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Elias Fast Hug - Management of The ICU Patient
Elias Fast Hug - Management of The ICU Patient
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
Components
Feeding
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
feeding
Adequate nutrition is vital for critically ill
Poor wound healing
Post operative complications
Sepsis
Nitrogen (Protein)
14 grams / day
Other
Water / vitamins / trace elements etc.
Malnutrition
Underfeeding Overfeeding
Loss of muscle mass Increased VO2
Diarrhoea / Constipation
Metabolic
Dehydration / Hyperglycaemia / Electrolyte imbalance /
Fine Bore Nasogastric Feeding Tube
NG
Tip
Parenteral Route:
When adequate Enteral intake delayed / impossible
Short bowel syndrome
Extensive GI surgery / Complications
Rebound hypoglycaemia
Trophic feeding
Not absorbing enough calories
Low volume enteral feed (to maintain gut integrity) + parenteral
feed
How much feed should we give?
nitrogen
no benefit from measuring nitrogen balance
nitrogen 0.15-0.2 g/kg/day
protein 1-1.25 g/kg/day
severely hypercatabolic patients (eg burns) may receive
up to 0.3 g nitrogen/kg/day
What should the feed contain?
carbohydrate
EN: oligo- and polysaccharides
PN: concentrated glucose
lipid
EN: long and medium chain triglycerides
PN: soya bean oil, glycerol, egg phosphatides
nitrogen
EN: intact proteins
PN: crystalline amino acid solutions
water and electrolytes
micronutrients
Feeding formula
Components
Feeding
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
Analgesia
Critically ill patients feel pain due to:
Their primary illness e.g. pancreatitis / surgical wounds
Routine procedures e.g. turning / suctioning / dressings
Psychological Effects
Causes anxiety / Contributes to lack of sleep
Post Traumatic Stress
Analgesia
Physiological Effects
Worsens delirium
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
Sedation
Compassion for the critically ill patient
Major tranquilizers
Haloperidol (also used in delerium)
Analgosedation
Opiods
Pharmacological considerations: Analgesia
& Sedation
Patient’s fluid volume status
Drug interactions
Sedation problems
Oversedation
Increased risk of nosocomial pneumonia
Increased rate of Neurological Investigation (CT)
Prolonged stay in the ICU + Polyneuropathy
Increased incidence of post – traumatic stress disorder and
depression
Increased use of inotropes
Monitoring Sedation
Ramsay Sedation Score
Ramsay Sedation Score
Important Concepts
“Analgosedation”
Agents with both sedating and analgesic properties
“Tube tolerance” for opioids
“Sedation Hold”
Assess mental status / communication / level of sedation /
neurological status
Important Concepts – Delirium
“acute confusional state characterised by
fluctuating mental status
inattention
and either disorganized thinking or altered level of
consciousness”
Inattention
Disorganized thinking
Altered consciousness
Cognitive deficits
Psychomotor disturbance
Hyperactive / Hypoactive / Mixed
Delirium: Diagnosis
CAM-
ICU
CAM-
ICU
– ICU
Spell “SAVE A HAART” loudly to patient
Ask them to squeeze your hand every time they hear the
letter “A”
Allowed 2 mistakes - squeezing on a non-A, not squeezing
on a A
Pass = Not delirious
midazolam
Daily sedation targets and spontaneous awakening trials if
tolerated
Correct biochemical, hypoxic and haemodynamic
derangements
Screen for infection, identify or treat most likely source
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
Thromboprophylaxis
Critically ill patients have numerous risk factors
Pharmacological
Subcutaneous LMW Heparin o.d. (e.g. Tinzaparin)
Intravenous unfractionated Heparin (infusion)
Subcutaneous unfractionated Heparin b.d.
Oral anticoagulants (Warfarin)
Don’t Forget Anything!
Feeding
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
Why Ensure Head Up Position?
Head of the bed inclined at 45 degrees
Can decrease gastroesophageal reflux in mechanically
ventilated patients
Can reduce rates of nosocomial pneumonia
Is indicated (20 – 30 degrees) in some patients e.g. raised
ICP
Don’t Forget Anything!
Feeding
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
Why Ensure Ulcer Prophylaxis?
Peptic ulceration is related to
protective barrier loss
Acid or biliary damage of the underlying mucosa
Barrier loss occurs secondary to critical illness
Highest risk
Prolonged mechanical ventilation
How to Ensure Ulcer Prophylaxis?
Small-bore feeding tubes
Enteral nutrition
Reduces incidence of stress ulcer bleeding
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycaemic control
Why Glycaemic Control?
As current studies stated that: “Keeping blood glucose
Breathing
Circulation
Disability / Neuro
Enteric
Fluids / Renal
Glucose / General
Haematology
Infusions / Lines
Airway
Type
COETT (cuffed oral endotracheal tube)
Tracheostomy
NIV (non-invasive ventilation: CPAP or BiPap)
Facemask / Nasal Cannulae
Duration
Time to change it for a new one?
Time to change tube to tracheostomy?
Time to escalate / de-escalate?
ETT
Tip
Carin
a
Breathing
What are the ventilation parameters
FiO2 / SaO2 / mode of ventilation / measurements
Review Investications
CXR: tube position / any pathology
Arterial Blood Gas
Circulation
What is the haemodynamic status?
Heart rate & rhythm / Blood pressure / CVP
Analgesia
Mood
Any delirium?
Enteric
Examine the abdomen
Any new signs? Any increase in size? Are we monitoring
compartment pressures?
Any surgical wounds?
Feeding
Are they receiving nutrition? Is it time to start?
Is the NG / NJ tube in the right place?
Are they absorbing feed?
Fluids / Renal
Fluid Balance
Are they positive or negative? What are we aiming for?
What is the urine output
Is the fluid regimen appropriate?
Renal
Any renal replacement therapy?
What are the electrolytes?
Glucose / General
What is the glucose?
Are they on insulin / should they be on insulin?
General Examination
Vascular sufficiency
Wounds
Drain sites
Pressure areas
Haematology (& Clotting)
What is the latest haemaglobin & WCC?
Oh’s Intensive Care Manual, 6 th Ed. Neil Soni & Andrew Bersten.
http://www.icudelirium.co.uk