion: i) Check both balloons for leaks ii) Inflate the gastric balloon with 300ml of air and check pressure reading. iii) Deflate all balloons completely and lubricate the tube b) Insert well in under direct vision using a laryngoscope then x-ray to ensure the tube is not folded up in the oesophagus. NB: inflating the gastric balloon in the oesophagus is virtually 100% fatal! c) Inflate the gastric balloon in 50ml increments up to 300ml while monitoring the balloon pressure. NB: If the balloon pressure exceeds 5mmHg above the pre-insertion pressure then incorrect (oesophageal) placement is probable and this mandates deflation of the balloon and reinsertion of the tube. d) Pull back until resistance is felt as the balloon rests against the gastric fundus. e) Note the measurement at the lips, and fix securely with gentle traction: i) Rope and pulley system with 500ml bag of fluid, or ii) Adhesive tape to face. f) Connect a pressure gauge to the oesophageal balloon, and inflate to a pressure of 40 mmHg. (inflation of the oesophageal balloon is usually not required) g) Recheck position on x-ray. h) After 12-24 hours, the balloons should be let down and if bleeding does not recur the tube may be removed (liaise with the gastroenterologist). i) Sclerotherapy is usually performed: ( 50% patients will re-bleed otherwise)

67

DRUGS AND INFUSIONS

A. 1. 2. 3. 4. 5. Policy Patients admitted to ICU must have all premorbid and current medications reviewed. Only medications that are applicable to the current admission should be transcribed to the ICU flowchart. All drugs, infusions and fluids are reviewed and written up daily on the ICU flowcharts following the 1100am ward round. Sticky labels for the commonly used infusions and drug protocols should be used where possible. All subsequent changes or additions to drug and fluid orders must be written and signed for on the flowchart. Nursing staff must be notified of these changes or additions as soon as charted. Verbal orders alone are neither sufficient nor legal. Vasoactive or hypertonic infusions (eg TPN) must be administered through dedicated lumens of a central venous catheter. Vasoactive infusions may not be used in the general wards. The concentration of infusions must not be changed (ie double strength) from the Unit infusion protocols outlined below. Standardisation of infusion concentrations is an essential quality control exercise to prevent confusion and potentially dangerous drug mishaps. Charting of drugs and infusions is only to be done by Intensive Care medical staff: parent clinics may not write on the ICU flowchart. Any suggested changes to drug and fluid orders must be discussed with the appropriate ICU medical staff. Patients discharged from ICU must have appropriate drugs, infusions and fluids written up on standard hospital forms in the blue folders to ensure continuity. Where appropriate, old drug charts should be re-written. Patients discharged on TPN must have their details entered in the TPN folder. Notify the Acute Pain Service about patients discharged under their care (ie epidurals, PCA). Principles of drug prescription in Intensive Care Ideally, drugs should only be prescribed where proven benefit has been demonstrated. Drugs should be prescribed according to Unit protocols and guidelines. Ensure that the drug doses are correct: seek advice if unsure. The risk and benefit of starting any drug must be carefully considered. Critically ill patients have altered pharmacokinetics and pharmacodynamics with the potential for toxicity and drug interactions.

6. 7. 8. 9.

B. 1. 2. 3. 4.

68 5. Where possible: a) Use drugs that can be titrated or prescribed to an easily measured endpoint. b) Use drugs that can be measured to monitor therapeutic drug levels. c) Avoid drugs with narrow therapeutic indices (eg digoxin, theophylline), particularly in patients with associated hepatic or renal dysfunction. d) Cease a drug if there is no apparent benefit. e) If two drugs are of equal efficacy, choose the cheaper drug (eg pancuronium vs vecuronium) as the cost of drugs in ICU is significant. Cardiovascular Drugs Inotropes

C. 1.

Inotropes (specifically catecholamines) are the most frequently used cardiotropic drugs in Intensive Care. Despite this, there are varied prescription practices and preferences for these drugs, which are usually based on the purported effects of the different agents. a) General principles: i) Defence of blood pressure in critically ill patients forms the basis of haemodynamic resuscitation and organ perfusion. This must be interpreted in the context of the patients pre-morbid blood pressure, particularly for those patients with renovascular hypertension or cerebrovascular disease. ii) Hypovolaemia is the most common cause of hypotension and low cardiac output in critically ill patients and must be assiduously monitored and corrected. iii) The main indication for inotropes is to increase myocardial contractility for a given preload and afterload. Clinically this equates with low mean arterial pressure (MAP) or cardiac output states. iv) MAP and CO should be interpreted in the context of pre-morbid cardiac function and the expected response to an acute insult. v) The use of inotropes in other than trivial doses requires regular haemodynamic monitoring (arterial line and CVC) and where indicated a PA catheter to assess flow (CO) as well as pressure. vi) Inotropes primarily increase cardiac output and mean arterial pressure. These agents have variable effects on heart rate and peripheral vascular resistance (systemic and pulmonary). vii) No single inotrope (or mixture of inotropes) has been shown to be superior to another.

69 viii) There is marked inter-individual variation in the response to inotropes. This is partly due to qualitative and quantitative changes in adrenergic receptor kinetics in acute illness. Similarly, prolonged exposure to catecholamine infusions may produce adrenergic receptor downregulation. The clinical implications are: a) Catecholamines (both endogenous and exogenous) act in a similar fashion with -adrenergic effects predominating at low doses and adrenergic effects at high doses. b) It is impossible to predict the dose range for an individual patient and prescription of inotropic infusions on a body weight basis (g/kg/min) is of little clinical utility. c) Infusions should be started at a low rate (3-5 g/min) and increased until a satisfactory clinical response occurs: (1) Improvement in MAP, peripheral perfusion and CO (2) No significant increase in HR or development of arrhythmias (3) Maintenance or increase in urine output (4) Reversal of acidosis. d) High concentrations of inotropes may be required to achieve the desired effect (>50 g/min) ix) Phosphodiesterase inhibitors (eg. milrinone): a) These agents increase cAMP via PDE3 inhibition (non-adrenergic action). This increases the entry of calcium into cells and increases cardiac output by: (1) Increased myocardial contractility (2) Systemic and pulmonary vasodilatation (3) Improved diastolic relaxation (lusitropy) in poorly compliant ventricles (diastolic failure) b) Resultant vasodilatation may require concomitant use of noradrenaline c) Long half-lives do not allow rapid titration. d) Doses should be reduced in renal failure.

70 b) Summary of cardiovascular effects of inotropes: Agent 1 effects 2 effects 1 effects 2 effects

chronotropy dromotropy inotropy Adrenaline Noradrenaline Dopamine Dobutamine Isoprenaline

+ = strong effect

inotropy vasodilatation bronchodilatation glucose/lactate

inotropy vasoconstriction

inotropy vasoconstriction

effects predominate at low dose + +

(+) mild effect

effects predominate at high dose (+) - = no effect

+ (+)

c) Inotropic agents used in ICU. Agent

Adrenaline

Standard Infusion
6 mg / 100 ml 5% dextrose
(ml/hr = g/min)

Uses
1. 2. 3. 4. 5. 6. 7. 1. Cardiopulmonary resuscitation Severe sepsis syndrome, septic shock Cardiogenic shock Acute severe asthma Anaphylaxis Maintenance of cerebral perfusion pressure Medical pacing (1st line drug) Vasodilated (vasoplegic) states eg septic shock (although adrenaline is equally as effective) No advantage over adrenaline/noradrenaline Produces more tachycardia than adrenaline Renal dose dopamine is not used Primarily a vasodilator, weak inotropic action Traditionally used in cardiogenic shock or low output, high afterload states (2nd line after adrenaline). Vasodilator, chronotrope (rarely used) Medical pacing (2nd line after adrenaline) Cardiogenic shock due to diastolic failure Pulmonary hypertension following valve replacement Catecholamine induced down regulation

First line drug at RAH

Noradrenaline

6 mg / 100 ml 5% dextrose
(ml/hr = g/min)

Dopamine

400 mg/ 100ml 5% dextrose

(ml/hr approx g/kg/min)

1. 2. 3. 1. 2.

Dobutamine

500 mg/ 100 ml 5% dextrose

(ml/hr approx g/kg/min)

Isoprenaline Milrinone

6 mg / 100 ml 5% dextrose
(ml/hr = g/min)

1. 2. 3. 4. 5.

10mg / 100 ml 5% dextrose 50g/kg loading dose/20 min 0.5 g/kg/min*

*Standard milrinone prescription for 70 kg patient:

Loading dose: 3500 g = 35 ml over 20 minutes Maintenance: 2100 g/hr = 20 ml/hr.

71 2. Vasopressor agents a) General principles i) Apart from the catecholamines, which have variable effects on the peripheral vasculature, vasopressors usually act directly on the peripheral vasculature and are primarily used to acutely elevate blood pressure. ii) The most common cause of hypotension in Intensive Care patients is hypovolaemia. Pressor agents should not be used as an alternative to fluid resuscitation. Indications (in ICU) a) Hypotension following sympathetic block (eg epidural anaesthesia) b) Tissue infiltration with local anaesthesia or nasal intubation c) Rarely, hypotension refractory to large doses of catecholamines (vasoplegia). In this situation, vasopressin may have a limited role. Complications a) Rebound hypertension b) Vagal response c) Tachyphylaxis Standard Infusion / Dose
10mg / 10ml 5% dex: titrate 30mg / 10ml 5% dex: titrate 20units/20ml 5%dex: 2.4ml/hr (0.04 u/min) Not available in Australia

b)

c)

Agent
Metaraminol Ephedrine Vasopressin Phenylephrine Methoxamine

Uses
1. 1. 2. 1. 2. Potent short acting vasoconstrictor Synthetic indirect sympathomimetic. Commonly used in anaesthesia, little benefit over adrenaline. Catechol resistant hypotension. Consultant authorisation mandatory.

3.

Antihypertensive agents a) General principles i) The most common cause of hypertension in Intensive Care patients is sympathetic drive due to pain, agitation or delirium. This should be treated with adequate sedation and analgesia. ii) Patients in the recovery phase of acute renal failure are often hypertensive. This usually represents resetting of endogenous neurohumoral mechanisms and as such does not need treatment. iii) Similarly, neurogenic hypertension is frequent following head injury or intracerebral haemorrhage and is generally self-limiting and does not require treatment. The use of vasodilators in this setting is relatively contraindicated. iv) Antihypertensives should be titrated against the patients premorbid blood pressure.

72 b) Indications i) Acute a) Acute perioperative control of hypertension post- cardiac, carotid, or cerebrovascular surgery, or for patients with critical myocardial ischaemia. b) Hypertensive crisis (malignant hypertension) c) Pre-eclampsia / eclampsia d) Phaeochromocytoma ii) Other indications for vasodilators a) Reduction of afterload in cardiac ischaemia and failure b) Adjunct to passive warming in hypothermia iii) Chronic a) Sustained hypertension >150/100 mmHg b) Ischaemic heart disease c) Cerebrovascular disease Complications i) Reflex tachycardia ii) Hypotension (especially in hypovolaemic patients) iii) Tachyphylaxis iv) Pulmonary vasodilatation causing shunt and hypoxia v) Cyanide toxicity (SNP) Standard Infusion & Dose
30mg / 100ml 5% dextrose (non PVC bottle and giving set) Range 2-25 ml/hr First line drug in RAH ICU 50mg / 250 ml 5% dextrose Range 3-40 ml/hr 10mg / 10ml 5%dex: titrate 10-20 mg as bolus 20-40 mg 6-8 hourly

c)

Agent
Glyceryl trinitrate (GTN)

Uses
1. 2. 3. 1. 2. Mainly venodilation: useful in cardiac ischaemia Less predictable control of hypertension Tachyphylaxis develops within 24-48h; will need additional agents for persistent hypertension Rapid control of hypertensive crises. Tachyphylaxis and metabolic acidosis may imply cyanide toxicity (total dose > 1.5mg/kg/24 hrs) Pure blockade, short acting antihypertensive Short to medium term parenteral antihypertensive. Often use with blockers for reflex tachycardia Useful in renovascular hypertension Long acting oral Ca++ antagonist. Caution in renal impairment Treatment of hypertension Left ventricular dysfunction, esp post-MI Left ventricular failure Diabetic nephropathy Caution in renovascular disease and renal failure

Sodium nitroprusside (SNP) Phentolamine Hydrallazine

1. 1. 2. 3. 1. 2. 1. 2. 3. 4. 5.

Amlodipine Captopril

5-10mg oral bd Start low dose ~ 3-6.25mg up to 50mg orally 8 hrly Syrup: 5mg/ml or tablets Acute hypertension: 6.25-25mg sublingually prn Start 2.5mg daily up to 20mg bd orally

Enalapril

73
Phenoxybenzamine Oral : 10mg/day until postural hypotension IV : 1mg/kg/day (dilute to 200500ml) : 1/3 dose over 1/24, 2/3 dose over 1/24 Start with 0.5mg, and increase up to 5mg bd orally 1-2mg IV bolus (up to 10 mg) Oral: 25-100mg bd 1. 2. 3. 1. 2. 3. 1. 2. 3. 4. 5. 6. 7. 1. 2. 1. 2. 3. 1. 2. 3. 4. 5. 1. 2. 3. 4. 1. 2. 3. Long acting blocker Preoperative preparation of phaeochromcytoma Idiosyncratic hypotension may occur -blocker Potent antihypertensive agent Beware first dose effect, esp if underfilled Used in high sympathetic drive states : neurogenic hypertension All grades of hypertension, including renovascular Cardiac ischaemia Control of reflex tachycardia with vasodilators Thyroid crisis Caution in poor LV function, asthma Renal excretion; virtually no hepatic metabolism As for atenolol Mainly eliminated by hepatic metabolism Ultra short acting -blocker Useful as trial for patients with poor LV function. Adjunct to vasodilators post cardiac surgery Acute, centrally mediated hypertension Useful post cardiac surgery Withdrawal states Care with hepatic or renal dysfunction May cause rebound hypertension with chronic use. Third line drug for chronic hypertension, esp if intolerant of ACEI Pregnancy induced hypertension May require diuretic / ACEI IV useful in centrally mediated hypertension Pre-eclampsia / eclampsia Phaeochromocytoma Sympathetic overdrive in tetanus

Prazosin

Atenolol

Metoprolol Esmolol

Oral: 25-100mg bd Loading dose 0.5 mg/kg Infuse 100mg/10ml and titrate Start 25g 150g IV. Oral: 75g bd up to 150-300g tds. 250mg - 2g /day oral bd 125mg - 250mg IV bolus

Clonidine

Methyldopa

MgS04

40-60mg/kg (or 4g) loading, infuse at 2 - 4 g/hr to maintain Mg level > 1.5 - 2 mmol/l

74 4. Antiarrhythmics a) General principles i) Prior to administration of antiarrhythmic agents, optimize correction of the following: a) Hypovolaemia b) Metabolic abnormalities ( K+, Mg++, HPO4=, alkalosis) c) Myocardial ischaemia or cardiac failure (especially post cardiac surgery) d) Sepsis e) Pain and agitation. ii) All antiarrhythmic drugs should be regarded as pro-arrhythmic. iii) Virtually all depress myocardial contractility. iv) Antiarrhythmics drugs are indicated when the arrhythmia causes haemodynamic compromise (hypotension or prolonged tachycardia >120-130/min) or in susceptible patients with myocardial ischaemia. v) Consider anticoagulation if AF > 48 hours Indications i) Termination of an acute arrhythmia ii) Prophylaxis for recurrence

b)

75 Agent
Amiodarone

Infusion concentration/Dose
Acute use: 900mg / 250ml 5%D: Load 100ml / 1 hr (5mg/kg) Infuse 10 ml/h for 24-48 hrs (15mg/kg/day) Chronic: 200-400 mg IV/oral daily

Uses
1. Effective in treatment and prophylaxis of: Rapid atrial flutter/fibrillation or MAT complicating acute illness, especially sepsis. Monomorphic ventricular tachycardia Generally does not suppress contractility Can cause acute hypotension of given too rapidly Less proarrhythmic potential than most other drugs Causes QTc, but rarely Torsade de pointes Renal excretion is minimal no need to change dose in renal failure Long term side-effects rare in short-term use. Interference with digoxin kinetics and assay. Interference with thyroid function tests. Acts principally as a calcium blocker Useful in atrial fibrillation and Torsade de pointes Conversion atrial flutter SR SVT 2nd line to Adenosine Ventricular rate control in rapid AF (usually 2nd line to amiodarone in critically ill) Narrow therapeutic index esp in renal failure and metabolic abnormalities ( K+, Mg, PO4, alkalosis) Proarrhythmic potential high in critically ill patients Minimal inotropic effect in critically ill patients Hypokalaemia potentiates effects Used in high sympathetic drive states : neurogenic hypertension Control of reflex tachycardia with vasodilators Caution in poor LV function, asthma Renal excretion; virtually no hepatic metabolism Class III and -blocking actions Low proarrhythmic potential Useful in: Supraventricular tachyarrhythmias Conversion atrial flutter/fib SR Diagnosis/ conversion of SVT (prolonged AV conduction) Sustained, recurrent VT (2nd line drug after amiodarone) No longer routinely used for prophylaxis for VT VF resistant to defibrillation (now questioned) Potent negative inotrope, causes convulsions Digoxin toxicity Tricyclic induced malignant arrhythmias

2. 3. 4. 5. 6. 7. 8. 9. 1. 2. 1. 2. 1. 2. 3. 4. 5. 1. 2. 3. 4.

Magnesium Verapamil Digoxin

5-10 mmol IV slow bolus Infuse at 2-5 mmol/hr 5-10 mg IV slow bolus Rapid digitalisation: 0.5-1 mg IV. Maintenance: 62.5-250 g IV/ oral daily (levels 0.6 - 2.3 nmol/l)

Atenolol

1-2mg IV bolus (up to 10 mg) 25 - 100mg oral bd

Sotalol

10-80 mg IV slow bolus (10-15 min)

1. 2. 3.

Adenosine Lignocaine

6-12 mg rapid IV push 0.4% solution = 4mg/ml : 60ml/hr (4mg/min) for 1-2 hrs 45ml/hr for 2-4 hrs 30ml/hr for 2-4 hrs 15mg/kg loading / 1 hr 300 mg/day (level 40-80 mmol/l)

1. 1. 2. 3. 4. 1. 2.

Phenytoin

76 5. Thrombolytic Therapy NB: All patients with acute myocardial infarction should be considered as potential candidates for primary angioplasty. The Cardiology cover must therefore be notified as early as possible of all patients with an acute MI. The duty cardiologist will decide between primary angioplasty, thrombolysis, and expectant management. a) Indications i) Acute myocardial infarction a) Thrombolytic therapy is now standard in the management of acute myocardial infarction; however, the patient should be advised of the potential risks and benefits. b) Administered in consultation with the duty cardiologist. c) Patient criteria (1) No specific age limit discuss with Cardiology (2) Ischaemic chest pain > 30 min & < 12 hrs (a) Benefit is inversely proportional to delay in thrombolysis, therapy should be considered a medical emergency (b) Late therapy may be inappropriate for small infarcts. (3) ECG evidence of acute infarction: (a) ST segment 2mm in two (or more) chest leads, or (b) ST segment 1mm in two adjacent limb leads, or (c) New LBBB (d) Posterior infarction (R in V1 + ST in V2) (e) Note: no benefit has been demonstrated for patients with ST-depression, T-wave inversion, or a normal ECG. (4) No contraindication. ii) Haemodynamically significant pulmonary embolism. a) An unequivocal diagnosis (usually spiral CT or angiogram) is necessary prior to thrombolysis b) Tenecteplase is preferred in life threatening pulmonary embolism Contraindications: i) Absolute: a) Lack of verbal informed consent. b) Active internal bleeding. c) Recent head trauma, major trauma or surgery within 3 weeks. d) CVA within 6 months. e) Refractory hypertension (> 200/100 mmHg) ii) Relative: a) Known bleeding diathesis b) Current use of anticoagulants (warfarin) c) Active peptic ulceration or other GI bleeding within 6 months. d) Prolonged CRP (> 10 mins) and/or traumatic resuscitation e) Pregnancy. f) Diabetic proliferative retinopathy. g) Non-compressible vascular puncture/injury.

b)

77 iii) Each of these relative CIs should be considered in view of the potential clinical benefit and risk to each patient. Complications i) Bleeding (incidence of cerebral haemorrhage is ~ 0.5%) ii) Anaphylaxis/anaphylactoid reactions: hypotension, rash, bronchospasm iii) Reperfusion arrhythmias Routine follow-up i) ECG at 1 and 4 hours post STK/TNK ii) Cardiac enzymes 6, 12 and 24 hours post infusion iii) IF ST-elevation persists 1 hr post-TNK, contact cardiology regarding rescue angioplasty.

c)

d)

Drug
Streptokinase STK

Dose
1.5 million units / 50mls NS over 60 mins via syringe pump

Protocol
1. 2. 3. 4. 150mg aspirin prior to therapy, then daily No IV heparin. Heparin 12,500u S/C 4 hours post commencement of STK, then bd for 14 doses STK can be re-used within 3 days for re-infarction 150mg aspirin prior to therapy, then daily Enoxiparin 30mg IV prior to TNK Enoxiparin 1mg/kg sc bd. Heparin 5000U IV pre-TNK Heparin infusion: APTT > 50-80 secs Local pressure Reverse heparin with protamine (check APTT) Cryoprecipitate 10 units + FFP 2 units Defibrination or intracranial bleed: EACA: 5g over 1 hr, then 1g / hr

Tenecteplase TNK

Tenecteplase - PTE Bleeding protocol:

Single dose: 1. 0.5 mg/kg over 10 sec 2. non-glucose containing line 3. flush line with N.Sal pre & post TNK Maximum dose = 50mg (=10,000U) As Above

1. 2. 3. 1. 2. 1. 2. 3. 4.

Monitor: APTT PR fibrinogen level Euglobulin clot lysis time

78 6. Antiplatelet Agents Agent

ReoPro (abciximab)

Usual dose
Bolus: 0.25mg/kg IV over 1 min, 10mins before PTCA Infusion: 0.125g/kg/min IV for 12hrs. (max rate = 10g/min)

Indications/Comments
Only to be ordered by Cardiology Binds to platelet glycoprotein IIb/IIIa receptor, inhibiting platelet aggregation and thrombus formation Primarily used with PTCA Used with aspirin and heparin (although no set protocol for heparin) Increased risk of major bleeding Only to be ordered by Cardiology Blocks platelet glycoprotein IIb/IIIa receptor Short half-life (1.4-1.8 hrs) Uses: unstable angina, non-Q wave MI Use with heparin and aspirin Continue through angiography, and for 1224hrs post-PTCA Check platelet count 6hrs post-bolus, then at least daily SEs: bleeding (major 1.4%), thrombocytpenia, fever Irreversibly modifies platelet ADP receptor, inhibiting aggregation Uses: prevention of vascular ischaemic events eg MI, CVA, PTCA

Tirofiban

Bolus: 0.4 g/kg/min for 30 mins Maintenance: 0.1 g /kg/min for at least 48hrs NB: reduce doses by 50% with severe renal insuff. (eg Creat clearance <30ml/min) 75mg orally daily 300mg oral loading dose prePTCA (then 75mg daily)

Clopidogrel

D. 1.

Respiratory drugs Nebulised bronchodilators a) General Principles i) These agents are the mainstay of treatment for bronchospasm in Intensive Care (including acute severe asthma). ii) They are not routinely used in all ventilated patients. iii) Once commenced, they must be reviewed daily regarding efficacy. This is assessed by improvements in audible wheeze, lung compliance, respiratory rate and blood gases. b) Indications: i) Pre-existing asthma / chronic airflow obstruction (CAO) ii) Acute severe asthma iii) Acute bronchospasm 2o to infection, aspiration or during mechanical ventilation iv) Acute exacerbation of CAO

79 2. Parenteral therapy a) Indications: i) Adjunctive therapy for acute severe asthma in patients not responding to nebulised agents ii) Selected patients who are difficult to wean from ventilation (usually due to CAO) iii) Maintenance in patients with chronic airflow obstruction Complications i) Hypokalaemia, metabolic alkalosis ii) Arrhythmias (theophylline) iii) Intercurrent infection (steroids) iv) Polyneuropathy (steroids) Infusion/ dose
Nebulised in N.Saline (1ml:1ml) continuously, 2 or 4 hourly Nebulised in addition to salbutamol (1ml:1ml) Nebulised 1 mg bd

b)

Drug
Salbutamol (nebulised) Ipratroprium bromide Budesonide (nebulised steroid)

Clinical uses
1. 2. 1. 2. 1. 2. 1. 2. 3. First line bronchodilator Used in severe hyperkalaemia Chronic airflow obstruction (CAO) Bronchorrhoea Steroid dependent CAO Acute exacerbation of CAO Acute severe asthma Rapid onset and offset of action Titrate until demonstrate pressor response (may require up to 100 g/min) Acute severe asthma Longer duration of action All patients with acute severe asthma; wean off over 48-72 hrs once broken Acute exacerbation of CAO No longer 1st line drug. May improve respiratory drive in CAO Narrow therapeutic index: proarrhythmic

Adrenaline (IV)

6 mg / 100 ml 5% dextrose (ml/hr = g/min)

Salbutamol (IV) Hydrocortisone

6 mg / 100 ml 5% dextrose (ml/hr = g/min) 100 mg IV 4 - 8 hourly

1. 2. 1. 2.

Theophylline

1000mg/100ml 5% dextrose Loading 5- 7mg/kg, Infuse 2-4ml/hr (1gm/day) Levels: 55 - 110 mol/l 500g + 10ml diluent (50g/ml) Add to 40ml NSal, infuse with syringe driver into nebuliser (set at 8l/min flow rate) at 2 - 4 ml/hr.

1. 2. 3.

Prostacyclin (inhaled)

1. 2.

Selected patients with ARDS with pulmonary HT and severe hypoxia. Consultant authorisation mandatory.

80 E. 1. Sedation, analgesia and muscle relaxants Sedatives and analgesics a) Adequate analgesia and anxiolysis are primary goals in the management of the critically ill patient. b) Pain and anxiety are associated with significant adverse physiological responses: i) Hypertension, tachycardia, increased myocardial oxygen consumption ii) Gastric erosion iii) Intracranial hypertension iv) Persistent catabolism c) Sedatives and analgesics in ICU are also associated with adverse effects: i) Respiratory depression ii) Prolonged ventilation and associated complications (eg nosocomial infections) iii) Emergence delirium and sympathetic overdrive, accidental extubation and removal of lines iv) Hypotension due to unmasked hypovolaemia. v) Gastroparesis, ileus vi) Increased cost, ventilator days d) Sedation protocol for Intensive Care patients. i) It is important, although often difficult, to obtain a reasonable balance between the awake, distressed patient and the patient that is oversedated: ii) Sedation should be given by infusion to maintain constant levels rather than peaks and troughs iii) Titrate infusions to clinical effect: there is marked interindividual variability and absolute doses are meaningless iv) Patients with renal, hepatic or associated encephalopathy may require lower doses (or no sedation at all) v) Prescribe the desired sedation level by circling the box above the morphine/midazolam infusion label on the flow chart: a) Light: easily roused, eyes open to speech, purposeful response default usually spontaneous respiration or partial ventilation nocturnal sedation b) Moderate: rouses to tactile or painful stimuli, eyes closed, usually partially or fully ventilated c) Heavy: no voluntary response to any stimulus weak cough on suction fully ventilated paralysis. vi) Nurse controlled sedation protocol a) Titrate sedation to prescribed level (as above) b) If patient becomes oversedated, halve sedation rate. c) If patient remains oversedated when assessed the following hour, halve sedation rate again and so on until desired level is reached or sedation is ceased.

81 If patient is undersedated, increase rate according to dose range prescribed. If insufficient, bolus sedation/analgesia may be indicated until a satisfactory level is attained. e) Grimacing is not a reliable sign and may only indicate awareness or reflex activity. f) Infusions should not be titrated to response during high intensity stimuli, eg suction. In this situation, bolus sedation may be required. vii) PCA or epidurals are considered when the patients are awake. Notify the Acute Pain Service of these patients (see next section) d) Drug
Morphine and midazolam Morphine Fentanyl Diazepam

Infusion/dose
Morphine 60mg + midazolam 30mg per 50ml 5% dextrose Rate: 1-30 ml/hr 1-5 mg IV, sc prn, or PCA per protocol 100-200 g IV bolus Infusion: 50-200 g/hr
(neat solution)

Clinical uses
1. 2. 3. 1. 2. 1. 2. 3. 1. 2. 3. 1. 2. Standard sedation/analgesia regimen Review rate/sedation at least daily Effects prolonged in renal failure First line analgesic May be useful in pulmonary oedema Haemodynamic stability Potent medium acting narcotic Useful for ICU procedures. First line anticonvulsant (IV) First line anxiolytic esp in delirium Larger doses may be required in acute alcohol withdrawal* Short term sedation of intubated and ventilated patients, where extubation is expected within 24-48 hrs Do not use in patients where prolonged ventilation is anticipated, except where repeated neurological assessment is required (eg. CHI), or in the presence of hepatic or renal failure. Anaesthesia for minor procedures where prompt return of consciousness is required (eg tracheostomy, CVC) Potent myocardial depressant No analgesic effect. Standard epidural analgesic regimen Plain bupivacaine may be used (0.25%) Maximal duration 4 days unless indicated First line major tranquilliser, use for delirium, agitation esp. in opioid / benzodiazepine withdrawal. blocker : may cause hypotension As for haloperidol; 2nd line tranquilliser More sedating, unpredictable & longer acting agent

IV: 2-10 mg prn Orally: usually 5-10mg bd-qid* 10mg/ml (neat solution), Start at 3ml/hr and titrate against effect

Propofol

3. 4. 5. 1. 2. 3. 1. 2. 1. 2.

Epidural cocktail (APS protocol) Haloperidol

Fentanyl 5g/ml and Bupivacaine 0.1% Rate: age related doses (as per APS protocols) 2.5-5 mg IV prn

Chlorpromazine

5-10 mg IV prn

82 2. Acute Pain Service Protocols a) b) c) Liaise with the APS (pager 22556, anaesthetic registrar after hours) for all patients on the following regimens. (Director Acute Pain: Dr P E Macintyre) Refer to Guidelines for Anaesthetists document by the Acute Pain Service. PCA (Patient Controlled Analgesia) i) Notify the APS as soon as a patient requiring a PCA is identified. ii) All patients with PCA should have a Acute Pain Service PCA Standard Orders form, completed and signed by the APS Anaesthetist, filed in the patients blue folder. iii) Monitoring and documentation as per standard order with all documentation performed on the ICU flowchart including pain and sedation scores. iv) Prescription a) Loading dose: zero *best to titrate for each patient before starting PCA b) Incremental dose: (1) Morphine 1 mg (1mg/ml solution) (2) Pethidine 10 mg (10mg/ml solution) (3) Fentanyl 20 g (20g/ml solution) (4) Start with half these amounts for patients > 70years. (5) Double the dose if analgesia is inadequate and the patient is getting > 3 doses per hour. c) Lockout period: 5 mins d) Background infusion: (1) 0 mg/hr before the patients opioid requirements are known. (2) If required (in selected patients) rate should not exceed the size of the bolus dose. e) PCA in the opioid dependent patient: (1) These patients may require much larger doses of opioid and a background infusion. (2) Calculate an appropriate background infusion on 75-100% their normal daily requirement. (3) Bolus-dose then the same as the background infusion in mg/hr. (4) Refer to APS guidelines for equi-analgesic doses of oral and IV opioids. v) Inadequate analgesia a) Consider another cause ie post surgical or post injury complication. b) If receiving 2 boluses/hr, re-educate patient re PCA mechanism c) If receiving 3 boluses/hr, increase size of bolus dose vi) Respiratory depression a) Sedation score = 2: resp rate > 6/min : reduce (eg half) bolus dose b) Sedation score = 2: resp rate < 6/min : reduce bolus dose, give naloxone 100g. c) Sedation score = 3: regardless of respiratory rate :give naloxone 100g, repeat prn.

83 d) Epidurals i) General principles a) Epidurals are usually placed by the Anaesthetist before surgery in appropriate patients and are subsequently managed by the APS when these patients are in ICU or HDU. b) These patients should have an Acute Pain Service epidural/intrathecal opioid analgesia standard orders form (UR 72.1) completed and signed by the APS anaesthetist c) Epidurals inserted in ICU patients are performed by ICU staff unless discussed with the APS. d) Notify the APS as soon as a patient requiring an epidural is identified and order the initial infusion rate and bolus dose range as appropriate. e) All patients must receive a test dose (3ml 2% lignocaine + 1:200000 adrenaline) and establishment of block prior to commencement of an infusion. For patients having epidurals in theatre, discuss this with the anaesthetist and ensure adequate documentation in the anaesthetic record. f) Monitoring and documentation as per standard APS orders, with all documentation recorded on the ICU flowchart including pain and sedation scores. g) The ICU nursing staff will administer boluses according to sedation and pain scores h) The epidural insertion site should be inspected at least once per nursing shift i) Catheters are removed within 4 days unless otherwise indicated by APS. Tips are no longer sent for culture. j) Suspected epidural haematoma or abscess mandates immediate neurosurgical assessment and CT/MRI. ii) Prescription: the standard RAH epidural cocktail is bupivacaine 0.1% and fentanyl 5 g/ml. a) Typical infusion rate (ml/hr): (1) Younger patients: 7-14 ml/hr, PRN bolus 3-6 ml. (2) Older patients: 4-8 ml/hr, PRN bolus 2-3 ml. b) Thoracic epidural infusions will generally require smaller volumes than lumbar. iii) Inadequate analgesia a) Give a bolus dose and increase the rate of infusion. b) Check position of catheter using a test dose of 3-8 ml 1% lignocaine and test for the level of sensory block with cold or alcohol. (1) Bilateral block suggests need for increased dose (rate or concentration) (2) Unilateral block: withdraw catheter and give another test dose. (3) No block or catheter blocked: use alternative method or replace epidural.

84 iv) Respiratory depression a) Sedation score = 2 & respiratory rate > 6/min: reduce (eg half) bolus dose and/or rate b) Sedation score = 2 & respiratory rate < 6/min: reduce bolus dose and/or rate, give naloxone 100g. c) Sedation score = 3, regardless of respiratory rate: cease infusion, give naloxone 100g and repeat prn d) Consider omitting opioid and increasing local anaesthetic concentration or changing to ropivacaine. v) Numbness/weakness a) Check for catheter migration into CSF b) Cease infusion temporarily and restart at a lower rate. e) Intrathecal morphine i) Dose limited to 200 g. ii) Frail elderly patients may only need 100g. iii) Given as a once only dose and will provide up to 24 hours of good analgesia. iv) Spinal catheters may be left in place and are labelled with a specific purple label. v) Inadequate analgesia: carefully administer alternative analgesia eg PCA. Treatment of other side effects i) Nausea/vomiting a) Metoclopramide 10mg IV 4 hourly prn. b) If metoclopramide ineffective, droperidol 500g (250 g if >55yrs) IV 4 hrly prn or tropisetron 2mg IV daily. ii) Severe itching a) Give naloxone 100g IV b) Repeat every 10 minutes prn up to a total of 400 g. iii) Urinary retention: catheterise iv) Hypotension : usually caused by hypovolaemia. a) Check for hypovolaemia, give fluid inotropes b) Temporarily cease / reduce infusion (epidural) Epidural catheters and anticoagulation i) Standard subcutaneous heparin / Enoxaparin a) Remove the catheter no sooner than 10 hours after last dose and 2 hours before next. ii) Warfarin a) Remove the catheter before second dose.

f)

g)

85 3. Muscle relaxants a) General principles i) The use of muscle relaxants for the critically ill patient is different to patients undergoing elective anaesthesia. ii) These agents have a limited role in Intensive Care and must not be used unless the patient is adequately sedated. iii) Non-depolarising agents (except rocuronium) should not be used for emergency (rapid sequence induction) endotracheal intubation Indications i) Depolarising: suxamethonium a) First line relaxant for emergency endotracheal intubation (see section on intubation) ii) Non-depolarising: pancuronium, vecuronium, atracurium a) Acute control of ventilation post intubation b) Patient transport / retrieval on oxylog ventilator c) Selected patients with poor lung compliance on PCV d) Acute procedures: tracheostomy, bronchoscopy Complications i) Hyperkalaemia, bradycardia (suxemethonium) ii) Polyneuropathy (especially with concomitant use of steroids) iii) Sympathetic overdrive, particularly in under-sedated patients iv) Adverse outcome in head injury when used as a measure to control ICP.

b)

c)

Relaxant
Suxamethonium

Dose
100-200 mg or 1-2 mg/kg

Comment
1. 2. 3. 1st line agent in Rapid Sequence Induction (RSI) Consider pre-treatment with atropine (0.6-1.2mg) if potential bradycardia Contraindicated in burns (>3 days), chronic spinal and neuromuscular disease, hyperkalaemic states
(K+ > 5.5)

Rocuronium

0.6 mg/kg 1.0 mg/kg for RSI

1. 2. 3. 1. 2. 3.

First line non-depolarising agent in ICU Rapid onset (60secs) 2nd line agent in RSI - used as alternative to suxamethonium Duration of action : 30-40 minutes 2nd line non-depolarising agent in ICU Long duration of action. Tachycardia rarely a problem in ICU patients.

Pancuronium

2-4 mg IV prn

86 F. 1. Anticoagulation General principles a) Anticoagulants are potentially dangerous drugs. b) All patients on systemic anticoagulation must have an APTT, INR and CBP performed daily. Indications a) Acute systemic anticoagulation: i) As a general rule, heparin infusions titrated to a therapeutic APTT are used in critically ill patients. This allows monitoring and the provision for reversal if indicated (eg procedures, bleeding complications). ii) High dose enoxaparin (eg 1mg/kg bd s/c) is as effective, but potentially more difficult to use in critically ill patients, due to inability to easily monitor activity and reverse effect. iii) Indications: a) Proven venous or arterial thromboembolism b) Myocardial infarction: as sole therapy or with following tPA c) Prosthetic heart valves: (1) prior to commencement of oral anticoagulants (2) during an acute illness, where oral anticoagulation is relatively contraindicated. d) AF in patients complicated by emboli < 70 years. e) AF for more than 48 hours, in which cardioversion is being considered f) Extracorporeal circuits eg CVVHDF g) IABP b) Partial anticoagulation (low dose IV heparin (500 u/hr), IV prostacyclin) c) Patency of CVVHDF circuits (always consider heparin free circuits) d) Oral anticoagulants (INR 2-4: rarely used in ICU) i) Prosthetic valves (mitral > aortic valves) ii) Previous thromboembolism iii) Maintenance of thromboprophylaxis in high risk patients (# pelvis) Protocol for DVT prophylaxis : subcutaneous enoxaparin a) Routine monitoring is not necessary. If required, measure anti-Xa levels b) Indications: virtually all ICU patients i) High risk patients: a) Previous history of DVT, embolism b) Post joint replacement c) Pelvic, lower limb fractures (consider high dose) d) Prolonged femoral venous catheters e) Prolonged immobility, neuromuscular wasting (eg Guillain Barre, polyneuropathy, spinal injury)

2.

3.

87 c) Contraindications: i) Young, short stay patients (<24hrs) eg overdoses ii) Post neurosurgery/eye surgery iii) Acute head injury with parenchymal lesions iv) Intracranial haemorrhage v) Active bleeding, coagulopathy vi) Thrombocytopenia vii) Patients on full anticoagulation viii) Previous documented HITS NB: Consult with appropriate specialty if unclear when safe to start enoxaparin (eg following head injury). In patients who cannot receive subcut heparin: i) TED stockings ii) Calf stimulators iii) Consider temporary IVC filter in high risk patients

d)

4.

Pelvic-Fracture Anticoagulation Regimen a) Check APTT/INR and if normal, then: i) Commence heparin 3500U sc tds, 48 hours post-injury/surgery. ii) Check APTT at 12:00, then adjust dose for 16:00 as follows: APTT < 24 24-28 29-32 33-37 > 37 Heparin Dose Alteration + 1000 U + 500 U 0 - 500U - 1000 U

iii) Repeat check APTT at 12:00 daily until stable, then at 48hr intervals. iv) Note: This is the target range for prophylaxis not treatment, disregard the new reference range (60-90s) for the IMVS. v) For removal of epidural catheters omit the 24:00 & 08:00 doses, remove the catheter at 12:00 and recommence heparin at 16:00. vi) Check platelet count no later than 5 days post commencement of heparin, then weekly thereafter. If >50% fall hold heparin and discuss with haematology. vii) Convert to oral warfarin after 7 days if indicated. a) Use RAH age adjusted Warfarin Loading Protocol (Section 7) b) Continue warfarin until full weight-bearing mobilisation.

88 5. Recommendations for perioperative anticoagulation in patients on warfarin a) Heparin infusion remains the first choice in ICU, as the effect is more readily monitored and reversed. b) Therapeutic enoxaparin should not be used in this setting (unless heparin is contraindicated). Protocol for Heparin Induced Thrombocytopaenia Syndrome (HITS) a) General principles i) Occurs in 1-5% patients: possible incidence with CVVHDF ii) Severe form a) 7-10 days after starting heparin b) autoimmune mediated platelet aggregation with thrombosis c) Not dose related: both with high dose and, in sensitised patients, low dose heparin (including vascular catheter flushes) d) Mild form: early onset, often less severe and dose related. b) Suspected HITS : unexplained thrombocytopaenia and/or thrombosis in a patient receiving heparin i) Consider other causes of thrombocytopaenia ii) Withhold all heparin and contact Dr John Lloyd (Haematologist) iii) HITS screen: 10ml blood in blue top container (includes LMWH cross reactivity) c) Confirmed HITS i) Cease all heparin (including flushing bags) ii) Consider indications for heparinisation or use other agent, eg danaparoid iii) Document heparin allergy in case notes iv) Cross reactivity with low molecular weight heparin test: a) None: (1) start enoxaparin (2) monitor the platelet count (*test is not 100% sensitive) b) Positive: + anticoagulation indicated (1) Life threatening thrombosis/embolism: (a) start danaparoid (b) consider a caval filter (2) Short-term anticoagulation eg patency of CVVHDF circuit: consider no anticoagulants or IV prostacyclin. (3) Prophylaxis: consider TED stockings or subcut danaparoid.

6.

89 7. Anticoagulants Drug
Warfarin Heparin (infusion)

Infusion / Dose
1. 2. 3. 1. 4. 1. Variable dose INR See age-adjusted Warfarin loading protocol below Daily INR 25000u/50ml = 500u/ml Start at 2ml/hr (1000u/hr): titrate against APTT: 50-80 secs. Prophylaxis: 40mg subcut daily 20mg subcut daily if Creat clearance < 30ml/min Treatment: 1mg/kg subcut bd - lean body mass 1mg/kg subcut once daily if Creat clearance <30ml/min 5000 u subcut bd 5000 u subcut 8 hrly <70 kg >70 kg or high risk DVT

Enoxaparin (Clexane) (subcut)

2.

Heparin (subcut) (Wakefield Hospital)

1. 2. 1. 2. 3. 4. 1.

Prostacyclin (infusion)

Dose: 0.2-0.6 g/kg/hr 500g (+10ml diluent): add to 40ml NSal = 10g/ml solution Start at 2ml/hr and monitor platelet count May cause hypotension IV loading dose: < 60kg 1500 U 60-75 kg 2250 U 75-90 kg 3000 U > 90 kg 3750 U Infusion: 2250U of danaparoid in 250ml 5% dextrose: 44 ml/hr (400 U/hr) x 4 hours 33 ml/hr (300 U/hr) x 4 hours 22 ml/hr (200 U/hr) Adjust dose to anti-Xa levels (target 0.5-0.8 anti-Xa U/ml) Long half life (25 hrs): cease early if changing to oral anticoagulants 750 U 8-12 hourly

Danaparoid sodium (Orgaran) Infusion

2.

3. 4.

Danaparoid (subcut)

1.

90 Age Adjusted Warfarin Loading Protocol*

Day 1 2 (16hrs after 1st dose) INR <1.4 1.5 1.6 1.7 1.82.3 2.42.7 2.83.1 3 (16hrs after 2nd dose) 3.23.3 3.4 3.5 3.64.0 >4 1.5 1.6 1.71.8 1.9 2.02.6 4 (16hrs after 3rd dose) 2.73.0 3.13.5 3.64.0 4.14.5 12 >4.5 Dose (mg) according to age (yrs) 50 yrs 10 10 0.5 10 5 4 3 2 1.5 1 0.5 0 1015 8 7 6 5 4 3.5 3 5165 yrs 9 9 0.5 9 4.5 3.5 2.5 2 1.5 1 0.5 0 914 7 6 5 4.5 3.5 3 2.5 6680 yrs 7.5 7.5 0.5 7.5 4 3 2 1.5 1 1 0.5 0 7.511 6 5 4.5 4 3 2.5 2 >80 yrs 6 6 0.5 6 3 2 1 1 1 0.5 0.5 0 69 5 4 3.5 3 2.5 2 1.5

Omit next dose, then 0.51.5 0.51.5 0.51

Nil. Hold dose.

*Roberts GW, Gallus AS, Druskeit T et al. Comparison of an age adjusted warfarin loading protocol with empirical dosing and Fennertys protocol. Aust NZ J Med. 1999; 29: 731-6.

NB. This table is meant only as a guide, and was developed for non-critically ill patients, whose pharmacodynamics may differ significantly from the intensive care population. INR must be checked daily.

91 G. Endocrine drugs 1. Insulin a) Indications: i) Diabetic emergencies DKA and hyperosmolar coma ii) Treatment of hyperkalaemia a) 50% dextrose 50ml, plus Actrapid 10U iii) Perioperative diabetic patients (both insulin and non-insulin dependent) iv) General ICU patients a) Hyperglycaemia 8 mmol/l or glycosuria associated with acute illness. Since the paper published by Van den Berghe (NEJM 2001,345:1359-1367) we have introduced tighter control of BSL in the critically ill. However because of the risk of hypoglycaemia and some doubt as to whether her patient group corresponds to ours we have chosen higher BSL goals than chosen in that study. Almost all critically ill patients will require insulin infusion using this protocol. This protocol is not designed for patients with diabetic ketoacidosis and is a guideline only. Some patients will require individual manipulation of dose. b) Subcutaneous sliding scale insulin may be used in a small number of less critically ill patients with a limited need for insulin and for recovering patients in whom venous access is not available. v) TPN patients may have insulin added to TPN if glucose intolerant: Use insulin requirement on IV protocol to guide the amount to add to TPN. b) ICU Insulin Protocol see following page. i) Protocol Precautions: a) If the insulin infusion is running at 10 units/hr or more and the BSL remains high, consider that the BSL measurement may be erroneous and take another sample from another site and send it to the lab for BSL check. b) Consider holding the insulin infusion if feed or glucose infusions are stopped. c) Potassium level (1) Administration of insulin reduces K levels. (2) Check K on ABG specimen at least twice daily and more often if the insulin infusion rate is high or changing acutely. (3) If [K] < 3.5 mmol/l notify MO ii) Discharge Management: a) Cease insulin infusion at least 4 hours prior to discharge from ICU and check BSL. b) Order ward management for BSL as indicated.

92

Perform BSL on admission

Target BSL = 5-7.9

BSL = 5-7.9 mmol/l

BSL outside 5-7.9mmol/l

Perform BSL 4 hrly

Commence Insulin Protocol ( as below )

BSL mmol > 15 10 - 14.9 8 - 9.9 5 - 7.9 3.5 - 4.9 < 3.5

Bolus Units IV 2 1 0 0 0 Call MO

Starting infusion Units/hr 2 1 0.5 0 0 0

Subsequent infusion Units/hr Increase by 1 U/hr Increase by 1 U/hr If BSL dropping continue current rate. If static or rising increase by 0.5 Continue current rate NB: If BSL dropping for 2 consecutive hrs decrease rate by 0.5. Cease infusion Cease infusion

Repeat BSL Hours 1 1 1 1 (2hrly if BSL stable for 6 hrs) 1 (4hrly if off insulin > 6hrs) 1

93 2. Diabetes insipidus: protocol for DDAVP a) Diabetes insipidus may occur in the following situations: i) Post ablative pituitary surgery ii) Severe head injury, esp. anterior cranial fossa #, trauma iii) Evolving brain death b) Indications for DDAVP i) Acute perioperative management (24-48 hours) of diabetes insipidus following pituitary surgery is usually fluid based. The requirement for DDAVP is uncommon and usually not indicated. ii) In the above situations: a) Persistent polyuria (>300 ml/hr for > 3-4 hours) in the absence of diuretics b) Altered conscious state or inability to detect thirst or take oral fluids c) Low urine osmolality in the presence of high plasma osmolality d) Pre-existing hyperosmolal state or predisposition to pre-renal failure where persistent polyuria may exacerbate this. c) Maintenance fluids should be prescribed in the usual manner according to fluid volume status, renal function and osmolality. d) Prescription i) Dose 1-2 g IV bd as required. (4 g is excessive) ii) Adjust maintenance fluids according to response. Steroids a) Indications Proven ICU indications
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Hypoadrenalism (Addisons disease/crisis) Acute severe asthma Acute spinal cord injury Panhypopituitarism Meningitis (esp. pneumococcal) Collagen vascular diseases (RA, SLE, PAN) Pneumocystis carinii pneumonia Immunosuppression eg transplant, GVHD Myasthenia gravis Septic Shock in non-responders to SST CAO (effect is small)

3.

Unproven ICU indications

1. 2. 3. 4. Non-infected fibroproliferative ARDS Myocarditis Bronchiolitis obliterans Cerebral oedema around abscess/tumour 5. Anaphylaxis

b)

Contra-indications / non-indications i) Active infection (excluding indications per above) ii) ARDS except as above iii) Acute head injury iv) Guillain Barre syndrome v) Fat embolism syndrome

94 c) Relative drug potencies Equivalent dose (mg) 100 25 20 4 125 1 Glucocorticoid activity 1 4 4 30 0.8 10 Mineralocorticoid activity 1 0.3 0 0 0.8 250

Drug Hydrocortisone Prednisone Methylprednisolone Dexamethasone Cortisone acetate Fludrocortisone d)

Short synacthen test i) Indication: a) Suspicion of hypoadrenalism b) Hyperkalaemia, hyponatraemia, hypoglycaemia, refractory acidosis c) May be in association with septic shock (incidence is 75%): (1) Refractory hypotension despite aggressive inotropic and fluid support (2) Relative hypothermia ii) Test: a) Semi-quantitative adrenal response to extrinsic ACTH b) Baseline serum cortisol c) 250 g synacthen IV d) Serum cortisol level at 30 and 60 minutes thereafter iii) Interpretation: a) Normal (septic): baseline > 1000 nmol/l, increment >250 nmol/l b) Hypoadrenalism: baseline < 200 nmol/l, no response to ACTH c) Intermediate: baseline 200-1000 nmol/l may or may not increment > 250 nmol/l iv) Increment < 250 nmol/l warrants steroid replacement therapy. Cortisol can be started immediately after the SST is taken and stopped if the cortisol increment is adequate. 50 mg hydrocortisone qid iv is the recommended dose for patients who do not increment and have septic shock. Fludrocortisone 50 gm daily NG can also be given. Protocol for steroids in acute spinal injury i) Indication: acute spinal injury with neurological loss within 8 hrs of injury ii) Loading dose: 30mg/kg methylprednisolone over 15 minutes iii) Infusion: 5.4 mg/kg/hr 45 minutes after completion of loading dose for, a) 23 hours if started within 3 hours of injury b) 47 hours if started 3-8 hours after injury.

e)

95 H. Renal drugs 1. General principles for use of diuretics in ICU a) Oliguria in acutely ill patients is frequently a manifestation of hypovolaemia, decreased cardiac output, direct renal toxicity, or a combination of these factors. Therapy should be directed toward these factors prior to the administration of a diuretic agent. b) Urine output, in the absence of diuretic use, represents one of the best markers of end-organ perfusion and is a useful guide to clinical management. Indications a) Symptomatic fluid overload i) Pulmonary oedema ii) Congestive cardiac failure: cor pulmonale b) Diuretic dependent renal function c) Hyperaldosterone states: ascites Contraindications a) Hypovolaemic and/or Na+-depleted states b) Known drug hypersensitivity (esp. sulphonamide group) Complications a) Hypovolaemia b) Hyperosmolal states due to inappropriate diuresis in hypovolaemia c) Potentiation of renal failure - 2o to hypovolaemia d) Electrolyte disturbance especially K+, Mg, PO4, metabolic alkalosis e) Naturesis and kaliuresis will alter urine electrolytes and osmolality for 24-48 hrs post dose.

2.

3.

4.

96 Drug
Frusemide

Infusion/dose
40-250 mg IV / oral prn / bd

Clinical uses
1. First line, potent loop diuretic 2. Doses may be increased in diuretic dependence 3. K+, Mg, PO4, metabolic alkalosis common 1. Carbonic anhydrase inhibitor: alkaline diuresis with HCO3- excretion 2. Used for severe metabolic alkalosis after correction of hypovolaemia: K+, Mg, PO4 3. May be useful in weaning CAL from ventilation with post hypercapneoic alkalosis 1. Potent osmotic diuretic 2. May cause hypovolaemia and hyperosmolal states. 3. Causes an osmolal gap (measured-calculated osmolality). 4. Maintain measured osmolality < 300 mosmol/l 5. Limited role in acute head injury after resuscitation for suspected acute intracranial hypertension. 6. Limited (unproven) roles in rhabdomyolysis, transfusion reactions, myoglobinuria for renal protection

Acetazolamide

250-500 mg IV

Mannitol

20% solution / 200 mg/ml

Dose 100 ml prn (20g)

(0.5g/kg is too much!!)

97 I. 1. Gastrointestinal drugs Stress ulcer prophylaxis a) General principles i) Clinically important GI bleeding in ICU patients is relatively uncommon (<2%). This is due to: a) Improved attention to cardiopulmonary homeostasis. b) Better sedation and analgesia and avoidance of muscle relaxants. c) Prompt and frequent use of enteral feeding. d) Prompt treatment of intercurrent sepsis. b) Indications for stress ulcer prophylaxis i) Absolute a) Pre-existing or subsequently proven peptic ulceration. These patients must receive H2 antagonists for the duration of their stay in ICU and continue upon discharge. b) Patients on proton pump inhibitors should continue, cf ranitidine ii) High risk critically ill patients (risk of bleeding 5%) a) Pre-existing or intercurrent coagulopathy b) Mechanical ventilation > 48 hrs c) Protocol i) Consider enteral feeding as soon as possible: a) If established: no need for further prophylaxis. b) Prior to enteral feeding, or if feeding is unsuccessful: ranitidine IV 50 mg 8 hrly (adjust for renal insufficiency) Acute GI bleeding a) Definition i) Overt bleeding: ii)

2.

- blood in the NGT - haematemesis or malaena

Plus either: a) MAP > 20 mmHg b) requirement of at least 2 units blood transfusion, Hb 2g/100ml in 24 hours

b)

Blood in the NG tube is frequently due to local erosion and by itself does not constitute clinically significant GI bleeding.

98 c) Management i) ABC / Resuscitation ii) Correct coagulopathy / cease heparin iii) Endoscopy sclerotherapy iv) Consider labelled red cell scan, angiography (+/-embolisation) or colonoscopy if the bleeding source not identified & Hb loss continues. v) Drug therapy for clinically significant GI bleeding: Pantoprazole 40 mg/day or bd iv.

3.

GI drugs Drug
Metoclopromide Erythromycin Droperidol Tropisetron

Dose
10 mg IV 6 hrly, prn 200 mg IV bd 0.625 mg IV prn 2 mg IV / oral daily

Clinical uses
1. 2. 1. 1. 2. 1. 2. Persistent vomiting, nausea Large gastric aspirates 2nd line after metoclopramide for large gastric aspirates. Potent, effective antiemetic Minimal side effects Third line antiemetic after metoclopramide and droperidol Use if anticholinergic side effects are to be avoided. Second line, antiemetic (not available at RAH) Peptic ulcer disease First-line stress ulcer prophylaxis First line RX for peptic ulceration Does not prevent acute rebleeding Reduce dose in renal failure. Refractory peptic ulcer, ulcerative oesophagitis Z-E syndrome Unproven role in acute GI bleeding Variceal bleeding (as effective as sclerotherapy) Enteric, pancreatic fistulae

Ondansetron Ranitidine

4 mg IV prn / 12 hrly 50 mg 8hourly IV 150-300 mg daily po

1. 1. 2. 3. 4. 5. 1. 2. 3. 1. 2.

Pantoprazole

Acute RX: 40 mg IV bd Maint. RX: 40 mg daily Bolus 50 g IV Varices: 50 g / hr Fistulae: 100-200 IV / sc 8-hrly

Octreotide

99 J. 1. Antibiotics Policy a) Prescription of antibiotics must conform to the recommended RAH guidelines (see below). b) The over-prescription and irrational use of antibiotics is associated with the development of bacterial resistance, nosocomial infections and drug related morbidity c) All antibiotics must be reviewed daily and where appropriate, discussed with Infectious Diseases or Microbiology. d) Record the day and expected course of antibiotics in the left-hand margin of the drug chart, eg D4/7 = day 4 of a 7 day course. e) Record date, type and results (including sensitivities) in the results folder. Principles of antibiotic prescription a) The treatment of infection consists of (in order of priority) i) Adequate resuscitation ii) Surgical drainage of infected collections where indicated iii) Rational prescription of antibiotics. b) General indications for antibiotics: i) Prophylaxis for invasive procedures and operations a) Proven indications (1) Abdominal surgery which involves a breach of the colonic mucosa (traumatic or elective), or draining an infected cavity (2) Selected obstetrical and gynaecological procedures: (a) caesarean section when the foetal membranes have been ruptured (b) vaginal hysterectomy (3) Insertion of a prosthetic device (4) Compound fractures (5) Amputation of gangrenous limb b) Unproven but recommended (1) Lacerations penetrating into periosteum or into joint cavities (2) Crush injuries (3) Insertion of neurosurgical shunt (4) Cardiac valve replacement (5) Arterial prosthesis

2.

100 Empirical antibiotics where infection is likely prior to definitive bacteriological diagnosis: a) Obtain as many cultures as possible before antibiotics commenced. b) In sick patients "best guess" antibiotics should be commenced prior to results c) When gram stain or culture results return, antibiotic cover should be rationalised to specific treatment for isolated organisms. iii) Specific infections where the organisms is known ii) c) Complications of antibiotics i) Systemic reactions a) Skin rashes b) Anaphylactoid / anaphylactic reactions ii) Specific organ toxicities iii) Nosocomial infection iv) Bacterial resistance v) Pseudomembranous colitis vi) Cost Drug level monitoring i) Gentamicin and vancomycin are frequently prescribed antibiotics that are potentially nephrotoxic and ototoxic. ii) Toxicity is related to trough levels, which must be measured in all patients receiving these drugs. iii) Peak levels are useful to assess efficacy and calculate clearance. iv) In patients with abnormal renal function, or the potential to develop renal failure, the dose and/or dosing interval must be adjusted in accordance with levels. Gentamicin prescription protocol i) Record gentamicin on sticky label: record dose and time of administration ii) Estimate lean body mass: a) Male: 50kg + 0.9kg per cm height > 150cm b) Female: 45kg + 0.9kg per cm height > 150cm iii) All patients (irrespective of renal function) a) Initial Dose: 5 mg/kg b) Measure first level 1 hr post-dose. c) Measure second level 6-10 hrs post-dose, or with 06:00 bloods. d) Liaise with pharmacy re further dose requirements.

d)

e)

101 f) Vancomycin prescription protocol i) Normal renal function: creatinine < 0.12 a) Dose: 1g IV bd b) Measure trough level with daily blood tests c) Adjust dosing interval (ie once or alternate daily) if trough > 15 mg/l ii) Abnormal renal function: creatinine > 0.12 a) Dose: 1g IV daily, or 0.5g IV bd b) Measure trough level with daily blood tests c) Adjust dosing interval (ie once or alternate daily) if trough > 15 mg/l iii) NB: The assessment of renal function by serum creatinine is sub-optimal. Elderly patients and those with low muscle mass may have a significantly impaired GFR in the setting of a high-normal creatinine.

3.

Antibiotic prophylaxis a) b) c) Required for selected post-operative patients in ICU and HDU Does not include the preoperative/induction dose given at induction of anaesthesia Table: (see over)

102 Specialty
Orthopaedics

Procedure
1. 2. Elective cases Traumatic wounds: involving bone or joint compound fractures 3. + severe tissue damage + myonecrosis / vascular injury 1. Colorectal 2. Biliary surgery Elective cases + severe bowel injury + myonecrosis or vascular injury Amputation CSF leakage (inc. basal skull #) Craniotomy (inc. ICP insertion) Craniofacial with breach of nasal or oral mucosa Coronary artery bypass surgery

Antibiotics
1. 2. 3. 1. 2. 1. 2. 3. 4. 1. 2. 1. 1. Cefazolin 1g IV 8h x 3 doses Cefazolin 1g IV 8h x 2 days + Gentamicin 5 mg/kg IV daily x 2 days + Benzyl pen. 3 g IV stat, 1.2 g IV 6h x 2 days Gentamicin 3 mg/kg or cefazolin 1 gm + Metronidazole 500mg IV single doses Gentamicin 3 mg/kg x 1 dose, or cefazolin 1g x 1 dose Cefazolin 1g IV 8h x 3 doses + Gentamicin 5 mg/kg IV daily x 2 days + Metronidazole 500 mg IV bd x 2 days + Benzyl pen. 3 g IV stat, 1.2 g IV 6h x 2 days (1) + Metronidazole 500 mg IV bd x 2 doses None: treat only if signs of meningitis Cefazolin 1g IV at induction Cefazolin 1g IV 8h x 3 doses + Metronidazole 500 mg IV bd x 2 doses Cefazolin 1g IV 8h x 3 doses Penicillin allergy: Vancomycin 1g (over 1 hr) + Gentamicin 240 mg at induction only Vancomycin 1g + 500mg 12 hrs later + Gentamicin 240 mg at induction Amoxycillin 1g IV on induction + 6 hours later or Vancomycin 1g IV + Gentamicin 2 mg/kg IV on induction *all high risk patients 2. Amoxycillin 1g IV on induction + second dose 6 hours later + Gentamicin 2 mg/kg IV on induction or Vancomycin 1g IV + Gentamicin 2 mg/kg IV on induction *High risk patients: Surgically repaired intracardiac lesions with residual abnormality Prosthetic heart valves Previous endocarditis

Abdominal Surgery

Vascular surgery

1. 2. 3.

Neurosurgery

4. 1. 2.

Head & neck, thoracic Cardiac Surgery

1. 1.

2. Endocarditis Prophylaxis* 1.

Cardiac valve surgery Dental/Resp. procedures: Dental + bleeding Adenotonsillectomy Rigid bronchoscopy GI & GU procedures: Oesophagoscopy GI surgery, Biliary, or Urological surgery ERCP Instrumental urology + UTI Vaginal hysterectomy Gynaecological sepsis Drainage of abscess

2. 1.

2.

*Medium risk patients: Congenital heart disease Significant valvular disease Mitral valve prolapse + regurgitation

103 4. Empirical antibiotics (prior to definitive bacteriological diagnosis) Type, comment

1. Community acquired pneumonia, immunocompetent admitted to ICU / HDU (ie respiratory failure) Nosocomial pneumonia Immunocompromised host No clinical signs of pneumonia Usually H. influenzae Suspected bacterial, usually: meningococcus pneumococcus, or H. influenzae

Infection
Pneumonia

Antibiotics
1. Ceftriaxone 1g IV daily + Erythromycin 1g IV 6h, consider Ciprofloxacin 400mg IV 12 hrly Flucloxacillin 1g 6h (if high suspicion of S.aureus) Timentin 3.1g IV 6 hrly + Gentamicin 5 mg/kg IV daily Contact ID Consider Ceftriaxone 1 g IV daily Ceftriaxone 1 g IV daily Ceftriaxone 2-4g IV daily (4g bd) + Penicillin 1.8g 4 hrly IV Dexamethazone 10mg qid (2 days) Consider Acyclovir 10mg/kg IV 8hrly if not definitely bacterial No treatment. Remove /change catheter Ceftriaxone 1gm IV daily Amoxycillin 2 gm IV 6 h + Gentamicin 5 mg/kg IV daily + Metronidazole 500 mg IV bd x 7 days Consult ID/Micro

2. 3. Aspiration Exacerbation of CAL Epiglottitis Meningitis/ encephalitis 1. 1. 1.

2. 3. 1. 1. 1. 2. 3. 1. 2. 1.

No antibiotics without evidence of proven infection

Urinary tract infection Intra-abdominal sepsis

1. 2. 1.

Without systemic sepsis in patients with a urinary catheter With systemic sepsis Faecal peritonitis, perforated viscus Recurring intra-abdominal sepsis or failed Rx with above regimen No evidence of infected necrosis Enhanced CT evidence infected necrosis Acute cholecystitis Ascending cholangitis

2.

2.

Pancreatitis

1. 2.

1. 2. 1. 2.

No antibiotics Meropenem 500 mg IV 8 hrly Amoxycillin 1 g IV 6 h + Gentamicin 5 mg/kg IV dly x 7 days Amoxycillin 2 gm IV 6 h + Gentamicin 5 mg/kg IV dly + Metronidazole 500 mg IV tds x 7 days Amoxycillin 2 gm IV 6 h + Gentamicin 5 mg/kg IV dly + Metronidazole 500 mg IV bd x 5 days Lincomycin 1.2g IV bd + Gentamicin 5 mg/kg IV dly x 7 days

Biliary sepsis

1. 2.

Gynae sepsis

1. 2.

Septicaemia secondary to PID Suspected staph infection

1. 2.

104
Suspected Bacterial Endocarditis 1. 2. Out of hospital: 3 sets of blood cultures, and review at 48 hrs In hospital, or prosthetic valve in situ: as above or if Penicillin sensitive Suspected candidiasis Suspected aspergillosis 1. Benzyl penicillin 1.8 g IV 4 h + Gentamicin 2 mg/kg IV tds Flucloxacillin 2g IV qid Vancomycin 1 g IV bd + Gentamicin 2 mg/kg IV tds Amphotericin 0.5 - 1 mg/kg/day, or Fluconazole 400 mg IV dly (in non-neutropaenic patients) Amphotericin 1 - 1.5 mg/kg/day

2. 1. 2.

Fungal septicaemia

1. 2. 1. 2. 3. 4.

Amphotericin: 10 mg (IV over 2 hrs) if OK, give the remainder of the dose over 4 hours Remove all potential sources of infection (lines, catheters, etc) Adjust the dose in renal insufficiency, or consider the use of Fluconazole if appropriate Consult ID for all proven fungaemias

Burns Cutaneous infections

No antibiotics without evidence of bacterial infection 1. 2. Wound infection + signs of systemic sepsis Synergistic gangrene or necrotising fasciitis (in addition to surgery hyperbaric oxygen) Severe oral infections Removal of the line will often be enough. Send line for culture and take blood cultures by venipuncture. If clinical signs of sepsis / prosthetic valve / arterial graft / high risk patient 1. 2. Benzylpenicillin 1.8 g IV 4 h + Flucloxacillin 1-2 g IV 6 h or Cefazolin 1g IV 8h Lincomycin 1.2 gm IV bd + Gentamicin 5 mg/kg IV daily or Benzylpenicillin 1.8 gm IV 4 hourly + Gentamicin 5 mg/kg IV daily + Metronidazole 500 mg IV bd Penicillin 1.2 g IV 4-6 hourly + Metronidazole 500 mg IV bd No antibiotics

3. Line sepsis 1.

3. 1.

2.

2.

Vancomycin 1 g IV *await cultures

105 5. Antibiotics for Specific Organisms 1st choice

Benzyl penicillin 1.2g IV 4-6 h Flucloxacillin 2 gm IV 6 h Benzyl penicillin 1.2g IV 4-6 h Ciprofloxacin 500mg po x 1dose Vancomycin 1g IV bd Amoxycillin 1-2 g IV 6 h + Gentamicin 5 mg/kg IV dly Benzylpenicillin 1.8g 4 hrly IV + Lincomycin 1.2g IV bd + Intragam 150 mg/kg/day x 5 days Ceftriaxone 1g IV daily Rifampicin 600 mg oral bd x 4 days Gentamicin 5 mg/kg IV dly Gentamicin 5 mg/kg IV dly Gentamicin 5 mg/kg IV dly Piperacillin 3 g IV 6 h + Gentamicin 5 mg/kg IV dly

Organism
Pneumococcus Staphylococcus aureus Meningococcus Meningococcus contacts MRSA Enterococcus Gp A Strep. With Shock

2nd choice
Ceftriaxone 1 IV dly Vancomycin 1gm IV bd or Cafazolin 1-2g IV 8h Ceftriaxone 1g IV dly Rifampicin 600mg po bd x 2 days Consult ID Vancomycin 1g IV dly + Gentamicin if SBE Consult ID Cease IG when pt. improves Amoxycillin 1-2 g IV 6 h (if sensitive) Ceftriaxone 1g IM dly x 2 doses Ceftriaxone 1g IV dly Meropenem 500mg IV 8h Ceftriaxone 1g IV dly Ceftazidime 2g IV 8h (if sensitive) or Ciprofloxacin 400mg IV bd + Gentamicin 5 mg/kg IV dly Erythromycin 1g IV 6h Pentamidine isethionate 4 mg/kg/day IV + methylprednisolone 40mg 6 hrly x 7days Consult ID or Bacitracin 25,000 o 6 hrly 7-10 days

Haemophilus influenzae H. influenzae contacts (meningitis) E. Coli Enterobacter Klebsiella Pseudomonas aeruginosa

Legionella spp. Mycoplasma pneumoniae Pneumocystis carinii

Ciprofloxacin 400mg bd Erythromycin 1g IV 6h Co-trimoxazole 15-20 ml IV 6 h + methylpred 40mg bd x 5d, methylpred 40mg die x 5d, methylpred 20mg die x 11d, Cease antibiotics 1. Metronidazole 400 mg o bd (or 500mg IV if npo) x 7-10 days 2. Repeat above Benzylpenicillin 1.8g IV 4 hrly + Gentamicin 5 mg/kg IV dly + Metronidazole 500 mg IV bd + surgical debridement hyperbaric oxygen

Clostridium difficile: 1. Mild / moderate 2. Severe, or relapse after RX

Clostridial infection (Polymicrobial Infection)

Lincomycin 1.2 gm IV bd + Gentamicin 5 mg/kg

NB: Dose for Ceftriaxone is 1.0g IV daily, except where the site of infection is meningitis or endocarditis, or the infection is life-threatening

106

FLUIDS AND ELECTROLYTES

A. 1. 2. Principles of fluid management in Intensive Care All fluids, infusions are reviewed daily and rewritten on the ICU flowchart. Assessment of volume status and fluid balance involves all of the following: a) Clinical markers i) Skin turgor, mucous membranes ii) Pulse, blood pressure, iii) Peripheral perfusion, capillary refill iv) RAP, PAOP v) CXR b) Biochemical markers i) Serum Na+, Cl-, osmolality ii) Urea / creatinine ( ratio) iii) Bicarbonate iv) Haematocrit c) Charted fluid balance (notoriously inaccurate!) i) Total intake including drug/infusion volumes ii) Total output including urine output, drains, NG losses, blood loss iii) Insensible losses due to pyrexia, transcellular shifts, etc. (NB: usually impossible to quantify accurately) Fluids should be considered in two components: a) Maintenance fluids i) Usually crystalloids, according to Na+: a) 4% dextrose - 1/5 N.Saline b) 5% dextrose c) N.Saline ii) Usual volumes: 30-40 ml/kg/day 80-120 ml/hr iii) TPN (refer to guidelines) b) Replacement / resuscitation fluids i) Usually colloids: a) Albuminex 4%, or b) Gelofusin ii) Blood and blood component therapy as indicated iii) Crystalloid replacement is usually used for excessive renal, enteric and burns losses (see below).

3.

107 4. Composition of commonly used fluids (1litre solution): Solution

N Saline N/2 Saline N/5 Sal. + 4% Dex. 5% Dextrose Hartmanns Gelofusin (500ml) Albuminex 4% (500ml) Na+
150 75 30 129 77 70 5.0

K+

Cl150 75 30 109 60 62.5

Ca++

Lact.

Gluc.

Osm.
300 150 282 278 274 274

Prot.

40 g 50 g 2 29

20g 25g

5.

Fluid management in burns patients a) b) c) d) The Royal Adelaide Hospital Burns Unit uses the modified Parkland regimen for fluid management. This is a guide - other clinical markers such as urine output, heart rate, blood pressure, CVP, serum sodium and osmolality, haematocrit must be taken into account when these patients are admitted to ICU. As a result, solutions may have to be modified in order to maintain the above parameters within normal ranges. Protocol: i) Assess patient burn surface area using accurate chart as % of body surface area (%BSA) ii) Assess patient weight. iii) Formula: a) Total fluid for 24 hours: 4ml x body weight x %BSA burnt b) During first 8 hours after the burn give the total fluid requirement as Hartmanns solution c) During second 16 hours after the burn give the total fluid requirement as Hartmanns solution d) Second 24 hours fluid is given as Albuminex 4% 0.5ml x body weight x %BSA burnt e) Other maintenance fluid is given according to the above physiological parameters f) The primary endpoint of fluid resuscitation is generally accepted to be urine output > 0.5-1 ml/kg/hr g) Use catecholamines only if adequate volume replacement is unable to maintain a satisfactory urine output or there is associated myocardial failure. iv) Commence enteral feed as soon as possible, per enteral feeding protocol.

108 B. 1. Nutrition Enteral nutrition a) b) Enteric feeding is the preferred mode of nutritional support and must be considered in all patients as soon as possible after admission to ICU. Advantages i) Early enteral feeding in trauma patients has been associated with improved outcome. ii) Use of the gut decreases mucosal atrophy, which may reduce bacterial translocation thereby reducing the incidence and duration of sepsis. iii) The incidence and severity of gastric erosions and stress ulceration may be reduced. iv) Cheaper than TPN v) Complications of central vascular access (especially infection) are reduced or avoided. Disadvantages i) Regurgitation / aspiration ii) Diarrhoea (other causes are more likely than enteral feed) Indications i) As soon as possible in all intubated / tracheostomised patients, where admission and duration of intubation is expected to be > 24-48 hours. ii) Patients with an operative jejunostomy may commence feeding within 6 hours of placement: liaise with surgeons first. iii) Consider endoscopic placement of a duodenal tube in all patients, especially those with gastroparesis. (Liaise with gastroenterology) Contraindications i) Recent abdominal surgery: liaise with surgeons before commencing feed ii) Pancreatitis: this is a relative contraindication only, liaise with the surgeons before commencing feed iii) Absent bowel sounds is not a contraindication. Protocol i) Liaise with the dietitian (who will order feeds) during the midday fluid round. ii) Outline any problems: eg hyperkalaemia, renal failure, osmolality iii) Place a 12F or larger nasogastric tube (to allow reliable aspiration) iv) Use orogastric tubes in patients with anterior and middle cranial fossa # v) Check position of feeding tube with abdo x-ray prior to feeding vi) Flush jejunostomy / gastrostomy tubes with 10-20 ml N.saline 6hrly if not being used. vii) Nurse the patient at 30-45o viii) Commence feed at 40 ml/hr and feed continuously according to the protocol. ix) Aspirate the tube 6 hrly (Including those no longer on low pressure suction or free drainage and PEGs). Do not aspirate jejunostomies, naso-duodenal/jejunal tubes or PEJs:

c) d)

e)

f)

109 a) Aspirate < 250 ml: (1) return aspirate to stomach (2) increase rate by 20 ml/hr (3) repeat aspiration at 6hrs and if < 250ml then to max rate (usually 80-100 ml/hr) b) Aspirate > 250 ml: (1) discard (2) halve feed rate (not less than 20 ml/hr) (3) continue to aspirate 6 hrly c) If persistent failure to tolerate feeds or aspiration consider: (1) Prokinetics: metoclopramide 10 mg IV 6 hrly, then erythromycin 200 mg IV bd (2) Reduce narcotic administration if possible. (3) Post-pyloric feeding tube. (a) Performed endoscopically by the GI Medical Unit, or (b) Feeding jejunostomy (4) TPN. d) Consider a PEG, PEJ or feeding jejunostomy in long term patients (eg Guillain Barre or severe head injury) Cease feeds 4 hrs prior to extubation, tracheostomy, ET tube change or going to theatre.

x)

2.

Enteral Protocol Commence Feed @ 40ml/hr

Nurse patient 30 Head-Up

Aspirate at 6 Hrs

Aspirate < 250ml

Aspirate > 250ml

Return Aspirate Rate by 20 ml/hr or Continue @ Max

Discard Aspirate Halve Rate (Min rate = 20 ml/hr) Do Not Stop Feed Start Prokinetics

110 3. Parenteral Nutrition a) General principles i) There is considerable evidence now available that TPN may be harmful in critically ill patients. Enteral nutrition is the preferred mode of support and TPN should only be considered for patients in whom this is not possible. ii) Refer to Clinical Duties Outside ICU, regarding the responsibilities and management of ward patients receiving TPN. iii) TPN is usually ordered by the Team 3 Consultant iv) IV access may be via a CVC or PICC line, with the later being preferred. v) TPN for ICU/HDU patients is prescribed during the midday fluid round. vi) From early 2003 TPN solutions will be pre-prepared and kept by Pharmacy. Indications for TPN in the patient who cannot be fed enterally are: i) GIT Failure > 7-10 days and expected duration of support > 5-7 days. a) Prolonged post operative ileus b) Enteric fistulae c) Pancreatitis (relative) Complications of TPN: i) Depression of immune function, esp. in cancer patients ii) Gut villous atrophy iii) Metabolic imbalance a) Electrolyte disturbances ( K+, HPO4=, Mg++) b) Glucose intolerance: hyperglycaemia and glycosuria c) Hyperosmolar dehydration syndrome d) Rebound hypoglycaemia on cessation of TPN e) Hyperbilirubinaemia f) CO2 production, esp in CAL patients iv) Fluid imbalance v) Trace element and vitamin deficiencies vi) Central venous access complications Protocol i) On commencement: a) Check CVC/PICC line with X-ray b) Add the following orders to the patient's drug folder: (1) B group vitamins sticker (2) Insulin Sliding Scale sticker (Check BSL) c) Commence TPN solution at a lower rate (40ml/hr) in starved patients due to the ICF movement of K / PO4 with refeeding. d) Prescribe the balance of fluid according to the patients serum chemistry and fluid requirements.

b)

c)

d)

111 Daily: a) Review the patient, CVC site, biochemistry, BSL chart and fluid balance. b) Prescribe TPN selecting the most appropriate option from the table below. c) These bags are pre-prepared and must not be altered, ie. no further additives. Patients requiring K+, PO4 etc. above the quantities provided must receive these in a separate line/infusion. d) Some patients on TPN will exhibit poor glycaemic control, ie. not be controlled by a standard sliding scale. This places the patient at significant risk of complications and should be managed actively. iii) Intralipid a) Commence TPN with lipid-free solutions (#3, #4) b) Lipid is indicated if the period of malnutrition > 4 weeks or if the patient is hypercatabolic. ii) e) RAH TPN Solutions: KCal
2300 82.5g for All 2250

Solution
Option #1 Option #2 Option #3 Option #4 1.

Protein

Lipid
500ml 20% None

Elects1
Yes No Yes No

K+
0 60 0 60

Volume

2000ml for All

2.

Added electrolytes: Sodium 73 mmol Chloride 80 mmol Acetate 82 mmol Potassium 60 mmol Phosphate 30 mmol Magnesium 5 mmol All options have trace elements (except iron + molybdenum), selenium and iodide.

112 f)
Water Calories Protein Sodium Potassium Phosphate Vitamins Replacement solutions

Average daily requirements:

30-40 30-40 0.5-1.0 ml/kg/day kcal/kg/day g/kg/day 1. Glucose: 2. Fat: 2g/kg/day @ 4.1 kcal/g 2g/kg/day @ 9 kcal/gram

1. 2:5 essential:total amino acids 2. 150:1 kcal:g N2 (non-nitrogen kcal) Dependent on renal function Dependent on renal function Trace elements as required. 1. Normal saline 10 ml KCl/litre 2. Normal saline 10 ml KCl/litre 3. Hartmanns solution

1.0 mmol/kg/day 1.0 mmol/kg/day 0.2 mmol/kg/day B groups daily B12, Folate, A, D, E, K weekly 1. Urine 2. Nasogastric/ileostomy 3. Pancreatic/biliary fistulae

C. 1.

Haemotherapy Red Blood Cells a) Resuscitation i) Abnormal bleeding is usually surgical and requires urgent surgical intervention. ii) Blood replacement should start with: a) Rapid blood loss leading to hypovolaemia and shock. b) Blood loss is estimated or anticipated to exceed 20-25% of blood volume, ie 1000-1500 ml in a normal adult. iii) A full cross match takes 30 minutes if marked urgent (not including the time for transfer of blood); this should be performed if possible while volume is replaced with crystalloid or colloid. iv) If blood is required faster than this the request Time Required box should be marked: a) Desperate group O Rh(D)-ve blood is issued immediately b) 10 minutes group-specific unmatched blood c) 30 minutes urgent full T&S NB: The requesting MO accepts full responsibility for (a + b) v) The platelet count and coagulation studies should be checked frequently in the setting of massive blood transfusion. Administer platelets and FFP according to coagulation studies. (see below)

113 b) Elective *as per NHMRC / ASBT guidelines. i) Haemoglobin values < 70g/L ii) Perioperative haemoglobin value of 80g/L iii) Haemoglobin 70g/L - 100g/L if any of the following are present: a) Ongoing bleeding. b) Dyspnoea, tiredness/weakness, angina, syncope. c) Cardiac ischaemia or cardiac failure due to anaemia. iv) Plasma sent for type & screen is held for 10 days for compatibility testing. However, if the patient has received blood transfusion, a new specimen is needed for cross-match every 72 hours.

2.

Platelets a) Prophylactic transfusion before surgery or other invasive procedure that could result in bleeding: i) Platelet count < 50 109/L ii) Platelet count > 50 109/L, with evidence of (inherited or drug-induced) platelet dysfunction. b) Prophylactic transfusion in marrow failure: i) Platelet count < 10 109/L a) except in patients in palliative phase where platelet transfusion is given only for clinically significant bleeding b) may be given at higher levels with clinical evidence of bleeding c) Therapeutic transfusion for uncontrolled haemorrhage: i) Platelet count < 100 109/L and/or evidence of platelet dysfunction. d) ITP: i) Only if life-threatening bleeding is present. Fresh Frozen Plasma (FFP) a) Prophylactic transfusion before surgery or other invasive procedure that could result in significant bleeding: i) Urgent correction of prolonged INR or APTT in warfarin overdose# or vit K deficiency ii) Correction of prolonged INR or APTT in liver disease iii) Correction of inherited coagulation factor deficiencies where specific coagulation factor concentrates are not available b) Therapeutic transfusion for uncontrolled haemorrhage in: i) Warfarin overdose# ii) Liver disease iii) Vitamin K deficiency iv) Inherited coagulation factor deficiencies where specific coagulation factor concentrates are not available v) DIC

3.

114 c) d) Plasma exchange in thrombotic thrombocytopenic purpura & related syndromes Massive transfusion (more than one blood volume per 24hrs) with coagulopathy: i) Indicated if the INR (prothrombin time) >1.5, or ii) APTT (activated partial thromboplastin time) >40 seconds # with adjunctive therapy of factor concentrates and low dose vitamin K.

e) 4.

Cryoprecipitate a) Bleeding and fibrinogen < 1.0 g/L in: i) DIC. ii) Massive transfusion. iii) Hereditary hypofibrinogenaemia. b) 10U of cryoprecipitate will plasma fibrinogen by ~ 1.0g/l c) Standard dose = 8U for hypofibrinogenaemia. DDAVP a) Standard dose = 0.3-0.4g/kg over 30 mins b) Increases in factor VIII:C, VIII:vWF and platelet adhesion. c) Indications: i) haemophilia A, type I von Willebrand's disease ii) bleeding post cardio-pulmonary bypass iii) uraemia, platelet dysfunction 2 aspirin iv) clinical scenarios where bleeding is uncontrolled in the presence of a normal platelet count, ie. suspected dysfunction -aminocaproic acid (EACA) a) inhibitor of fibrinolysis b) may be indicated in major uncontrolled haemorrhage, especially where there is evidence of defibrination: i) loading dose: 5g over 1 hr ii) infusion: 1g/hr Disseminated intravascular coagulation (DIC) a) Definition i) DIC occurs when the balance of the haemostatic and fibrinolytic systems becomes disordered. It occurs in response to severe pathophysiological stimuli and is a part of multisystem organ dysfunction (often associated with ARDS and acute renal failure). It is characterised by: a) Microthrombi formation causing microvascular obstruction b) Consumption of platelets and clotting factors c) Abnormal fibrinolysis

5.

6.

7.

115 b) DIC screen: i) Complete blood picture a) microangiopathic haemolytic anaemia with red cell fragmentation b) haemolysis c) thrombocytopenia ii) Extended coagulation screen: a) prolongation of TCT, APTT, PT b) hypofibrinogenaemia c) low factor VIII d) excess fibrinolysis with elevated FDPs iii) Liver and renal function tests Treatment i) Treatment of the underlying cause ii) Replacement of blood components in the bleeding patient a) FFP - based on INR/APTT b) cryoprecipitate - for marked fibrinogen deficiency iii) Controversial therapies: - heparin, fibrinolytics (tPA) - anti-fibrinolytics (EACA) - consultant approval only

c)

8.

Activated Protein C - Drotrecogin alfa (activated) a) Xigris is a recombinant form of human Activated Protein C. b) Pharmacological effects i) Antithrombotic effect by inhibiting Factors Va and VIIIa. ii) Indirect profibrinolytic activity through its ability to inhibit plasminogen activator inhibitor-1 (PAI-1) and limiting generation of activated thrombinactivatable-fibrinolysis-inhibitor. iii) APC may exert an anti-inflammatory effect by inhibiting human tumor necrosis factor production by monocytes, by blocking leukocyte adhesion to selectins, and by limiting the thrombin-induced inflammatory responses within the microvascular endothelium. c) One study at a planned interim analysis showed a significantly lower all cause 28 day mortality (210/850, 25% vs. placebo 259/840, 31% p=0.005) d) Administration of Xigris for severe sepsis/DIC requires approval of the Duty Consultant and hospital administration due to the high cost of the drug.

116 9. Blood transfusion reaction protocol a) Plasma can cause reactions ranging from mild pruritus, erythema and urticaria through to severe flushing, hypotension, fever, angioedema, bronchospasm and fulminant anaphylaxis. b) Suspected Reaction Protocol i) Stop the transfusion immediately do not disconnect the IV line. ii) Recheck the patient identification on the blood product pack label against the patients wristband and verbally with the patient if possible. If there is an unexplained discrepancy, discontinue the transfusion and treat as per (iv, v) iii) Mild Reactions a) Temperature rise < 1.5 C b) Mild or no hives or rash. c) Then slow the rate and continue the transfusion of the same unit of blood product. iv) Severe Reactions a) Severe hives and/or a rash Rx: anti-histamine. b) Temperature increase >1.5C and is the only clinical sign or symptom Rx: anti-pyretic. c) Hold, then restart the transfusion of the same unit of blood product after approximately 20 minutes. d) If there are further signs & symptoms of a reaction discontinue & order a transfusion reaction investigation v) If there is a sudden and acute change in the patients condition a) eg. cyanosis, bad headache, backache, or significant change in pulse or blood pressure for no apparent clinical reason b) discontinue & order a transfusion reaction investigation vi) Investigation of a transfusion reaction: a) A transfusion reaction investigation form (IMVS 224) should be completed and sent to TMU with: (1) a description of the relevant clinical findings and vital signs (2) a post-reaction 10ml EDTA blood specimen, preferably from vein other than that used for transfusion, along with (3) the remains of any used and unused blood packs and the attached administration set. b) If there is a major reaction, it is also recommended that the first urine specimen voided after reaction is saved, and patients urine output over the next few hours is recorded. c) Further blood samples for biochemical assays, coagulation tests, and cultures will be needed. vii) Haemovigilance a) The IMVS and RAH are participating in the Blood Safe haemovigilance scheme, an adverse incident reporting system aimed at the quality and safety improvement of transfusion practices. b) Contact the Transfusion Safety RN (Pager: 1575, Tel: 22975)

117
Type Febrile non-haemolytic transfusion reaction (FNHTR) Signs & Symptoms Pyrexia (> 1C rise) Rigors/chills Anxiety Treatment Withhold transfusion. Mild fever without other symptoms may be treated by slowing infusion. An antipyretic may be helpful. Investigate as for suspected HTR if the reaction is significant. Discontinue. Institute treatment for fluid overload, e.g. diuretic Prevention Consider use of leucodepleted red cells or platelets if a recurrent problem.

Circulatory Overload

Distended cervical veins. Pulmonary oedema Dyspnoea. Headache. Heaviness in limbs.

Allergic

Flushing Urticaria, itchy hives Facial edema Dyspnoea from laryngeal edema or bronchospasm, sometimes cyanosis and collapse Pyrexia Rigors/chills Lumbar pain Pain along vein Jaundice Haemoglobinuria Oliguria later uraemia

Anaphylaxis

Acute Haemolytic Transfusion Reaction (HTR)

Slow rate of flow. Consider anti-histamine. Watch for laryngeal edema and development of anaphylaxis. Discontinue transfusion immediately. Institute treatment for anaphylaxis, e.g. Adrenalin, steroids Discontinue transfusion immediately. Get expert advice immediately. Save all used packs, blood samples. Save all urine. Collect fresh blood samples. Discontinue transfusion immediately. Acute medical emergency get advice immediately. Save used packs, all blood samples, with labels. Save all urine. Anti-shock treatment and antibiotics. Maintain blood pressure & cardiac output with fluid support. May require ventilatory support.

Give all fluids slowly to Patients with compromised cardiac or renal status. Use red cell concentrates. If anticipated, give diuretic. When anticipated, use prophylactic antihistamines. Use of Medi-Alert Wristband in proven IgA deficient patients. Extreme care in Collecting the correct blood sample for T&S. Careful compatibility Testing by laboratory. Careful technique in Storing & labelling blood. Careful identification of the correct recipient. Storage at correct temp. Do not remove from refrigerator until immediately before transfusion

Infected blood

Non-cardiogenic pulmonary edema. Transfusion related acute lung injury (TRALI): rare

Bacterial sepsis with hyperpyrexia Pain in limb & chest Headache Pallor Burning pain along vein Low blood pressure Rapid pulse Profound collapse & shock Dyspnoea ARDS picture within 6 hours after transfusion.

Difficult, usually in the setting of multiparous blood donor with anti-recipientWBC antibodies.

118 D. 1. Guidelines for management of electrolytes General principles a) Total body water (60% total body weight): i) intracellular fluid : predominant ions : K+, PO43 ii) extracellular fluid: a) 75% interstitial fluid: predominant ions : Na+, Clb) 25% plasma volume (PV) Osmotic equilibrium is maintained by Na+/K+ pump i) ECF ions therefore reflect total osmolality: Calculated osmolality = 2 Na+ + urea + glucose ii) Magnesium is a cofactor for this pump

b)

ECF
Na Cl HCO3
+

ICF
ATP
Mg
++

HPO4 = Protein ++ Mg

Plasma - Interstitium

c) d)

Most electrolyte disturbances in critically ill patients relate to changes in the distribution and concentrations of the predominant ECF and ICF ions. As a general rule, changes in one ion will be reflected in the associated cation or anion.

119 e) Electrolyte disturbances should be considered in terms of the following groups: i) Erroneous results a) Lab error b) Bloods taken from a drip arm c) Haemolysed specimen - traumatic (old IA lines), delayed samples ii) Decreased or increased intake iii) Decreased or increased losses: usually a) Renal b) Extra renal: GIT, skin losses iv) Transcellular shifts. Treatment should be directed at the underlying cause. Rapid correction of electrolyte disturbances may be deleterious. The following paragraphs outline the common electrolyte disturbances. Na+ < 130 mmol/l

f) g) h) 2.

Hyponatraemia: a)

Aetiology / classification i) Hyperosmolal: measured osmo > 290 a) Hyperglycaemia b) Mannitol c) Ethanol, Methanol, Ethylene Glycol ii) Isoosmolal: measured osmo 270-290 a) Hyperlipidaemia | b) Hyperproteinaemia | - not seen with ion-specific electrodes c) IVT arm sample iii) Hypoosmolal: measured osmo < 270 a) Hypovolaemia (Na+ depletion) (1) Renal (a) Diuretics (b) Addisons (c) Polyuric renal failure (2) Extra renal (a) GIT (b) Burns (3) Transcellular water loss b) Hypervolaemia (Water excess) (1) Extra renal (a) Excessive intake (IV 5%D) (b) Oedematous states - CCF, cirrhosis, nephrotic synd. - albumin (2) Renal (a) Acute renal failure, CRF

120 c) Normovolaemia (1) Psychogenic polydipsia (2) SIADH (3) Hypothyroidism (4) Acute adrenal insufficiency

b)

Diagnosis & Management: i) Iso & Hyper-osmolal: a) Factitious: ignore and manage underlying condition b) Hyperglycaemia: BSL 10 mmol/l Na+ 3 mmol/l (1) Hyponatraemia per se is real, but treatment is directed at the underlying cause, where correction of the hyperglycaemia will correct the plasma [Na] as shown (2) NB: Total body Na deficit may co-exist with hyperglycaemia / DKA c) Mannitol: (1) Na early, then diuresis & late Na are more problematic (2) maintain adequate plasma volume with N.saline initially d) Alcohols: permeate solutes, [Na] less problematic ii) Hypovolaemic states: a) Restore volume with colloid or normal saline according to clinical markers: urine output, plasma [Na], RAP b) Aim for slow Na+ correction : 2 mmol/l/hr, unless seizures. c) Urine Na+ is uninterpretable after diuretics or catecholamines for 24 hours after dose

iii) Hypervolaemic states: *most common clinically a) Fluid restriction < 15 ml/kg/day (1) Water Excess ~ (140 - Na+ )/140 x (B.Wt x 0.6) eg., 70kg patient with plasma [Na] = 120 mmol/l: = (140 - 120)/140 x (70kg x 0.6) = 6 litres (2) Will slowly correct excess - ADH group & reset osmostat (3) Treat the underlying cause - CCF, nephrotic synd., ascites iv) SIADH a) Diagnosis (1) Hypo-osmolar hyponatraemia (2) Urine osmo > plasma osmo (3) Urine Na+ > 40 mosm/l (4) Normal endocrine, renal, hepatic, cardiac function, no diuretics (5) Corrected by fluid restriction alone b) Management: fluid restriction

121 v) Severe Symptomatic Hyponatraemia : fitting, or decreased consciousness a) Resuscitation / ABC b) Hypertonic saline (3, 20, 29%) is rarely indicated; always discuss use with the Duty Consultant c) Correct [Na+] rapidly only to 120mmol/l d) Thereafter, slow correction with N.saline over 24-36 hours ( 2 mmol/l/hr) e) Treat the underlying cause. Na+ > 145 mmol/l

3.

Hypernatraemia: a)

Aetiology / classification: always hyperosmolar i) Hypovolaemic H2O loss > Na+ + (most body fluids have a [Na ] < plasma net water loss) a) Renal (1) Diuretics, glycosuria (2) ARF/CRF, partial obstruction (3) Diabetes insipidus b) GIT losses : Diarrhoea, vomiting, fistulae, SBO c) Respiratory- IPPV with dry gases d) Skin losses (1) Fever, high ambient temperature (2) Thyrotoxicosis (3) Vasodilatory states (4) Exfoliative skin disorders, burns ii) Iso-hypovolaemic pure water loss ( plasma osmotic pressure, tends to maintain intravascular volume mild-moderate decrease in ECF & ICF) a) Inadequate water replacement b) Unconsciousness c) Reset osmostat d) Central diabetes insipidus: head injury, post surgery e) Nephrogenic diabetes insipidus: (1) 1 : congenital renal resistance to ADH (2) 2 : hypokalaemia, hypercalcaemia, lithium, multiple myeloma, sickle cell anaemia, nephrocalcinosis, amyloid iii) Iso-hypervolaemic Na+ gain > H2O gain (plasma osmolality ADH secretion ECFV, with subsequent renal escape, oedema in this group is rare) a) Iatrogenic (major cause): NaHCO3, feeding formulae, TPN b) Mineralocorticoid excess: usually have 1-3 l of excess TBW (1) Conn's, Cushing's syndromes (2) Steroid excess

122 b) Management i) Hypovolaemic states a) Restore volume according to clinical markers: BP, HR, urine output, RAP (1) Colloid: initial resuscitation, severe hypovolaemic states (2) Hartmanns solution - slightly hypo-osmolar ii) Slow Na+ correction: 2 mmol/l/hr a) Water deficit: ~ (Na+ - 140)/140 x (B.Wt x 0.6) eg. 70 kg patient, with plasma [Na] = 160 mmol/l ~ (160-140)/140 x (70 x 0.6) ~ 6.0 litres 1litre water replacement will raise Na+ 3-4 mmol/l b) In addition to basal fluid requirements & ongoing losses c) Replace over a 24-48 hr period with 5% dextrose d) Monitor [Na+] regularly e) Manage aetiological causes f) Cease causal drugs and inappropriate IVT g) DDAVP for central DI K+ < 3.0 mmol/l

4.

Hypokalaemia: a)

Aetiology / classification: i) Transcellular shift a) Alkalaemia pH ~ 0.1 [K+]pl ~ 0.5 mmol/l b) Catecholamines / Salbutamol c) Insulin d) Familial periodic paralysis e) Anabolism - refeeding effect f) Hypomagnesaemia - ICF K+ depletion ii) Reduced intake a) Starvation b) TPN iii) Increased clearance a) Renal (1) Diuretics distal tubular flow (a) PT agents - acetazolamide, mannitol (b) Loop agents - frusemide, bumetanide (c) Early DT - thiazides (2) Steroids / Mineralocorticoid excess (3) Anionic drugs (a) Antibiotics (penicillins) (b) Amphotericin

123 (4) Hypomagnesaemia, Hypocalcaemia (5) Lithium (6) RTA I, II Non-renal (1) GIT (a) Villous adenoma (b) Ureterosigmoidostomy (c) Fistulae, malabsorption syndromes (d) Diarrhoea, Laxatives (2) Skin losses

b)

b)

Management: i) Treat underlying cause ii) Correct hypovolaemia: volume contraction will potentiate both alkalosis and hypokalaemia iii) Always add Mg++: normomagnesaemia is essential for correction of hypokalaemia iv) Causes and treatment of hypophosphataemia same as K+ v) Potassium preparations a) KCl: 10 ml = 1g = 13.4 mmol/l b) KH2PO4: 10 ml = 10 mmol/l c) K-acetate: 10 ml at 5 mmol/ml 50 mmol K+ + 50 mmol acetate (bicarbonate) K+ > 5.0 mmol/l

5.

Hyperkalaemia: a)

Aetiology / classification: i) Artefactual a) Drip arm specimen b) Tourniquet / Haemolysed specimen (extravascular) c) Thrombocytosis > 750,000 Leukocytosis > 50,000 ii) Transcellular exchange a) Acidosis pH ~ 0.1 [K+] ~ 0.5 mmol/l b) Tissue breakdown c) Rhabdomyolysis, haemolysis (intravascular), ischaemia / reperfusion d) Severe burns e) Tumour lysis syndrome f) Leukaemia g) Familial periodic paralysis h) Suxamethonium i) Insulin deficiency: DKA NB: normo- or hypo-kalaemia in the presence of severe DKA is associated with a marked total body K+ deficit, which must be addressed prior to correction of the acidaemia.

124 ECF tonicity: movement of water from cells the [K+]ICF and passive diffusion seen with large doses of mannitol given rapidly (1.5-2.0 g/kg) . Hyperkalaemia of DKA is due to this in addition to the acidaemia & insulin deficiency k) -blockers iii) Increased intake - rarely a problem unless impaired renal function a) Direct IV/oral b) Drugs (penicillins) c) Transfusion iv) Reduced clearance a) Acute renal failure (1) Any cause for distal tubular flow, or distal NaCl delivery (2) Hypoaldosteronism (mineralocorticoid deficiency, Addisons) - K+ is multifactorial (K+ICF K+ECF, distal tubular flow and DT aldosterone effect) b) Type IV RTA c) Potassium sparing diuretics (1) aldosterone antagonists - spironolactone (2) distal Na+ channel inhibitors - amiloride, triamterene j) b) Management: i) The clinical scenario will dictate treatment ii) Acute K+ > 6.0 mmol/l is a medical emergency iii) Associated with acute ECG changes, or haemodynamic compromise: In following order, a) CaCl2 10 ml IV stat b) NaHCO3 50 ml IV stat c) Glucose 50% 50 ml + Insulin 10 units d) Salbutamol nebs continuously iv) Refractory or persistent: a) CVVHDF b) intermittent dialysis v) Chronic K+ or slow rate of rise or no ECG changes: Resonium 30g oral / PR 8 hourly vi) Address aetiological factors vii) Normalise renal function / volume status

125 6. Acid base disturbances in Intensive Care a) Acid base disturbances in Intensive Care are frequently mixed metabolic and respiratory disorders b) Correction of these disturbances should be directed at the underlying cause and maintenance of cardiopulmonary homeostasis. c) Primary correction of an acid base disturbance with acid or alkali is seldom required. d) Rules of thumb *these are approximations only i) Primary metabolic disturbances: last 2 digits of pH will reflect PaCO2 a) Met Acid to min 7.10 eg pH 7.25 PaCO2 25 mmHg b) Met alkalosis to max 7.60 eg pH 7.57 PaCO2 57 mmHg ii) Primary respiratory acidosis: a) HCO3 ~ 1mmol/l per 10mmHg PaCO2 above 40 to max 30 iii) Primary respiratory alkalosis a) HCO3 ~ 2.5mmol/l per 10mmHg PaCO2 below 40 to min 18 iv) Chronic respiratory acidosis HCO3 ~ 4mmol/l per 10mmHg PaCO2 above 40 to max 36 Metabolic acidosis a) Appreciation of acid base (specifically metabolic acidosis) must be taken in the context of the anion gap: Anion Gap = [Na+ + K+] - [Cl- + HCO3-] ~ 12-17 mmol/l Unmeasured cations
Mg++ Ca++ IgG ~ 1.2 mmol/l ~ 2.2 mmol/l Small ~ 7.0 mEq/l

7.

Unmeasured anions
Albumin H2PO4HSO4Organic ~ 15 ~2 ~1 ~5 ~ 23 mEq/l mmol/l mmol/l mEq/l mEq/l

b)

This allows classification of metabolic acidosis into raised or normal anion gap acidoses. NB: While this is a classical text book subdivision, trainees should be aware that the measurement of chloride in the lab is highly variable and assessment of the anion gap should always be viewed within the clinical context.

126 c) Aetiology of raised anion gap: i) Renal failure - H2PO4- , HSO4- (rarely > 23) ii) Lactic acidosis - types A&B * normal AG does not exclude a lactic acidosis iii) Ketoacids (-OH-butyrate, acetoacetate) : diabetes mellitus, starvation, alcohol iv) Rhabdomyolysis - organic acids v) Drugs / poisons: a) Aspirin - salicylate, lactate, ketones b) Ethanol - acetoacetate, lactate c) Methanol - formate (formaldehyde), lactate d) Paraldehyde - formate, acetate, lactate, pyruvate e) Ethylene glycol - oxalate f) Xylitol, Sorbitol - lactate g) Fructose - lactate Aetiology of low or normal anion gap: i) Hyperchloraemic metabolic acidosis a) Resolving renal failure b) Resolving DKA c) Renal tubular acidosis / carbonic anhydrase inhibitors d) Mineralocorticoid deficiency e) Pancreatic, enteric fistulae f) Ureterosigmoidostomy g) IV HCl, NH4Cl, Arginine ii) Metabolic alkalosis due to HCO3- gain iii) Hypoalbuminaemia iv) Myeloma - IgG has positive charge, 's AG v) Increased Mg++ or Ca++ (rarely) vi) Artefactually elevated Clvii) ? Hyperlipidaemia Management i) High anion gap a) Treat the underlying cause b) No indication for HCO3 ii) Normal anion gap a) Treat underlying cause. b) Replace HCO3 serum level and losses (1) Approx. deficit = (24 - [HCO3]) x (B.Wt. x 0.6) mmol/l (2) Eg. for a 70kg patient with a [HCO3] = 4 mmol/l deficit = (24 - 4) x (70 x 0.6) = 840 mmol (= ml of standard bicarb solution) replace 1/3-1/2 of this amount then remeasure blood gases.

d)

e)

127 8. Metabolic alkalosis a) Aetiology / classification i) Common causes: a) Diuretics b) Vomiting c) Post-hypercapnia > 48 hours d) Any fluid loss replaced with insufficient Na+ H+ excretion (contraction alkalosis) e) Commonly associated with hypovolaemia and/or hypokalaemia however, actual causation by these is debated ii) Increased proton losses: acid loss is either renal or GIT a) Renal (1) Na+ reabsorption (hypovolaemia, dehydration, etc.) (2) Cushing's syndrome, exogenous steroids (3) Hyperaldosteronism 1 / 2 (4) Bartter's syndrome (JGA hyperplasia) (5) Liddle's syndrome (6) Hypercalcaemia / hypomagnesaemia NDI (7) Drugs: steroids, diuretics, carbenoxolone b) GIT (1) N/G suctioning, protracted vomiting (2) Diarrhoea iii) Increased bases a) Administration of NaHCO3 b) Metabolism of exogenous acid anions - citrate, lactate, acetate c) Milk/alkali syndrome d) Renal conservation of HCO3- acidosis, hypercarbia iv) Factors tending to maintain an alkalosis a) Hypovolaemia b) Hypokalaemia c) Hypochloraemia d) Hypomagnesaemia e) Chronic hypercapnia f) Mild chronic renal failure b) Management i) Correct hypovolaemia: a functional ECF volume is essential for the correction of alkalosis ii) Inotropic support of cardiac output and GFR iii) Correct K+, Mg++, PO4 iv) Consider acetazolamide if the alkalosis is persistent: provided the above are corrected.

128 9. Respiratory acidosis a) Aetiology i) Any cause of hypoventilation respiratory failure ii) May be acute or chronic b) Management i) Restore ventilation ii) No indication for HCO3

10. Respiratory alkalosis a) Aetiology i) Any cause of hyperventilation in ICU: ii) Early hypoxia iii) Anxiety, hysteria iv) Prescribed hyperventilation (rarely indicated) v) Neurogenic hyperventilation b) Management i) Treat underlying cause ii) Neurogenic hyperventilation is a marker of severity of head injury

129

CLINICAL MANAGEMENT
The following clinical protocols are designed to facilitate clinical management of patients in the Intensive Care. These protocols may vary from other ICUs and do not represent the sole means of patient management. However, they do represent the standardised approach that this ICU has evolved over the years. Each clinical scenario is managed according to the particular situation and individual patient - it is neither practical nor appropriate to apply rigid policies to clinical situations. However, as clinical medicine is more of an art than a science, these protocols are designed to assist in areas that are unfamiliar and to standardise approaches by all staff members of the Unit. The following protocols are outlined. A. B. C. D. E. F. G. H. I. J. Cardiopulmonary resuscitation Failed intubation drill Respiratory therapy Management of cardiothoracic patients Renal failure Neurosurgical protocols Microbiology protocols Drug overdose Withdrawal of therapy Organ donation and brain death

130 A. Cardiopulmonary Resuscitation

Basic Life Support

Stimulate & Check Responsiveness

Call for Help

Open Airway

Check Breathing

IF not : 2-5 rescue breaths

If OK

(eg. movement or pulse - delay < 10s)

Assess for Signs of Life

Absent
Chest Compressions

Unprotected Airway Ratio = 15:2 Rate = 100

Protected Airway Ratio = 5:1 Rate = 100

*1 or 2 Rescuers

Provide Ventilation & Oxygenation

If OK

Assess Rhythm & Check Pulse

ACLS

131 Advanced Life Support Flowchart

CARDIAC ARREST
BLS Algorithm if appropriate Precordial thump* if appropriate Attach defibrillator / monitor

Assess Rhythm
Check Pulse

VF / VT

Not VF / VT

Defibrillate x3 as necessary

Monphasic = 200, 200, 360J Biphasic = 150, 150, 150J

During CPR
If not already: CPR 1 min
check electrode/paddle positions and contact attempt/verify: ETT / IV access give adrenaline every 3 mins correct reversible causes consider: antiarrhythmics (amiodarone, Mg) atropine / external pacing buffers

CPR 3 min

132 Potentially reversible causes for cardiac arrest: NB: During both Basic and Advanced Life support the following must be considered: 1. 2. 3. 4. 5. 6. 7. 8. 9. Hypoxaemia Hypovolaemia Hyperkalaemia / hypokalaemia Hypothermia Tension pneumothorax Cardiac tamponade Toxic / therapeutic disturbance Thromboembolism Mechanical obstruction

133 B. Failed intubation drill

Endotracheal Intubation

FAILURE
SpO2 < 90%

Maintain Cricoid Pressure & Bag-Mask Ventilation

YES

Able to Ventilate

NO

IF 2 Attempt Consider: bougie/stylet smaller ETT

nd

Fail

LMA Fastrac &

Call for HELP

IF 3 Attempt

rd

Call for HELP

Consider: LMA Fastrac Fibre-optic

Fail

CRICOTHYROIDOTOMY

134 C. 1. Respiratory therapy Respiratory failure a) Definition: failure of efficient gaseous exchange: i) Hypoxaemia: PaO2 < 60 mmHg a) FiO2 = 0.21 b) PB = 760 mmHg c) No intracardiac shunt ii) Hypercarbia: PaCO2 > 50 mmHg a) No primary metabolic alkalosis Causes i) Neuromuscular a) Depressant drugs b) Intracranial catastrophe c) Spinal d) Guillain Barre Syndrome e) Tetanus ii) Skeletal a) Flail chest b) Kyphoscoliosis iii) Extraparenchymal a) Pneumothorax b) Haemothorax c) Pleural effusions iv) Lung parenchymal a) ARDS b) Pneumonia c) Contusion d) Haemorrhage v) Cardiac a) Pulmonary oedema vi) Airways a) Upper airway obstruction b) Acute and/or chronic airflow obstruction (CAL/COAD, asthma, bronchiectasis)

b)

135 2. Oxygen delivery capacities of available oxygen circuits. Apparatus/Device Oxygen flow (l/min)
2 4 6 5 6 8 10 12 2-8 6 - 15 Variable Variable Variable

Approximate FIO2 (%)

28 35 45 35 50 55 60 65 24 - 50 (per manufacturer) FiO2= 21% + 4% per l/min 21 - 100 21 - 100 Airmix : 60 No airmix 100

Nasal catheters

Semi - rigid masks (eg Hudson, CIG)

Venturi type mask (eg Ventimask, Accurox) Reservoir plastic masks (eg Non rebreathing bag) Anaesthetic circuits Ventilators (include CPAP) Oxylog

3.

Humidification a) b) All intubated patients must have adequate humidification of inspired gases for optimal mucociliary function and conservation of temperature. Optimal humidification requires the following i) Delivery of gas to the trachea at a constant temperature (32-36oC) ii) Relative humidity 75-100% saturation iii) No increase in circuit resistance iv) No increase in circuit dead space v) Applicable to spontaneous and controlled ventilation vi) Sterile inspired gas

136 c) Types of humidifiers available i) Heat/moisture exchangers (HME) a) Effective for most patients: first line humidifier b) Patients must have minute volume > 8-10 l/min c) Incorporates bacterial filter d) Change HME daily e) Cannot be used with a nebuliser f) Change to wet circuit (FP) in patients with bronchorrhoea or mucous inspissation ii) Fisher Paykel (FP) evaporative humidifier (wet circuit) a) Indicated in patients with bronchorrhoea or mucous inspissation b) Set chamber to 40C and chamber control to -3C to minimise rainout c) Hypothermic or heat-loss susceptible patients (eg burns) iii) Inspiron (aerosolised T-piece) a) Relatively inefficient humidification b) Allows variable FiO2 : 0.21-0.7

4.

Nebulised bronchodilators a) b) c) d) e) See section on respiratory drugs. These agents are the mainstay of treatment of bronchospasm in Intensive Care (including acute severe asthma). They are not to be routinely used in all ventilated patients. Once commenced, they must be reviewed daily regarding efficacy. This is assessed by improvements in audible wheeze, lung compliance, respiratory rate and blood gases. Indications: i) Pre-existing asthma / chronic airflow obstruction (CAO) ii) Acute severe asthma iii) Acute bronchospasm 2o to infection, aspiration or during IPPV iv) Acute exacerbation of CAO All patients admitted to ICU for acute severe asthma: i) Should receive a Respiratory Medicine consult (if not admitted under that Unit). ii) Should not be routinely started on empiric antibiotics, unless there is clinical evidence of infection (also applies to exacerbation of CAL).

f)

137 5. Mechanical ventilation a) b) c) Mechanical ventilation is one of the mainstays of Intensive Care Medicine: an understanding of the indications, complications, practical aspects of mechanical ventilators and respiratory failure is essential. Standardisation of default ventilation modes and settings is essential for patient safety, particularly in a large Unit with large numbers of staff. Registrars should familiarise themselves with the ventilators, understand the default settings and common modes of ventilation. The nurse educators and senior CCRNs are useful resource people to aid in troubleshooting and assistance with the ICU ventilators. All changes to ventilation orders must be recorded on the flowchart. Notify the nurse at the bedside of changes that have either been prescribed or altered. All ventilator alarms must be addressed as soon as possible: patient disconnection or barotrauma are potentially lethal. The default FiO2 for any patient initially connected to a ventilator is 1.0 (100%). This is only changed after the first blood gas, which should be done as soon as possible. Indications for mechanical ventilation i) Respiratory Failure (cf) ii) Maintenance of cardiopulmonary homeostasis a) Following cardiac arrest b) Post operative support in high risk surgical patients c) Control of intracranial pressure. d) Patient transport/assessment iii) Relaxant anaesthesia Parameters for institution of ventilation i) Clinical assessment is the most important means of diagnosing respiratory failure. ii) Do not delay institution of ventilation for results, blood gases or mechanical measurements if the clinical condition warrants. This includes a) Threatened airway b) Fatigue / exhaustion c) Failure of secretion clearance d) Overt respiratory failure

d) e) f) g)

h)

138 iii) Objective measurements are adjuncts to diagnosis and assessment and must be used in the clinical context. These include: a) Mechanical measurements: (1) Rate: RR > 35 bpm (2) Tidal volume: VT < 5 ml/kg (3) Vital capacity: VC < 15 ml/kg b) Oxygenation indices (1) PaO2 < 75, FiO2 > 0.4 (2) PaO2/FiO2: < 150 (3) P(A-a)O2: > 350 mmHg c) Ventilation indices (1) PaCO2: > 60 mmHg i) Principles in optimising ventilation in ICU patients i) Optimise oxygenation: a) Use lowest FiO2 to achieve adequate PaO2 (generally > 80 mmHg, but depends on the patient) b) PEEP (5-10 cmH2O) to maintain FRC and substitute for physiological PEEP ii) Optimise PaCO2: a) Adjust relative to premorbid PaCO2 b) Permissive hypercapnia in patients with poor lung compliance iii) Optimise patient-ventilator interface: a) Reduce work of breathing through ETT and ventilator circuit: use inspiratory pressure support (10-20 cmH2O) in all ventilated patients b) Prevent gas trapping: measurement and manipulation of auto-PEEP c) Use Automatic Tube Compensation (ATC) settings, if available. iv) Optimise sedation and analgesia v) Minimise volutrauma (barotrauma) a) A modified ARDSNet Protocol for ventilation has been introduced at the RAH (see following section #6). b) This protocol is not the default setting for ventilation of patients on arrival in the ICU, rather this protocol should be prescribed by the registrar for patients at risk of barotrauma and acute lung injury, where no contraindication exists (eg acute CHI, severe asthma). Modes of mechanical ventilation used in ICU i) Synchronised intermittent mandatory ventilation (SIMV) + PEEP (Pressure limited to 40 cmH2O): a) Indications: (1) Default ventilation setting (2) Baseline / intermediate ventilation mode to begin weaning (3) Patients with normal lung compliance (Total CL > 30 ml/cmH2O) (4) Mean airway pressure < 25 cmH2O

j)

139 Complications (1) Patient ventilator dyssynchrony, gas trapping (2) Barotrauma / volutrauma ii) Pressure control ventilation (PCV) + PEEP: a) Indications (1) Requirement for full ventilation: ie. not a weaning mode (2) Patients with poor lung compliance (3) Mean airway pressure > 25 cmH2O (4) High risk of barotrauma (eg ARDS, acute severe asthma) b) Complications (1) High sedation requirements, occasional use of muscle relaxants (2) Patient ventilator dyssynchrony, gas trapping iii) Pressure Support Ventilation (PSV) + PEEP a) Indications (1) Stand alone mode of ventilation in patients with adequate respiratory drive and mechanics (2) Weaning from ventilation (3) Patients gas trapping, auto-PEEP and high work of breathing (eg CAL) (4) Incipient or overt left ventricular failure during weaning b) k) Complications of mechanical ventilation i) Haemodynamic a) Reduced preload | b) Increased RV afterload | unmasked hypovolaemia ii) Respiratory a) Altered V/Q ratios b) Nosocomial pneumonia c) Volutrauma d) Ventilator dependency e) Neuromuscular denervation f) Increased oxygen consumption iii) Metabolic a) Post-hypercapnoeic metabolic alkalosis b) SIADH iv) Local a) Pressure effects from prolonged intubation, tracheostomy or face masks

140 l) ICU ventilators: i) Drager EVITA 2 Dura ventilator a) b) The Evita 2 are a replacing the Servo as the default ventilator at the RAH. Modes include :- SIMV, Pressure Control, Pressure Support, CPAP. Non-invasive ventilation modes are also available. Specific features: (1) Auto flow: automated adjusted inspiratory flow according to lung mechanics during controlled ventilation (2) Rise time: manual adjustment of steepness of inspiratory pressure rise during all modes (3) Automated expiratory pause hold for determination of auto-PEEP and occlusion pressure (P0.1) (4) 100 O2 suction button: delivers 100% oxygen for 3 minutes (5) Programmable default parameters (6) Preset emergency and apnoea ventilation parameters (7) High and low respiratory rate range (8) Automatic tube compensation to assist weaning (9) Automated respiratory mechanics module: (a) static and dynamic compliance (b) inspiratory airway resistance (c) negative inspiratory pressure (d) vital capacity (10) Liquid crystal and LED display for all parameters (11) Nitric oxide delivery system Default settings: SIMV: 600 x 12 | PS = 20 | PEEP = 5 | FiO2 = 1.0 (1) Press Mode setting button (2) Select the desired parameter via the respective button. Adjust the displayed value via the rotating knob, then press to select the desired value. (3) Select mode: SIMV (a) Select tidal volume: 0.6 l (b) Select respiratory rate: 12 bpm (c) Adjust TInsp. so that I:E ratio is 1:2 (default 2.5 secs) (d) Rise time: 0.2 secs (e) Pressure support: 20 cmH2O (f) PEEP: 5 cmH2O (g) FiO2: 1.0 (4) Extra settings mode: (a) Flow trigger: 5 l/min (b) Backup ventilation (CMV) : off

c)

141 d) PC (Pressure control) + PEEP PSV (1) The actual settings that are set on the ventilator must be prescribed. This is important as the settings for pressure control ventilation on the Servo are different and may cause confusion. (2) Default settings: PInsp = 30 x 12 | PEEP = 5 | FiO2 = 1.0 | I:E=1:2 (3) This is equivalent to the default settings for PCV on the Servo. (4) Select mode: PCV+ (5) Settings: (a) Select total inspired level of pressure (Pinsp) which includes PEEP: Default: 30 cmH2O (b) Select desired rate: 12 (c) Adjust TInsp. so that I:E ratio is 1:2 (default 2.5 secs) (d) Rise time: 0.2 secs (e) Pressure support: 20 cmH2O (f) Select PEEP: 5 cmH2O (g) FiO2: 1.0 (6) Alarms / limits unchanged from default (7) Do not exceed total inspired pressure > 40 cmH2O (8) Tidal volume is determined by the patients compliance (9) Ensure I:E ratio is 1:2: alteration of the I:E ratio is potentially hazardous and should only be done following discussion with the duty consultant. Measurement of auto-PEEP (1) Measurement of intrinsic PEEP at the end of expiration + closed glottis (2) Not accurate in spontaneous ventilation modes or with patient effort: patients should be paralysed or deeply sedated (apnoeic) (3) If I:E ratio is altered: auto-PEEP must be measured (4) Press Special procedure button (a) Select PEEPi, press start to begin the automatic 7sec manoeuvre (b) Read off the auto-PEEP and trapped gas volume (Vtrap) (c) The value displayed is misleading and includes applied PEEP, so that determining the actual value of auto-PEEP requires the applied PEEP to be subtracted from the displayed (PEEPi) value. (5) Adjust applied PEEP if auto-PEEP > 0-1 to obtain total applied PEEP Measurement of occlusion pressure (P0.1) (1) Measurement of mouth pressure at the start of inspiration against a closed glottis for 100msec. (2) Pressure is dependent on diaphragmatic effort and reflects neuromuscular drive (3) Normal value = 3-4 mbar (4) Higher values eg > 6 mbar reflect fatigue

e)

f)

142 (5) Press Special procedure button (a) Select P0.1 and press start to begin (b) Read off P0.1 PS (pressure support) + PEEP (1) Settings described above for use with SIMV, PCV (2) Stand alone settings: (a) Select mode: CPAP (b) Rise time: 0.2 secs (c) Pressure support: 20 cmH2O (d) PEEP: 5 cmH2O (e) FiO2: 1.0 (3) A text box appears in the bottom left hand corner once pressure support mode is selected. This displays the total inspired pressure including applied PEEP. This box is largely redundant as the pressure waveform displays the same information. CPAP (1) As above for PS but with Pressure support set to 0.

g)

h) ii)

Siemens 900C Servo: a) b) This was the standard ventilator at the Royal Adelaide Hospital and Wakefield Hospitals. Specific features: (1) Expiratory pause hold for determination of auto-PEEP (paralysed patients only) (2) Inspiratory pause hold (3) Rapid gas change facility (4) High and low respiratory rate range Default settings: SIMV: 600 x 12 | PS = 20 | PEEP = 5 | FiO2 = 1.0 (1) Select mode: SIMV + Press support (2) Settings: (a) Divide a preset minute volume (eg 9l) by the appropriate rate (15 bpm) to achieve the desired tidal volume (600 ml). (b) Set the intermittent mandatory ventilator rate (12 bpm) which must be less than the dividing rate. (c) Set pressure support (PS) = 20 cmH2O (d) Set PEEP = 5 cmH2O (e) FiO2 = 1.0 (100% oxygen ) until adequacy of ventilation and oxygenation is checked by blood gas analysis (f) Insp time = 25%, pause = 10% (I:E ratio = 1:2) (g) Square waveform (3) Alarms/limits (a) Upper pressure limit: 40 cmH2O (b) Trigger sensitivity: -2 cmH2O (c) Oxygen analyser: 10mmHg from set FiO2

c)

143 5 l above average minute volume (d) Upper volume limit: (e) Exhaled minute vol.: 80% below average minute volume PC (Pressure control) + PEEP (1) Default settings: PCV: 25 x 12 | PEEP = 5 | FiO2 = 1.0 | I:E = 1:2 (2) Select mode: SIMV + PEEP : Choose settings below before changing the mode: (3) Settings: (a) Select inspired level of pressure above PEEP (= peak inspired pressure): 20-30 cmH2O. (b) Select PEEP (5-10 cmH2O) (c) Select desired rate on preset rate dial (10-12 bpm) (d) Inspiratory time and pause set at 25 and 10% respectively. (I:E = 1:2) (e) Select Pressure control mode (other modes now become deactivated) (4) Alarms / limits unchanged from the default settings (5) Do not exceed total inspired pressure > 40 cmH2O. (6) Tidal volume is determined by the patients compliance. (7) Alteration of the I:E ratio is potentially hazardous and should only be done following discussion with the duty consultant. Measurement of auto-PEEP (1) Measurement of intrinsic PEEP at the end of expiration + closed glottis (2) Not accurate in spontaneous ventilation modes, or with patient effort: patients should be paralysed or deeply sedated (apnoeic) (3) If I:E ratio is altered: auto-PEEP should be measured (4) Press expiratory pause hold button under flap in left hand corner (a) Watch airway pressure gauge until no longer moving (b) Read auto-PEEP above applied PEEP from pressure gauge (5) Adjust applied PEEP if auto-PEEP > 0-1 to obtain total applied PEEP PS (pressure support) + PEEP (1) Select mode: SIMV + PEEP : Choose settings below before changing mode settings (2) Settings (a) Select inspired level of pressure above PEEP (= peak inspired pressure): 10-20 cmH2O. (b) Select PEEP: 5-10 cmH2O (c) Select Pressure support mode (other modes now become deactivated) (3) Tidal volume and rate is determined by the patients compliance and respiratory drive (4) Alarms / limits unchanged from default (5) Do not exceed total inspired pressure > 40 cmH2O

d)

e)

f)

144 (6) Do not use PS alone if the patient is bradypneoic due to sedation: add a reduced SIMV rate to maintain a minimum minute ventilation. iii) Puritan-Bennett 7200 ventilator a) b) This is the standard ventilator at St Andrews Hospital ICU. Specific features: (1) Flow by: enable flow triggering for spontaneous modes (PSV, CPAP) (2) Automated expiratory pause hold for determination of auto-PEEP (paralysed patients only) (3) 100 O2 suction button: delivers 100% oxygen for 2 minutes. (4) Preset emergency and apnoea ventilation parameters (5) High and low respiratory rate range for neonates (6) Automated respiratory mechanics module: determines static and dynamic compliance, inspiratory airway resistance, negative inspiratory pressure and vital capacity. Default settings: SIMV: 600 x 12 | PS = 20 | PEEP = 0 | FiO2 = 1.0 (1) Select mode: SIMV (2) Use keyboard: press enter after setting each parameter (3) Settings: (a) Select tidal volume: 0.6 l (b) Select respiratory rate: 12 bpm (c) Sensitivity: 1 cmH2O (d) Waveform: decreasing ramp (e) Peak inspiratory flow rate: 40 l/min (f) FiO2 = 1.0 (4) Select Pressure support mode, type in 20 cmH2O, press enter. (5) Manually add 5 cmH2O PEEP after the patient is connected: initial setting does not allow PEEP to be added. (6) Apnoea settings (a) Interval 20 secs (b) CMV: 500 x 10 x 1.0

c)

145 (7) Alarms/limits (a) Upper pressure limit 40 cmH2O , Low pressure 3 cmH2O (b) Low PEEP 0 cmH2O (c) Low tidal volume 80% below expected tidal volume (d) Low minute volume 4 l/min (e) High resp rate 30/min PC (Pressure control) + PEEP PSV (1) Default prescription: PCV: 25 x 12 | 5cm PEEP | FiO2 = 1.0 | I:E = 1:2 (2) Select mode: Pressure control (3) Settings: (use keyboard: press enter after setting each parameter ) (a) Select inspired level of pressure above PEEP (= PIP): 20-30 cmH2O (b) Select I:E ratio = 1:2 by selecting inspiratory time = 2 secs, expiratory time 4 secs. (c) Update parameters by pressing enter (4) Manually adjust PEEP if necessary (5) Select Pressure support mode if required, type in level (cmH2O) and press enter (6) Alarms / limits unchanged from default (7) Do not exceed total inspired pressure > 40 cmH2O (8) Tidal volume is determined by the patients compliance (9) I:E ratio sets the respiratory rate, initial I:E ratio = 1:2 NB: Alteration of the I:E ratio is potentially hazardous and must only be done with consultant supervision. Measurement of auto-PEEP (1) If the I:E ratio is altered auto-PEEP must be measured (2) Press Auto PEEP button (a) Select end expiratory interval (5-15 secs) (b) Begin manoeuvre (c) Read off auto-PEEP (3) Adjust applied PEEP if auto-PEEP > 0-1 to obtain total applied PEEP PS (pressure support) + PEEP (1) Settings described above for use with SIMV, PCV (2) Stand alone settings: (a) Select CPAP mode (b) Enter Pressure support mode and select level of support (3) Manually adjust PEEP if necessary CPAP (1) As above for PS with Pressure support mode off or set to 0. Flow by (1) Select flow by mode (2) Select base flow 5 l/min and flow sensitivity 3 l/min for all spontaneously ventilating patients (CPAP, PSV)

d)

e)

f)

g) h)

146 6. RAH-ARDSNet Ventilation Protocol a) Initial Ventilator Set-up and Adjustments (Draeger) i) Mode: SIMV + PS = 5 cmH2O ii) Resp. Rate: 18 bpm iii) Inspiratory Flow Rate: Autoflow iv) Tidal Volume: 6 ml/kg IBW Tidal Volume Settings are determined by calculated Ideal Body Weight i) Males = 0.91 x (height [cm] 152.4) + 50 ii) Females = 0.91 x (height [cm] 152.4) + 45.5 iii) Calculate IBW and Vt = 6 x IBW iv) NB: This is available as an Excel calculator on all Unit PCs Maintenance / Management i) Adjust RR to achieve the pH goals according to ABGs. (see below). ii) Adjust Vt according to plateau pressure goals. NB: Observe spontaneous tidal volumes and adjust PS downwards if volumes generated are higher than the calculated goal Vt. iii) Adjust FIO2 according to SpO2 and PaO2 iv) Check and adjust I:E ratio. Goal pH pH = 7.20 7.45 i) Acidosis management: pH < 7.20 a) RR until pH >7.20 or PaCO2 < 25mmHg (1) max RR = 35bpm b) If pH < 7.20 and RR = 35, then (1) Vt by 1 ml/kg IBW steps until pH > 7.20 (2) Pplat. goal may be exceeded ii) Alkalosis management: pH > 7.45 a) Decrease RR if possible Goal Plateau Pressure: Pplat < 30 cmH2O i) Check inspiratory plateau pressure with a 0.5sec inspiratory pause every 4 hrs and after each change in PEEP or Vt. ii) Method (Draeger): go into measurements + press inspiratory hold for 0.5sec Pplat will appear on the screen next to Pplateau for 1 second. iii) Pplat > 30 cmH2O a) Vt by 1 ml/kg IBW steps b) min Vt = 4ml/kg IBW iv) Pplat < 25 cmH2O and Vt < 6ml/kg IBW a) Vt by 1ml/kg IBW until Pplat >25 cmH2O or Vt = 6ml/kg IBW.

b)

c)

d)

e)

147 f) Goal Arterial Oxygenation: PaO2 = 5580 mmHg or SpO2 88 95% i) If SpO2 or PaO2 are outside goal range, use the following table to make adjustments to achieve the correct FiO2 / PEEP combinations for the PaO2 range required. ii) Take ABGs only as clinically indicated, changes can be made according to SpO2. iii) Examples: a) If a patient is on FiO2 0.4 and a PEEP of 5 and the PaO2 = 54 mmHg the next step would be to increase the PEEP to 8 cmH2O. b) If a patient was on FiO2 = 0.9 / PEEP = 14 and the SpO2 = 99% the next step would be to decrease the FiO2 to 0.8.
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 16

g)

4. Goal Inspiratory:Expiratory Ratio = 1:1.0 1:3.0 1 16 i) After any change in RR, check the I:E ratio and modify the Tinsp. if necessary. ii) Do not inverse the I:E ratio with this protocol risk of breath stacking and hypotension.

148 7. Non-invasive ventilation a) b) Definition: Mechanical ventilation using a face mask Modes i) Continuous positive airway pressure (CPAP) ii) Assisted Spontaneous Ventilation (ASV) by Pressure Support (PS). Indications i) Adjunct to weaning from ventilation (eg via a tracheostomy tube - CPAP only) ii) Incipient respiratory failure from high work of breathing states that are potentially reversible within 24-48 hours: a) Acute exacerbations of CAL b) Cardiogenic pulmonary oedema c) Acute quadriplegia d) Post-extubation hypoxia due to pulmonary oedema or atelectasis iii) Acute respiratory failure where intubation is considered too hazardous or inappropriate: a) Advanced CAL b) Cystic fibrosis c) Febrile neutropaenia with pulmonary infiltrates d) PCP pneumonia Prerequisites i) Adequate glottic reflexes should be present to protect from aspiration: moribund patients require intubation where appropriate ii) Patients receiving CPAP or BiPAP are generally managed in Intensive Care. (This excludes patients managed in S2 - thoracic medicine, coronary care, cardiothoracic or A&E). iii) If an HDU patient requires CPAP/BiPAP, they should be moved to an ICU bed for 1:1 nursing. iv) If there is no ICU bed, selected patients may be managed in HDU: a) Tracheostomised patients with isolated PEEP dependency - ie slow weaning b) Rapidly resolving respiratory failure with face mask CPAP/BiPAP (1) Diuresing pulmonary oedema (2) Resolving stridor

c)

d)

149 v) Complications a) Aerophagia, gastric distension b) Apiration c) Claustrophobia and mask intolerance d) Pressure necrosis of nasal bridge e) Dry secretions f) Barotrauma g) Reduction in cardiac output

e)

Ventilators: do not use Servo CPAP mode i) Drager CPAP circuit. a) Standard inspiratory flow rate is 40 l/min b) Select CPAP (cmH2O) on external PEEP valve c) Select FiO2 (air / oxygen mix with two rotameters) d) Always use with wet humidified circuits (Fisher Paykel) ii) Face mask pressure support via Servo 900C in pressure support mode iii) BiPAP ventilator: spontaneously ventilating, non - intubated patients a) Select IPAP = inspiratory pressure support b) Select EPAP = PEEP c) Oxygen may be entrained at 2-6 l/min iv) CPAP via Drager EVITA a) Select CPAP in <OtherModes> b) Set CPAP/PEEP and FiO2 c) Adjusting Press Support and Press Rise Time will add assisted breaths to CPAP. See ASV. v) Whisperflow: used at Wakefield Hospital a) Oxygen flow rates: 6-120 l/min + entrained air (does not require medical air) b) Oxygen concentration 30-100% c) External PEEP valve (PEEP level specific) d) Settings: (1) Adjust flow knob to 60-90 l/min on Ohmeda flow sensor (2) Adjust oxygen flow until desired FiO2 obtained on analyser (3) Adjust PEEP valve to desired level (4) Measure exhaled tidal volume in intubated patients (5) Always use with wet humidified circuits (Fisher Paykel) + smooth bore tubing (6) Must have continuous flow present throughout respiratory cycle. (7) Pressure relief valve must be set > 5 cmH2O above set PEEP vi) CPAP via Puritan Bennet (St Andrews Hospital) NOTE : Do not use Servo in CPAP Mode as resistances are excessive.

150 f) Assisted Spontaneous Ventilation i) The Drager Evita is best configured to achieve ASV by Pressure Support. The same settings as CPAP on Evita with adjustment of Press Support and Press Rise Time to provide the assisted breaths Default settings: a) Pressure support (above PEEP) 5 cmH20 b) PEEP 5 cmH2O c) Inspiratory time 4 sec d) Trigger 5 l/min ii) Face mask pressure support via Servo 900C in pressure support mode iii) BiPAP ventilator: spontaneously ventilating, non - intubated patients a) Select IPAP = inspiratory pressure support b) Select EPAP = PEEP c) Oxygen may be entrained at 2-6 l/min iv) Vision BiPAP a) Currently only available at St Andrews b) Specific features (1) Microprocessor controlled spontaneous breathing assist ventilator in either CPAP or spontaneous/timed breathing mode (S/T). (2) Mixes pipeline oxygen with ambient air from a blower to a preset pressure. (3) Monitors machine pressure against proximal airway (mask pressure) to ensure accurate & responsive delivery of pressure despite circuit leaks. (4) Responds by internal algorithm to detect respiratory cycling and leak adjustment. (5) Nasal, face & full head masks can be used. (6) Liquid crystal displays (a) IPAP, EPAP, rate, oxygen (b) Vt, Vmin, PIP, insp. time/total cycle time. (c) Leak(patient & total), % patient triggered breaths (d) Graphical display of pressure, volume & flow. c) Operation machine starts up in mode previously used. (1) Press <Mode> hard key to display CPAP or S/T mode (2) Select soft key parameters displayed & turn adjustment knob accordingly (3) Press <Activate New Mode> soft key to select the new mode. The ventilator will continue in old mode until activated. d) CPAP Mode (1) Default setting CPAP 5 cm H2O, FiO2 1.0 (2) Only CPAP setting & FiO2 soft keys are active. e) S/T Mode (1) Default setting IPAP 15 cmH20, EPAP 5 cmH20, Rate 12, Timed insp 1 sec, FiO2 1.0, IPAP rise time 0.1 sec (2) Adjust settings accordingly

151 f) Setting modification (1) Press <Parameter> hard key (2) Select soft key & turn adjustment knob. (3) Press <Monitoring> hard key to activate & return to monitoring screen Alarm limits (1) High Pressure 30 cmH20 (2) Low Pressure 5 cmH20 (3) Low Min Vol 0 l/min (4) High resp rate 30 b/min (5) Low resp rate 6 b/min (6) Low press delay 20 sec

g)

8.

Weaning from ventilation a) General principles i) No mode of weaning has been demonstrated to be superior to another ii) Short-term patients with acute resolution of respiratory failure (eg postoperative, drug overdose, trauma) may be rapidly weaned and extubated from full ventilation. iii) Long-term patients with multiple intercurrent problems take longer and effectively go at their own pace. iv) It is important to balance over-sedation and prolonged ventilation against rapid weaning, patient exhaustion and failed weaning or extubation. Clinically important determinants for weaning from ventilation: i) Resolution of the process requiring ventilation ii) Completion of therapeutic options that require ventilation (eg debridements, operations) iii) Clinically and radiologically resolving lung disease iv) Appropriate conscious state; cooperative patient v) Appropriate peripheral motor function vi) Adequate analgesia vii) Haemodynamic stability viii) Metabolic, acid-base stability Methods i) Spontaneous effort is required for the patient to be weaned: PCV is not a weaning mode. ii) SIMV with reducing rate and tidal volume in conjunction with PSV and PEEP is standard iii) Use PSV + PEEP alone once the patients spontaneous rate is less than the apnoea alarm on the ventilator. iv) Intubated CPAP v) BiPAP

b)

c)

152 vi) T-piece weaning: intermittent T-piece and positive pressure (PSV / CPAP / SIMV) vii) Extubation to non-invasive ventilation. Objective measurements are adjuncts to assessment of weaning success. These are not specific and must be interpreted in the clinical context. Of these, respiratory rate and the expired tidal volume are the most sensitive. i) Mechanical measurements a) Rate (f): < 30/min b) Tidal volume: > 5 ml/kg c) f/VT: < 100 ii) Oxygenation indices a) PaO2/FiO2: > 200 b) PEEP < 10 cmH2O c) P(A-a)O2 < 350 mmHg iii) Ventilation indices a) PaCO2 < 60 mmHg

d)

9.

Extubation protocol a) Ensure equipment, monitoring and adequate assistance as for intubation. b) Extubation is preferentially done during daylight hours and is a medical responsibility. c) Extubation criteria: i) Return of adequate conscious state to maintain adequate protective laryngeal reflexes and secretion clearance. ii) Adequate pulmonary reserve: a) Resp rate: < 30 b) FVC: > 15 ml/kg c) PaO2/FiO2: > 200 iii) In patients with upper airway surgery or swelling the demonstration of an adequate air leak around the deflated endotracheal tube cuff. iv) Plastic surgical and ENT patients require consultation with the Parent Clinic. Those patients with intermaxillary fixation and wiring must have a person from the Parent Clinic familiar with the placement of the wires and a wire cutter present during extubation. d) All patients must receive supplemental oxygen post extubation.

153 10. Protocol for ventilation in the prone position a) General principles i) This technique may improve oxygenation in up to 60% of patients with severe ARDS. This may buy time, however no benefit in outcome has been demonstrated to date. ii) Prone ventilation in critically ill patients is potentially hazardous: a) Difficult airway and patient access b) Increased risk of endotracheal tube dislodgment or malpositioning c) Difficulty in tracheal suction d) Pressure necrosis particularly involving the face. e) High incidence of facial oedema f) Labour intensity g) Difficulty in performing CPR iii) The decision to ventilate a patient prone should be made by the Duty Consultant. iv) Patients must only be turned if adequate numbers of staff are available, ideally during working hours, in discussion with senior nursing staff. Indications i) Local or anatomical factors, eg posterior burns ii) Severe ARDS a) Rationale of improved oxygenation in prone ventilation in ARDS: (1) Improvement in FRC by alveolar recruitment (2) Preferential redistribution of pulmonary blood flow improved V/Q ratios (3) Uniform distribution of lung water and exudate (4) Reduction in intrapleural pressures (5) Non-restriction of abdominal contents (6) Reduction of diaphragmatic splinting and improved movement of the posterior diaphragm. b) Timing (1) Severe ARDS with PaO2:FiO2 ratio < 100 (2) Pulmonary hypertension : MPAP > 35 mmHg (3) Non-response to standard supportive care (a) Optimisation of fluid balance (b) Treatment of infection (c) Circulatory support

b)

154 c) Contraindications i) Absolute a) Inadequate staff b) Spinal injury unstable c) Pelvic fracture unstable / orthopaedic traction ii) Relative a) Anterior UWSD b) Patients on CVVHDF c) Patients on IABP d) Morbid obesity e) Patients unable to lie flat Procedure i) Staff required a) An intensive care doctor b) Minimum of four nurses ii) Essential monitoring / equipment a) Electrocardiograph (ECG) electrodes placed on the back b) Arterial line c) Pulse-oximetry d) End-tidal carbon dioxide monitor e) Intubation /resuscitation trolleys f) Closed suction device in situ g) 2 secure IV accesses. iii) Safety check before turn a) Check ETT position on CXR prior to turn b) ETT should be secured with cotton tape and adhesive tape c) Check security of tracheostomy tapes d) Secure all invasive lines and drains. Ensure they have enough room for the turn. e) Ensure patency, accessibility and sufficient slack for turn f) Recirculate dialysis if in progress g) Deflate air mattress h) Ensure the patient is heavily sedated i) Consider the use of neuromuscular blocking drugs j) Apply lubricant to the eyes and close with tape or plastic film k) Replace head pillow with a small foam gel pad.

d)

155 iv) Procedure a) Explanation to patient and relatives where appropriate b) The doctor must take control of the head and airway and coordinate the turn c) Place the patient flat on their back with arms by the side d) Lift the patient (on a draw sheet) to side of the bed away from the ventilator, ie. turn towards the ventilator. e) Place a firm pillow or foam support under the hips and shoulders f) Tuck lower hand under hip g) Slowly roll the patient onto the pillows/foam taking care of lower the arm & shoulder h) Place the head to one side, check the eyes are shut i) Check the airway, oxygen saturation, ventilation, invasive lines and haemodynamic response j) Place the arms in an anatomical position: check a/c and elbow joints k) Check all potential skin pressure points l) Take an arterial blood for gas analysis m) Re-inflate the air mattress. v) Maintenance a) Routine ICU observations b) Hourly face pressure care and head repositioning c) Monitor plantar flexion, neck hyperextension and facial oedema d) Continuous ETCO2 monitoring whilst prone e) ABG as soon as the patient is stabilised. vi) Duration a) If there is a major deterioration in the arterial oxygenation, the patient must be turned supine as soon as possible. b) If the oxygenation is unchanged or improved, leave prone for up to 12 hrs. Some patients may show gradual improvement over this period. c) Repeat rotations once per shift according to clinical progress / response. d) In general, patients should not be turned at night. e) Ensure all safety issues are followed in reverse when return patient to supine position.

156 D. 1. Management of Cardiothoracic Patients General Principles a) Wakefield Hospital ICU is a predominantly cardiothoracic ICU b) The following guidelines apply to elective post-cardiac surgical patients. Respiratory a) Following surgery commence all patients on default Servo 900C ventilation settings: SIMV + PS + PEEP + FIO2 = 1.0 b) After the first ABG, adjust the FIO2 to maintain a PaO2 > 80mmHg c) Wean from ventilation according to past history, surgery performed and current clinical status d) Extubation criteria: i) Temperature > 36C ii) Awake, able to obey commands iii) Adequate analgesia iv) Cardiovascular stability, on minimal inotropes v) Adequate gaseous exchange: PaO2 > 80 mmHg on FIO2 0.5 vi) Minimal bleeding: < 100 ml/hour e) Respiratory failure post-op secondary to collapse / consolidation is common. i) Ensure good analgesia and frequent, effective physiotherapy ii) CPAP may be required in the first 48 hours. f) Patients with poor LV function / recurrent acute pulmonary oedema are prone to extubation failure and may benefit from the use of ACE inhibitors, inodilators or a trial of spontaneous ventilation prior to extubation. Management of bleeding a) Perform appropriate investigations: ACT, APTT, INR, platelet count. b) Treat abnormalities of above: i) Protamine 50 mg slow IV if ACT >150 or APTT > 60 sec ii) FFP if INR > 1.5 iii) Desmopressin (DDAVP): 0.4g/kg over 20 minutes. if blood loss > 200 mls/hour. c) If bleeding continues or is brisk: i) platelet transfusion of 5 units, irrespective of platelet count. ii) perform CXR to exclude tamponade iii) initiate review by cardiothoracic surgeons d) Consider re-opening if: i) bleeding > 200 ml/hr for 3-4 hrs, or ii) total loss > 1500-2000 ml.

2.

3.

157 4. Hypotension a) Hypovolaemia i) Return pump blood as soon as possible ii) Correct fluid/blood losses as appropriate maintain Hb >80 g/L and CVP ~ 6-10 mmHg b) Myocardial failure i) Adrenaline is the first line inotrope used to maintain an appropriate MAP (usually MAP > 70-80 mmHg) ii) Consider insertion of a PA catheter if adrenaline > 10g/min required and the patient is euvolaemic iii) Consider echo to exclude tamponade, acute MI, papillary muscle rupture, or VSD. iv) Consider pacing (either epicardial or transvenous) if hypotension is rate related (HR < 60). A-V sequential pacing is the ideal mode (DDD) v) Consider IABP if hypotension persists despite inotropes vi) Consider milrinone for patients with predominantly diastolic cardiac failure or pulmonary hypertension. c) Vasodilatation i) Commence noradrenaline if the patient appears vasodilated with persistent hypotension. ii) Consider: a) arginine vasopressin (0.03-0.04 u/min), or b) terlipressin (1mg over 5mins q6h prn) if available iii) Consider insertion of a PA catheter to determine CO, SVR and SV to aid in management.

158 d) Tamponade i) This is a medical emergency. If suspected, the cardiothoracic surgeon and duty consultant must be notified immediately. ii) Diagnosis: a) Refractory hypotension despite adequate volume replacement and inotropic support b) Cessation / reduction of blood coming from drains c) Globular heart shadow on CXR and muffled heart sounds may be present but are unreliable signs d) Diastolic equalisation of right-sided pressures if a PA catheter has been inserted. e) Echocardiographic evidence of tamponade. iii) Treatment a) Support MAP with aggressive volume replacement and inotropic support. b) Ensure sufficient blood is cross-matched ( 6 units) c) If stable, reopening in theatre is the definitive treatment d) In life-threatening situations the chest may need to be opened in ICU.

5.

Hypertension a) MAP should be kept at approximately 70 mmHg for the first 24-36 hrs. b) This may vary according to the patients premorbid blood pressure. c) Management: i) Ensure adequate analgesia ii) Nitroprusside 50 mg in 250 ml 5% dextrose: titrate to maintain MAP of 70 mmHg. iii) If nitroprusside infusion > 40-50 ml/hr (2 g/kg/min), consider: a) -blocker: atenolol 1-2 mg IV, or esmolol 10-25 mg (if no contraindication) b) Clonidine: 25-50 g IV (up to 300g/24 hrs) c) Hydralazine: 10-20 mg IV Sedation a) Generally as per general ICU sedation protocols b) In patients expected to be extubated within 24 hrs consider dexmedetomidine (Precedex): i) 2:1 -agonist activity ~ 1600:1, providing both sedation and analgesia ii) loading dose: 0.5-1.0 g/kg/min over 10 mins iii) infusion: 0.2-0.7 g/kg/hr iv) patients coming from theatre may not require a loading dose v) complications: hypotension, bradycardia, sedation

6.

159 7. Anticoagulation a) All patients receive subcutaneous heparin i) < 70 kg 5000U 12 hrly ii) > 70 kg 7500U 12 hrly b) Patients with saphenous vein grafts should receive aspirin 300mg po daily post-extubation, or via a NGT if extubation is delayed. c) Commence patients with valve replacements on warfarin (5mg nocte) from the second post-operative day if extubated. d) Patients with a mitral valve replacement ventilated > 48 hours may require heparinisation. e) Newer drug therapies i) Platelet ADP receptor blockers a) Irreversible inhibition of platelet aggregation: b) Ticlodipine 250mg b.d. c) Clopidogrel 75mg o.d. ii) Platelet glycoprotein IIb/IIIa receptor blockers a) Abciximab (ReoPro): (1) Bolus: 0.25 mg/kg given 10-60 minutes prior to PTCA (2) Infusion: 0.125 g/kg/min for 12 hrs. (Max rate 10 g/min) b) Tirofiban (1) Infusion: 0.4 g/kg/min for 30 mins. 0.1 g/kg/min for 12 hrs. c) All inhibit platelet aggregation d) Thrombocytopaenia common ~ 2.5% e) Partially reversible by platelet transfusion. Antibiotic prophylaxis a) See guidelines in antibiotic section in Drugs.

8.

E. 1.

Renal failure Policy a) The advent of continuous renal replacement therapies (CVVHDF) has largely changed the management of acute anuric renal failure in Intensive Care. b) The mortality from acute renal failure remains high: from 8% in isolation to 70% when associated with other organ or system failures. c) The decision to commence a patient on CVVHDF should be discussed with the duty consultant. d) Potentially nephrotoxic drugs must be prescribed with caution and where applicable titrated against drug levels. e) The renal unit should be notified early of patients who are potential longterm dialysis candidates.

160 2. General principles of renal failure in critically ill patients. a) b) c) d) The minimum urine output required to excrete the obligatory daily solute load is ~ 0.5 ml/kg/hr While non-oliguric renal failure is clinically easier to manage and is probably associated with lower morbidity, the effect of converting oliguric to nonoliguric renal failure on mortality is unknown. Interpretation of renal function must be taken in the context of pre-morbid function. High-risk patients are: i) Pre-existing renal failure (creatinine > 0.12) ii) Hypertensive patients iii) Diabetics iv) Vasculopaths v) Following AAA, crush injury, large contrast media loads vi) Diuretic dependent renal function (eg CCF, CRF) Causes of ARF in ICU patients is usually multifactorial: i) Pre-renal azotaemia: this is the most common association with renal failure in ICU. This may be due to any cause for hypovolaemia, hypotension and low cardiac output. ii) Intra-renal insult, vasomotor nephropathy: in ICU patients a multilevel endothelial insult that affects glomerular filtration, tubular concentration and perfusion distribution (ATN is a pathological diagnosis and understates the lesion). This may be compounded by direct nephrotoxic agents, such as myoglobin, contrast media and aminoglycosides. iii) Post-renal obstruction is uncommon, but should be excluded. iv) Increased abdominal pressure probably exerts its effect at all the above levels: consider decompression when this exceeds 20 mmHg. Analysis of urinary electrolytes is rarely useful: these are impossible to interpret in the presence of diuretics or natriuretic agents (eg catecholamines) for at least 24 hours after administration. Analysis of urinary sediment must always be considered in patients with suspected interstitial nephritis (eg following penicillins), glomerulonephritis, or endocarditis. This procedure is performed by the Renal Unit. Renal perfusion scans may be indicated for: i) Demonstration of renal perfusion where vascular integrity may have been compromised (eg post-AAA, aortic dissection or major trauma). ii) Persistent anuria in high-risk patients on dialysis for ARF. iii) Renal transplant viability. Renal biopsy: demonstration of cortical necrosis, glomerulonephritis, interstitial nephritis and renal architecture.

e)

f) g) h)

i)

161 3. Renal protective strategies a) The following principles are the mainstays of renal protection practiced in this Unit: i) Fluid resuscitation to maintain circulating blood volume ii) Haemodynamic support of blood pressure and cardiac output using inotropes (adrenaline, noradrenaline, dobutamine). Taking into account the patients premorbid function and BP. iii) Exclusion of post-renal obstruction in susceptible patients by abdominal ultrasound. iv) Avoidance of nephrotoxic drugs, especially: a) Aminoglycosides b) Amphotericin c) Contrast media d) NSAIDs v) Careful prescription and monitoring of gentamicin and vancomycin where indicated. vi) Prompt treatment of intercurrent infection. Unproven strategies advocated for renal protection: i) Frusemide infusion/high dose ii) Mannitol infusion /intermittent iii) Aminophylline infusion iv) N-acetyl cysteine v) Calcium channel blockers Low dose dopamine has been shown to be ineffective by the ANZICS Clinical Trials Group Although these strategies may temporarily increase urine output, none have been proven to reduce the incidence of dialysis dependent renal failure or mortality. Inappropriate polyuria may worsen hypovolaemic states and complicate fluid management. Spontaneous return of urine output is usually a sign of general improvement which may be masked by these strategies.

b)

c) d) e) f)

162 4. Indications for dialysis a) Symptomatic acute renal failure: i) Uncontrolled acidosis ii) Uncontrolled hyperkalaemia iii) Pulmonary oedema iv) Symptomatic uraemia (urea > 35 mmol/l) a) Encephalopathy b) GIT haemorrhage c) Pericarditis Severe sepsis i) Developing oliguric renal failure ii) Removal of cytokines / mediators is an unproven indication. Recent trials suggest a benefit from high volume (50-150 ml/kg/hr) ultrafiltration in sepsis and fulminant hepatic failure. This remains experimental and is not currently a standard practice. Diuretic resistant pulmonary oedema Drug removal i) Salicylate ii) Methanol iii) Theophylline iv) Ethylene glycol v) Lithium Other drug overdoses (eg ecstasy/fantasy) associated with severe hyperpyrexia / rhabdomyolysis / acidosis. Dialytic therapy a) Standard Modes i) Continuous veno-venous haemodiafiltration - performed by ICU staff ii) Intermittent haemodialysis / haemofiltration - performed by Renal Unit Continuous veno-venous haemodiafiltration (CVVHDF) i) Standard form of continuous renal replacement therapy in this Unit ii) It is essential that registrars familiarise themselves with the circuit and procedure. Circuit diagram:

b)

c) d)

e) 5.

b)

c)

163 Standard CVVHDF setup at Royal Adelaide Hospital

To Patient

Ultrafiltrate Replacement

Heparin

Ultrafiltrate

Dialysate Solution

164 d) Procedure i) Access: a) Arrow G+ard Blue: 20cm 3-lumen, antibiotic-impregnated catheters are preferred for longer term patients b) Arrow Blue: 20cm 3-lumen, catheters are available for patients allergic to sulpha-class drugs. c) Gambro: 25cm 2-lumen catheters are kept in the unit for femoral placement in larger patients. ii) The Prisma dialysis machine is the standard unit used at the RAH. iii) Orders for the Prisma should be written on a standard sticker. Haemofiltration solution Baxter haemofiltration solution (5 litre) Rate = 1000 ml/hr NB: A lactate free solution is available as a 3l bag, however this should not be used without consultant approval and must have sufficient ( 90 mmol) bicarbonate added prior to use. 100-120 ml/min Pumped controlled + weight calculated. = pre-dilution + (negative balance) Baxter HF solution Default = 500 ml/hr (max = 2000 ml/hr) Integrated infusion system Low systemic: 2000-5000u Heparin stat, 500-1000u/hr or nil if possible Delivered pre-filter Check APTT at 6 hours

Blood flow rate Ultrafiltration Predilution Anticoagulation

iv) No anticoagulation is required for patients with endogenous coagulopathy. v) For patients with proven HITS and LMWH cross-reactivity, after a trial of CVVHDF without heparin, consider: a) Prostacyclin 4 ng/kg/min, or b) Danaparoid 1000-2000U stat. 200 U/hr e) Principles of CVVHDF i) Advantages of CVVHDF over conventional intermittent haemodialysis: a) Effective and more flexible control over fluid balance b) Greater cardiovascular stability c) Does not require attendance of Renal Unit staff d) May have a role in modification of the septic response. e) Some trials suggest improved patient mortality, however this is not yet proven.

165 ii) Haemodiafiltration combines: a) Haemofiltration (1) Convective solute and fluid removal down a hydrostatic pressure gradient to form an ultrafiltrate (UF) (2) Clears middle molecules (>500 D) and fluid (3) UF formation is dependent on the pressure gradient and membrane characteristics (effective pore size & surface area) (4) Predilution replacement of ultrafiltrate with balanced salt solution increases the availability of urea for convective transfer by favouring its movement from red cells. b) Haemodialysis (1) Diffusion of solute down a concentration gradient across a semi-permeable membrane, running dialysate fluid countercurrent to blood flow (2) Clears urea, creatinine, electrolytes (molecules ~ 50-120 D) (3) Solute clearance is adjusted by changing the dialysate fluid concentration, blood and dialysate flow rates.

iii) Ultrafiltration replacement: a) Overall fluid balance is set directly on the machine via Fluid Removal. Note the replacement rate does not dictate overall fluid removal on the Prisma machine. b) The requirement for volume removal depends on the fluid status and haemodynamic stability of the patient c) Replacement fluid is usually haemodiafiltration (HD) fluid d) HD fluid has a [K+] = 1.0mmol/l and additional K+ should be added for all patients except those who are acutely hyperkalaemic: (1) K-Acetate (5mmol/ml) (a) Indicated in severe acidosis, where the acetate is effectively metabolised to bicarbonate. (b) Adding 2.5ml per 5L HD bag [K+] = 3.5mmol/l (2) KCl (13.6mmol/10ml) (a) Preferred in patients with a normal or alkalotic pH (b) Adding 10ml per 5L HD bag [K+] = 3.7mmol/l e) The default rate is 500ml/hr, which may be set to a maximum of 2000ml/hr iv) Frequency: aim for creatinine < 0.3 mmol/l, urea < 30 mmol/l a) Catabolic and unstable generally require continuous dialysis b) Once stable: one filter per day will usually suffice

166 v) Drug prescription a) Multiple drug classes require dose alteration in renal failure. b) Drugs where levels may be measured (gentamicin, vancomycin, digoxin) are prescribed according to levels. c) Antibiotics such as meropenem, ciprofloxacin and fluconazole vary according to creatinine clearance and the presence/absence of dialysis, consult Antibiotic Guidelines, pharmacy, or Clinical Microbiology.

vi) Heparin lock both catheter lumens 8 hourly when not in use: a) Withdraw 2 ml and discard, then flush with 2 ml normal saline b) Flush 1.5 ml solution (5000u heparin/2ml) into each lumen. vii) Complications of CVVHDF a) Bleeding b) Hypothermia c) Prolonged exposure to heparin: incidence of HITS d) Prolonged venous access: infection, thrombosis e) Prolonged exposure to extracorporeal circuit and membrane (cuprophane > polyacylonitrile) ? immune paresis f) Air embolism g) Increased nursing workload h) Catheter flow disruption rapid blood volume changes

167 F. 1. Neurosurgical protocols Neurotrauma in ICU a) b) Close liaison and communication with the neurosurgeons is essential for the coordinated management of acute head injury. The ICU management of the neurotrauma patient consists of: i) Acute trauma resuscitation and retrieval ii) Liaison and coordination with other clinics in the multiple trauma patient. iii) Cardiopulmonary / renal / metabolic homeostasis. iv) Maintenance of cerebral homeostasis NB: refer to cerebral perfusion pressure (CPP) algorithm v) Transport for neuro-imaging Principles of ICU management: i) Ventilation a) Maintain normoxia: PaO2 > 80 mmHg b) Ventilation to normocapnia: PaCO2 = 35-40 mmHg ii) Haemodynamics: a) Maintain perfusion pressure: (1) MAP > 90 mmHg in the absence of ICP measurement (2) CPP > 70 mmHg (3) NB: use inotropes if required once euvolaemic b) Fluid maintenance (1) Maintain euvolaemia (2) Crystalloid/colloid depending on Na+ and measured osmolality (3) Avoid dehydration if patients become polyuric (DI / mannitol) iii) Osmotherapy: a) Patient must be euvolaemic and normotensive (relative to premorbid BP) before the administration of mannitol b) The indications for the use of mannitol prior to ICP monitoring are signs of transtentorial herniation or progressive neurological deterioration not attributable to systemic pathology. c) Measured osmolality should not to exceed 320 mosmol/l (NB: mannitol and alcohol cause an osmolal gap ie measured calculated osmolality) d) A unirnary catheter is essential. e) Standard dose : 100 ml 20% Mannitol (0.25 g/kg is too much)

c)

168 iv) Traumatic seizure prophylaxis: a) Indications: (1) Closed head injury with structural damage (intracerebral or paraxial haematomas) (2) Penetrating head injuries (3) Pre-existing epilepsy (4) Phenytoin prescription: (a) 15 mg/kg loading over 30 minutes (b) 300 mg daily x 10 days only (c) Monitor levels: therapeutic 40-80mol/l v) Antibiotics: (for neurotrauma per se) a) Routine prophylaxis for insertion of monitoring catheters: cefazolin 1g stat b) Base of skull fractures: antibiotics are not indicated in the absence of signs of meningitis c) Nosocomial infections: as per infectious diseases guidelines. vi) Sedation: a) Consider the use of propofol in patients where regular review of CNS status is required (majority of patients) b) Control large sympathetic swings with morphine/midazolam fentanyl boluses (100-200 g IV) c) The use of muscle relaxants is relatively contraindicated d) Consider -blockade or clonidine in labile neurogenic hypertension. vii) Nutrition: a) Establish enteral feeding as soon as feasible b) Maintain BSL in the normal range: hyperglycaemia is common in the acute phase and may precipitate a hyperosmolal state with resultant polyuria. Use insulin infusions if necessary. viii) Stress ulcer prophylaxis if anticipated ventilation > 48 hours: see protocol ix) Thromboprophylaxis: a) All patients should have TED stockings. b) Anticoagulation is relatively contraindicated, however may be commenced when indicated following discussion with Neurosurgery c) Patients at high risk of PTE (eg # pelvis, previous DVT/PTE): (1) Consider sequential calf-compression device (2) Considered for a caval filter x) Nurse patients at 30o head-up elevation. xi) Avoid hyperthermia.

169 d) Monitoring of head injured patients: i) Cardiorespiratory: a) In adition to routine ICU monitoring, consider End-tidal CO2 (1) Interpret with caution & calibrate with PaCO2 when, (a) Change in ventilation (b) Sudden rise in ICP (c) Jugular bulb desaturation (< 55%) (2) Adjust ETCO2 to PaCO2 35-40 mmHg ii) Neurological: a) ICP monitoring (1) ICP monitoring inserted by neurosurgeons as indicated (2) Indications: (a) Severe closed head injury (GCS < 8) (b) Abnormal CT Scan (c) Brain swelling following evacuation of intracranial haematoma (d) Intracerebral haematomas where decision to operate will depend on ICP (e) Polytraumatised patients in whom cerebral status cannot be adequately assessed (eg patients requiring ventilation) (f) Rarely in non-traumatic causes of raised ICP: meningitis, Reyes syndrome. b) Ventricular drain: (1) Closed system (2) Daily CSF for M,C&S (3) Set height for drainage according to neurosurgical consultation.

170 Jugular bulb oximetry protocol

Indications Severe CHI where maintaining CPP > 70 mmHg requires high-dose catecholamines, such that a reduction in target CPP may be achieved. Site Selection Cannulate side of maximal parenchymal injury on CT, or cannuilate Left IJ in the presence of diffuse injury

Insertion: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Full surgical scrub and drape Connect SjO2 catheter to optic cable Perform Pre-insertion Calibration of SjO2 catheter Connect 3-way tap and flush catheter with heparinised saline Retrograde insertion of needle/ Seldinger wire into IJV Insert peel-away sheath and introducer Remove wire and introducer, leaving sheath Insert SjO2 catheter until mild resistance is felt, level with the external auditory meatus. Aspirate and flush catheter Check light intensity monitor Secure with Tegaderm - do not coil catheter! Check position on lateral Cx spine xray: level with C1 Connect continuous hep.saline flush @ 3 ml/hr

Calibration: Pre-insertion 1. 2. 3. 4. 5. 6. Performed to test integrity of optical system only. Leave catheter in package and connect optical cable Press CAL on monitor Depress the lid of the reference curvette until clicks Select P for pre-insertion calibration Wait for CAL OK message before continuing insertion.

Calibration: In-vivo 1. 2. 3. 4. 5. 6. To be performed 12 hourly Press CAL on monitor Select I for in-vivo calibration. The machine will store the current SjO2 reading. Aspirate blood via SjO2 catheter with AGA syringe and enter into Blood Gas analysis machine. Analyse ASAP. Adjust stored value to equal measured value with the up/down keys. Press OK when complete

Trouble-Shooting: 1. 2. Poor light intensity: adjust head-position (neutral), check catheter position Abnormal reading (< 55%): perform in-vivo calibration

171 Cerebral perfusion pressure algorithm

InitialTargets to Optimise CPP 1. 2. 3. 4. Maintain euvolaemia with IV fluids Commence inotropes to maintain CPP > 70 mmHg (MAP ICP) Maintain normocarbia, PaCO2 35-40 mmHg Avoid hyper-osmolality, target plasma < 320 mosm/kg

TARGET FAILURE: ICP > 20 mmHg for > 10min. OR 1. 2. 3. 4.

SjO2 < 55%

5. 6. 7. 8.

Ensure accurate ICP and SjO2 readings: calibration and light intensity Consider CSF drainage if intraventricular catheter in situ Ensure adequate sedation Exclude contributing factors Neck position / venous obstruction 30 head-up position Fever, Seizures Consider NMJ blockade Consider mannitol (100ml) Consider short-term hyperventilation prior to CT Notify neurosurgeon on-call

Surgical Lesion

URGENT CT Scan

Management as per Neurosurgical opinion.

Non-Surgical Lesion 1. 2. 3. Attempt to maintain CPP > 70mmHg with fluids/inotropes IF CPP controlled but requiring high dose inotropes insert SjO2 catheter and trial lower CPP target > 60mmHg, providing SjO2 maintained > 55% IF CPP not controlled, consider additional therapies after discussion with Duty ICU and Neurosurgical Consultants: Propofol/barbiturate coma Decompressive craniectomy

172 2. Subarachnoid haemorrhage Classification:

Grade 0 1 2 3 4 5 Description Non-ruptured Asymptomatic, minimal headache, slight nuchal rigidity Moderate to severe headache, nuchal rigidity, no neurologic deficit (other than cranial nerve palsy) Drowsy, confused, mild focal deficit Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity Deep coma, decerebrate rigidity, moribund patient GCS 15 13-15 13-14 13-14 7-12 3-6

a)

Principles of ICU management: i) Admission to ICU/HDU: a) Acutely prior to angiography or surgery b) Post-operatively ii) Priorities a) Monitoring of airway and adequacy of ventilation b) Maintenance of adequate cerebral perfusion maintain appropriate MAP (relative to premorbid BP) c) Monitoring of conscious state (GCS) d) Neurological causes of reduced GCS notify neurosurgeons (1) Rebleed from aneurysm (2) Vasospasm (3) Hydrocephalus iii) Monitoring: a) Pulse oximetry b) Arterial line c) ICP in patients with a ventricular drain in situ: (1) May be set at a level (usually 10 cm) above head and/or (2) Connected to monitor transducer (3) Daily CSF for Culture Treatment i) Specific drug therapy: a) Nimodipine: (1) Indications (a) CT proven SAH (b) IV preferably through central line (2 mg/hr) *may be given through a peripheral IV (c) Change to oral as soon as possible (2) Complications: hypotension

b)

173 Triple H therapy (hypertensive / hypervolaemic / haemodilution): not a standard or proven therapy a) may be indicated post aneurysmal clipping to maintain adequate CPP and flow through area of vasospasm b) Induced hypertension must be titrated to a mean arterial pressure: systolic blood pressure is not an accurate measurement of systemic pressure c) Principles: (1) Maintain IV volume (a) Continue IV filling until urine output > 1ml/kg/hr, or clinical evidence of volume overload (b) Hypervolaemia may not be readily achievable in a healthy patient: maintain adequate volume status especially if polyuria ensues. (c) Monitor electrolytes 8 hrly: maintain normal osmolality and potassium. (2) Relative hypertension: (a) Arterial monitoring is mandatory (b) Commence noradrenaline if MAP < 20 mmHg below premorbid level (c) Titrate to MAP 20 mmHg above premorbid level (d) Reset targets if high doses are required (> 40g/min), or if polyuria, arrhythmias or other complications ensue. d) Complications: (1) Pulmonary oedema, myocardial ischaemia (2) Polyuria, electrolyte disturbances (3) Increased complexity of patient management iii) Chemical (papaverine) angioplasty a) Limited role in angiographically proven arterial narrowing (vasospasm) b) Requires transport for angiography and may be performed on consecutive days. iv) Operative therapy: a) Early (within 3 days) : currently recommended at RAH (1) Advantages (proposed): prevention of rebleeding, reduction of vasospasm, prevention of ischaemia (2) Disadvantages: high intraoperative risk of rupture, difficult dissection b) Late (after 11 days) (1) Advantages: easier procedure, opportunity to monitor. (2) Disadvantages: re-rupture, prolonged vasospasm v) Anticonvulsants: as directed by Neurosurgery vi) Steroids not indicated ii)

174 3. Status epilepticus a) Definition: i) More than 30 minutes of: a) Continuous seizure activity b) Two or more sequential seizures without full recovery of consciousness between seizures b) Principles of ICU management i) Assessment of airway and adequacy of ventilation a) Intubate and ventilate if appropriate b) Avoid muscle relaxants after intubation ii) IV access iii) Control of seizures: a) Diazepam: 10-20 mg IV prn, or Midazolam: 1-10 mg/hr via infusion b) Phenytoin: 15 mg/kg load, then 300 mg daily check for previous administration therapeutic 40-80mol/l c) If refractory: (liaise with neurologists) (1) Clonazepam 1-2 mg IV prn or by infusion 0.5-2 mg/hr (2) Consider Valproate if focal seizures: 200-500mg oral 8 hrly (3) Thiopentone infusion (a) Loading dose: 5mg/kg of 25mg/ml solution (2500mg / 100ml N.sal) (b) Infusion: 1-3 mg/kg/hr (~ 150 mg/hr or 6 ml/hr) iv) Look for a cause and treat appropriately: CT scan if unclear a) Previous epilepsy b) Intracranial pathology: (1) Vascular (haemorrhage, thrombosis), spasm, infection, tumour c) Extracranial (1) Metabolic: exclude hypoglycaemia, thiamine deficiency (2) Check electrolytes: especially Ca++, Mg++, K+, PO4 d) Infection e) Severe hypertension c) Maintenance of homeostasis i) Ensure adequate hydration: maintenance fluids according to creatinine/urea, Na+ and osmolality ii) Ensure adequate urine output: prolonged seizures may be associated with rhabdomyolysis

175 4. Exclusion of acute cervical spinal injury following trauma a) Safe practices are vital to prevent secondary damage to the cord b) Spinal immobilisation should be practiced in all patients with; i) significant distracting injury or injury above the clavicles ii) altered conscious state for any reason (head injury, alcohol, drugs etc) iii) neck pain or tenderness iv) abnormal neurological signs or symptoms NB: Hard collars allow up to 73% of normal flexion and extension and so still need appropriate spinal care even if in place. Soft collars do not provide effective C-spine immobilisation. c) Clinically clearing the C-spine requires ALL of the following criteria to be fulfilled; i) normal conscious state, with no drugs or alcohol on board ii) no neck pain, or neck tenderness iii) no abnormal neurological signs or symptoms iv) no significant distracting injury, or significant injury above the clavicles and then, v) normal head control (unassisted) vi) pain-free movement d) If all of these are confirmed, the hard-collar can be removed, and the C-spine cleared. e) If the C-spine can not be clinically cleared for any reason, radiology needs to be performed (the majority of patients seen in Trauma Resus) f) Virtually all patients presenting to Trauma Resus require a trauma series of adequate AP, lateral, and odontoid C-spine plain views g) A complete series of 3 plain views will still miss up to 7% of C-spine injuries hence the importance of clinically clearing (if possible) the C-spine even if the Xrays appear normal. h) If the C-spine cannot be clinically cleared following normal plain films, maintain spinal precautions and liaise with the Trauma Registrar. i) Clearing the C-spine in the patient with altered conscious state: i) If drugs, alcohol or minor closed head injury are the problem, they are often resolved within 24 hours maintain spinal precautions until that stage, and then assess clinically ii) If the patient is unconscious, and likely to stay so for some time, clinical clearance will not be possible, therefore: a) Perform a complete plain Xray series b) CT C0-2 in all, during first visit to scanner c) CT any suspicious areas on the plain films d) CT may be required to visualise cervicothoracic junction iii) If these films are all documented normal, the collar may be removed and the C-spine cleared as per RAH protocol. iv) Any ongoing concerns are referred to the Trauma and/or Spinal Registrar j) Flexion-extension views of the C-spine must not be performed, unless ordered by the Spinal Unit, with the Spinal Fellow in attendance

176 k) As with the C-spine, the thoracolumbar spine should be imaged in all patients in whom it can not be clinically assessed. This should be done prior to arriving in ICU l) 25% with a spinal injury at one level will have a second non-contiguous injury. Therefore, if a fracture is found anywhere in the spine, the entire spine should be Xrayed m) Spinal Xrays should ideally be performed in an Xray area (Trauma Resus Room or Xray Dept) prior to ICU admission. Quality of spinal Xrays performed in ICU is usually very poor n) The Trauma Registrar must document the status of spinal clearance on the Trauma Form

G. Microbiology protocols 1. Policy a) The diagnosis of infection in critically ill patients is both important and difficult. b) Sepsis is the most common cause of death in critically ill patients. It must be aggressively sought and promptly treated with surgical drainage (where indicated) and appropriate antibiotics. c) Simple preventative measures are the most important factors in the containment of nosocomial infection and development of bacterial resistance: i) Compulsory hand washing and alcohol hand rub by all staff who come into contact with patients ii) Attention to aseptic technique for invasive procedures iii) Attention to invasive procedure protocols outlined in the procedures section iv) Avoidance of over-prescription of antibiotics d) Regular routine microbiological examination in critical care patients is not cost effective. Investigations should only be ordered on specific indications. e) Septic screens must follow the guidelines below.

177 2. Definitions a) Systemic Inflammatory Response Syndrome (SIRS) i) Describes the inflammatory process that occurs in response to a variety of clinical insults resulting in a clinical picture suggestive of sepsis ii) The syndrome includes at least 2 of the following: a) temperature > 38o or < 36o C b) heart rate > 90 bpm c) respiratory rate > 20 bpm, or < 32 mmHg PaCO2 d) WCC > 12,000/mm3, or < 4,000/mm3, or > 10% immature (banded) neutrophils iii) SIRS is non-specific and may be due to non-infectious causes: a) Trauma b) Haemorrhagic shock c) Post-operatively after major surgery d) Pancreatitis e) Burns f) Blood transfusion g) Drug reactions h) Intracranial pathology esp intraventricular blood and thalamic pathology b) Sepsis: the presence of SIRS 2 to infection c) Septic shock: decreased vital organ perfusion/function 2 to sepsis d) Nosocomial infection is defined as infection that occurs during hospitalisation that was neither present, nor incubating on admission. e) Colonisation is defined as the presence of microorganisms that do not elicit an inflammatory response. Septic screen a) Routine, performed only on the clinical suspicion of sepsis: i) New pyrexia ii) WCC or marked WCC iii) platelets iv) Deterioration in gaseous exchange or pH v) Cardiovascular instability a) Hypotension / relative hypovolaemia b) Increased or new inotrope requirement vi) Oliguria or increased creatinine b) Screen: i) urine (microscopy and culture) ii) tracheal aspirate (gram stain and culture) iii) blood culture x 2 iv) gram stain and culture of any other drainage fluid, eg wound, pleural etc.

3.

178 c) Other i) Fungal cultures ii) CSF iii) Pleural tap iv) Sinus x-rays v) Bronchoscopy specimens (BAL) Interpretation of results. i) Urine: a) UTI in a catheterised patient is defined as: (1) > 105 bacteria + positive culture of organisms, plus (2) > 500 WBC/HPF. b) Bacteria and white cells are a normal finding in the urine in a catheterised patient c) Treatment with antibiotics will not result in clearance of colonisation and is only indicated if it is thought that the patient is systemically unwell from this source d) The only effective treatment is catheter removal e) Bladder wash-out may be beneficial. Tracheal aspirate i) Bacterial cultures of tracheal aspirates often grow a mixture of colonising oral flora. These can include gram positive cocci (inc. S. aureus and S. pnuemoniae), H. influenzae, other gram negative bacilli and yeast. ii) Treatment with antibiotics will not result in a clearance of colonisation and is only indicated if it is thought that the patient is systemically unwell from this source. Blood cultures i) May be contaminated by skin organisms: care must be taken with technique: a) Clean the skin with an alcohol or betadine swab b) Clean the top of culture medium bottle with an alcohol swab: allow to completely dry before injecting. c) Use a sterile needle and aseptic technique during venipuncture d) Inject blood immediately into bottle with same needle: do not touch needle. ii) Blood cultures are best taken by venipuncture, next best alternative is from the arterial line. iii) Skin organisms grown from a single bottle are usually considered a contaminant but must be interpreted in the context of the patient.

d)

e)

f)

179 4. Investigation of pneumonia a) Community acquired pneumonia: i) Usual organisms: S. pneumoniae, H. influenzae ii) Less commonly: a) Bacterial: Legionella sp., Gram neg bacilli, S. aureus b) Viral: Influenza A, B, Parainfluenza, Adenovirus, RSV c) Other : Mycoplasma pneumoniae, Chlamydia psittaci (birds), Coxiella burnetti (sheep or cattle), TB, Chlamydia pneumoniae iii) Investigations a) Haematology - High (> 15000) or Low (< 3000) WCC - coagulopathy b) Biochemistry - note renal function and LFTs c) CXR d) ABGs e) Microbiology: * prior to antibiotic Rx where possible (1) Blood cultures x 2 (2) Endotracheal aspirate (a) M,C&S + urgent gram stain (b) Legionella culture (c) Respiratory viral Ag & culture NB: If not intubated, then collect a nasopharyngeal aspirate for respiratory viruses (3) Serology - Legionella, Mycoplasma, Resp. viruses (4) Urine - L. pneumoniae 1 Ag * only where high index of suspicion or outbreak (5) Pleural fluid - M,C&S b) Community acquired pneumonia Immunosuppressed Host: i) Possible organisms a) As above plus (1) Bacterial: Nocardia (2) Viral: CMV, HSV, varicella zoster (3) Fungal: candida, cryptococcus, aspergillus (4) Protozoal: pneumocystis carinii b) Consider non-infective causes of a similar picture eg. ARDS ii) Investigations: * As per above, plus a) Sputum or tracheal aspirate (1) Fungal stain and culture. (2) Pneumocystis stain. (a) HIV patients only all others require BAL (3) Acid fast bacilli. b) Viral studies, request CMV, HSV detection as well. c) Consider BAL if initial cultures negative

180 d) (1) PCP staining on BAL only for HIV(-) patients HIV serology

iii) Treatment prior to microbiological diagnosis: refer to antibiotic guidelines c) Nosocomial pneumonia in ICU i) Principles: a) Accurate diagnosis and appropriate treatment are important but difficult. b) Incidence: 20% of all ICU patients 70% of patients with ARDS major cause of death in patients with ARDS c) Clinically indistinguishable from pulmonary fibrosis, alveolar haemorrhage, atelectasis and other causes of lung infiltrates d) Clinical diagnosis, including use of tracheal aspirate, has poor sensitivity and specificity e) Appropriate antibiotics do improve outcome; empiric broadspectrum antibiotics are potentially harmful. ii) Consider nosocomial pneumonia when: a) new and persistent CXR changes b) tachycardia, tachypnoea c) fever or hypothermia - temperature >37.5 or <35.5 d) leucocytosis or leucopaenia - WCC: >10 or < 4 x 109/l e) purulent sputum f) deterioration in lung function iii) Confirmation of pulmonary infection: a) Tracheal aspirate with quantitative culture is the most practical method of diagnosing nosocomial pneumonia. Quantitative culture should be specifically requested when required. b) Sensitivity and specificity may be comparable to bronchoalveolar lavage and protected brush specimens c) Preliminary results to direct therapy may be obtained on gram stain d) Consideration should be given to obtaining pulmonary samples by bronchoalveolar lavage (or open lung biopsy) for patients with: (1) persistent signs of pneumonia (2) inadequate response to antibiotics (3) inabililty to obtain adequate tracheal aspirates, or (4) to exclude non-infectious causes of respiratory failure (eg interstitial fibrosis or alveolar haemorrhage). e) Bronchoalveolar lavage is only of value if the patient has been antibiotic free for > 48 hours. Refer to BAL in procedure section. f) Septic screen including blood cultures should also be performed.

181 5. Vascular catheter sepsis a) Refer to the invasive procedures section b) Suspect line sepsis when: i) Evidence of systemic infection a) New, unexplained fever b) Unexplained or in WCC c) Deterioration in organ function d) Positive blood culture by venipuncture with likely organisms (coagulase negative staph, candida), and/or ii) Evidence of local infection - inflammation or pus at the insertion site iii) The following patients are more susceptible to line infections: a) Prolonged vascular access (> 7-10 days). The incidence of line infection increases exponentially after 4 days. b) Endovascular infection (SBE, prosthetic graft infection) c) Cutaneous infection d) Burns e) Severe intra-abdominal infection (pancreatitis) or deep seated infections (empyaema / abscess) iv) The incidence of line sepsis with the antibiotic impregnated lines is around 1% and most of these are due to Candida spp. c) Protocol i) Take blood cultures from a peripheral vein. ii) Positive blood cultures from the line may only indicate colonisation so blood culture bottles must be carefully labelled as to site of sampling a) Organisms commonly implicated in line sepsis are those that normally colonise the skin: Staph spp., C. albicans but in ICU gram negative organisms can also be involved. iii) On suspicion of line sepsis the line should be removed iv) The tip of the catheter should be sent for culture. To avoid contamination of the catheter tip with skin organisms the skin should be cleaned thoroughly with alcohol, allowing at least one minute drying time, before removing the catheter. v) Catheter related bloodstream infection is defined as infection where the same organism is grown from the blood and from the catheter tip. d) Treatment i) Removal of the infected line will usually clear the bacteraemia and result in a fall in temperature and resolution of septic signs ii) Antibiotics are only indicated if septic signs continue after the catheter has been removed, or the patient is high risk (eg. prosthetic implants) iii) If this occurs more blood cultures should be taken prior to starting antibiotics iv) Refer to antibiotic guidelines.

182 e) Further venous access: i) In ICU, as central access is usually required for inotropes or TPN, removal of a line usually involves reinsertion of another ii) If possible wait 24 hours before reinsertion iii) Whenever possible insert a new line at a different site iv) Guidewire exchanges are not performed unless: a) Mechanical problems in a new catheter (leaks/kink & < 4 days old) b) Difficult or limited central access (eg burns)

6.

Bacterial Meningitis a) Dexamethasone should be used in all patients with a high probability of bacterial meningitis. b) It should be started ASAP, preferably before or at the same time as antibiotics. c) Ideally this should occur in A&E, however should be checked upon admission to ICU, especially for patient retrieved directly into the unit. d) The dosage should be 10mg 6 hrly for 2-4 days. e) Antibiotics are as per ID guidelines. Fungal infections a) General principles i) The incidence of systemic fungal infections in Intensive Care patients has increased in recent years. ii) This is due increased numbers of immunosuppressed patients admitted to ICU, the use of broad-spectrum antibiotics and prolonged use of intravascular catheters. iii) Fungaemia is generally used as an indication to commence antifungal therapy. Whilst candidaemia is associated with significant mortality, systemic infections can occur even when blood cultures are negative. b) Risk factors for candidaemia and disseminated candidiasis: i) Neutopaenia ii) Long term CVC use iii) Candida colonisation iv) Broad spectrum antibiotics v) Haemodialysis vi) Immunosuppressants. c) Antifungal prophylaxis i) Systemic prophylaxis is not recommended for general ICU patients. ii) Solid organ transplant patients do not require prophylaxis. iii) Fluconazole prophylaxis is effective and tolerated in bone marrow transplant and neutropaenic cancer patients.

7.

183 d) Indications for antifungal therapy i) Candiduria in high risk patients with deteriorating clinical status ii) Single positive blood culture in a high-risk patient iii) Isolation of candida from any sterile body site (except urine) iv) Positive microscopy for yeast from a sterile specimen v) Histological evidence of yeast or mycelial forms in tissue from high-risk patients. e) Specific antifungal therapy i) Fluconazole a) Patients with candidaemia:400 mg IV daily ii) Amphotericin B (when organism resistant to fluconazole): a) Unstable patients with candidaemia: 1.0 mg/kg/day b) Suspected or confirmed aspergillosis: 1.0-1.5 mg/kg/day 8. Protocol for patients with necrotising soft tissue infections a) General principles i) This is a generic group of patients with life threatening infections involving combinations of mucocutaneous, fascial and myofascial planes. ii) These infections represent a medical emergency: patients may present with severe septic shock and rapidly developing multiple organ failure. iii) In rapidly progressive infections, local signs of inflammation may underestimate the degree of underlying tissue necrosis. iv) These infections are usually due to one or more of the following organisms: a) Anaerobes (clostridium spp, bacteroides) b) Gram positives (group A streptococcus, staphylococcus) c) Gram negatives (enteric organisms). b) Management protocol: i) Appropriately trained personnel, familiar with the severity of the patient's condition and with appropriate resuscitative equipment, must accompany these patients during all phases of their management. ii) The hallmarks of management involve a detailed multidisciplinary approach coordinated by the duty Intensive Care consultant and involving the following: a) Prompt and effective resuscitation, restoration of vital organ perfusion and control of metabolic emergencies (eg hyperkalaemia, hypoglycaemia, coagulopathy). This is coordinated by the Intensive Care team and must not significantly delay surgery. b) Early, aggressive and repeated surgical debridement. (1) A roster for surgeons specifically for necrotising soft tissue infections was developed in 1999. (2) The Duty Anaesthetist must be notified as soon as surgery is planned.

184 c) Prompt identification of organisms with early prescription of appropriate empirical, then specific antibiotics as required (refer empirical and specific antibiotics section). The duty Infectious Diseases consultant must be notified as soon as possible. d) Hyperbaric oxygen therapy is an adjunctive therapy in selected patients. Notify the duty hyperbaric medicine consultant as soon as possible. (1) HBO must not delay debridement and resuscitation must be maintained during treatments. (2) Indications for hyperbaric oxygen: (a) Progressive bacterial (clostridial) gas gangrene. (b) Selected patients with severe multisystemic disease not responding to resuscitation, antibiotics and surgery. (3) The number of HBO treatments on a given day will depend on the stability of the patient, availability of staff and timing of surgery. (4) As a general rule, patients undergoing surgical debridement will return to the Intensive Care Unit following surgery for stabilisation and assessment prior to subsequent transfers for HBO. This will be co-ordinated by the duty Intensive Care and hyperbaric medicine consultants.

H. Drug overdose 1. General principles a) The majority of drug overdoses are polypharmacological and respond to general supportive measures. b) Overall, early mortality is low and usually relates to cardiorespiratory arrest. Following admission morbidity relates primarily to aspiration pneumonitis, or a delay in definitive respiratory care. c) There is a poor correlation between depth of coma and preservation of glottic reflexes. Accordingly, if there is any doubt the patient should be intubated. d) Antidotes such as naloxone or flumazenil should not be used as an alternative to supportive measures such as intubation and ventilation, particularly if gastric lavage and/or charcoal are used. These agents may be useful for the diagnosis of the cause of coma. Their limitation for treatment relates to their short half-lives.

185 e) ICU/HDU admission criteria following an overdose: i) Intubated patients ii) Uncontrolled seizures iii) Reduced level of consciousness with concern for potential development of airway compromise iv) Persistent hypotension v) ECG criteria: a) Ventricular or supraventricular tachyarrhythmias b) Sinus tachycardia > 140/min with tricyclics or thyroxine c) 2nd or 3rd degree block d) QTC interval > 0.5, QRS interval 0.12ms e) Acute RBBB. vi) Metabolic disturbance requiring HDU-level of care Gastric lavage i) The place of gastric lavage in acute poisoning is debatable and is only of benefit in the acute phase (< 1 hr) of ingestion of life threatening poisons. (unless a sustained release preparation) ii) Endotracheal intubation is an absolute prerequisite for patients with impaired consciousness and/or reduced gag reflexes. iii) Procedure a) Only use a 16G nasogastric tube b) Large bore sump tubes are contraindicated c) Use warmed water and instil 1ml/kg only d) Recover this volume completely before subsequent lavages e) Continue until returned lavage is clear. Charcoal i) Adequate airway reflexes must be present before considering charcoal: as with gastric lavage, if there is any doubt, intubate the patient. ii) Charcoal aspiration has a high morbidity and mortality. iii) Install 50g stat + 50g 4 hourly if indicated. iv) Indications: a) Virtually all patients presenting with drug overdose. v) Charcoal ineffective / contraindications a) Elemental metals: - iron, lithium, boron b) Pesticides: - malathion, organophosphate, DDT, carbamate c) Strong acids or alkalis d) Cyanide e) Late presentations > 4-6 hours vi) With mixed overdoses involving opioids, GI transit may be delayed and the addition of Sorbitol 70% or Go-lytely may be considered.

f)

g)

186 2. Management of the unconscious, undetermined overdose

RESUSCITATION (ABCDEFG) 1. Airway 2. Breathing 3. Circulation 4. Dont Ever Forget Glucose Consider: 1. 2. 3. Glucose 50% Naloxone 2mg Thiamine

History: 1. Patient 2. Relatives 3. SAAS Crew

Examination: 1. Trauma 2. Neurological Disease 3. Metabolic disorders 4. Endocrinopathy

Investigation: Blood Biochem: Electrolytes Glucose Renal LFTs Drugs: Paracetamol Salicylate Theophylline

Urine Drugs: Barbiturates Benzodiazepines Opioids Tricyclics Amphetamines Specific agents: Cannibis Cocaine Others

Metabolic Acidosis

Other (where appropriate) ECG Measured osmolality HBV, HCV, HIV Arterial Blood Gas

Normal Anion Gap 1. 2. Acid ingestion Toluene sniffing

Raised Anion Gap + Osmolar Gap

NO Metabolic Acidosis 1. 2. 3. 4. 5. 6. 7. 8. 9. Sedatives Hypnotics Paracetamol 1 Theoplylline 2 Anticholinergics Organophosphates Phenothiazines Lithium Carbon monoxide 3

OG < 10 Salicylates Cyanide Lactic acidosis

OG > 10 Ethanol Methanol Other alcohols

Osmolar Gap = (Measured calculated osmolality) Calculated Osmo = 2x(Na + K) + Gluc + Urea

1. NAC in all cases 2. Consider haemodialysis / charcoal perfusion for severe toxicity 3. Consider hyperbaric O2

187 3. Specific therapies / protocols a) Paracetamol i) Potentially hepatotoxic dose in a fit adult is 150mg/kg: 9g or 18 x 500mg tablets ii) This dose may be markedly less in high risk individuals: toxicity has been reported at 4-6g a) Chronic alcoholics b) Pre-existing liver disease c) Habitual or sequential overdosers. iii) N-acetyl cysteine protocol a) Indications (1) Patients with potentially hepatotoxic doses (>150mg/kg) (2) All patients with a history of ingestion and evidence of severe toxicity (altered liver function tests, prolonged INR, renal failure, acidosis, hypoglycaemia or FHF) regardless of what time they present post-ingestion. (3) The Rumack-Mathew Nomogram is useful in predicting hepatotoxicity in fit patients with a clear history of time of ingestion: the plasma level 4 hours after ingestion is read off the nomogram. (NB: mol/l = g/ml x 6.62) (4) If there is any doubt administer NAC: it is safe up to 24 hours after ingestion and there is evidence that late administration is associated with a decrease in hepatic encephalopathy and mortality. (5) Death is likely above line A, unlikely below line C, and treatment should be implemented above line B.
300
A 30 0 B 20 0 2 .0

Plasma Paracetamol (m g/l = g/m l)

200

D eaths Likely

1 .32

75 50

50 30 20 D eaths U nlikely

(m mol/l)
16 20

100

C 10 0

0 .66

0 .33 0 .2 0 .13

25

10

8 12 H ours A fter Ingestion

188 b) Regimen: dilute each dose in 200 ml 5% dextrose (1) 150 mg/kg over 15 minutes stat (2) 50 mg/kg over 4 hours (3) 100 mg/kg over 16 hours

b)

Lithium i) peak serum concentrations occur ~ 2-4 hrs post-ingestion ii) long t ~ 8 hrs, with predominantly renal excretion a) ~ 30-60% is excreted after 12 hrs b) oliguria & dehydration potentiate toxicity iii) therapeutic levels ~ 0.6-1.2 mmol/l iv) minor toxicity < 2.0 mmol/l a) vomiting, diarrhoea, slurred speech, blurred vision b) ataxia, coarse tremor, confusion & fasciculations v) severe toxicity 2.0 mmol/l a) nausea, vomiting, diarrhoea b) ataxia, tremor, hyperreflexia, extensor spasms, seizures, coma c) potentiation of sedatives and muscle relaxants d) flaccid paralysis, coma and cerebral oedema occur > 3.0 mmol/l e) hypotension, syncope, cardiac failure, arrhythmias (? hypokalaemia) (1) refractory ventricular tachycardia, bradycardia or asystole f) nephrogenic DI, polyuric renal failure vi) NB: chronic toxicity usually presents as thyroid or renal dysfunction, acute toxicity usually presents as neurologic or cardiac dysfunction vii) Treatment: a) gastric lavage b) maintain euvolaemia - saline loading & enhanced diuresis per se is of no value c) consider alkalinisation of urine - NaHCO3, acetazolamide d) indications for dialysis (1) plasma level > 4.0 mmol/l (2) plasma level ~ 2-4 mmol/l, plus either (a) deteriorating clinical status (b) acute renal failure (3) CVVHD is effective but slow 2 to large VdSS e) no useful effect from: (1) diuretics - frusemide (may worsen toxicity) - spironolactone (2) activated charcoal

189 c) Narcotics and benzodiazepines i) Treatment of benzodiazepine and opiate overdose (eg heroin) is generally supportive ii) Naloxone (0.4 g IV) may be useful for diagnostic purposes. iii) Naloxone and Flumazenil by infusion have no established role in benzodiazepine or narcotic overdose and should not be used, except for diagnostic purposes only. Carbon monoxide i) CO poisoning is the most common presenting poisoning (cf. drug O/D). ii) General supportive measures take priority: place patient on 100% oxygen as soon as possible and continue until COHb levels, other drug screens and resuscitation are complete. iii) Hyperbaric oxygen therapy (HBO): a) Recent evidence suggests a benefit from HBO in CO poisoning in terms of neurpsychiatric outcome. b) Current indications at RAH: one or more of the following (1) History of, or actual impaired consciousness related to CO exposure (2) Presenting COHb: 15%, or > 25% at the time of exposure (if known) (3) Neurological signs on presentation (including mini-mental state [MMS] impairment) (4) Evidence of cardiac ischaemia/arrhythmias c) HBO Treatment and Dosage Regimen: (1) First HBO within 6 hours of exposure if possible (2) Controlled ventilation (FiO2 = 1.0) for unconscious or uncontrollable patients (3) Not less than 2x HBOs within the first 24 hours of therapy, more if unconscious, or seriously affected (4) If neurological and/or MMS impairment persists, HBO continues on at least a daily basis (5) Treatment is ceased when no discernible benefit is obtained. d) If a delay of more than 24 hours between exposure and commencement of HBO, discuss case with referring personnel. e) If greater than 48 hours, and fully conscious, no HBO. Cyanide i) Pure cyanide poisoning is rare ii) Decontamination should not be necessary if the identity of the agent is certain, and the patient has survived to hospital iii) Patients burnt or exposed to smoke inhalation in severe house or building fires may be exposed to potentially lethal doses. iv) Cyanide levels are difficult to perform and there is a considerable delay in obtaining a result. v) Indications for empirical treatment of cyanide

d)

e)

190 a) b) c) d) History of ingestion / exposure Unexplained lactic acidosis in an overdose patient (exclude salicylate, methanol, theophylline first) Burns patients in building fires with a persistent or unexplained metabolic acidosis Regimen: (1) 100% oxygen (2) Sodium thiosulphate first line choice. (a) Give 12.5g (50ml of 25% solution) IV at 1.25g/min (5ml/min). (b) If acidosis persists 30-120 minutes after administration, repeat with half the original dose. (c) Paediatric dose is 412.5mg/kg up to 12.5g, or based on haemoglobin level. (3) Sodium nitrite 300mg IV over 3 minutes. (a) If used, should give thiosulphate immediately following it. (b) If symptoms / acidosis return, can repeat both the nitrite and thiosulphate at half their original doses, 30-120 minutes later. (c) Monitor methaemoglobin must not exceed 40%. (4) Hydroxocobalamin 50mg/kg (not available in these doses)

f)

Methanol i) Methanol poisoning is a medical emergency with a high mortality ii) Small doses are associated with high mortality (minimum toxic dose reported is only 15ml of 40% methanol) iii) All undetermined overdoses with a persistent, or unexplained high anion gap metabolic acidosis must have a measured osmolality performed to determine the osmolal gap (measured calculated osmolality). If this is >10 mosmol/l, request a serum methanol. (Remember ethanol will also cause an osmolal gap but is not associated with a severe acidosis) iv) Treatment a) Ethanol (1) Use in all with acidosis, regardless of symptomatology (2) Check baseline BAL if > 0.1g/dl, no need for loading dose (3) Dosing assumes typical volume of distribution and elimination kinetics titrate to BAL of 0.1g/dl Using absolute ethanol (IV) Loading dose Maintenance (not on dialysis) Maintenance (on dialysis) Non-drinker 600 mg/kg 66 mg/kg/hr 169 mg/kg/hr Drinker 600 mg/kg 154 mg/kg/hr 257 mg/kg/hr

(4) IF on CVVHDF, then safer to dialyse against desired [ETOH] (a) 0.1g/dl = 5ml ETOH / 5l Bag (inc. replacement) (b) first bag may be run at 0.2g/dl = 10ml ETOH / 5l bag

191 b) CVVHDF / haemodialysis is indicated if: (1) > 30 mls 100% methanol ingested, or (2) methanol level > 50mg/100ml, or (3) metabolic acidosis of any degree, or (4) acute renal failure, or (5) developing ocular manifestations Folate 50-100 mg IV 4 hrly. Forced diuresis has little effect

c) d) g)

Organophosphates i) There are a large number of preparations with variable LD50s and toxicity. ii) The diagnosis is essentially clinical: a) Miosis, blurred vision, sweating. b) Muscle faciculations then paralysis. c) Bradyarrhythmias, tachyarrhythmias, hypotension. d) Bronchoconstriction, rhinorrhoea, salivation, dyspnoea. e) Fatigue, irritability, LOC, seizures, death. iii) Red cell cholinesterase levels: a) Do not correlate with clinical severity b) Provide a sensitive indicator of exposure. iv) Treatment a) Self-protection is the first and most important concept! b) Atropine: reverses muscarinic effects only and therefore will not reverse paralysis! (1) Titrate 0.6-2.4 mg at three to five minute intervals until signs of successful atropinisation are noted (drying of secretions, breathing less laboured, reduction of ventilatory resistance). Over 10-20 mg, or infusions of up to 5 mg/hr may be required in severe poisoning (2) NB: HR and pupil size are not useful for clinical monitoring after nerve agent exposure. c) Ventilatory and CVS support as indicated. d) Diazepam IV for seizures e) Pralidoxime Iodide: efficacy is unclear, however give ASAP. (1) 2g IV over 30 minutes, then (2) 500 mg/hr (2.5g/100 ml N.saline @ 20 ml/hr) for 5 hours only.

192 I. Withdrawal of treatment a) The ability of Intensive Care to replace or support vital organ function has resulted in some patients surviving for long periods of time without improvement or a terminal event. In such patients, with no realistic chance of survival, decisions to withdraw or withhold life-sustaining therapies are commonly made. In the RAH ICU approximately 50% of all deaths are preceded by such a decision. Withholding and withdrawal of therapy entail a number of difficult ethical and legal issues. Medical consensus (including at least 2 Intensive Care consultants and the admitting clinician) is mandatory. Such consensus must be recorded in the case notes, as well as a description of the process by which the decision was made. Withdrawal of treatment requires considerable compassion, time and understanding in counselling families and patients to ensure that all parties understand and accept the plan of management. The wishes of the patient and family are vitally important in making decisions regarding the patients management. There is no ethical or legal difference between withholding and withdrawal of life supporting therapy. Assisted suicide and active euthanasia are medically and ethically distinct, illegal and should never occur. The administration of medication to relieve suffering and ensure comfort of the dying patient is appropriate and clearly indicated, notwithstanding a side-effect of such administration may be to hasten the process of the patients death (ie. a double-effect). Withdrawal of treatment is a consultant responsibility.

b)

c)

d) e) f)

g)

J. 1.

Brain Death and Organ Donation Declaration of brain death a) This procedure is an absolute requirement prior to organ donation b) Declaration must be made by two members of the ICU staff: i) The Duty ICU consultant, and ii) Another ICU doctor who is more than 5 yrs qualified. c) Declaration may be supported by either clinical or non-clinical certification.

193 2. Clinical certification of brain death a) Families may derive considerable benefit from witnessing the clinical testing for brain death. Many find it helps them understand the totality and finality of brain death, which can be a difficult concept to grasp. Clearly this requires compassion, support and explanation by the medical staff but it is an option which families should be offered. The procedure is completed on a Certification of Brain Death form (MR150.0) and documented in the case notes. Record time and onset of coma. Pre-conditions: i) A recognised cause of coma must be identified. ii) Potentially reversible causes of coma must be excluded: a) Coma caused by drugs or poisons. b) Neuromuscular blocking drugs c) Hypothermia. Core temp must be > 35oC d) Metabolic or endocrine disturbance: (1) Normal renal and hepatic function (2) Normoglycaemia (3) Normal electrolyte profile. Clinical assessment of brain stem function: This procedure is performed separately by 2 doctors, at least 2 hours apart, with the first test at least 4 hours after the onset of coma (with this period being longer in the case of hypoxaemic/ischaemic primary injuries). i) Absent pupillary responses to light, both direct and consensual ii) Absent corneal reflexes iii) Absent vestibulo-ocular reflex a) no nystagmus on injection of 20ml iced water into the ear b) check tympanic membranes prior to this procedure c) occulo-cephalic reflexes are often tested, but are not formally required iv) Absent gag / cough reflex v) Absent response to pain in the cranial nerve distribution. vi) Apnoea following disconnection from ventilator: a) Preoxygenate patient with 100% oxygen b) Disconnect ventilator and connect to bag with 100% oxygen insufflation at low flow (1-2 l/min) c) Wait until PaCO2 > 60 mmHg and pH < 7.30 (1) confirm this by blood-gas analysis (2) ensure PaO2 > 60mmHg d) Look for apnoea clinically The 2 practitioners may choose to be present at each examination, however, each must perform and be responsible for one of the 2 examinations From the onset of coma until the second set of testing, there should be a continuous period of observation by nursing staff

b) c) d)

e)

f) g)

194 h) i) The time of death is the time when certification of brain death is completed ie. at completion of the second examination and documentation in the case notes. There is no legal requirement for certification of persons not considered for organ donation, however this is encouraged as it allows appropriate counselling of the relatives and the cessation of inappropriate medical intervention.

3.

Non-clinical certification of brain death a) Objective demonstration of the absence of cerebral blood flow is required if brain death is suspected and the preconditions (2b) for clinical certification cannot be met. A 6 hour period of observation of absent brain function is still required prior to the examination. Absence of cerebral blood flow may be established by either: i) Radionuclide cerebral perfusion scan (recommended) ii) 4 vessel cerebral angiography (rarely performed at the RAH) Certification of brain death is by 2 doctors, not including the clinician who performed the investigation at (c.), who have considered the onset of coma, the clinical examination and the results of the investigation performed.

b) c) d)

4.

Organ donation a) General principles i) Identification of potential organ donors is the responsibility of all Intensive Care staff. ii) A potential organ donor is any patient who is, or may become brain dead. All potential donors should be referred for consideration. There are no automatic exclusion criteria. iii) Notify the Donor Coordinator from the South Australian Organ Donation Agency (Ph: 83781671) when a potential donor is identified. Criteria for organ donation i) The patient has been declared brain dead. ii) Usually, no patient history of: a) HIV, Hepatitis B or C. (may be acceptable for HBV/C positive recipients) b) IV drug abuse or a practicing homosexual c) Untreated bacterial fungal or viral infection (treated infection may be considered). d) Malignancies other then primary brain tumours and minor skin lesions. e) Treatment with hormones of human pituitary origin. f) Dementia (or family history). g) Disease of the donor organ. iii) All brain dead patients should be discussed with the Donor Coordinator, regardless of these listed contraindications.

b)

195 c) Procedure: i) Organ donation should not be discussed with the family until brain death has been certified and the family informed. ii) Counselling families with regard to brain death and organ donation requires considerable compassion, knowledge, skill and time. While this is primarily a consultant responsibility, advanced trainees are encourage to participate in the process. iii) The wishes of the patient and family are paramount. iv) A donor kit is kept in the cupboard in Q4A which contains a check-list, plus all the forms and specimen bottles required. v) Following consent for organ donation, blood should be sent for: a) HTLV-1, HIV 1 + 2 b) HbsAg, HbsAb, HbcAb, HCV c) CMV-IgG, EBV, RPR d) Group and X-match e) Tissue typing volume of blood varies according to blood group f) Mark the request forms: Urgent Organ Donor, Copy to:SAODA vi) Coronial approval will be sought by the Transplant Coordinator where required. vii) The RAH designated Medical Administrator can give permission for donation if all efforts to find relatives have failed. viii) Notification of the recipient and procuring teams (which may come from interstate) and coordination of operating theatre time, collation of results and investigations is done by the Transplant Coordinator(s). Management of the organ donor: i) The situation is time critical as it is not possible to stabilise a brain dead patient indefinitely. Cardiovascular failure usually occurs within 48 hours. ii) Maintain normothermia, using active warming devices if necessary. iii) Maintain MAP > 70 mmHg with fluid or inotropes if necessary. iv) Ensure that the patient is adequately volume loaded before using high doses of inotropes, as such doses may reduce organ viability. v) Diabetes insipidus should be aggressively treated with fluid replacement and DDAVP (1-2 g IV bd). vi) Ventilation: a) Adequate oxygenation (PaO2 > 60 mmHg ; FIO2 < 0.5 is preferred) b) PaCO2 ~ 35-45 mmHg vii) Check biochemistry and maintain normal electrolytes. viii) Consider non-depolarising muscle relaxants if spinal reflexes persist, as these may be disconcerting for relatives and attending carers.

d)

196

Index
A
Acetazolamide 96 Acid-base disorders 125 Anion gap 125 Metabolic acidosis 125 Metabolic alkalosis 127 Activated Protein C 115 Acute Pain Service Epidurals 83 Intrathecal morphine 84 PCA 82 Protocols 82 Adenosine 75 Admission Policy 12 Admissions, new patients 15 Adrenaline 70 Advanced Life Support 131 Amiodarone 75 Anion Gap 125 Anti-arrhythmics 74 Antibiotics Gentamicin dose 100 Vancomycin dose 101 Antibiotics 99 level monitoring 100 principals 99 prophylaxis 101 therapy, empirical 103 therapy, organism specific 105 Anticoagulation 86 Table 89 Anti-emetics 98 Antihypertensives 71 Table 72 Antiplatelet Agents 78 ARDSNet Ventilation Protocol 146 Arterial Lines 35 Aseptic technique 14 Atenolol 73, 75 Atypical pneumonia 179 Basic Life Support 130 Brain death 192 Clinical assessment 193 Broncho-Alveolar Lavage 52 Bronchodilators 78 Bronchoscopy 51 BSL Protocol 92

C
Calf stimulators 87 Captopril 72 Cardiac arrests 23 Cardiothoracic Protocols 156 Cardiovascular Drugs 68 Central venous lines 36 Cerebral perfusion pressure algorithm 171 Cervical Spine Clearance protocol - trauma 175 Clinical Duties Daily management in ICU/HDU. 16 Clinical Management Protocol & Guidlines 129 Clonidine 73 Consent in ICU 18 Consults Cardiac arrest / MET calls 23 Duties outside ICU 21 Haematology patients 22 MET Calls 25 Pager, Consults 21 Pager, Emergency 21 Policy 21 TPN 22 Trauma Calls 24 Ward Calls 22 Coroner's Cases 12 CPR 130 Cricothyroidotomy 50

D
Danaparoid sodium 89 DDAVP Bleeding 114 in DI 93

B
Bacterial Meningitis 182

197
Organ donation 195 Deaths Policy 12 Dialysis CVVHDF circuit diag. 163 Indications 162 Modes 162 procedure 164 Digoxin 75 Discharge Policy 12 Disseminated intravascular coagulation 114 Diuretics 95 table 96 Documentation 16 by Registrars 16 Consent in ICU 18 Daily entry in ICU 17 Discharge Summaries 17 HDU admission summary 17 ICU Admission Note 17 Dopamine 70 Droperidol 98 Drug overdose 184 Activated charcoal 185 Admission criteria 185 Carbon monoxide 189 Cyanide 189 Gastric Lavage 185 Lithium 188 Management algorithm 186 Methanol 190 Narcotics and benzodiazepines 189 Organophosphates 191 Paracetamol 187 Drugs Anti-arrhythmics 74 Table 75 Antibiotics 99 Anticoagulants, table 89 Anticoagulation 86 Anti-fungals 104 Antihypertensives 71 Antiplatelet Agents 78 Diuretic, table 96 EACA 114 Endocrine 91 GIT 97 GIT, doses 98 Inotropes 68 Inotropes, effects 70 Inotropes, table 70 Milrinone 69 Muscle Relaxants 85 Muscle Relaxants, table 85 Perioperative anticoagulation 88 Policy and principles 67 Renal 95 Respiratory 78 Respiratory, table 79 Sedation & Relaxants 80 Sedation, table 81 Steroid, doses 94 Steroids 93 Thrombolytics 76 Thrombolytics, table 77 Vasopressors 71 Warfarin, loading 90 DVT Enoxaparin protocol 86 Pelvic Fracture Protocol 87

E
EACA 114 Emergencies Counter disaster 30 Fire 29 Hospital 29 Endotracheal Intubation 45 Endotracheal Tubes 46 Enoxaparin 89 Enteral nutrition 108 Epidural catheters 39 Erythromycin 98 Esmolol 73 Extubation 152 Extubation protocol 49

F
Failed Intubation Drill 133 Fluids & Electrolyes 106 Body fluids 107 Burns 107 Daily Requirements 112 Enteral nutrition 108 Enteral protocol 109 Hyperkalaemia 123 Hypernatraemia 121 Hypokalaemia 122 Hyponatraemia 119

198
Management 118 Metabolic acidosis 125 Metabolic alkalosis 127 Parenteral nutrition 110 TPN Solutions 111 Frusemide 96 Fungal infections 182 Urinary catheters 38 Infection Control in ICU 13 Information Technology 32 Inotropes 68 Effects 70 Table 70 Insulin 91 Insulin Protocol 92 Intra-Aortic Balloon Counterpulsation 61 Intubation 45 Fibreoptic 52 IV, central lines 36 IV, peripheral 34

G
GI bleeding 97 GTN 72

H
Haemodynamic variables 41 Haemodynamic Variables 42 Hand-washing 13 Heparin 89 HITS Protocol 88 Humidification 135 Hydrallazine 72 Hyperkalaemia 123 Hypernatraemia 121 Hypokalaemia 122 Hyponatraemia 119

J
Jet Ventilation 51 Jugular bulb oximetry 59 Jugular bulb oximetry protocol 170

L
Lignocaine 75

M
Magnesium 73, 75 Mannitol 96 Mechanical ventilation 137 Complications 139 Drager Evita 140 Extubation 152 ICU ventilators 140 Indications 137 Modes used 138 Non-invasive ventilation 148 Prone position 153 Puritan-Bennett 7200 144 Seimens 900C 142 Weaning 151 MET 9, 21, 23, 25 Methyldopa 73 Metoclopromide 98 Microbiology 176 Bacterial Meningitis 182 Blood cultures 178 Catheter sepsis 181

I
ICP monitoring 169 ICU procedures Arterial Lines 35 Balloon counterpulsation 61 Broncho-Alveolar Lavage 52 Bronchoscopy 51 CVC lines 36 Endotracheal intubation 45 Epidural catheters 39 Jugular bulb oximetry 59 Minitracheostomy 56 Oesophageal balloon tamponade 66 Pericardiocentesis 58 Peripheral IV 34 Pleural drainage 43 Pulmonary arterial catheters 39 Tracheostomy 53 Transvenous pacing 64

199
Fungal infections 182 Nosocomial pneumonia 180 Tracheal aspirate 178 Milrinone 70 Minitracheostomy 56 Muscle Relaxants 85 Table 85 Pulmonary arterial catheters 39

Q
Quarantine policy 15

N
Nebulised bronchodilators 136 Necrotising skin infections 183 Neurosurgical protocols 167 Neurotrauma 167 Non-invasive ventilation 148 Noradrenaline 70 Nosocomial pneumonia 180

R
Ranitidine 98 Rapid sequence induction 47 Renal failure 159 Research 31 Respiratory failure 134 Reteplase 77 Retrievals Activation 27 Familiarisation 26 Intrahospital transportation 28 Policy Documents 26 Rapid Response 26 Rostering and job descriptions 9 Royal Adelaide Hospital 5

O
Octreotide 98 Oesophageal balloon tamponade 66 Organ donation Donor management 195 Principles 194 Orientation for Registrars 10 Oxygen delivery circuits 135

S
Salbutamol 79 Sedation & analgesics 80 Sedation, protocols 81 Septic screen 177 Short synacthen test 94 Sodium nitroprusside 72 Sotalol 75 Spinal Injury, steroids 94 St Andrews Hospital 5 Staffing Consultant Medical Staff 6 Registrars 7 Retrievals 10 Senior Nursing Staff 7 Status epilepticus 174 Steroids 93 Streptokinase 44, 77 Stress ulcer prophylaxis 97 Subarachnoid haemorrhage 172 Grades 172 HHH therapy 173 Supervisors of Training 8

P
Pacing, cardiac 64 Pantoprazole 98 Parenteral Nutrition 110 Pericardiocentesis 58 Perioperative anticoagulation 88 Phenytoin 75 Pleural drainage 43 Pneumonia 179 Prokinetics 98 Prone position 153 Prostacyclin 79, 89 Protocols ALS 131 BLS 130 Cardiothoracic Patients 156 Failed Intubation 133 Reversible causes for ALS/BLS 132

200

T
Tables Haemodynamic variables 42 TED stockings 87 Theophylline 79 Thrombolytics 76 Table 77 Total Parenteral Nutrition 22 TPN 110 Tracheostomy 53 Transfusion Cryoprecipitate 114 DDAVP 114 FFP 113 Platelets 113 Reaction protocol 116 Reactions, table 117 Red Blood Cells 112 Transvenous pacing 64 Trauma Cervical Spine Protocol 175 Trauma Calls 24 Traumatic seizure prophylaxis 168

U
Urinary catheters 38

V
Vasopressin 71 Vasopressors 71 Table 71 Verapamil 75

W
Wakefield Hospital 5 Ward round Fluids 20 ICU 19 Laboratory results 20 Presentation 19 Warfarin 88 Age adjusted loading 90 Pelvic Fracture Protocol 87 Weekly programme 11 Withdrawal of treatment 192