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ICU Overview

 

Flow:

6:45am: Sign Out from Night Team

7-9 am: See patients

*All patients need: Daily Sedation Vacation, ABG, CXR*

-           Things to review:

  • Talk with RT:
    • # days of intubation
    • Vent Settings
    • Ready for SBT?
    • For ARDS patients: following ARDSnet protocol?
      • Low TV: goal 6mL/kg of predicted weight
      • Ask RT to measure Peak Plateau Pressure
        • Goal <30
      • Goal Pa02 >55 on ABG
  • Talk with RN:
    • GCS
    • Current drip settings
    • Tube feed residuals
    • Current urine output
    • Significant overnight events
  • Chart review:
    • 24 hour vitals: give ranges for all values
    • Total I/O 24hrs and since admission
    • ABG + CXR all patients every AM before rounds
      • Report the vent settings at which the ABG was drawn
      • Calculate A-a gradient
    • Labs/Imaging
  • Physical Exam
    • GCS
    • Assess all lines
    • Complete physical

9:00am: Pre-round with senior and Fellow

9:30am: Ready for Rounds

Post Rounds:

-           Orders

-           Procedures: central/arterial lines if discussed on rounds

-           Transfers:

Afternoon

-           Family Meetings

-           Procedures

-           Review plan with senior + update sign out

Orders

-           All orders should be in before lunch

-           Senior will input orders during rounds

-           Intern and senior will confirm that all orders are in before lunch to make sure nothing was missed

-           Daily CXR and ABG; renew labs and meds

 

Transfers:

  1. Round with attending and confirm pt is ready for transfer
  2. Call Admit RN; she will give you the hospitalist to call
  3. Call Hospitalist; give overview of ICU course
  4. Write transfer summary: if written 1 st can be helpful before talking with hospitalist
  5. Transfer Order
  6. Med Rec: must be done before patient can be transferred

 

Procedures:

-           Ideally after rounds before lunch

 

Social Worker/Palliative Care:

-           Round with team every morning

-           Intern should call family ASAP when patient is admitted to ICU

-           Social Worker will arrange family meeting after the 3 rd day in ICU

  • Updates
  • Goals of care/Code Status

-           Intern and Senior should both be present for family meetings

 

 

Academic Half Day

-           Interns: Wednesday PM

  • I will take your pager and take care of patients until you get back
  • You’ll sign out to night team and write the progress note

-           Seniors: Tuesday AM

  • The Fellow will be there for you to pre-round with
  • We’ll go over the plan for your patients in the afternoon

 

 

KEY ICU JOURNAL ARTICLES/CONCEPTS

 

# All ICU patients:

-           GI PPx: IV Protonix

-           DVT PPx: Heparin/Lovenox; unless contraindicated

-           Elevate head of bed 30 degrees if intubated

-           Daily sedation vacation

-           Daily assessment for extubation readiness

  • Is patient ready to do SBT today?

-           Daily oral care with chlorhexidine

 

# All Sedated Patients

-           Daily Sedation Vacation

-           AVOID Versed (BZD)

-           Use Propofol + Fentanyl OR Precedex + Fentanyl

  • Non benzodiazepine sedative preferred over Versed

 

# 2009 SEDCOM Precedex vs Versed

-           Bottom Line:

  • Versed: Benzo (Midazolam)
  • Precedex: Non Benzo
  • No difference between time to target sedation level
  • Precedex resulted in LESS time on vent , LESS delirium, LESS tachycardia/hypertension
  • Precedex: more bradycardia however

-           At CRMC: PRECEDEX > Versed. Avoid benzo sedative

 

# Rapid Shallow Breathing Index for SBT

-           RSBI= RR/TV

-           RSBI>105 predicts weaning failure

-           RSBI<105 associated with weaning success

 

 

 

# 2001 RIVERS Trial: Early Goal Directed Therapy (EGDT) in Sepsis

-           Bottom Line:

  • In Severe Sepsis or Septic Shock, EGDT decreases the risk of mortality, if started in ER prior to ICU admission
  • EGDT
    • Central Line + Arterial Line
    • Continuous central venous oxygen sat monitoring
    • Goals:  Start in ER prior to ICU admission
      • CVP goal 8-12 via IVF boluses
      • MAP goal >65 via pressors if needed
      • UOP >0.5ml/kg/hr
      • Scv02 >70% achieved with PRBC and Dobutamine if needed

# Surviving Sepsis Campaign

http://www.sccm.org/SiteCollectionDocuments/SSCBundleCard_Web.pdf

-           Within 3 hours

  • Measure lactate level
  • Get Blood Cultures X2 before antibiotics
  • Give broad spectrum antibiotics
  • Give crystalloid IVF 30ml/kg if hypotensive or if lactate >4

-           Within 6 hours

  • Give Vasopessors for refractory hypotension to maintain MAP>65
  • Reassess volume status
    • Repeat exam: vitals, capillary refill, cardiopulmonary, pulse, skin findings
    • OR 2 of the following:
      • Measure CVP
      • Measure Svc02
      • Passive leg raise or fluid challenge; while monitoring BP

 

 

 

 

 

  1. ARDSnet Protocol
    1. http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
      1. Low Tidal Volume
        1. 6ml/kg of predicted body weight
      2. High PEEP Low Fi02 vs Low PEEP High Fi02
        1. Patient dependent
      3. Goal Pa02 >55
      4. Goal Plateau Pressure <30 (prevent barotrauma)
      5. Goal CVP <4 (keep them dry)

 

  1. SBT/Weaning from Vent
    1. Contraindications to SBT
      1. Fi02 >0.5
      2. PEEP>8
      3. Minute Ventilation >15 L/min
      4. MAP <60
      5. On Pressors
      6. On ECMO
      7. Active GI Bleed
      8. Hemoptysis
      9. Paralysis/neuromuscular blocking agent
      10. Brain Death
    2. If no contraindications, have RT perform SBT
    3. Criteria for FAILING SBT
      1. RR >35 for >5 min
      2. SPO2<92%
      3. Rapid Shallow Breathing Index (RSBI) >100
      4. Tachycardic, Hypertensive, Hypotensive
      5. Accessory muscle use
      6. New/worsening arrhythmia
    4. WHY did patient fail? What happened during SBT

 

 

 

 

 

 

 

 

  1. 2000 ARDSNet Trial
    1. Bottom Line:
      1. In patients with ARDS, low TV (6ml/kg predicted body weight) had lower mortality and more ventilator free days
      2. Trial stopped early due to significant decreased mortality in low tidal volume arm
    2. Protocol Used
      1. Low TV 6ml/kg PBW
      2. Goal Plateau Pressure 25-30
    3. ARDS Definition
      1. Pa02/Fi02 Ratio </= 300
      2. B/L pulmonary infiltrates c/w edema
      3. Exclusion of cardiogenic pulmonary edema
        1. PCWP <18 without evidence of LAE
          1. LHC
          2. ECHO

 

  1. 2006 FACTT (Fluid Management in ARDS)
    1. Bottom Line
      1. Among patients with ARDS, conservative fluid management strategy with goal CVP <4 improves lung function, decreases days on vent, reduces days in ICU
        1. However no difference in mortality compared to liberal fluid management
    2. Surviving Sepsis Campaign
      1. Supports conservative fluid management in sepsis-induced ARDS without tissue hypoperfusion

 

 

 

 

 

 

 

 

 

 

 

  1. 2010 ACURASYS Trial: Paralysis in ARDS
    1. Bottom Line:
      1. Paralysis with Cisatracurium for 48 hrs in patients with early severe ARDS improves 90 day survival and increases ventilator free days
      2. Paralysis was induced early, within 48 hours of severe ARDS diagnosis
    2. Results
      1. 9% absolute reduction in morality at 90 days
      2. Reduction in barotrauma (5% vs 11.7%)
      3. Reduction in pneumothorax (4% vs 11.7%)
      4. Reduction of days on ventilator
      5. Reduction of days in ICU

 

 

  1. 2013 PROSEVA: Prone Ventilation in ARDS
    1. Bottom Line
      1. In Severe ARDS (P:F ratio <150), prone positioning reduces 28-day mortality
    2. In general at CRMC:
      1. Maximize Sedation: if ineffective in 48 hrs THEN
        1. Paralysis: if ineffective THEN
          1. Prone

 

  1. 2008 CORTICUS Trial: Hydrocortisone in Septic Shock
    1. Bottom Line:
      1. Hydrocortisone hastens the reversal of shock but does not confer a survival benefit among patients with septic shock
    2. Surviving Sepsis Campaign
      1. If IVF and pressors reverse hemodynamic instability, then DO NOT use IV Hydrocortisone
      2. If IVF and pressors cannot reverse shock, then OK to use Hydrocortisone 200mg IV daily
        1. Commonly used at CRMC if patient still unstable despite 6L IVF + Pressors
      3. If IVF alone resolve hypotension and pressors are not required, then DO NOT use hydrocortisone
      4. Don’t use hydrocortisone in septic patients without shock

 

  1. Daily Sedation Vacation
    1. Bottom Line:
      1. Daily sedation holidays reduce days on ventilator, days in ICU, days in hospital

 

  1. 2002 HACA Hypothermia for Cardiac Arrest
    1. Bottom Line
      1. Among patients with ROSC after WITNESSED cardiac arrest duet o VF or pulseless VT, therapeutic hypothermia (32-34C) improved neurologic outcomes and reduced mortality at 6 months
    2. WITNESSED cardiac arrest due to VF or Pulseless VT with ROSC achieved
      1. Hypothermia protocol order set in Epic
    3. UNWITTNESSED or Out of Hospital Arrest
      1. Hypothermia NOT associated with reduction in mortality or better neurologic outcomes

 

  1. 2009 NICE-SUGAR: Intensive Glycemic Therapy in ICU
    1. Bottom Line:
      1. Intensive glycemic control led to MORE deaths compared to conventional control
      2. Target glucose <180 in ICU patients

 

 

  1. 2003 PneumA: 8 vs 15 days of antibiotics in VAP
    1. Bottom Line
      1. Equivalent mortality in Non-Pseudomonal VAP patients treated with 8 vs 15 days of antibiotics
      2. Does not apply if pseudomonas is suspected based on gram stain (GNR)

 

 

 

 

  1. 2014 PEITHO: tPA for Submassive PE
    1. Bottom Line:
      1. Tenecteplase (tPA) + UFH reduces all cause mortality or hemodynamic decompsensation at 7 dayse compared to placebo
      2. Tenecteplase is associated with increased risk of bleeding however

 

  1. 1995: NINDS tPA in ischemic stroke
    1. Bottom Line
      1. If symptom onset within 3 hours; tPA significantly improved NIHSS scores but did not confer survival benefit
    2. Absolute Contraindications to tPA (MDCalc)
      1. ICH on CT
      2. HTN: SBP>185 or DBP>110
      3. Head trauma/stroke/neuro surgery in previous 3 months
      4. Symptoms suggest SAH
      5. H/o ICH
      6. Seizure at stroke onset
      7. Active Internal Bleeding
      8. AV Malformation/neoplasm/aneurysm
      9. Known bleeding diasthesis
      10. Blood Glucose <50 or >400