I.

Key concepts in Intensive Care Medicine

1) Identification and initial stabilization of acutely deteriorated patients
Repetitive evalution of physiological functions with simultaneous treatments of the
abnormalities.

intensive care is always a team job. Call for help

Keep it simple and make it quick

ICU nightmare is an airway problem in tracheostomized patients. Be prepared

to deal with this problem by carefully studying the algorithm

USG protocol:
RUSH and POCUS in shock
FAST in trauma

Emergency shock profound hypotension:

IV Ephedrine 10mg boluses
IV Metaraminol 1mg repeat as needed
IV Adrenalin 0.1mg boluses

Agitated patients:
IV Haloperidol 2.5-5mg bolus (Antipsychotic)
IV Midazolam 2mg bolus (Benzodiazepines)- monitor respi

Epileptic seizures:
Open airways, oxygen, IV access
IV Benzodizepines- midazolam 0.15mg/ kg max 10mg and repeat in 5 mins if still
fitting
IV Levetiracetam 40mg/kg max 3g or IV Phenytoin 20mg/kg over 30mins
Rapid sequence intubation

Dantrolene in malignant hyperthermia

Keep it simple and make it quick. Once you fix the physiology you can take time to
gather more information, re-evaluate patient’s response to your treatment and
think about underlying cause.
 2) ICU Routines and Bundles of care
Resuscitation fluids: correct intravascular deficit and increase preload
Replacement fluids: Correct loses of interstitial fluids or electrolytes
Maintenance fluids: Cover the needs of water and electrolytes that cannot be given by
enteral route
Creep fluids: Dilutant of other intravenous drugs (average 800cc/day)

Body fluid components: Intracellular and Extracellular

Extracellular further divided into intravascular (plasma) and extravascular (lymph,
interstitial fluid)

Water movement between compartments is determined by osmotic and hydrostatic

pressures through semi-permeable membranes.

Exogenous fluids: Iso-, Hypo-, Hypertonic solutions

Isotonic fluids target extracellular compartment, distribute proportionally between
intravascular (1/5 of infused volume) and extravascular (4/5 of infused volume)

Crystalloids solutions: Unbalanced and Balanced

Unbalanced: NACL: high NaCl, induce renal afferent vasoconstriction and reduce renal
flow and GFR. Causes hyperchloremic acidosis. Eg: D5%, DS, NaCl 0.9%, NaCl 3%, NaCl
7.5%.

Balanced: Contains other anions than chloride such as metabolizable organic acid
(lactate, acetate, gluconate). Designed not to change patient’s acid base status. Eg:
Lactate ringer, Acetate ringer, Acetate gluconate (Plasmalyte), Acetate malate
(Isofundin)

ROSE concept: Liberal fluid strategy during early resuscitation to maintain/ preserve
organ function and more restrictive fluid strategy during recovery phase, aiming
negative fluid balance
Minutes: Resus
Hours: Optimization
Days: Stabilization
Weeks: Deescalation

Maintenance basic electrolytes and glucose:

Water: 1ml/kg/h
Glucose: 1-1.5g/kg/day
Na and K: 1mmol/kg/day
Sign of organ perfusion: Urinary output, capillary refill time
Interstitial fluid volume assessed by skin turgor

Severe metabolic alkalosis, normal saline can be used instead of balanced solution.

Critical illness changes metabolism to adopt starvation.

Physiologically during fasting, glucose level reduces to near 3mmol/L, suppress insulin
secretion, leads to hydrolysis of fat to free fatty acid. Free fatty acid released into the
blood to liver to be converted into ketone bodies (acetoacetate and 3-
hydroxybutyrate)- water soluble and a readily available energy source.

Low insulin levels and high ketones in blood prevents most tissues and organs from
using glucose as an energy source and glucose is saved to feed the brain. Crucial
ability to survive prolonged starvation.

Reserves of protein influence survival. Few days after starvation, the only source of
glucose in the blood is gluconeogenesis from amino acids. Thus, minimizing glucose
oxidation (by oxidizing fats) is key to minimizing protein catabolism. Indeed, providing
energy substrates fully reverses all those changes and induces anabolism.

In critical illness, significant changes to the adaptation to starvation.

Counterregulatory hormone (Adrenal axis & systemic inflammation) induce net
protein breakdown and insulin resistance. Released amino acids converted to glucose
leading increase blood glucose levels. Insulin fails to control blood glucose level and
muscle catabolism.
Mobilization of free fatty acids is limited by poor perfusion to adipose tissue which
reduce the ability to control protein catabolism.
Due to stress response, energy expenditure increases above baseline.
Importantly, providing energy substrates to critically ill only partially reverse the
metabolic changes.

Hyperglycemia during critical illness was a result of insulin resistance of critical illness.

Nutritional targets:
Energy expenditure is measured using indirect calorimetry (based on O2 consumption
and CO2 production), feedings should be individualised
Hypocaloric (70% of measured expenditure) given during acute phase and gradually
increase 100%
Many centre doesn’t have calorimetry, thus calorie estimation, 2.5kcal/kg/day, protein
1.3g/kg/day.
In obese patient, lesser calorie and higher protein, adjusted or ideal body weight is
used and count 2.0-2.5g protein/kg/day

Enteral nutrition should be started if pt unlikely to resume full feeding in 48H

Polymeric formula: mostly used, contain enough protein, 1.0, 1.5 or 2.0 kcal per ml.
Oligomeric formula: pt with impaired pancreatic secretion or short bowel. Contain
peptides instead of protein

Preferred way: continuous administration via NG or NJ tube.

Contraindications for enteral feeding:
-hypoxic intestine (uncontrolled shock- start low dose feed when vasopressor dose is
stable and lactate going down, uncontrolled hypoxia and hypercapnia, overt bowel
ischemia)
-high pressure intestine (abdominal compartment syndrome, low dose feed in
controlled abdominal hypertension)
-damaged intestine (mechanical ileus, active UGIB, anastomotic leak, intestinal
perforation, high output fistula without distal access

Parenteral bags contain protein, glucose and lipids. Doesn’t contain vitamins and trace
elements (should be prescribe and added in the form of 1 vial each of water-soluble
vitamins and lipid-soluble vitamins and trace elements

Insulin infusion started if blood glucose >10mmolL and target at 6-8mmol/L

Patient without insulin secretion such as pancreatectomy and type 1DM require
continuous insulin infusion at a minimum rate of 0.5IU/hr or long acting sc insulin.

REDOXS Study- feeding unstable critically ill patient

Increased calories debt= bad clinical outcome
www.criticalcarenutrition.com

Common issues with feeding and what to do:

-Nondefecation: no BO (not constipation) for several days without any symptoms of
abdominal distension, pain- continue enteral feeding
-avoid refeeding syndrome by reducing feeding rate to half normal rate in patient
with severely malnourished and chronic alcoholic abuse patient. Replace potassium,
magnesium and phosphate. Higher dose of thiamine
-diarrhea: if suspecting enteral feeding, stop for 1 day and reassess, if EN is to blame,
restart in half dose. Consider stop or deescalating antibiotics (send stool for C. diff).
Probiotic usage but not in pancreatitis patient.
-pancreatitis patient: gastric feeding is an option but if failed due to swollen
retroperitoneum always compress on gastric outlet, to use nasojejunal tube.
Parenteral feeding is rare.
-renal and liver failure patient, feeding as all other patients
-prone position, EN is possible but may be poor tolerance. Give higher dose of EN
during supine position periods.

Here’s an explanation of how a glucose infusion could interfere with physiological

regulation and potentially lead to symptomatic hypoglycemia:

1. Physiological Regulation During Fasting:

o During fasting, the body maintains blood glucose levels through several
mechanisms, primarily by breaking down glycogen stores in the liver
(glycogenolysis) and, when glycogen stores are depleted, by producing
glucose from non-carbohydrate sources (gluconeogenesis).
o Hormones like glucagon and cortisol are involved in these processes,
ensuring that the body maintains a steady supply of glucose for
essential functions, particularly for the brain, which relies heavily on
glucose.
2. Impact of Glucose Infusion:
o Administering an exogenous glucose infusion introduces an external
source of glucose, leading to a rapid increase in blood glucose levels.
o The body responds to this sudden influx of glucose by releasing insulin,
a hormone that facilitates the uptake of glucose into cells and lowers
blood glucose levels.
o If the infusion continues, the body’s reliance on endogenous glucose
production (glycogenolysis and gluconeogenesis) decreases, as the
immediate demand for glucose is being met by the external source.
3. Risk of Hypoglycemia After Stopping the Infusion:
o If the glucose infusion is suddenly stopped, there is a risk that the insulin
levels, which have increased in response to the infusion, will remain
elevated for some time.
o This elevated insulin can cause a rapid decrease in blood glucose levels
because it continues to promote glucose uptake by cells, despite the
absence of an ongoing glucose supply.
o Since the body's endogenous glucose production mechanisms have
been suppressed due to the exogenous glucose, there may be a lag
before these mechanisms ramp up again to maintain blood glucose
levels.
 o This lag can result in a drop in blood glucose to levels that are
symptomatic of hypoglycemia (such as confusion, weakness, sweating,
and even loss of consciousness).

In summary, a glucose infusion can interfere with the body's natural glucose
regulation during fasting by causing an insulin-mediated decrease in blood glucose
once the infusion stops. This can lead to symptomatic hypoglycemia due to the
temporary mismatch between insulin levels and the body's endogenous glucose
production. The doctor wisely avoided this risk by recognizing that the patient's blood
glucose level was a normal physiological response to fasting and did not require
external intervention.

VTE prophylaxis is standard of care in ICU and hospital wards, continued till patient is fully
ambulatory and discharged from hospital.
Subgroup of ICU patient with higher risk of thromboprophylaxis failure are those with high
vasopressor and increased BMI
Preferred agent: LMWH
SC Enoxaparin 40mg OD and SC Dalteparin 5000units OD (GFR >30ml/min and no extremes
in body weight.
Contraindicated in HIT (Heparin induced thrombocytopenia)
Complex cases (renal failure and extreme body weights), guide dosing according to plasma
antiXa activity with target range of 0.2-0.4 IU/ml 3-4 hr after the dose.

Contraindications: active bleeding, operation in next 12 hours (spinal neuraxial anesthesia),

moderate and severe coagulopathy, severe bleeding diathesis, thrombocytopenia (<50 or
<100 with bleeding risks).
LMWH should not be given 12hr before epidural catheter insertion or removal and next dose
should be given 3-4 hrs after the procedure.

Other alternatives:
UFH (Unfractionated heparin) in renal failure patient, SC UFH 5000u 2-3 times daily. Reduce
usage due to higher risk of HIT compared to LMWH. Cheaper cost.

Fondaparinux: indirect inhibitor of factor Xa, use in history of HIT. Dose SC 2.5mg OD.
Creatinine clearance 30-50ml/min, lower dose of SC 1.5mg OD. Contraindicated in creatinine
clearance <30ml/min, if necessary, 1.5mg dose can be used

DOAC: Rivaroxaban in those low bleeding risk, taking orally.

Mechanical methods of thromboprophylaxis: IPC (Intermittent pneumatic compression) and

Graduated compression stockings.
IPC: improved leg deep vein circulation and prevent venous stasis. Should be apply >90% time
in bed. Contraindicated in limb ischemia due to peripheral vascular disease. Complication of
skin break down in old frail patient.
Compressions stockings: no evidence of efficacy in ICU patients

Immobility: risk for ICU-acquired weakness, thromboembolism, respiratory dysfunction,

pressure ulcers > these complications prolong mechanical ventilation > associated with long
term physical, cognitive and psychological disability.

Prone position improves V/Q mismatch, improve respiratory mechanics, reduce ventilator
associated lung injury, promote secretion drainage. Require 5 persons to prone patient.
PROSEVA trial

ICU acquired weakness (ICUAW), developed within days due to critical illness. Viewed as
manifestation of multi-organ failure at the level of skeletal muscle (CIM, CIP or both, critical
illness neuromyopathy). Signs: generalized symmetric muscle weakness of limbs and
respiratory muscles. Sensation, facial and ocular muscles are spared.
CIM: Critical illness myopathy; CIP: Critical illness polyneuropathy.

ICUAW risk factors: illness severity, female sex, immobility, hyperglycaemia, older age,
parenteral nutrition, neuromuscular blocking agents in combination of corticosteroid.

Medical research council (MRC) score to evaluate muscle strength in critically ill patient. 5-
point Oxford scale in 6 muscles group evaluation in each of 4 limbs with total score of 60.
Score <48 indicates ICUAW.
Movement tested on each sides:
Arm Abduction; Elbow Flexion; Wrist Extension; Hip Flexion; Knee Extension; Ankle
Dorsiflexion.
No treatment, and prevention is the key by modifying risk factors: avoiding hyperglycaemia,
early parenteral nutrition, minimizing sedation/ paralysis and promoting early mobilization.

ABCDEF Bundle: Protocolized physiotherapy and mobilization

A: Access, prevent and manage pain
B: Both spontaneous awakening and breathing trials
C: Choice of Analgesia and sedation
D: Delirium: Access, prevent and manage
E: Early mobility and Exercise
F: Family encouragement/ empowerment

Early mobility if cardiovascular, respiratory and neurologic status are stable. Vasoactive
infusions and mechanical ventilations are not generally a barrier is patient is otherwise stable.

Goal directed mobility protocol

PADIS guidelines 2018 (Pain, Agitation/ Sedation, Delirium, Immobility, Sleep disruption)
VAP
Scoring using Clinical Pulmonary Infection Score (CPIS)
Your center, monitor incidence of VAP? Criteria? Audit VAP prevention?

VAP pathogenesis:
Oropharynx microflora directly enter the lungs during the intubation causing early VAP
Hospital MDR Gram -ve bacteria colonization at oropharynx
Endoluminal biofilm as source of bacteria colonization at ETT intraluminal surface
Leaking of secretion into lungs after collected at inflated cuff (due to microscopic fold)
Tracheal wall ischemia/ Mucosal damage due to inflated cuff
Impaired mucociliary apparatus due to suboptimal humidification and inhaled heated air.

VAP is preventable and VAP incidence is one of the quality markers of intensive care.
Incidence ranges between 2-16 cases per 1000 ventilator days

*A care bundle is a set of interventions that, when used together, significantly improve ICU
patient outcomes. Can be vary between regions/ hospitals.

Care bundle of VAP prevention:

1) General measures:
-staff education and training on ETT/ airway manipulation
-regular hand hygiene and environmental hygiene/ cleaning
-adequate ICU staffing
-orotracheal intubation favor over nasotracheal intubation
-limiting mechanical ventilation duration, daily sedation holds and weaning protocols

2) Prevention of aspiration
-control and maintenance of cuff inflation pressure – 20-30 cmH2O
-aspiration of subglottic aspiration- only use ETT with subglottic suction port
-semi-recumbent position, head elevation 30-45 degree. If contraindicated, consider bed
rotation
3) Prevention of contamination of equipment
-avoid scheduled changes of ventilator circuit, only changes when it’s soiled/ contaminated
-avoid reusing single use items and use single patient nebulizers and resuscitation equipment
whenever possible
-HME (Heat moisturizer exchanger) is more effective in VAP prevention compared to heated
humidifiers
-use of filter to protect mechanical ventilation circuit
-avoid draining condensate toward the patient
4) Prevention of aerodigestive tract bacteria colonization
-regular oral hygiene at least twice a day: brushing teeth, gum, tongue
-topical application of chlorhexidine gluconate 0.12-2% (6-8Hrly)
-stress ulcer prophylaxis, reduce the gastric pH and promote bacterial overgrowth. Limit the
use to patient who has not achieve full feeding and on steroid treatment
-selective decontamination of digestive tract is not routinely recommended but can be
considered in settings with low prevalence of antibiotic resistance
-prophylactic short course of systemic antibiotic in emergent intubation of reduce GCS patient
but not widely/ routinely recommended

ICU Ward Round • LITFL • CCC Clinical Governance

https://litfl.com/icu-ward-round/

3) Intrahospital transport
Safe patient transfer is an important skill to learn- transporting critically ill patient require
continuous delivery of organ support in an unfavourable environment.

Risk factors of adverse events:

-equipment complications- lines or tubes dislodge
-clinical deterioration of pt
-limited staff for resuscitation
-limited lab and investigation result
-limited monitoring during the transport
-limited therapy options due to lack of appropriate equipment

Meticulous planning is mandatory:

1) Patient’s assessment and risk-benefit analysis regarding the transport
-will the investigation change the clinical management
-adequately stabilize the patient
-discuss on measures if adverse events happen/ patient deteriorate

2) Planning on resources (staff and equipment) for stabilization and resuscitation

-Junior/ senior doctors, airway trained, number of nurses, special professionals like ECMO
perfusionist, transport personnel.
-checklist over equipment and drugs needed on transport
-phone call to accepting department make sure they are ready
-conduct “team time out” as a final check

3) Handover and documentation

-document of monitor readings, intervention, events.
-handover to other department using ABCDE protocol (airway, breathing, circulation,
disabilities, environment), AMPLE protocol (allergies, medication, past medical history, last
meal, events)

Team time out: one team member go through a list and feedback by everyone to check off
the items on the lsit. Closed-loop-communication

How to calculate O2 demand and supply?

Practical note:
-save to stop IVD, low dose insulin infusion, K supplement, feeding, non essential drugs
-vasopressors and sedatives to be prepared in syringe pump
-extra syringes for sedative and emergency drugs such as ephedrine
-pt on high ventilator setting FIO2, PEEP, to connect to transport ventilator to see how the
change effects the gas exchange

4) Human Factors and Non-technical skills

Human Factors- individual, organisational, environmental
Non-technical skills- leadership and followership, team assembly and disassembly, decision
making, task management, situational awareness, communication within a team,
communication with pts and families

Human factors ‘Dirty Dozen’ described by Gordon Dupont

Intensive care is a team job and patient outcomes depend on the performance of whole team
rather than its individual members. 4 key team-work processes that predict pt outcomes:
*Team communication- interdisciplinary communication is vital to develop shared goals for
each patient.
*Team leadership- team leaders facilitate development of shared goals and oversee team
decision- making. Demanding tasks are delegated to team members, whilst the team leader
maintains general oversight. Elaine Bromiley case- example of lack of leadership case during
airway emergency
*Team coordination- share mental mode for goals, tasks and roles of responsibilities of all
team members facilitates team decision-making and allows for rapid adaptation of the team
to its task demands. Situational awareness (important and challenging in seeing bigger
picture) as synthesis of large amount of data and high cognitive load
*Team decision-making- collective leadership emphasises shared responsibility between all
members of the multidisciplinary team. Team decision should be collaborative where possible.
Flat-hierarchy and ‘no-blame’ culture encourage/ empower junior team member to share/
offer their input. Hallmarks of well performing ICUs. Tool- TEAM (team emergency assessment
measure) utilised for resuscitation training.

Crisis communication- drs and nurses always perform separate tasks in parallel. For effective
communication, it must be:
Directed, complete, clear, concise timely
Closed loop communication- involve a call and response
Standardised communication- specific phases with universal meaning

Crisis resource management (CRM)- educational curriculum derived from aviation industry to
improve safety, communication and decision making.
Handover:
Standardising tools improve information transfer and quality of handover
Tool: ISBAR (Identity, Situation, Background, Assessment, Reccommendation)
Identify: introduce self; name/ age/ hospital number/ ward/ team of pt
Situation: Symptoms/ problem, stability of pt
Background: hx of presentation/ past medical history/ brief list of ICU issues
Assessment: Impression of situation/ vital signs/ treatments administered
Recommendation: ongoing plan/ pending tasks to complete/ reviews required

5) Approach to difficult decisions and end-of-life care

ICU aim to provide organ support while the underlying acute illness improves over time with
targeted treatment.
Some conditions do not improve with treatment and sometime the insult of the acute organ
dysfunction is too severe, particularly if patient is frail or has a high burden of chronic disease.
15-20% of patients do not survive their ICU admission

Withholding treatment defined as a decision not to start or increase a life-sustaining

intervention.
Withdrawing treatment defined as a decision to stop a life-sustaining intervention.

Reasons to withhold or withdraw therapies fall into on of the following:

-rapidly progressive single or multiple organ failure where additional therapies are not
expected to prevent imminent death
-survival to hospital discharge is not expected, either because the illness is progressive or
unresponsive to treatment or because underlying frailty or chronic disease burden limits the
patient’s ability to recover
-survival is expected to be associated with a level of physical or cognitive impairment not
consistent with the patient’s wishes or best interest.

The presumption should always be in favour of prolonging life.

Family communication at the end of life in the ICU

-

End of Life Care in ITU

Once symptom control has been optimised, all other treatments including vasopressors and
ventilatory support are discontinued.
Practice varies and it is essential that a clear plan is communicated so all the team members,
family and pt (if able to communicate) understand the process
Find out about any culture and religious that still need to be addressed.
Ensure monitoring has been discontinued and alarms silenced.
Organ support often reduced in step wise fashion so symptoms can be reassessed after each
step, such as stopping vasopressors, then reducing oxygen and ventilatory support followed
by extubation to room air. Process of withdrawal needs to be individualised and documented
for each patient.

Diagnosis of death by neurological criteria (Brain death/ brainstem death)

End of life care common drugs and its indications

Pain/ dyspnoea: IV/SC Morphine 1.25-2.5mg hourly if required (Can consider other opiate)
Respiratory secretions: SC Hyoscine butyl bromide 20mg hourly if required (Maximum usually
120mg in 24 H) (Can consider other anticholinergic)
Dyspnoea, anxiety or agitation: SC Morphine 1.25-2.5mg hourly if required (Can consider
other benzodiazepines)
Nausea, vomiting, or agitation: SC Haloperidol 0.5-1.5mg every 4 hourly if required or SC
Levomepromazine 2.5-5mg every 12 hour.