Florida Handbook of Critical Care

HANDBOOK OF CRITICAL CARE

Division of Critical Care Medicine Department of Anesthesiology University of Florida College of Medicine Shands Hospital at the University of Florida

Revised 060109

FACULTY:

Darwin N. Ang, MD Scott B. Armen, MD John Armstrong, MD Azra Bihorac, MD, FASN Lawrence J. Caruso, MD Phillip Efron, MD Elamin M. Elamin, MD, FACP Ronald Freeman, MD Andrea Gabrielli, MD, FCCM T. James Gallagher, MD, FCCM A. Joseph Layon, MD, FACP (Division Chief)

Lawrence C. Martin, MD Bhiken Naik, MD Carl W. Peters, MD

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TABLE OF CONTENTS Useful Telephone Numbers……….4 Section 1: Procedures……….5 Section 2: Neurology / Neurosurgery……….11 Section 3: Cardiovascular……….22 Section 4: Respiratory……….26 Section 5: Fluid Administration……….39 Section 6: Hematology……….40 Section 7: Metabolic……….41 Section 8: Abdomen – GI……….46 Section 9: Renal………47 Section 10: Infectious Disease……….50 Section 11: Nutritional Support……….55 Section 12: Pain Control and Sedation……….61 Section 13: Administration…………………64

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Useful Telephone Numbers

(Area Code 352)

SICU main number Pod 1 main number Pod 2 main number Pod 3 main number Pod 4 main number Pod 5 main number

265.0025 265.0428 265.0442 265.0491 265.0251 265.0252

Burn ICU main number

265.0200

CICU Main Number Pod 1 Pod 2 Pod 3

265.0024 265.0097 265.0098 265.0099

Neuro ICU 8th floor

265.0082

Recovery room (PACU)

265.0038

Division Numbers Poppy Meehan 265.0486 A. Joseph Layon, MD, FACP (Chief) Andrea Gabrielli, MD, FCCM Bhiken Naik, MD

265.1062 (Fax)

Keisha Dawkins 273.8958 (5th Floor) Azra Bihorac, MD, FASN Amin M. Elamin, MD, FACP T. James Gallagher, MD, FCCM

392.7029 (Fax)

Myrtle Williams 273.8956 (5th Floor) Lawrence J. Caruso, MD Ronald Freeman, MD Carl W. Peters, MD (supervisor for ARNPs / PAs)

392.7029 (Fax)

Transcriptionists (Chuck / Kathy / Martha / Marti)

846.1302

Department Numbers

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265.0077 (2nd floor Residency office; Fax 265.6922) 273.6575 (5th floor Chairman’s office; Fax 273.8612) 265.8012 (1329 Building; Fax 265.8013)

Section 1:

Procedures

A. PROCEDURES— General: 1. Our Units use a “Universal Consent” for common procedures. This paperwork will be given to families / patients upon arrival to the unit. After the patient, or more likely, the patient’s surrogate, has had time to read the material, the resident will be asked to answer questions and, with the patient’s RN, witness the consent. This function is extremely important to the proper functioning of our unit and cannot be ignored. This job is not handed off to PA / ARNPs or students. 2. All invasive procedures require supervision by a faculty member / Fellow, and full surgical, sterile precautions. The following is not to be violated except in a life threatening emergency: a. Patient, site, and procedure re-identification will be performed by physician with nurse. If sedation level is altered in a significant manner [i.e., addition of new agent, necessity for NMB], a pre-sedation evaluation must be performed by physician. The ICU nurse will provide you with the paperwork; b. For invasive procedures, the patient’s RN will be at the bedside for the duration of the procedure. CVL placement will utilize a CVL quality Check-sheet that is completed contemporaneously with line placement by the patient’s RN. c.

Central Venous Line Placement Procedure: i. Patient, site, and procedure re-identification will be performed as above; ii. Patient’s RN is at bedside with check-sheet; iii. The site for the procedure will be evaluated / re-evaluated and all needed equipment will be present; iv. Mask and hat will be donned; v. Wash hands prior to donning gloves; vi. After donning a mask, hat, and sterile gloves, the patient will be surgically prepped using tinted Chlorprep®; Betadine is no longer used. A “back and forth” rather than a “circular” motion is used. The prep will be allowed to dry and the sterile gloves will then be discarded; vii. After donning a sterile gown and new sterile gloves, the patient will be completely draped. Nothing but the operative site will be in view. 1. If there is any clarification needed as to what this means, you will ask the CCM attending; viii. Chlorprep®, tinted or clear, will be used to re-clean the pre-prepped area after draping is completed; ix. Ultrasound will be used for all central venous lines – excepting the SCV – to identify the appropriate vessel; x. Once the needle is placed into the central vein, it will be transduced using IV extension tubing to ensure that it is, indeed, venous; xi. The catheter is threaded over the wire into the vein. Special care is taken so that the wire is always visible. Once the catheter is placed into the central vein, it is stabilized and all ports are aspirated to ensure that there is blood return; xii. Thereafter, the catheter is sutured in place, the Biopatch® placed, and a non-occlusive clear dressing applied;

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xiii. Anyone in the unit has the authority and responsibility to stop your procedure if they see a break in technique. If you are so informed, you will abort the procedure and begin again, from “i” above; xiv. After completion of a procedure, dispose of sharps and clean up any mess; xv. Order a Chest radiograph for line placement; the reason is “Pneumothorax”. Take the patient out of Trendelenberg position; xvi. No one may access the CVL without using Chlorprep® or alcohol to the access site and donning gloves. d. Central Venous Line Wiring Procedure: i. Patient, site, and procedure re-identification will be performed as above; ii. Patient’s RN is at bedside with check-sheet; iii. The site for the procedure will be evaluated / re-evaluated and all needed equipment will be present; iv. Mask and hat will be donned; v. Wash hands prior to donning gloves; vi. After donning a mask, hat, and sterile gloves, the patient’s CVL site will be surgically prepped using tinted Chlorprep®. The catheter body itself will be prepped and then covered with a sterile towel, leaving only the port to be accessed visible; vii. The prep will be allowed to dry and the sterile gloves will be discarded; viii. After donning a sterile gown and new sterile gloves, the patient will be completely draped. Nothing but the operative site will be in view. 1. If there is any clarification needed as to what this means, you will ask the CCM attending; ix. Chlorprep®, tinted or clear, will be used to re-clean the pre-prepped area after draping is completed; x. The patient is then placed in Trendelenberg position unless contraindicated (elevated ICP, femoral line); xi. The catheter will be accessed as follows: 1. 9 French Introducer: The PA catheter port is prepped with a Q-tip saturated with Chlorprep® and allowed to dry. Thereafter, the wire is placed through this port. The body of the catheter is handled while wrapped in a sterile towel; 2. Double or Triple Lumen Catheter: The Distal port is clamped, then disconnected from IV solution and prepped with a Q-tip saturated with Chlorprep® and allowed to dry. Thereafter, the wire is placed through this port. The body of the catheter is handled while wrapped in a sterile towel. xii. The catheter is removed over the wire, never losing sight of the wire itself. Sterile 4x4s and gentle pressure are used to limit blood loss from the catheter site. xiii. The new catheter is threaded over the wire into the vein. Special care is taken so that the wire is always visible. Once the catheter is placed into the central vein, it is stabilized and all ports are aspirated to ensure that there is blood return; xiv. Thereafter, the catheter is sutured in place, the Biopatch® placed, and a non-occlusive clear dressing applied; 6

xv. Anyone in the unit has the authority and responsibility to stop your procedure if they see a break in technique. If you are so informed, you will abort the procedure and begin again, from “i” above; xvi. After completion of a procedure, dispose of sharps and clean up any mess; xvii. Order a Chest radiograph for line placement; the reason is “Pneumothorax”. Take the patient out of Trendelenberg position; xviii. No one may access the CVL without using Chlorprep® or alcohol to the access site and donning gloves. 3. The CCM Fellow or attending must be present for procedures until otherwise noted. 4. Even if the fellow is present, the CCM attending must be notified for all procedures. 5. All lines are tracked on the blue “line sheet” in the front of the chart. Date placed and removed, type of line and size, site placed, reason removed. This is the resident’s responsibility. B. PROCEEDURES — Specific 1. CENTRAL LINES: a. All central line placements, as well as PA catheter placements, require sterile precautions as detailed above. The CCM attending or Fellow must be present for the procedure. b. We use “pig-tailed” (J-tipped) antibiotic coated catheters. They generally remain in place for eighteen (18) days. When changed, a new site is used unless there is a very good reason not to. Our 9 Fr PA catheter introducers and 12 Fr dialysis catheters (both made by Arrow) are antimicrobial coated, thus they, too, may remain in place for up to eighteen (18) days. The PA catheters we have are not antibiotic coated, and are changed after six (6) days. c.

We do not, as a matter of course when changing a line, send the intracutaneous segment of the catheter for quantitative culture.

2. ARTERIAL LINES: a. Indications for arterial catheterization a. Continuous direct blood pressure monitoring, especially when the blood pressure must be kept within narrow limits (e.g. subarachnoid hemorrhage requiring HHH therapy) b. Need for access for repeated blood sampling (e.g. during treatment of large deviations in acid-base status, GI hemorrhage, or electrolyte abnormalities) c. Hemodynamic instability, as when a patient is receiving inotropes or vasopressors d. When non-invasive blood pressure is unreliable, such as in the morbidly obese or those with peripheral vascular disease b. Contraindications to arterial catheterization (based on selected site of insertion) a. Local infection or injury b. Presence of an arterial graft in the selected extremity c. Inadequate collateral flow c. Locations for insertion of an arterial catheter (Most  Least preferable) a. NOTE: This order of preference is subject to variability based on the clinical situation, or on CCM attending or primary service preference b. RADIAL Artery: easily accessible; chose the non-dominant extremity c. FEMORAL Artery: easily accessible, long duration of function; however, limits mobilization of patient, and may be prone to infection. Use at least an 8cm catheter, 4-Fr; in older patients a 12 cm, 5 Fr is preferable. d. AXILLARY 1. Artery runs in the sheath with the nerve bundle, so could see a high degree of disability if complications occur. Should not be used if systemic anticoagulation in use. 2. Axillary – left side preferable due to higher risk of embolization to the CNS from right side axillary cannulation; use 3- or 4-French catheter, 5cm length unless 7

skin-to-artery distance dictates otherwise; insert as proximal as can be reasonably secured in place e. Dorsalis pedis – temporary, & a measure of last resort; never to be used in one with peripheral vascular disease (actual or potential, such as in those over ~ 40 years old) d. Complications of peripheral artery catheterization – keep in mind during daily examination or your patients a. Local ischemia, inflammation, or infection b. Hematoma formation c. Arterial spasm d. Bleeding from cannula disconnection e. Thrombosis f. Proximal or distal embolization g. Limb ischemia or necrosis h. Sepsis i. Pseudoaneurysm j. Arteriovenous malformation e. Preparation: a. Minimum allowable operator / site preparation requires operator to wear hat, mask, sterile gloves, and to prep the site meticulously with Chlorprep solution and sterile towel coverage. b. The femoral artery area, because of its greater potential to harbor infective organisms in areas adjacent to insertion site, warrants more rigorous preparation: full surgical prep and draping are required along with full operator barrier protection (hat, mask, sterile gown, and sterile gloves). c. Prior to beginning the insertion, ensure that the insertion site is thoroughly and aggressively anesthetized for patient comfort (allowing sufficient time for onset of action of the local anesthetic agent), and that the patient is appropriately restrained / sedated to avoid movement that may lead to harm. 1. For example, for the radial artery cannulation, draw up 2 to 3 mL of 0.5% to 1% lidocaine without epinephrine. 2. Using a new 25 to 27 gauge needle, instill 0.5 to 1 mL of the local anesthetic just lateral to, just medial to, and superficial to the radial artery. After the 2 to 3 mL is instilled, wait about 5 minutes and the place the catheter. Analgesia will be excellent. f. Catheter types a. For radial artery: 20 gauge 2-inch; 22 gauge may be used for particularly small vessels; do not use larger gauge catheters, which would increase the chance of arterial thrombosis. b. For other (femoral, axillary) sites, chose 4F (most often) or 5F 8 – 12cm catheter kits; the 4F 8cm kit usually will suffice for all but the most obese individuals.

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g. Radial artery site:

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h. Femoral artery site:

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Section 2:

Neurology / Neurosurgery

A. Traumatic Brain Injury Initial Resuscitation of Blood Pressure and Oxygenation Background In head injured patients, both hypotension (defined as a systolic BP < 90 mm Hg) and hypoxia (defined as apnea, cyanosis, or a PaO2 < 60 mm Hg) are associated with measurably worsened clinical outcome. This occurs presumably because hypotension and hypoxia cause secondary injury in vulnerable brain tissue. While these insults may occur at any point in the clinical course of a patient with head injury, they often occur in the prehospital setting or during Emergency Department (ED) resuscitation. Patients with severe TBI may mask hypovolemic hypotension because of the Cushing’s response to intracranial hypertension. As such, patients may benefit from, minimally, central venous monitoring during the period of acute fluid resuscitation to adequately assess their intravascular volume. A gradual increase in blood pressure associated with a gradual decrease in pulse (even if both are within normal limits) should suggest the development or progression in intracranial hypertension. Goals of Therapy 1. To avoid hypotension and hypoxia in patients with severe head injury. 2. To urgently treat hypotension and hypoxia, thus minimizing exposure of vulnerable brain tissue to these secondary insults. Guidelines 1. Hemodynamic resuscitation begins in the ED with the placement of two large-bore (14 or 16 gauge) IV’s when possible. A SCV or femoral 9 Fr introducer / 2-lumen dialysis catheter may be placed in lieu of peripheral IVs. 2. A subclavian central line should be placed when possible for volume-status assessment. The femoral 9 Fr introducer may be used to place a long central venous pressure line as long as two large-bore IV’s are available for fluid resuscitation. 3. Internal jugular lines are not practical in the ED setting since most patients will be wearing cervical collars. 4. A temperature-sensing Foley catheter should be inserted during the initial resuscitation. This will help assess the patient’s fluid status as well as core body temperature. 5. Systemic blood pressure should be recorded every five minutes during the initial resuscitation (in the ED) via automated sphygmomanometer. An arterial blood-pressure catheter (preferably in the radial artery) should be placed as soon as possible to allow for continuous blood pressure readings. 6. Volume resuscitation with 0.9%NS or blood (when appropriate) is the first intervention. Plasmalyte™ may be considered as an alternative resuscitation fluid, especially in patients with metabolic acidosis. 7. Strict avoidance of ANY hypotonic (0.45% and 0.225% NaCl, Lactated Ringer solution) and Dextrose containing solutions should be observed during acute resuscitation and as routine maintenance fluids in the intensive care unit (ICU). 8. At a minimum, systolic BP should be maintained above 90 mm Hg. Ideally, mean arterial pressure (MAP) will be maintained between 70 and 80 mm Hg, since a systolic blood pressure of 90 mmHg may be inadequate in the setting of elevated ICP. 9. Systemic hypertension generally should not be treated in the acute setting of TBI, since this may reflect the body’s natural response to intracranial hypertension. a. None-the-less, antihypertensive medications may be administered if the systolic blood pressure is greater than 220 mm Hg. b. Beta blockers are the drug of choice in the absence of bradycardia. Calcium channel blockers or nitrates may be used as well, though the latter may theoretically increase ICP by causing 11

cerebral vasodilation. Hydralazine should be avoided since it is thought to uncouple cerebral blood flow from metabolism. 10. Pressors may be necessary in addition to volume resuscitation, especially in the setting of acute spinal cord injury (SCI). Norepinephrine, Neosynephrine, or vasopressin are the pressors of choice. Neosynephrine may induce bradycardia in SCI and is generally reserved for use in TBI. a. The use of pressors in the acute setting should be agreed upon by ED, Trauma, Anesthesia and Neurosurgery attendings as applicable. 11. Early intubation may be necessary to avoid hypoxemia in patients with severe head injury. While there is theoretical concern about pulmonary oxygen toxicity in patients receiving an FiO2 > 0.6, concerns of systemic and cerebral hypoxia take precedence. a. Treatment with supplemental oxygen will be initiated in the field and continued after arrival to the ED; 100% O2 will be given prior to intubation and continued during the initial postintubation period. FiO2 will be adjusted according to the post-intubation arterial blood gas (ABG). b. Rapid-sequence induction (RSI) should be carried out using propofol (0.5 to 1 mg / kg), sodium thiopental (0.5 to 1 mg / kg), or etomidate (0.1-0.3 mg / kg) and succinylcholine (0.25 mg / kg). c. Succinylcholine may theoretically increase ICP by depolarizing skeletal muscle, though patient outcome is unlikely affected by its use. d. A back-up plan must be ready to implement in the event of a difficult intubation. e. Etomidate – even with only one dose – may block the 11 – beta – hydroxylase step of steroid synthesis and result in adrenocortical insufficiency. 12. Ventilation rate should be controlled to maintain adequate oxygenation. Because of the significant effects of ventilation on cerebral blood flow, hyperventilation during the acute resuscitation should be reserved only for patients with evidence of acute brain herniation. Hyperventilation can also decrease venous return, cardiac output, and blood pressure, thereby increasing the incidence of secondary brain injury. 13. Initial use of barbiturates and propofol beyond intubation – while neuroprotective – should be avoided until resuscitation is complete as they may cause hypotension. 14. Initial laboratory studies should include the following: a. Post-resuscitation Arterial Blood Gas b. Basic Metabolic Profile (Electrolytes, BUN, Creatinine and Glucose) c. Phosphorus, Magnesium, iCa d. CBC with platelets e. Coagulation panel (PT/PTT/INR) f. Serum Osmolarity g. Type and Screen (cross # of units as necessary) h. Urine toxicology Cerebral Perfusion Pressure (CPP) Background Cerebral perfusion pressure (CPP) = MAP – ICP. Cerebral ischemia may be the most important secondary event affecting outcome after severe traumatic brain injury. Cerebral perfusion pressure therapy is designed to prevent secondary ischemic insults to vulnerable traumatized brain tissue. While the optimal CPP may vary from individual to individual, evidence from studies using transcranial Doppler ultrasound (TCD) and from the Traumatic Coma Data Bank suggest that a CPP of 60 to 70 mmHg is an appropriate goal. This target may vary according to the patient’s individual autoregulatory set point. Goals of Therapy 1. To avoid secondary cerebral ischemia of traumatized brain by ensuring adequate cerebral perfusion. 2. To maintain euvolemia or slight hypervolemia, in order to ensure adequate cerebral and systemic organ perfusion. Guidelines 1. CPP Management 12

a. CPP of 60 to 70 mmHg [CPP = MAP – ICP] will be maintained using volume and pressors as necessary. i. Higher is not necessarily better. b. Threshold CPP will be tailored to individual patients using cerebral monitoring tools such as ICP, jugular venous oxygen saturation (SJVO2), Brain tissue O2 (PbtO2) and EEG. 2. Hemodynamic Monitoring a. Insufficient evidence exists currently to recommend one method of hemodynamic monitoring in the head injured patient over another. Therefore, we will recommend that all patients undergoing ICP monitoring receive a central venous catheter (CVP) preferably via the subclavian route (to avoid possible IJ thrombosis or carotid artery puncture). If necessary, the IJ may be used. b. An arterial catheter, preferably at the radial site, will also be placed. By convention, the arterial pressure transducer will be placed at the level of the right atrium. However, for CPP calculations, the transducer should be zeroed at the level of the tragus, as this is the pressure that the brain will “see”. c. In order to minimize the effect of head-of-bed (HOB) elevation on CPP, HOB should be raised no more than 30˚ to 45˚. This strategy also addresses the observation that cerebral blood flow drops as the HOB elevation exceeds 45˚ – even in the setting of a constant CPP, and with the arterial-line zeroed at the Tragus. d. Pulmonary artery catheters will be used at the discretion of the treating physician, particularly in patients who cannot be managed via other methods (CVP line, non-invasive hemodynamic monitoring, echocardiography). 3. Pressor and Volume Therapy a. CVP will be maintained between about 10 and 15 mmHg; if a PA catheter is used, then PCWP (10 to 15 mm Hg) or EDVI (100 to 150 mL / m2) will be maintained as an initial approximation of optimal range. A Starling Curve will not be generated as this may result in fluid overload. SsvcO2 or SvO2 should be kept > 65% to 70%. b. Because pressure measurements may be altered by changes in intrathoracic pressure which accompany use of PEEP / CPAP, ARDS / ALI, and increased intra-abdominal pressure, attention must be paid to ensure that intravascular pressures are correlated with other measures of volume status such as urine output and heart rate in order to ensure euvolemia. c. When pressors are used for CPP management, attention will be made to ensure that the patient is adequately fluid resuscitated before instituting a pressor infusion. Initial pressor of choice is phenylephrine (0.1 to 5 mcg / kg / min), with norepinephrine (0.01 to 1.0 mcg / kg / min), or vasopressin (0.01 to 0.04 Units / min) as alternative choices. Epinephrine (0.01 to 1.0 mcg / kg / min) is considered a second-tier choice. With any of these agents, great attention must be paid to ensure that volume status is maintained to avoid precipitating metabolic / renal abnormalities. B. INCREASED INTRACRANIAL PRESSURE (ICP) Elevated ICP means persistent values above 20 to 25 mmHg. Treatment for elevated ICP follows the TBI Flow Diagram:

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Severe TBI CPP management flow sheet st

1 Tier Therapy

Surgery as indicated

GCS ≤ 8

CHECK •

Patient position (head neutral, elevated HOB 30° to 45º Check Bed Indicator) Equipment functioning properly (good waveform) No recent interventions (respiratory, nursing) Exclude seizure activity Antiseizure prophylaxis (load with Dilantin)

• • • •

Insert Art line, ICP monitor, ETCO2, CVP, Licox,, CVP or PAC*

Goals of management: 1. Maintain CPP > 60 to 65 (CPP = MAP – ICP) 2. Fluids therapy as noted 3. Osmolality < 320 mOsm / L, Na+ 145 to 155 mEq / L 4. Hct 25% to 30% 5. Sedation / analgesia / NMB as noted 6. Brain / core temperature 37 ± 0.5 °C 7. O2 sat > 93%, PaCO2 35 to 40 mmHg 8. Brain PO2 (PbtO2) > 20 mm Hg 9. Blood sugar 80 to 110 mg / dL with Insulin infusion

FLUID THERAPY, VASOPRESSORS •

Basic monitors include Arterial pressure monitoring, End-Tidal CO2 monitoring, ECG, Bladder Temperature, SpO2, and CVP / PAC Arterial line zeroed at level of tragus Maintain CVP 5 to 10 mmHg, or PCWP 10 to 15 2 mmHg or EDVI 100 to 150mL / m Use 0.9% Saline Solution or Plasmalyte solution Maintain Hct ~ 30% (Use packed RBC’s) Once volume loaded, assess SsvcO2 or SvO2 before use of vasopressors If SsvcO2 or SvO2 > 65% to 70%, use Phenylephrine 0.1 to 5 mcg / kg / min Norepinephrine 0.01 to 1 mcg /kg / min For vasopressor resistant hypotension, may use Vasopressin 0.01 to 0.04 Units / min If SsvcO2 or SvO2 < 65% to 70%, consider Epinephrine 0.01 to 1 mcg / kg / min or

• • • • • • • • • • •

Low MAP

Consider repeating CT scan

ICP > 20 mm Hg for 5 mins

• • • • •

Ventriculostomy if GCS < 8 unless contraindicated or unfeasible If contraindicated / unfeasible subdural bolt acceptable Consider SjvO2 monitoring Consider PbtO2 & Brain Temperature monitor by 3-way bolt Set to drain at 10 cm above external auditory canal To set at lower level call Neurosurgery Elevate ventriculostomy by 5 cm per day if ICP < 20 and drainage < 4 mL / hr

• • • • • •

PbtO2 > 20 OR SjvO2 > 50%

PbtO2 < 20 Or SjvO2 < 50%

CSF DRAINAGE OPTIONS •

Sedation / Analgesia / NMB

Check perfusion indices

Sedate to sedation score 4. The meaning of a BIS score is unclear in TBI Midazolam 0.1 to 0.4 mg/kg /hr iv infusion Fentanyl 0.5 to 3 mcg/kg/hr iv infusion Propofol 5 to 50 mcg/kg/min iv infusion Consider neuromuscular blockade

• • • •

ICP > 20 mm Hg for 5 mins

Fluid therapy, vasopressors

SEDATION AND ANALGESIA •

CHECK

CPP < 60 mm Hg

Consider repeat CT Administer FIO2 100% x 15 minutes Check MAP & PaCO2 Increase MAP until CPP > 70 mmHg If perfusion indices normalize accept ICP up to 30 mmHg**

• • • •

Check MAP & PaCO2 Is MAP appropriate ? Ensure adequate sedation Titrate PCO2 to 30 to 35 mmHg

Persisting CPP deficit ICP > 30 mmHg Drain CSF if ventriculostomy present

HYPEROSMOLAR THERAPIES • • • •

Mannitol 0.25 to 0.5 gm / kg bolus OR Mannitol 0.25 to 0.5 mg / kg every 6 hours OR Hypertonic saline (3%) 100 to 200 mL over 30 minutes + Measured serum osmolarity and serum Na levels every 4 to 6 hours nd

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TIER THERAPY

• •

Check perfusion indices - is there evidence of hyperemia ? (PbtO2 > 50 mm Hg) If hyperemic consider deepening sedation, including low dose barbiturates

• • •

Not hyperemic - is the patient salvageable ? Assess: Mechanism of injury, best GCS, age, pupil reactivity, CT scan Focal frontal contusions with initial good GCS – consider decompressive craniectomy Barbiturate therapy – pentobarbital infusion to EEG 90% burst suppression PAC in place Dose is 1 to 5 mg / kg IBW bolus over 15 to 30 minutes Infusion 1 to 5 mg / kg IBW / hr

• • • •

PaCO2 MANAGEMENT • •

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•

Persisting CPP deficit ICP > 30 mmHg

Hyperosmolar therapies

Persisting CPP deficit ICP > 30 mmHg Consider 2nd tier therapy

APPENDIX *PA catheter may be used at physician’s discretion **ICP threshold of 30 may be tolerated if perfusion indices are within the normal range and CPP is maintained > 70 mmHg except if temporal lobe contusions are present on CT scan

Goal PaCO2 is 35 to 40 mm Hg Acute Hyperventilation to PaCO2 to 30 mm Hg may be considered for up to 2 hours with uncontrollable ICP SjvO2 or PbtO2 monitoring preferable in this situation

1. Mild hyperventilation to a PaCO2 as low as 30 mmHg. 2. Maintenance of cerebral perfusion pressure (CPP) of 60 to 70 mmHg. (CPP = MAP – ICP); may require use of neosynephrine or norepinephrine to maintain MAP. 3. Mannitol 0.25 gm/kg to 0.5 gm/kg; Mannitol can be repeated usually every four hours as necessary until serum osmol = 320 mOsm / kg H2O. 4. 23% saline solution 30 mL IV as a bolus; frequent Na+ checks are necessary. 5. Maintenance in head up position of 30° to 45° and neutral head position. 6. Fentanyl and versed continuous infusions. 7. Neuromuscular blocking agents if needed 8. Barbiturate Coma a) Rarely used as neurologic outcome usually does not improve. b) Inducement of barbiturate coma when used requires cardiovascular monitoring with the use of a pulmonary artery catheter. c) Loading dose of pentobarbital: 1 to 5 mg/kg over 15 to 30 minutes. d) Endpoint: 90% burst suppressed EEG e) Pentobarbital maintenance: 1 to 5 mg / kg / hour. 9. Decompressive craniectomy: used very infrequently. C. VASOSPASM 1. Vasospasm ordinarily develops after subarachnoid hemorrhage (SAH) from a ruptured cerebral aneurysm. It usually occurs between post bleed day 3 and 14. The likelihood of vasospasm relates to the amount of blood present in the basilar cistern as seen on CT scan. The Fisher grading system of I to IV refers to the amount of blood in the basal cisterns. The greater the amount (higher Fisher grade) the greater the likelihood of vasospasm; Fisher grade III carries the highest risk of vasospasm. 2. Diagnosis: Vasospasm is suspected by clinical symptoms, and diagnosed by angiography or CT angiography. In other institutions, it may be diagnosed by transcranial Doppler. When angiography is not done, vasospasm can be inferred if blood is known to exist in the cisterns and the patient has a depressed mental status, absent any new changes on CT scan. 3. Prevention of vasospasm: a) Nimodipine is given to all patients with SAH. b) Ensure volume status is adequate with appropriate monitoring – CVP of 10 to 15 mm Hg, FLoTrak with SVV less than 10%, or a PA catheter. c) Hydration with normal saline or 0.45% NS + 75 mEq Na acetate ( which = isotonic saline solution) infusing at 125 to 150 mL / hour. d) As an option, some patients may also be supplemented with 5% albumin 250 ml every six hours. e) At surgery, attempts may be made to remove as much blood as possible, usually with irrigation. f)

Maintenance of MAP between 100 and 130 mm Hg. (usually with neosynephrine 0.5 to 5 mcg / kg / min)

4. Treatment of vasospasm: 15

a) Normal saline or 0.45% NS + 75 mEq Na acetate infusing at 125 to 150 mL / hour b) Maintenance of high cerebral perfusion pressure with neosynephrine or norepinephrine to maintain systolic BP of 180 to 200 mm Hg or MAP 100 to 130 mm Hg. c) In addition, in some patients 5% albumin may be continued at 250 mL q6h. d) Frequently place a central line and keep CVP 10 to 15 mm Hg e) In severe cases, placement of PA catheter with maintenance of cardiac index  2.5 L / min / m2. If patient is already fluid-loaded, this may require the use of an inotropic agent, usually dobutamine at 5 to 10 mcg / kg / min. f)

Maintenance of appropriate PCWP ~ 15 mm Hg or an end diastolic volume index (EDVI) ~ 100 ml / m2. This may require 250 ml of 5% albumin q 4 hr

g) While, typically, volume status is aimed at CVP of 12 to 15 mm Hg, if the step to a pulmonary artery catheter is made, PAWP or EDVI are titrated through the creation of a pressure-volume (Starling) curve. This pressure-volume curve details the lowest PAWP or EDVI with the highest cardiac index. The fluids used for the generation of this relationship may be either isotonic / hypertonic crystalloid or 5% albumin solution. Pushing fluids to an arbitrary PAWP / EDVI number is not an acceptable manner of handling hemodynamics, as one may either undershoot the cardiac optimum or keep the patient volume underloaded. h) Magnesium sulfate infused at 250 mg / hr is used to prevent delayed ischemic injury. i)

HMG-CO A inhibitors are administered for their anti-inflammatory and neuroprotective effects.

D. GLASGOW COMA SCALE Category Eye Opening

Response None To Pain To Voice Spontaneous

Score 1 2 3 4

Verbal

None

1

Incomprehensible Garbled Words Confused Speech Oriented Speech

2 3 4 5

Flaccid Abnormal Extension Abnormal Flexion Withdraws Localizes Follows Commands

1 2 3 4 5 6

Motor

Best score is 15 and the lowest is 3. Glasgow Coma Scale has some relation to outcome, after closed head injury. Scores of 6 or less have a high likelihood of poor outcome. Scores between 6 and 9 are somewhat indeterminate with regard to outcome. Scores of 10 or greater usually have a reasonable outcome. Severe head injury is GCS  8, moderate is 9 to 12 and mild is >12. E. REFLEXES 1. Corneal: This measures function at the level of the pons. It measures the 5th afferent and 7th efferent cranial nerves.

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2. Pupillary: One dilated pupil can often represent transtentorial herniation. Pupillary function measures midbrain activity. 3. Doll’s Eyes: This measures activity at the midbrain and level of the pons. This test requires rapid movement of the supine head from the right and left positions. Eyes which stay in the midline indicate normal function. Eyes that do not move but track with the head represent a lesion. This test should not be performed in patients with suspected or known cervical injury. 4. Oculo-Vestibular (Cold Calorics): This test also measures function at the midbrain and pons. One hundred (100) mL of iced saline is injected into each ear. Intact function is indicated by both eyes moving to the side of the stimulus. Do not perform in patients with perforated tympanic membrane, otorrhea, or basilar skull fracture. 5. Apnea: Measures medullary function. 6. Gag: This also measures medullary function, as well as the 9th afferent and 10th efferent cranial nerves. 7. Peripheral Sensory Innervation Levels: Nipples-T4, Umbilicus-T10. F. BRAIN DEATH CRITERIA In order to test for brain death, the following criteria must first be met: 1. An injury or event to the brain that can lead to or directly cause irreversible brain damage without any likelihood of functional recovery. 2. The patient must be normothermic, and have laboratory parameters that are within approximately normal limits. 3. The patient must be areflexic to all the usual stimuli. This includes absence of corneal, pupillary, and gag reflex; no response to cold calorics and / or absent doll’s eyes. Patients should be unresponsive to all painful stimuli. 4. When the above criteria are met, brain death may be termed present IF one of two studies are also positive: a) Blood Flow Study: Radio-labeled technetium is injected and nuclear medicine scans performed to detect blood flow within the brain. This study requires evaluation by a certified radiologist familiar with the technique. At times, blood within the venous system can be mistaken for cerebral blood flow. If herniation has already occurred, and even though brain death has taken place, there may be the appearance of blood flow within the brain again. This study is to be read only by a nuclear radiologist. b) Apnea Test: Brain death can also be determined by apnea test. In addition to #1 through #3 above, the following criteria should be met in advance: i. Blood pressure must be within 20% of the patient’s usual blood pressure. ii. Temperature greater than 36° C. iii. Serum sodium between about 128 and 155 mEq/L. iv. Patient has not received any drugs, which may cause respiratory depression. v.

Oxygen saturation greater than 85%.

vi. Failure of the apnea test will require a combination of a PCO2 > 60 mm Hg and a pH < 7.25. vii. Failure to breathe shall be determined by a board certified or board eligible neurologist, neurosurgeon, internist, surgeon, or anesthesiologist at the bedside. viii. Respiratory attempts will be determined either by direct observation or movement of a Wright respirometer placed in line in the airway. 17

ix. Blood gas must be drawn prior to placing the patient back on the ventilator. To Perform the Apnea Test: 1. Baseline blood gas results. 2. Place patient on T-piece on 100% O2. Place a Wright respirometer in line. A Mapleson-D device may be used if CPAP is required for maintenance of saturations. 3. Nurse, respiratory therapist and attending physician at bedside to detect any respiration. The test continues until the pCO2  60 mm Hg and pH  7.25. 4. Based on the initial blood gas, it can be assumed that the PaCO2 will increase by 3 mm Hg / min. In addition to direct observation, the spirometer can detect even small breaths. Occasionally the spirometer may move, because of high flow rates through the T-tube; not due to any patient effort. G. SEIZURES 1. Causes: a) Hypoxemia. b) Hyponatremia. c) Hypoglycemia. d) Low Dilantin level. e) Intra-cerebral bleed. f) Drug / alcohol withdrawal. g) Trauma 2. Treatment: a) Maintenance of oxygenation and airway with intubation, if necessary. b) Versed at 1 to 10 mg IV. c) Pentothal at 50 to 500 mg IV. d) If actively seizing, load with Phosphenytoin at 1000 mg IV, if not previously on Dilantin. Phosphenytoin at the same dose may be given more rapidly than phenytoin (Dilantin). e) Correction of electrolytes. H. SPINAL SHOCK Spinal shock can occur with a spinal cord injury from level T4 up. This is due to a sympathetic blockade and also results in bradycardia from blockage of the cardio-accelerator fibers. 1. Treatment of Spinal Shock a) Fluid administration, often as much as 3 to 6 L of isotonic crystalloid solution may be required. b) Pressors – Once intravascular volume has been restored (CVP 10 to 15 mm Hg, minimally), vasoconstriction may be required with the use of 1 to 5 mcg / kg / min of neosynephrine or 0.01 to 0.04 units / minute vasopressin. I. SIADH This usually occurs with and is related to head trauma. 1. Diagnosis: a) Serum osmolarity  280 mOsm / kg / H2O. b) Urine osmolarity  400 mOsm / kg / H2O (or otherwise inappropriately high in face of low serum osmolarity). c) Serum Na+  130 mEq / L. Urine Na+ concentrations cannot always be relied on to make the diagnosis but are often in the low double digits. 2. Treatment: a) Fluid restriction, when able. Usually, this is not possible in surgical patients. b) 3% saline at 30 to 40 mL / hr to raise serum Na+  130 mEq / L. c) If not contraindicated, loop diuretic to reduce free water. d) If Na+  125 mEq / L, correct no faster than 0.5 mEq / L / hr (12 mEq / day) J. DIABETES INSIPIDUS This usually follows head trauma or severe hypoxemia. 18

1. Diagnosis: a) Urine volume  200 mL / hr. b) Urine Na+  20 mEq / L. c) Serum Na+  145 mEq / L. d) Urine specific gravity  1.004. 2. Treatment: a) Fluid replacement – D5W at amounts calculated to restore free water deficit. b) To calculate free water deficit: Assume goal is serum Na of 140 mEq / L. Total Body Water (TBW) = Weight in Kg x 0.6 Then: Free H2O Deficit = (TBW)

Current PNa+ - !40 140

To calculate the percentage of UOP that is Free Water (as DI begins to be corrected): % Free H2O = Urine Volume (mL) 1 – {Na+ + K+} urine {Na+ + K+} plasma This gives an indication of the amount of UOP that is free H2O and thus needs to be repleted with water, as opposed to being UOP resultant from the replacement process itself. c) d) e) f)

Oral intake, if able. D5W as a continuous infusion (50 to 150 mL / hr) – follow glucose closely. Usually, urine can be replaced each hour with D5W at 0.5 to 0.75 mL per 1.0 mL of urine loss. Pitressin at 1 to 5 units IV q6h; this should be used prior to DDAVP to prevent possible inducement of SIADH. g) DDAVP at 1 to 5 units IV every 12 hrs.

K. CEREBRAL SALT-WASTING SYNDROME This usually develops after aneurysmal SAH. It is a hypovolemic syndrome. 1. Diagnosis: a) Serum Na+  130 mEq / L. b) Urine Na+  100 mEq / L. c) Serum osmolarity is usually at the low end of normal. 2. Treatment: 3% saline at 30 to 40 mL / hr to maintain serum Na+  130 mEq / L. L. SEDATION Propofol – 5 to 50 mcg / kg / min – when turned OFF patient will usually return to baseline neurologic status in 15 minutes. Other agents include versed 1 to 2 mg / hr continuous infusion Haldol (2.5 to 5 mg IV q4h) may also be used – usually for the elderly or agitated patient. Watch for prolonged Q-T interval M. Ventriculostomy Procedure: 1. All invasive procedures in the SICU / NeuroICU require full surgical, sterile precautions. The following will not to be violated except in a life threatening emergency: 2. Patient, site, and procedure re-identification will be performed by physician with nurse. 3. If sedation level is altered in a significant manner [i.e., addition of new agent, necessity for neuromuscular blockade], a pre-sedation evaluation must be performed by physician. The ICU nurse will provide the paperwork and the CCM Team will assist with this; 19

4. In non-intubated patients, local anesthesia and / or minimal amounts of midazolam is used for analgesia / sedation. The non-cooperative patients will have their ventriculostomy placed in the Operating Room. 5. Prophylaxis: a. b.

If a non-emergent procedure, vancomycin, 1 gm IV will be given 60 minutes before the initiation of the procedure If emergent and the patient is not allergic to Beta-lactam antibiotics, oxicillin 2 gm IV x 1 is administered as the preparation commences.

6. Hands will be washed prior to initiation of procedure; 7. The site for the procedure will be re-evaluated and all needed equipment will be present. The patient’s nurse or other assistant will be at the bedside with the operator; 8. Hands will be re-washed; 9. After donning a mask, bonnet, and sterile gloves, the patient will be surgically prepped. The sterile gloves will be discarded after prep; 10. A sterile gown and new sterile gloves will be donned and then the patient will be completely draped. Nothing but the operative site will be in view. a. If there is any clarification needed as to what this means, you will ask the Neurological Surgery or CCM attending; 11. Technique: a.

b. c. d. e. f. g.

Clip the hair with electric clippers (do not shave with razors as this can nick the skin and increase the risk of infection). Clip a very large area to include a wide margin around both the cranial incision as well as the exit site of the catheter. The exit site of the catheter should be as distant from the cranial incision as possible (at least 6 cm). A curvilinear incision is made so that a twist-drill burr-hole can be made at Kocher’s point (mid-pupillary line just in front of the coronal suture, or can be measured 10 cm behind the nasion and 3 cm lateral to the midline). A small retractor is placed. A twist-drill burr-hole is made with the handheld twist-drill. The dura is punctured carefully with the back-end of the tunnel passer. A BACTI-SEAL™ (antibiotic-impregnated) ventricular catheter is inserted through the burr-hole aiming for the frontal horn of the lateral ventricle. Only BACTISEAL™ ventricular catheters will be used. The catheter should be exited out the skin using the tunnel passer as distant from the cranial incision as possible (at least 6 cm). The incision is closed with a water-tight running nylon suture (CSF leakage through the incision is a confirmed risk factor for CSF infection).

12. Anyone in the unit has the responsibility to, and may, stop the procedure if they see a break in technique. If so informed, the operator will abort the procedure and begin again, from “a” above; 13. After completion of a procedure, dispose of sharps and clean up any mess.

20

Table 1

Table 2

Table 3

21

Section 3:

Cardiovascular

A. HYPERTENSION CONTROL 1. Initially, patients should be started on regularly scheduled antihypertensive agents. 2. PRN agents are only meant to supplement the scheduled drug and indicate the need for a higher dose of the scheduled drug. 3. In the elderly (> 70 yrs.), a blood pressure below 170 mm Hg systolic will usually not be required, let alone be achieved. 4. Initial treatment requires IV medications. Oral meds are not reliably absorbed. 5. Hypertension secondary to inadequate pain control will usually not subside without adequate pain control. Agents to control blood pressure and suggested dosages 1. Enalapril: 0.625 mg to 5 mg IV every 6 hrs 2. Metoprolol: 20 mg IV every 2 to 4 hrs on a regularly scheduled basis. 5 to 20 mg IV every 1 hr PRN basis. Enteral Dose: 50 – 200 mg bid. 3. Hydralazine: 10 to 40 mg every 1hr PRN basis. A good drug to use if patients have bradycardia (HR  60 beats / min). 4. Labetalol: 0.2 to 1.6 mg / kg / hr either intermittently or as a continuous infusion. This controls both heart rate and blood pressure. i)

The intermittent dosing regimen may be written as follows: (1) Find the ideal body weight of the patient (for this example assume 70 kg) (2) Decide the range in which to keep the Systolic BP (here assume 120 to 140 mm Hg) (3) Then write the order: Labetalol IV to keep SBP between 120 and 140 mm Hg as follows: 15 mg IV 30 mg IV dosed every 10 minutes until SBP control 60 mg IV achieved. May repeat hourly. 120 mg IV

5. Nitroprusside: 0.5 to 5.0 mcg / kg / min. Try to limit this drug to less than 24 hrs to avoid thiocyanate / cyanide toxicity. This agent requires a central line for administration. 6. Nitroglycerine: 1 to 10 mcg / kg / min. Less potent than nitroprusside and also a good venodilator. B. HYPOTENSION In septic shock, blood pressures may be as low as 60 to 80 mm Hg systolic. Other causes of hypotension include hypovolemia or cardiogenic shock.

Almost all post-operative hypotension results from inadequate fluid replacement. Agents to improve blood pressure: Alpha Agents – Usually these drugs have no effect on heart rate or contractility. 1. Phenylephrine (neosynephrine): 1 to 5 mcg / kg / min. 2. Norepinephrine (Levophed): 0.1 to 1.0 mcg / kg / min. Since both of the above agents can cause significant vasoconstriction to the gut, lactic acid levels should be monitored every 2 to 4 hrs to ensure that gut malperfusion does not develop. 22

Inotropic Drugs These agents are used to increase cardiac contractility and may also improve blood pressure. 1. Dopamine: 1.5 to 15 mcg / kg / min, low dose 1.5 to 3 mcg / kg / min may improve urine output but not renal blood flow. 2. Dobutamine: 5 to 20 mcg / kg / min. In septic patients, may cause hypotension due to peripheral vasodilation. However, this is usually a desired quality in patients with primary cardiac disease. 3. Epinephrine: 0.01 to 4.0 mcg / kg / min. Doses above 1 mcg / kg / min are considered high dose. This is the most potent of the inotropic agents. It will cause vasoconstriction and tachycardia. 4. Milrinone: Load with 50 mcg / kg over 10 minutes, then 0.375 to 0.75 mcg / kg / min. It can cause significant peripheral vasodilation. It is often necessary to add an alpha agent, such as neosynephrine or norepinephrine to maintain an acceptable blood pressure. C. CARDIAC FUNCTION In our unit, cardiac output is determined by continuous methodology. The pulmonary artery catheter has a heating element that warms blood as it flows past the element. This change in temperature is registered on a thermister near the tip of the catheter. Cardiac output is then calculated by the change in temperature over time. Cardiac Output  Temp

↑ Start—————→ Time C.O.  1/ Temp Slow flow or low cardiac output means that warm blood will remain around the thermister for a longer period of time and result in a greater temperature change. Cardiac output is a function of: 1. 2. 3. 4.

Heart rate Preload Afterload Contractility

Therefore, changes in cardiac function can best be assessed by focusing on stroke volume Cardiac Output    Stroke Volume   Heart Rate  

and, if available, the ejection fraction: Stroke Volume     EF  End Diastolic Volume  

Cardiac Index Ranges Cardiac index and oxygen delivery requirements will vary depending on the patient’s metabolic needs. There is no specific cardiac index goal. The appropriate cardiac output and oxygen delivery can be inferred from a normal mixed venous oxygen saturation (SVO2) of 65 to 80% and the absence of elevated lactic acid. When these criteria are met, the specific cardiac index is of less importance. 23

Preload Clinically, preload is best indicated by a pulmonary capillary wedge pressure (PCWP) and / or end diastolic volume index (EDVI). Each patient will have a different PCWP value that results in the best stroke volume. In most patients, this will range between 14 to 22 mm Hg. End diastolic volume index (EDVI) actually provides a better correlation with stroke volume than does wedge pressure. We think EDVI usually provides better information that wedge pressure. End diastolic volume index is calculated by the computer each time it determines cardiac output. Most times EDVI ranges between 90 and 120 ml / m2. Occasionally patients may require values as high as 140 to 160 ml / m2. Afterload This refers to the tension developed in the myocardium during contraction. Tension increases as impedance goes up in the vascular bed. We can best measure changes in impedance by calculation of systemic vascular resistance index (SVRI). Always remember SVRI is a calculated value and it will always vary inversely to cardiac output, since the formula is: SVRI 

MAP  CVP Cardiac Index

Contractility We cannot measure contractility directly. However, it can be best inferred by changes in stroke volume. Heart Rate For patients with coronary artery disease (known or suspected because of age or other factors), heart rates over 100 beats / min can cause significant ischemia because of increased myocardial oxygen requirements and limited coronary blood flow. In these at-risk patients, it is best to keep the heart between 60 to 80 beats / min if possible. Agents to reduce heart rate 1. Metoprolol – PRN dose of 5 to 25 mg IV every 1 hr. Regular scheduled dose 20 to 40 mg IV every 2 hrs. 2. Propranolol – 1 to 6 mg IV every 1 min until control achieved. 3. Esmolol load with 0.5 to 1 mg / kg, then start an infusion of 50 to 250 mcg / kg / min (This drug is very likely to depress myocardial contractility). The loading dose usually needs to be re-administered when the drug dose is increased. Beta Blockers may be contraindicated in patients with known bronchospastic disease. Instead use: 1. Diltiazem (calcium channel blocker) – load with 0.25 mg / kg, then begin an infusion of 10 to 25 mg / hr as a continuous infusion. This drug may not work as well on younger patients. D. DYSRHYTHMIAS The most common cardiac dysrhythmias in surgical patients include: 1. Atrial fibrillation – Often due to low potassium, low magnesium, hypoxemia or hypotension. The ventricular rate can be controlled by: a) Drugs i. Metoprolol – 5 to 25 mg every 1hr. ii. Diltiazem – 10 to 25 mg / hr continuous infusion after a loading dose as above. iii. Digoxin – 0.5 mg IV and repeat in 1 to 2 hrs. A daily dose would be 0.125 to 0.25 mg based on patient’s age and renal function. iv. Amiodarone – 150 to 300 mg IV bolus, then 60 mg / hr continuous infusion for 6 hrs; 30 mg / hr for 18 hrs, then 15 mg / hr. b) Cardioversion – Indicated when blood pressure is compromised or patient has no response to drug therapy. This requires synchronized cardioversion. Begin at 50 joules and increase up to 360 j (if using a monophasic defibrillator) maximum. Remember to sedate the patient and synchronize. If cardioversion will occur after more than 48 hours of atrial fibrillation, an echocardiogram may be necessary to rule out the presence of an atrial clot. 2. Ventricular fibrillation – Immediate cardioversion at 360 j. Repeat as necessary. Amiodarone may be used as a continuous infusion at 60 mg / hr after bolus of 150 to 300 mg. This will hopefully prevent the patient from returning to ventricular fibrillation. 24

3. Frequent PVCs – Maintain potassium 4.5 mEq / L and magnesium above 2 mg / dL. Patients should also be warm with temperatures greater than 36 C. 4. Torsades de Pointe (multi-focal ventricular tachycardia)– magnesium above 2 mg / dL. May give 2 to 4 gm magnesium IV push to break rhythm. Table 1

Note that these are “ballpark” normals. Table 2

CaO2 = 1.34 x (Hgb) (%Sat) + (PaO2) (0.003) CvO2 = 1.34 x (Hgb) (%Sat) + (PvO2) (0.003) CcO2 = 1.34 x (Hgb) (%Sat) + [(713) (FiO2) - 40] (0.003)

25

Section 4:

Respiratory

A. OXYGEN The FiO2 should not exceed 0.4 to 0.6. FiO2 > 0.6 may cause lowered PO2 due to blunted hypoxic vasoconstriction and resorption atelectasis. Oxygen toxicity begins about 48 to 72 hours after 100% oxygen. Inspired oxygen can be delivered by several different modes. 1. Nasal cannulae: Restricted to 1 to 3 L / min. Flows of 5 to 6 L / min can be uncomfortable. Dependent on the degree of mouth breathing, with entrainment of room air, the FiO2 usually varies between 22% and 25% (increases ~ 3% per L / min). 2. Face mask oxygen: Delivers humidified gases to the patient. Flows can be varied to maintain a FiO2 as high as 0.6 to 0.7. A higher FiO2 usually requires a reservoir using corrugated tubing attached to the mask. 3. Venti mask: This allows for precise delivery of oxygen up to 0.6 and is useful in patients with chronic lung disease. It will limit the FiO2 and prevent apnea due to a high PaO2. A venti-mask does not deliver humidified gases. 4. Non-rebreathing mask: This mask has a bag attached which acts as a reservoir to supply a high concentration of oxygen. Since the mask cannot be completely sealed, patients rarely receive 100% oxygen. This is only interim therapy until the patient’s original problem can be corrected. B. MECHANICAL VENTILATION AND OXYGENATION Patients generally require ventilation and intubation because of problems with either oxygenation or ventilation, or for airway control. 1) Oxygenation Low oxygen levels can be a result of mechanical problems. These can include: a) Pneumothorax b) Mucous plugs c) Right mainstem intubation d) Increased secretions e) Significant atelectasis f) Occasionally, pleural effusion g) Bronchospasm Each of a) b) c) d) e) f)

the above requires specific interventions, such as: Pneumothorax: chest tube Mucous plugs, lung collapse, and increased secretions: bronchoscopy Mainstem intubation: repositioning of the endotracheal tube Bronchospasm: bronchodilator such as albuterol Secretions: glycopyrrolate 0.2 mg IV every 4h. Pleural effusion: Thoracentesis or chest tube placement.

Once mechanical causes of decreased oxygenation are resolved, we can usually assume that any other decreases in oxygenation are due to reduced lung volume from: a) Hypoventilation after surgery; b) Increased fluid administration with the development of pulmonary edema, or ARDS; c) ARDS from sepsis. d) One cannot, however, forget to consider the possibility of a pulmonary embolus in any case where there is risk of deep venous thrombosis (such as on the OR table). 2) Low lung volumes and ARDS Major surgical procedures, trauma and ARDS all cause reduced PO2 due to low lung volumes. In the case of ARDS, other factors (inflammatory mediators, capillary leak) come into play. CPAP restores lung volume. Increase CPAP in 5 cm H2O increments to improve PaO2. Normally, we target a PO2 of three times the FiO2 (i.e., 40% oxygen = PO2 of 120 mm Hg; 30% oxygen = PO2 of 90 mm Hg). This is the PaO2 / FiO2 ratio. Baseline CPAP is 5 cm H2O. 26

3) Hypoventilation / Hypoventilatory Respiratory Failure Problems usually involve the inability to breathe effectively because of a handful of problems: a) Weakness (intrinsic or due to incomplete reversal of neuromuscular blocking agents) b) Sedation c) Neurological impairment d) Bronchospasm e) Increased work of breathing f) The differential diagnosis of Hypoventilatory Respiratory Failure is more complex: (1) Increased Resistive Load: (a) Bronchospasm (b) Airway edema / secretions / scarring (c) Upper airway obstruction (d) Obstructive sleep apnea (2) Increased Lung Elastic Load: (a) Intrinsic PEEP (b) Alveolar edema (c) Pulmonary infection (d) Atelectasis (3) Increased Chest Wall Elastic Load: (a) Pleural effusions (b) Pneumothorax (c) Rib fractures (d) Pulmonary tumor (e) Obesity (f) Ascites / Abdominal distension (4) Increased Minute Volume Loads: (a) Sepsis (b) Pulmonary embolus (c) Hypovolemia (d) Increased calories with increased CO2 production (5) Decreased Respiratory Drive: (a) Drugs (morphine, etc) (b) Lesions of the Brain Stem (esp. the Ventral and Dorsal Respiratory Groups, Lateral PontoMedullary Lesions) (c) Sleep disordered breathing (d) Hypothyroidism (6) Impaired Neuro-Muscular Transmission: (a) Phrenic nerve injury (b) Spinal cord lesion (c) Neuromuscular blocking agents (d) Aminoglycosides (e) Guillain – Barre Syndrome (f) Myasthenia gravis (g) Amyotrophic lateral sclerosis (h) Botulism (7) Muscle Weakness: (a) Fatigue (b) Electrolyte derangement (c) Hypoperfusion state (d) Hypoxemia (e) Myopathy Pressure support ventilation will decrease the work of breathing. Although not always true, rapid respiratory rates are usually considered indicative of an increased work of breathing. We prefer patients to breathe less than 28 times per minute. Baseline pressure support levels are usually 5 or 10 cm H2O. These can be increased by 5 cm H2O increments until the patient’s respiratory rate is < 28 / min. The maximum pressure support level should be a tidal volume less than that delivered by the mandated ventilator breath. Work of breathing can be non-invasively measured with a consult to the Pulmonary Research Team (Andrea Gabrielli, Michael Banner, Steve Bonnet). 27

Bronchospasm In general, metered dose inhaler (MDI) is more effective than nebulized agents. Thus the former should be used, with a spacer, whenever possible. In the non-intubated patient, nebulize 2.5 mg of albuterol in 5 ml of saline every 1 to 4 hours. For very thick secretions, albuterol 2.5 mg PLUS N-acetyl cysteine 2 mL of 20% solution nebulized every 4 to 6 hours for approximately 72 hours is effective in thinning out the secretions. This mixture is a bronchial irritant, so we use it for only about 72 hours before changing back to other agents. In an intubated patient, albuterol MDI (4 to 10 puffs every 1 to 4 hours) or Combivent® MDI (10 puffs every 2 to 4 hours and prn), a mixture of albuterol and ipratropium, both delivered via a spacer is very effective. Combivent should be used when there is a history of anticholinergic-responsive COPD. Stridor Patients with upper airway stridor, as may be seen following extubation, may also require therapy with racemic epinephrine 0.5 ml diluted in 3 ml of saline. This may be administered every 10 to 60 minutes to reduce upper airway or vocal-cord edema. A single dose of dexamethasone (4 to 6 mg IV) and / or Heli-Ox (75% helium, 25% oxygen) may also help. C. PROCEDURES 1. Intubation a) Intubation should be carried out by an experienced individual as this is usually a life-threatening situation. ALWAYS assume that the patient has a difficult airway and make sure you have a backup plan for accessing the airway if DL doesn’t work. b) Have available both a #4 Macintosh and a #2 or #3 Miller blade. c) Have adequate suction available. d) Position the patient as needed (in line stabilization if suspected or known cervical injury). e) Have an Ambu or Mapelson bag and mask available. f) Many patients, depending upon the situation, can be intubated with minimal to no sedation. g) Short acting agents such as pentothal, propofol, or etomidate are best. Administer pentothal in 50 mg increments, propofol in 30 to 60 mg increments, and etomidate in 5 to 10 mg increments. Maintain cricoid pressure during the procedure. h) Following intubation, listen for breath sounds over the chest and for air being introduced directly into the stomach. i) CO2 detectors must be utilized. j) A chest film will confirm that the tip of the tube is in the appropriate location, approximately 4 cm above the carina, or at the level of the clavicular heads. k) EVERY intubated patient will have pulse oximetric and continuous capnographic monitoring. 2. Airway Evaluation Patients intubated and ventilated for airway protection must have the airway evaluated prior to extubation. a) Cuff leak – When the cuff is deflated, an air leak indicates minimal cord edema provided a patient has an appropriate sized tube in place. A leak should be present during spontaneous breathing or at < 25 to 30 cm H2O inflation pressure. b) Direct laryngoscopy will indicate not only the degree of difficulty to reintubate the patient, but also whether or not any edema is present that would preclude extubation at that point. We usually first sedate with pentothal or etomidate. DL is not performed prior to every extubation. D. VENTILATION MODES 1. IMV The majority of patients are ventilated in the IMV mode with pressure support. The IMV rate is usually 10 to 12 breaths per minute. We always attempt to use the lowest ventilator rate consistent with a PaCO2 below 50 mm Hg and a pH between 7.25 and 7.40, and a spontaneous respiratory rate between about 12 and 28 breaths per minute. The usual ventilator tidal volume should be 6 – 8 mL / kg. At a rate of 8 to 10 breaths per minute, PCO2 and pH will be within a normal range. 28

Occasionally, severe acidosis from hypercapnia will occur despite increased minute ventilation. This type respiratory acidosis may induce cardiovascular instability and require the use of a base, such as bicarbonate or THAM™ (tris-hydroxy aminomethane). 2. Pressure support To improve PCO2 and / or pH, alter the ventilator rate. Use pressure support to reduce the spontaneous rate, thereby reducing work of breathing. 3. Pressure controlled ventilation (PCV) Generally limited to patients with significant ARDS as indicated by development of bilateral infiltrates on chest x-ray. We may also initiate PCV when peak inflation pressures on conventional ventilation exceed 50 cm H2O. PCV requires an inspiratory time of at least 1.5 to 2.5 seconds. Tidal volume is adjusted based on the ∆P, which is the difference between the peak pressure selected and the level of CPAP. Attempt to keep the ventilator rate < 16 / min. 4. Initiation of Mechanical Ventilation Protocol: IMV / PSV or Assist Control a. Protocol: 1. Initiate PetCO2 measurement and obtain ABG in 30 minutes a. Calculate PaCO2 – PetCO2 gradient with first ABG 2. VT 7 mL / kg IBW 3. Initial FiO2 1.0 a. If SpO2 95% or more and / or PaO2 / FiO2 200 or more ( i.e. PaO2 of 85 mmHg with FiO2 = 0.4), wean to 0.3 to 0.4 4. Mechanical rate = 10 to 14 bpm, keep PetCO2 between 35 and 45 mm Hg a. Increase by 2 bpm up to 16 to 18 bpm for PetCO2 greater than 45 mm Hg 5. Initial CPAP 5 cm H2O a. May increase to 10 cm H2O in 2 to 3 cm H2O increments every 10 minutes to allow decrease in FiO2 as above b. Notify MD of auto-PEEP by expiratory flow waveform analysis 6. Calculate compliance and resistance in Volume Controlled Mode with VT = 7 mL / kg IBW, Flow Rate 60 L / min a. Compliance = Vt / Pplateau b. Resistance = [Pplateau – PEEP] / Flow c. Measure compliance with each CPAP change d. Maintain plateau pressure less than or equal to 30 to 35 cm H2O 7. PSV initial set to VT spontaneous 6 - 8 mL / kg IBW with spontaneous RR no more than 30 bpm 8. Maintenance of Mechanical Ventilation a. Follow progress with PetCO2 and SpO2 b. Keep PetCO2 between 35 and 45 mm Hg [depending upon the PaCO2 - PetCO2 gradient] c. Keep SpO2 95% or greater d. Increase FiO2 to 1.0 if SpO2 less than 92% and ICU staff e. Wean FiO2 to 0.3 to 0.4 for SpO2 greater than 95% f. Return to previous settings for SpO2 less than 95% 9. ABG every 24 hours with PaCO2 – PetCO2 gradient calculated a. ABG prn after ICU staff bedside patient evaluation for i. SpO2 less than 92% on FiO2 of1.0 ii. Patient agitation or intolerance of mechanical ventilation iii. PetCO2 less than 20 or greater than 50 mm Hg 10. Call MD for 29

Persistent SpO2 92% or less or with increasing O2 requirements over 0.6 RR spontaneous 30 bpm or more PetCO2 less than 20 or greater than 50 mm Hg Plateau pressure greater than 35 cm H2O i. After suctioning, checking circuit, and so forth, discuss increase sedation and / or initiation of A/C, VC+, or APRV with fellow or attending e. CPAP more than 10 cm H2O f. Blood pressure systolic less than 90 mm Hg (or a change of greater than 20 mm Hg) or other evidence of hemodynamic instability g. Patient agitation or intolerance of mechanical ventilation h. Reactive airways / bronchospasm i. Neurological instability (such as increased ICP, decreased PbtO2)

a. b. c. d.

5. Weaning from Mechanical Ventilation Protocol: IMV / PSV a. Protocol:

1. IMV / PSV a. Wean mechanical RR to 2 bpm as long as PetCO2 between 25 and 45 mm Hg, and VT and RR spontaneous are > 5 ml / kg IBW and 30 or less, respectively b. Wean PSV 2 cmH2O at the time to 10 cmH2O as long as VT and RR spontaneous are > 5 ml / kg IBW and 30 or less, respectively 2. Wean CPAP in 2 to 3 cm H2O increments every 30 minutes to 5 to 10 cm H2O to keep SpO2 95% or greater with an FiO2 0.3 to 0.4. 3. Obtain weaning parameters: a. NIF greater than negative 25 cm H2O b. FVC greater than or equal to 10 mL / kg IBW c. + cuff leak after oropharyngeal and ETT suctioning d. Document the percent of cuff leak (Vt after deflation / Vt before deflation) e. Notify MD if negative cuff leak (Percent cuff leak less than 15%) f. f / VT less than 100 with PSV of no more than 5 cm H2O, decreased to this level for measurement 4. If weaning parameters acceptable contact MD for: a. SBT on T-piece for no longer than 30 to 60 minutes in sitting position when possible b. All Patient care held unless necessary c. Calculate RSBI at end of SBT d. NOTE: Discontinue SBT and place back on previous settings if clinical / ventilatory deterioration + notify MD 5. Call MD for a. SpO2 92% or less b. RR spontaneous 30 bpm or more c. PetCO2 less than 20 or more than 50 mm Hg d. Systolic blood pressure less than 90 mm Hg (or greater than 20 mm Hg change) or other evidence of hemodynamic instability e. Patient agitation or intolerance of mechanical ventilation f. Reactive airways / bronchospasm 6. If SBT a. b. c.

tolerated X 1 hour notify MD with results for: Possible extubation Prolongation of SBT Increase in ventilatory support if applicable

7. Discuss the following with Faculty / Fellow MD before extubation: a. Airway anatomy / History of difficult intubation 30

b. c. d. e. f.

Pulmonary mechanics Mental status Quality / quantity of ETT secretions Hemodynamics Surgical plan

6. Initiation of Mechanical Ventilation Protocol: Pressure Regulated Volume Control (VC+) a. Protocol:

1. Initiate PetCO2 measurement and obtain ABG in 30 minutes a. Calculate PaCO2 – PetCO2 gradient with first ABG 2. VT = 7 mL / kg IBW 3. RR = 10 to 14 bpm, keep PetCO2 between 30 and 45 mm Hg a. Increase by 2 bpm up to 16 to 18 bpm for PetCO2 greater than 45 mm Hg 4. Initial FiO2 1.0: a. If SpO2 95% or more and / or PaO2 / FiO2 200 or more ( i.e. PaO2 of 85 mmHg with FiO2 = 0.4), wean to 0.3 to 0.4 5. Initial CPAP 5 cm H2O a. May increase to 10 cm H2O in 2 to 3 cm H2O increments every 10 minutes to allow decrease in FiO2 as above b. Notify MD of auto-PEEP by expiratory flow waveform analysis 6. Set Ti guidelines a. Calculate compliance and resistance in Volume Controlled Mode with VT = 7 mL / kg IBW, CPAP of 10 cm H2O, Flow Rate 60 L / min b. Compliance = Vt / Pplateau c. Resistance = [Pplateau – PEEP] / Flow d. Calculate Time constant (τ) = C x R e. Set initial Ti as 3 x τ i. Titrate optimal Ti by observing inspiratory flow waveform for return to baseline 7. Call MD for a. Persistent SpO2 92% or less or with increasing O2 requirements greater than 0.6 b. RR spontaneous 30 bpm or more c. PetCO2 less than 20 or greater than 50 mm Hg [depending upon the PaCO2 – PetCO2 gradient] d. Plateau pressure more than 35 cm H2O needed to keep VC+ VT 7 mL / Kg IBW i. Discuss with Fellow or Faculty initiation of either: 1. Assist Control VC+ 2. Pressure Controlled Ventilation (non volume controlled) 3. APRV ii. Discuss permissive hypercapnia with Fellow / Faculty e. CPAP more than 10 cm H2O f. Patient agitation or intolerance of mechanical ventilation g. Reactive airway / bronchospasm h. Systolic BP less than 90mm Hg (or a change of greater than 20 mm Hg) or other evidence of hemodynamic instability i. Neurological instability (such as increased ICP, decreased PbtO2) 8. Alarms a. Set VT alarm at 10 mL / kg IBW b. Set PIP alarm (plateau) at 45 cm H2O

31

9. Monitoring a. Follow progress with PetCO2 and SpO2 b. Keep PetCO2 between 30 and 45 mmHg c. Keep SpO2 95% or greater i. Increase FiO2 to 1.0 if SpO2 less than 92% ii. Wean FiO2 to 0.3 to 0.4 for SpO2 greater than 95% iii. Return to previous settings for SpO2 less than 95% d. ABG every 24 hours with PaCO2 and PetCO2 gradient documented e. ABG prn after ICU staff at bedside to evaluate patient for: i. SpO2 less than 92% on FiO2 of 1.0 ii. Patient agitation or intolerance of mechanical ventilation iii. PetCO2 less than 20 or greater than 50 mm Hg 10. Call MD for: a. Persistent SpO2 92% or less or with increasing O2 requirements over 0.6 b. RR spontaneous 30 bpm or more c. PetCO2 less than 20 or greater than 50 mm Hg d. Systolic Blood pressure less than 90 mm Hg (or greater than 20 mm Hg change) or other signs of hemodynamic instability e. Patient agitation or intolerance of mechanical ventilation f. Reactive airways / bronchospasm 7. Weaning from Mechanical Ventilation Protocol: VC+ a. Protocol:

1. Mandatory rate / PSV a. Wean mechanical RR to 2 bpm as long as PetCO2 between 25 and 45 mm Hg b. NOTE: Keep Ti constant during RR weaning c. When RR = 2 switch to Volume controlled IMV-PSV d. Wean PSV 2 cmH2O at a time to 10 cmH2O as long as VT and RR spontaneous are > 5 ml / kg IBW and 30 or less, respectively 2. CPAP a. Wean CPAP in 2 to 3 cm H2O increments every 30 minutes to 5 - 10 cm H2O to keep SpO2 95% or greater with an FiO2 0.3 to 0.4 b. NOTE: Stop CPAP weaning if mandatory VT less than 5 mL / Kg IBW 3. Discuss a. b. c. d. e. f.

the following with Faculty / Fellow MD before extubation: Airway anatomy / History of difficult intubation Pulmonary mechanics Mental status Quality / quantity of ETT secretions Hemodynamics Surgical plan

8. Order Sheet Only (MD Orders) – What do you write on the orders to initiate MV ? a. □ Initiate and Maintain Mechanical Ventilation per RT protocol using: i. □IMV / PSV ii. □AC iii. □ VC+ SIMV iv. □ VC+ AC 9. Order Sheet – What do you write on the orders to initiate a wean ? a. “Wean Mechanical Ventilation per Physician Approved Protocol” Daily Chest Film 32

Generally, patients on mechanical ventilation require a daily morning chest x-ray. Other patients based on their clinical condition may also require a daily chest x-ray. On occasion, more frequent chest radiographs may be required. But, if you can think of no reason to get the study, then don’t. E. BRONCHOSCOPY 1. Bronchoscopy is usually carried out because of: a) significant secretions coupled with decreased oxygenation; b) the need to obtain deep cultures (see BAL methodology, below); c) the need to restore lung volume in patients with significant atelectasis. 2. Patients require sedation for this procedure. Etomidate in 5 to 10 mg increments, pentothal in 50 mg increments, or propofol in 10 to 30 mg increments appear to work best. 3. The diagnosis of pneumonia likely does not always require BAL. A bronchoscopically obtained sputum specimen sent for Gram Stain and non-quantitative culture may be all that is needed. This is a controversial issue today (2009). 4. Bronchoalveolar Lavage: General indications: 

Quantitative cultures for ventilator associated pneumonia



Non-resolving pneumonia



Diffuse lung infiltrates (interstitial and / or alveolar)



Suspected alveolar hemorrhage



BAL can be diagnostic in the appropriate clinical setting for: o

Infections 

Bacterial



PCP



Mycobacterial



Fungal



Viral

o

Alveolar hemorrhage

o

Malignancies 

Lymphangitic carcinomatosis



Bronchoalveolar carcinoma



Other malignancies

Preparation and Anesthesia 

BAL should be planned to be performed prior to any other bronchoscopic procedure.



Review radiographs to determine ideal site of alveolar lavage. o



33

In diffuse infiltrates, the right middle lobe (RML) or the lingula in the supine patient is preferred.

Premedicate with bronchodilators and / or warm the saline solution for those at risk for bronchospasm.



Sedation with benzodiazepine & narcotic & / or propofol will allow patient comfort and minimize cough reflex. o

Example: 

o

Midazolam (1 to 4 mg / hour infusion) & fentanyl (10 to 100 mcg / hour infusion)

Propofol: 10 to 50 mcg / kg / min

Technique 

Minimize use of topical anesthesia as there may be bacteriostatic effects of lidocaine.



Advance bronchoscope until wedged in a desired subsegmental bronchus at the desired location.



“Clear” suction channel with 20 mL of non-bacteriostatic saline, suction and discard.



Attach Leukin’s trap to suction channel.



Infuse 20 mL of non-bacteriostatic saline with a syringe, observing the flow of saline at the distal tip of the bronchoscope.



Maintaining wedge position, apply gentle suction (50 to 80 mmHg), collecting the lavage specimen in the collection trap.



Repeat steps 6 and 7, as needed to a total 60 to 80 mL non-bacteriostatic saline, to obtain an adequate specimen.



o

Observe for flow of bubbles returning from the alveolar space.

o

Gentle re-orientation of bronchoscope tip may allow better return of fluid.

o

Distal airways may collapse at higher negative suction pressures.

o

Reduction in pressure or intermittent suctioning may help with distal airway collapse.

BAL specimen should be processed as soon as possible. o

Common Studies we send: 1. Gram Stain 2. Quantitative bacterial and fungal cultures

Common Tests/Analysis Gross observation 

Pulmonary alveolar proteinosis o



Opaque or translucent brownish or sandy colored fluid, sediments out into two layers if left to sit

Alveolar hemorrhage o

Sequentially more hemorrhagic with each aliquot

Cell count and differential

34



Alveolar macrophages (Normal > 80%)



Neutrophils (Normal < 3%) o

Nonspecific, but suggests active alveolitis

o

IPF, ARDS, infection, connective tissue disorders, Wegener's granulomatosis, pneumoconiosis

Microbiology 





Stains and Immunohistochemistry o

Gram stain: Bacterial

o

Giemsa: Intracellular bacterial

o

KOH preparation: Fungal

o

Periodic acid-Schiff (PAS): Pulmonary alveolar proteinosis

o

Auramine-rhodamine, Auramine-O, or Ziehl-Neelson: Mycobacterial

o

Modified acid fast stain (Kinyoun): Nocardia

o

Silver methenamine: Pneumocystis carinii pneumonia, fungal

o

Direct fluorescent antibody testing (DFA) for Legionella

Polymerase chain reaction (PCR) o

Mycobacteria tuberculosis

o

Possible for numerous pathogens but clinical utility still unclear

Quantitative cultures o

Particularly for ventilator associate pneumonia 

Greater than or equal to 10,000 cfu / mL is a positive quantitative study. 



In the proper setting (high risk patient, changing infiltrates, febrile state) a count of greater than or equal to 8,000 cfu / mL is positive.

Diagnostic of infection if organism identified:

Pneumocystis carinii Toxoplasma gondii Strongyloides stercoralis Legionella pneumophila Cryptococcus neoformans Histoplasma capsulatum Mycobacterium tuberculosis Mycoplasma pneumoniae Influenza A and B viruses Respiratory syncytial virus 

Colonization by organism possible:

Bacteria Herpes, cytomegalovirus Aspergillus Candida Atypical mycobacteria Cytology 

Intracellular Bacteria by Giemsa Stain o

35

5% or greater positive implies bacterial infection



Cytomegalic cells o



Viral pneumonias (cytomegalovirus, herpes)

Oil red O stain o

Indicates neutral fat droplets that can be seen in fat embolism

Complications/Adverse events 

No complications in up to 95%



Cough



Transient fever (2.5%)



Transient chills and myalgias



Transient infiltrates in most (resolves in 24 hours)



Bronchospasm (< 1%)



Transient fall of lung function



Transient decrease in baseline PaO2



In patients with already severely compromised respiratory status, the loss of lung function may necessitate the need for augmentation of mechanical ventilatory settings.

F. CHEST TUBE 1. Chest tubes are placed under completely sterile conditions, except in extreme situations. 2. Drainage of blood and fluid are usually done at the 4th or 5th intercostal space in the mid-axillary line. Provide adequate local anesthesia, including the pleura. Use a 34 or 36 Fr. tube and place posteriorly. 3. Always insert your finger into the chest cavity to identify the cavity for placement of the tube. Also, use your finger – not a metal clamp – to guide the tube into its appropriate location. 4. For pneumothorax use a 28 Fr. tube and position anterior. 5. In an emergency with suspected tension pneumothorax, a chest tube can be placed anteriorly at the 2nd interspace – mid clavicular line. a) Incision should be made over the top of the 2nd rib. b) The first goal is to simply make the hole in the chest to allow air to evacuate and restore some semblance of blood pressure. 6. Once chest tubes are placed, the incision can be closed with a U-type suture. 7. If you use sterile Vaseline gauze, do not tightly seal the area. Otherwise, this will result in subcutaneous emphysema, since the air will become trapped below the skin instead of leaking out around as well as through the chest tube. 8. A chest x-ray will be required to document full expansion of the lung. G. ESTABLISHMENT OF AN EMERGENCY AIRWAY 1. An airway can be established with bag and mask as a first line of support. Often times use of either an oral or a nasal pharyngeal airway will improve the situation. When Mapelson circuitry is used, one must be sure that adequate ventilation has occurred by observing chest movement. 2. Intubating LMA a) The intubating LMA is available in each pod. 36

3. Cricothyrotomy a) Cricothyrotomy may be also used. Each pod has its own cricothyrotomy kit. Important steps in this process, to be carried out in the following order, include: i. a vertical skin incision above the cricothyroid membrane ii. use of a metal needle without a plastic catheter iii. passage of the wire through the needle into the airway followed by removal of the needle iv. the dilator is placed over the wire and then the cricothyrotomy tube itself placed over the dilator and into the airway. b) Placement of cricothyrotomy should be followed by a call for consultation from either the ENT or Trauma Surgery service. Table 1 Pulmonary Mechanics Abbreviation

Definition

Normal value

TLC FRC

Total lung capacity Functional residual capacity

80 ml / kg 40 ml / kg

IC

Inspiratory capacity

40 ml / kg

ERV RV

Expiratory reserve volume Residual volume

30 ml / kg 10 ml / kg

VT

Tidal volume

5 ml / kg

VE

Minute ventilation (exhaled)

100 ml / kg / min

VA

Alveolar ventilation

60 ml / kg / min

VD PIP

Dead space Peak inspiratory pressure

ml = weight in lbs. 10 cm H2O tidal, 40 cm H2O max

EIP (on ventilator)*

End-inspiratory (plateau) pressure

Less than PIP

EEP* Compliance

End-expiratory pressure VT / EIP

0 cm H2O 2 ml / cm H2O / kg

Effective compliance

VT / EIP – PEEP on ventilator

1 ml / cm H2O / kg

Resistance

ΔP (in cm H2O) / Flow (in L per second)

VD / VT

PaCO2 - PetCO2 PaCO2

0.20 to 0.35

* Normal EIP value depends on ventilator settings. EEP on ventilator in the SICU / IMC / BICU usually no less than 5 cm H2O

1. Alveolar Gas Equation PAO2 = PIO2 – PaCO2 / 0.8 Where PIO2 = inspired fraction of O2, and 0.8 = respiratory exchange ratio 2. Alveolar – Arterial Oxygen gradient A – aO2 = PAO2 – PaO2 3. Tidal Volume Vt = Compliance x ΔP 4. Minute Volume VE = Vt x f f = respiratory rate 5. Compliance = Vt / ΔP 6. Time Constant Tau = compliance x resistance (reported in seconds) Inspiratory time is usually set at 3x Tau 37

Table 2

38

Section 5:

Fluid Administration

A. MAINTENANCE FLUID Is generally D5 NS plus 20 ml KCl. Maintenance rates are usually 75 to 125 ml / hour. B. VOLUME RESUSCITATION Usually Plasmalyte, 0.9% saline solution, or Lactated Ringer’s solution. A typical bolus is 500 mL to 1000 mL (10 to 20 mL / kg), which can be repeated several times. A bolus should flow in as rapidly as possible. When patients have continued problems with hypovolemia, maintenance fluids should be one of these three isotonic solutions. C. 3% SALINE Used for patients with hyponatremia (sodium less than 130 mEq per liter). Also used when a large volume resuscitation is underway. This agent will reduce the overall volume of free water necessary. Usual rate is 30 to 60 ml / hr. This fluid is generally not bolused. D. ALBUMIN THERAPY Albumin should only be used when serum albumin < 2.0 gm / dL which significantly reduces serum oncotic pressure. For volume replacement, 5% albumin should be utilized. This comes in 250 ml bottles. To artificially raise serum albumin levels to improve oncotic pressure, 50 ml of 25% albumin is usually infused every 4 to 6 hours, for a total of 8 to 12 dosages. In trauma patients this solution is rarely needed; crystalloid is as effective. E. HYPERCHLOREMIC METABOLIC ACIDOSIS This condition usually arises from excessive sodium chloride administrative. Serum bicarbonate will be less than 20 mEq / L. Fluid then should be changes to either D5W plus 150 mEq sodium acetate or D5 0.45% saline plus 75 mEq sodium acetate, as the maintenance and replacement fluid. The acetate will be metabolized by the liver to bicarbonate and will correct the acidosis. Table 1

39

Section 6: Hematology Although in a patient with coronary artery disease the Hgb / Hct should, particularly when the patient is acutely stressed, be maintained at levels of 10 gm / dL and 30%. Otherwise, however, blood is transfused only if there are signs of inadequate DO2, such as tachycardia, elevated lactate. In general, we OVERTRANSFUSE PRBC…….and such units of PRBC are associated with an increased morbidity and mortality. Thus, DO NOT transfuse without much thought and discussion, excepting a major life-threatening hemorrhage A. FRESH FROZEN PLASMA Used to correct elevated PT (> 1.5 x mid-range of normal sec), INR > 1.5, or PTT (> 45 sec). Infuse the selected amount (2 to 4 units) then repeat PT, INR, and PTT. None-the-less, in the absence of bleeding, FFP should likely not be given with even these values barring a procedural need. B. CRYOPRECIPITATE Used when fibrinogen levels are less than 100 mg / dL, usually 6 to 10 units. C. PLATELETS Allow to decrease to 20,000 if no active bleeding. With active bleeding, platelets should be kept between 50,000 and 100,000. When multiple platelet transfusions are required, single donors are preferred because of antibody production. Usually 6 to 10 units are infused. One unit of random donor platelets increases the platelet count by about 10,000 cells / microL; one unit of single donor platelets will cause an increase of about 50,000 cells / microL. D. SUBCUTANEOUS HEPARIN Used in most patients for prophylaxis of deep vein thrombosis. Dosage is 5,000 units sc tid. For patients less than about 50 kg, one should consider the same dosage bid. Low molecular weight heparin (Lovenox™) at a dose of 30 mg sc twice daily is very effective in the prevention of DVT. The combination of heparin and sequential compressive devices is very effective in decreasing the risk of DVT (by about 80%). E. LOW MOLECULAR WEIGHT HEPARIN Action greater against Factor XA than AT III. Follow anti factor Xa levels. PT / PTT unchanged by low molecular weight heparin. Can also be used for DVT prophylaxis. F. COUMADIN DOSAGE 1. Anti-coagulation for DVT INR 1.8 to 2.0 2. Anti-coagulation for cardiac valve INR 2.5 to 3.0 G. HEPARIN INDUCED THROMBOCYTOPENIA After heparin exposure 50% drop to or less than 100,000. Time to develop: up to 4 days – initial exposure / 24 hours after second exposure Treatment – D/C all heparin including sc and line flushes. Send heparin antibody level. DVT prophylaxis can be maintained with fondiparaneaux (Artixtra®) 2.5 mg SC daily as long as renal function is normal (Ccr > about 30 mL / min) H. TREATMENT OF ELEVATED INR Hold Coumadin Vitamin K 5 to 10 mg IV if bleeding; SC if not bleeding actively FFP 2 to 6 units if high risk for active bleeding I.

ANTI-COAGULATION FOR DVT Follow the heparin administration protocol.

J.

HEPARIN PROTOCOL 1. We have three approved heparin protocols: a) High Risk for Bleeding protocol, with unfractionated Heparin goal of 0.25 to 0.35 units / mL b) Acute Coronary Syndrome / DVT protocol, with an unfractionated Heparin goal of 0.3 to 0.6 units/mL c) PE protocol, with an unfractionated Heparin goal of 0.3 to 0.7 units / mL

40

Section 7: I.

Metabolic

GLUCOSE A. Regulated by continuous insulin fusion to be in the 100 to 140 mg / dL range. A sliding scale is generally inappropriate in the ICU as one is unsure of the perfusion of the subcutaneous tissue. Thus, a sliding scale regular insulin regimen is a sure way NOT to gain control of a patient’s glucose. Initiate the insulin protocol. B. Transition from IV to Subcutaneous Insulin (“Three-Legged Stool” approach) 1. Obtain “Subcutaneous Insulin Orders” form. 2. Sum last 6 hours of insulin infusion requirements and multiply by 4 to calculate total daily insulin to be prescribed. Consider 10-20% reduction if patient is clinically improving. a) If patient was receiving insulin at home prior to current admission, compare total daily insulin calculated amount with previous home dose. Consider consulting endocrinology if calculated dose is more than 125% of home dose. b) Also consider endocrinology consult if patient is insulin-naïve and total daily insulin dose is greater than 0.6 units / kg / day. 3. Basal Insulin: a) If eating meals, prescribe 50% of total daily insulin as glargine (LANTUS) once daily at 2200. b) If receiving continuous enteral nutrition, prescribe 40% of total daily insulin as glargine (LANTUS) once daily at 2200. 4. Nutritional Insulin: a) If eating meals, prescribe remaining 50% of total daily insulin as aspart (NOVOLOG) in 3 divided doses with meals. b) Monitor blood glucose before each meal and at bedtime. c) If receiving continuous enteral nutrition, prescribe remaining 60% of total daily insulin as regular (HUMULIN R) in 4 divided doses given every 6 hours. (1) Monitor blood glucose every 6 hours. 5. Correction Insulin: Select “high-dose scale” unless type I diabetic, then consider alternate scale. a) Evaluate use of correction insulin every morning, and adjust basal or nutritional insulin as clinically appropriate. b) If eating meals and fasting blood glucose is elevated, then increase insulin glargine (LANTUS). Otherwise, increase insulin aspart (NOVOLOG) around appropriate, earlier meal. For example, if pre-dinner blood glucose is elevated, then increase lunchtime insulin. Decrease in similar fashion with a low blood glucose value. c) If receiving continuous enteral nutrition and any blood glucose value is elevated, then increase regular insulin dose(s) accordingly. In same patient, if any blood glucose value is unacceptably low, then decrease glargine (LANTUS) by 10-20%. 6. Write order to discontinue insulin infusion 2 hours after first dose of glargine (LANTUS).

Clinical Example: Receiving continuous tube feedings Time 0100 0200 0300 0400 0500 0600

Insulin Rate (units/hr) 2.7 2.7 1.5 1.5 1.8 1.8

Sum

12

41

o

Last 6 hour sum = 12 units. Multiply by 4 for total daily insulin: 12 units x 4 = 48 units. With clinical improvement, decrease by 10-20%: 48 units x 80% = 38 units.

o

Basal Insulin: 40% x 38 = LANTUS 15 units SC daily at 2200.

o

Nutritional Insulin: 60% x 38 = 23 units / 4 doses = HUMULIN R 6 units SC every 6 hours.

o

Correction Insulin: Select “high dose scale” unless type I diabetic, then consider alternate

scale.

o

Write additional order to discontinue insulin infusion 2 hours after first dose of LANTUS.

Clinical Example: Eating diet Time 0100 0200 0300 0400 0500 0600

Insulin Rate (units/hr) 2.7 2.7 1.5 1.5 1.8 1.8

Sum

12

o

Last 6 hour sum = 12 units. Multiply by 4 for total daily insulin: 12 units x 4 = 48 units. With clinical improvement, decrease by 10-20%: 48 units x 80% = 38 units.

o

Basal Insulin: 50% x 38 = LANTUS 19 units SC daily at 2200.

o

Nutritional Insulin: 50% x 38 = 19 units / 3 doses = NOVOLOG 6 units SC TID with meals.

o

Correction Insulin: Select “high dose scale” unless type I diabetic, then consider alternate

scale.

o

Write additional order to discontinue insulin infusion 2 hours after first dose of LANTUS.

Goal blood glucose values: fasting & pre-meal = 90 – 130 mg/dL; continuous enteral nutrition = 100 – 140 mg/dL A. CORTISOL STIMULATION TEST Patients with severe sepsis / septic shock, or those with suspected ACI will be evaluated in the following manner: 1. A baseline serum cortisol will be obtained a. If the patient is unstable and it is thought that steroids need be administered immediately, dexamethasone, 2 mg IV every 6 hours will be administered b. Use of dexamethasone will not interfere with the fluoro-immmunoassay used to evaluate cortisol levels. 2. Artificial ACTH (Cosyntropin™) 1 microgram will be infused intravenously over 30 minutes. a. The baseline cortisol level will serve as Time 0 (T0) level. b. At 30, 60, and 90 minutes after the infusion of Cosyntropin™ is completed, cortisol levels will be obtained. 3. A positive test – signifying absolute ACI – will be present if: a. Baseline (T0) of less than 15 mcg / dL 4. A positive test – signifying either relative or absolute ACI – will be present if: a. The baseline (T0) cortisol level is less than or equal to 15 mcg / dL AND none of the values (T30, T60, T90) show an increase above baseline of greater than or equal to 9 mcg / dL b. The baseline (T0) cortisol value is greater than 34 mcg / dL AND none of the values (T30, T60, T90) show an increase above baseline of greater than or equal to 9 mcg / dL. 5. A negative test – signifying the absence of either relative or absolute ACI – will be present if: a. The baseline (T0) cortisol level is greater than 15 mcg / dL AND any of the values (T30, T60, T90) show an increase of greater than or equal to 9 mcg / dL 6. In the presence of a positive test – indicating the presence of ACI – intravenous cortisol will be administered as an infusion of 10 mg / hour. a. Treatment is usually required for approximately 7 days b. Thereafter, a rapid wean, decreasing by one-third or one-half the dose of hydrocortisone each day, is acceptable once hemodynamic stability is achieved c. If there remains concern as to the functionality of the hypothalamic – pituitary – adrenal axis, the Cosyntropin stimulation test may be repeated when the patient has recovered, prior to discharge. References: 1. Siraux V, et al: Relative adrenal insufficiency in patients with septic shock—Comparison of low-dose and conventional cosyntropin tests. Crit Care Med, 2005;33:2479 2. Keh D, Sprung CL: Use of corticosteroid therapy in patients with sepsis and septic shock—An evidencebased review. Crit Care Med, 2004;32(Suppl):S527 3. Annane D, et al: A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to cosyntropin. JAMA, 2000;283:1038 4. Cooper MS, Stewart PM: Corticosteroid insufficiency in acutely ill patients. N Engl J Med 2003;348:727734

42

Table 1. Features Suggesting Corticosteroid Insufficiency. Symptoms Weakness and fatigue Anorexia, nausea, vomiting Abdominal pain Myalgia or arthralgia Postural dizziness Craving for salt Headaches Memory impairment Depression Findings on physical examination Increased pigmentation Hypotension (postural) Tachycardia Fever Decreased body hair Vitiligo Features of hypopituitarism Amenorrhea Intolerance of cold Clinical problems Hemodynamic instability Hyperdynamic (common) Hypodynamic (rare) Ongoing inflammation with no obvious source Multiple-organ dysfunction Hypoglycemia

Unlikely to be seen in the ICU

Fever and hypotension, particularly, may be the only ICU findings

Note these carefully in ICU patients

Laboratory findings Hyponatremia Hyperkalemia Hypoglycemia Eosinophilia Elevated thyrotropin levels

Lab findings may be masked in the ICU

B. DIABETES INSIPIDOUS AND SIADH See description in the neuro section. C. HYPOKALEMIA Patients are susceptible to cardiac arrhythmias when potassium levels are allowed to remain below 4.5 mEq / L. The electrolytes protocol should be utilized. Ordinarily, 60 mEq of KCl are infused over a three hour period and the potassium rechecked. Whenever K+ < 4.5 mg / L another 60 mEq of KCl is infused over three hours. D. MAGNESIUM When serum magnesium is < 2.0 mg / dL 2 to 3 gm MgSO4 may be necessary. E. INSULIN INFUSION ORDERS FOR CRITICALLY ILL PATIENTS 1. All patients in the ICUs will be placed on our ICU Insulin Protocol unless they are being transitioned to subcutaneous insulin for Floor transfer (see above). 2. During tube feed interruptions, stop infusion until tube feed preparation can be restarted. 3. If enteral or parenteral infusion rates are decreased, reduce insulin infusion rate by ½ and call physician 43

for order clarification. Table 2: Insulin Preparations Available: Insulin Type / Action Rapid-acting analogue (clear) Onset: 10–15 min

Trade Names Humalog® (insulin lispro) NovoRapid® (insulin aspart)

Peak: 60–90 min Duration: 4– 5 h Fast-acting (clear) Onset: 0.5–1 h

Humulin®-R Novolin® -R

Peak: 2–4 h Duration: 5–8 h Intermediate-acting (cloudy)

Humulin®-N

Onset: 1–3 h

Humulin®-L

Peak: 5–8 h

Novolin® -NPH

Duration: up to 18 h Long-acting (cloudy)

Humulin®-U

Onset: 3–4 h Peak: 8–15 h Duration: 22–26 h Extended long-acting analogue

Lantus®* (insulin glargine)

Onset: 90 min Duration:24 h Premixed (cloudy) A single vial contains a fixed ratio of insulin (%rapid / %intermediate)

44

Humalog® 75/25 Humulin® 70/30, 50/50 Novolin® 70/30

Table 3

45

Section 8:

Abdomen - GI

A. GI PROPHYLAXIS H2 Blockers Ranitidine – 150 mg / day or 6 to 12 mg / h continuous infusion (preferred) Decrease gastric acid secretion; alkalinize the stomach This agent is our first choice in ventilated and bleeding patients Proton pump inhibitor Protonix – 40 mg / d Will decrease gastric acid and increase pH – potential for ventilator associated pneumonia. B. ABDOMINAL COMPARTMENT SYNDROME Increased intrabdominal pressure due to fluids, blood or dilated bowel. Signs and symptoms include: 1. Elevated peak airway pressures and inability to effectively ventilate. 2. Low or no urine output. 3. Bladder pressure > 30 mm Hg 4. Tense abdomen C. LIVER TRANSPLANTS Rejections medications ordered by transplant service. All patients have post-op ultrasound of portal vein to rule out thrombosis/clot. Do not completely correct clotting factors unless ongoing continued bleeding. Table 1

Table 2

46

Section 9:

Renal

A. HEMODIALYSIS INDICATIONS: 1. Acidosis 2. Fluid overload 3. Hyperkalemia, (> 6.5 mEq / L) 4. Uremia (BUN > 100 mg / dL). Hemodialysis is carried out daily or every other day. New data suggests better outcome with every day dialysis. B. CVVH INDICATIONS Patients require dialysis but are hemodynamically unstable. Please consult the appendix, which lists drugs during renal failure which require decreased dosage. C. CREATININE CLEARANCE This can be calculated on a 2 hr to 24 hr urine collection. The formula is: Creatinine clearance 

urine creatinine concentration  volume (ml / min) serum creatinine

2 hour clearance as valid as a 24 hour collection. Normal = 100 ml / min. At age 70, this will probably decrease to at least 50 ml / min. D. FRACTIONAL EXCRETION OF SODIUM An indicator of pre-renal disease if the value is > 1%. Calculation: FENa =

 urine sodium  plasma creatinine     100  plasma sodium  urine creatinine 

E. DIURETICS Remember these drugs are also potent vaso-dilators. Lasix 10 to 200 mg In patients with elevated BUN / creatinine the dosage almost always has to be 40 to 80 mg as a minimum. Continuous infusion is 1 to 20 mg / hour Bumex 2 to 6 mg Continuous infusion 1 to 2 mg / hour Diuretics can be used to convert oliguric to non-oliguric renal failure. Outcomes do not change but management is considerably easier; best is, however, CVVH. When attempting to develop a negative fluid balance, continuous infusions are often more successful than bolus administration.

47

Table 1

Table 2

48

Figure 1

Table 3 Labs in Acute Renal Failure

49

PRERENAL

ARF

BUN: Cr

> 20:1

10-15:1

Urine Na (mEq / L)

< 20

> 40

Urine Osmol (mOsm / L)

> 500

< 350

FENa

< 1%

> 2%

Section 10:

Infectious Disease

A. FEVER WORKUP: 1. “Fever” in the SICU and IMC is 38.5° C or greater; 2. In the Burn ICU, because of the hypermetabolic state, fever is 39.3° C or greater (see below). 3. While the workup of fever is relatively complex, if infection is considered, the following should be remembered: i. For an initial culture evaluation of a fever, occurring more than 24 hours after a surgical procedure, Two (2) to sets of blood cultures, one urine specimen for culture and a sputum specimen should be obtained. ii. If there are pulmonary infiltrates and / or if the patient has been mechanically ventilated for more than two (2) to three (3) days, a deep sputum specimen or brochoscopically directed sputum specimen is obtained. Send for Gram stain and non-quantitative cultures. iii. A CBC with manual differential count (looking for elevated Band forms) should be obtained. iv. Consideration should be given, depending upon the time post-operatively and the surgical site, of a surgical site infection / abscess. v. If the patient spikes again within 24 hours, you generally need not repeat cultures. If greater than or equal to 24 hours, repeat the blood cultures (2 sets); vi. The sputum and urine specimens need not be resent for culture any more frequently than every 48 to 72 hours, generally speaking. 4. With the Fellow / attending, and with the assistance of our Critical Care Clinical Pharmacy colleagues, in the setting where infection is considered likely, initiate antimicrobial therapy. Drugs should be chosen based upon the most likely site of infection and organism. 5. Common initial antimicrobial choices include: i. Pneumonia / VAP: cefepime, vancomycin, fluconazole ii. Sepsis: cefepime, vancomycin, fluconazole iii. If an intra-abdominal process is considered, the utilization of metronidazole ought be considered. iv. Because of a suspected risk for antibiotic-induced, Clostridium difficile related colitis, we prefer not to use Clindamycin in our units. 6. Cultures and sensitivities are to be checked at least daily and reported to the Fellow / attending on rounds. The importance of up-to-date culture and sensitivity data cannot be

overemphasized.

7. Once sensitivities are obtained from the laboratory, antibiotics must be altered after discussion with the attending / Fellow / ICU Pharmacist 8. Stop dates for the antimicrobials should be written at the time the drugs are begun: i. Pneumonia / VAP: 5 to 8 days of IV drugs (non-Pseudomonal / Acinetobacter, in these cases, 10 to 14 days) ii. Recurrent VAP, Sepsis / Septic Shock: 10 to 14 days of IV drugs 9. Communicate decisions and concerns with the surgical service. B. Fever Workup in the Burn Unit 1. Patients with burn injury are hyperthermic as a result of the burn and have a shift in their thermoregulatory set point. As a result, a temperature of ≥ 39.2 C is considered the threshold for a fever workup instead of the standard 38.5 C. Patients immediately post-op may be febrile from seeding during debridement and typically do not warrant extensive workup. 2. Fever workup in any of our patients – Burned or not – includes the following: a. Look at the patient and perform physical exam with emphasis on the following areas: i. Wounds: wound infection or cellulitis ii. Lungs: Rhonchi or decreased breath sounds suggestive of secretions and consolidation iii. Heart: Murmur possibly due to endocarditis 50

iv. Extremities: look for evidence of DVT – warmth and swelling, particularly asymmetric v. Central lines, arterial lines, peripheral IVs for evidence of infection b. CBC with manual diff (manual diff must be explicitly ordered) c. Chest x-ray d. Urinalysis, urine culture (Not needed if done in past 72 hours unless urine looks dirty) e. Blood cultures – 2 sets of peripheral draws (Femoral vein stick if unable to obtain peripherals). Please DO NOT culture through lines as this typically does not add useful data. If the peripheral cultures are positive, the line will likely need to be removed. f. If pneumonia is suspected, obtain a bronchoscopically guided deep sputum specimen or a BAL. Newly admitted patients undergoing bronchoscopy for assessment of inhalation injury do not need BAL. 3. Indications for empiric antibiotics a. Hypotension or organ failure / dysfunction - Start Vanc / Cefepime and Cipro or Aminoglycoside b. Evidence of wound infection / cellulitis – Start Kefzol if less than Post-Burn Day (PBD) 3, Vanc if PBD 3 or greater. c. Positive UA – Start TMP/SMX or Cefazolin. Levofloxacin if later than PBD 14 d. High suspicion of pneumonia – Start Vanc and Cefepime e. Add fluconazole if intra-abdominal infection or yeast suspected Antibiotics should be tailored (narrowed down as much as possible) as soon as cultures are back, and no later than 72 hours 4. ANTIBIOTICS Typical drugs, indications and dosages in patients without renal failure include: Indication Dosage Route Drug Vancomycin Staph and some 1 g bid IV strep infections Penicillin

Clostridial infections

4 million units q4h

IV

Flagyl

Anaerobic infections

500 mg q6h

IV

Cefepime

Broad coverage

1 g q12h

IV

Imipenem

Broad coverage and specifically pancreatitis

500 mg q6h

IV

Tobramycin

Pseudomonal and 7 mg/kg q24h gentamycin infections



10 hr drug levels should be tested to determine that appropriate dosage interval has been given.

Drug Amikacin

Indication Broad coverage particularly in face of resistance to other antibiotics

Dosage 5 mg/kg qd

Route IV

Diflucan

Antifungal

400 mg qd

NG pref

400 mg bid

IV

Ciprofloxacin

Some gram negative coverage A. PULSE-DOSE AMINOGLYCOSIDES

Dose = 7 mg / kg for gentamycin & Tobramycin Dosing Wt = IBW: 51

IV

Male = 50 kg – 2.3 (inches over 60) Female = 45 kg – 2.3 (inches over 60) if pt > 20% over IBW, add 0.4 (actual wt – IBW) Dosing Interval (Initial): CrCl (ml / min) > 60 59-40 39-20

Interval q 24 hours q 36 hours q 48 hours

CrCl = (140-age) x IBW / (72 x SrCr) [x 0.85 for female] Exclusion Criteria for Pulse-Dosing: Ascites, > 20% burn, CF, ESRD, enterococcal endocarditis, hypermetabolic state, pregnancy, pediatric patients. Lab Recommendations: Day 1: baseline SrCr, RANDOM level 8 to 12 hrs post-infusion Day 3: SrCr Day 5: SrCr and repeat RANDOM level 8 to 12 hrs post-infusion *Obtain random level if SrCr rises > 0.4 mg / dl above baseline. B. TIPS FOR ORDERING DRUG LEVELS 1. Always specify when the level is to be drawn (i.e. “trough level prior to 4th dose” or “random level in the a.m.”). Orders for a drug level without specifying a time are generally drawn at 0400 regardless of the relationship to the time of the dose and are most often uninterpretable. 2. If you want the drug held until the level results are back, notify the nurse and write an order so stating. 3. Levels are primarily to help you assess therapeutic efficacy and/or toxicity. If at any time you suspect or need to confirm efficacy or toxicity, order a level. 4. Patients with unstable renal function or volume status may require more frequent drug level monitoring. 5. Once a patient has stabilized on a drug-dosing regimen, you do not need to monitor drug levels as frequently (i.e. every 5 to 7 days). For example, vanc 1 gm q 12h results in a trough of 7 mcg/ml after 3 doses, you do not need to recheck another trough level for 5 days unless the renal function changes. 6. When using digoxin to treat a. fib., monitoring the patient clinically (i.e. heart rate) is of more value than a serum concentration. If the patient is stable (i.e. renal fxn and dosing), serum digoxin levels do not need to be obtained more than once a week. Do not obtain a digoxin level until at least 24 hours after loading digoxin. 7. If you add or discontinue a drug which interacts with the monitored drug, you may need to recheck the level once a new steady-state has been achieved (typically three doses) – i.e. cipro will increase theophylline concentration by about 25%, therefore if you add cipro to a patient on theophylline, recheck the theophylline level in 24 hours. 8. Most drugs do not need to be dose adjusted until CrCl falls below 50 ml / min. CrCl can be estimated by using the Cockrauft-Gault equation: CrCl 

(140  age) x IBW (0.85 for female) SrCr  72

IBW = 50 kg = 2.3 kg (inches over 60) for male 45 kg + 2.3 kg (inches over 60 for female) (IBW = ideal body weight) 52

9. You will often see a rise in serum drug levels (indicating less ability to clear the drug) before you will see a rise in serum creatinine. This should cue you that the patient’s renal function is declining and appropriate measures should be made (including adjusting the dosage of other medications, removing potentially nephrotoxic agents, perhaps obtain a urine creatinine to confirm renal function). 10. Decrease in renal function is defined as increase in SrCr by 0.5 mg/dl or more or a rise in SrCr to 1.5 mg / dL or higher. If you have any questions, call the pharmacy satellite (5-1518) or page Aimee LeClaire (413.1000). Figure 1

Table 1

E. Antimicrobial Therapeutic Drug Monitoring 1. Peak is defined as the maximum plasma drug concentration. A peak level should be drawn following the infusion of a monitorable drug.

53

2. Trough is defined as the minimum plasma drug concentration. A trough level should be drawn immediately preceding a dose. Conventionally dosed aminoglycosides: 1-2 mg/kg (x DBW*) IV every 8 – 12 hours Concentration Peak (mcg/mL) Trough (mcg/mL)

Gentamycin, tobramycin 5 – 10 0.5 – 2

Amikacin 25 – 35 4 – 10



Obtain peak concentration ½-hour following completion of infusion of aminoglycoside.



Obtain trough concentration ½-hour prior to dose.

Once Daily Aminoglycosides: 7 mg/kg (x DBW*) IV every 24 hours Concentration Trough (mcg/mL)

Gentamycin, tobramycin 5 feet) Adjusted Body Weight for Obesity = IBW + 0.25 (Actual Body Wt - IBW) Body Mass Index (BMI): wt (kg) / ht (meters2)

III. Calculating protein goals

Patient Condition

Gram /kg Actual/Adjusted BW

Under-stressed patient Mild Stress: stroke, AMI or UA, COPD exacerbation Anabolism, Moderate Stress, pneumonia, ARDS, pancreatitis, surgery Major Stress / Sepsis Burn Major Burn Multiple Trauma / Closed Head Injury Hepatic failure Mild failure Moderate-severe failure Hepatic encephalopathy Acute renal failure without dialysis Acute renal failure with dialysis Intermittent hemodialysis CVVHD Peritoneal dialysis

0.8-1 gram / kg 1-1.2 g/kg/day 1.2-1.5 g/kg/day 1.5-1.75 gram / kg 1.5-2 gram / kg 2-2.5 g/kg 1.5-2 g/kg 1 – 1.2 gm/kg/day 1.2 – 1.5 gm/kg/day 0.8-1.2 gm/kg/day 0.8-1.2 gm/kg/day 1.2 – 1.5 gm/kg/day 1.5-2.5 gm/kg/day 1.2 – 1.5 gm/kg/day

IV. Calculate total calories (use either method) a. Harrison Benedict Equation i. Men: BEE (kcal) = 66.47 + 13.57(wt kg) + 5(ht cm) –6.77(age yrs) ii. Women: BEE (kcal) = 655.1 + 9.56(wt kg) + 1.85(ht cm)-4.67(age yrs)

55

Disease State/Stress

Stress Factor Range

Surgical patient, transplant, sepsis, hepatic failure, moderate infection Head trauma, closed head injury, severe infection Burns 20-40% BSA Burns >40% BSA Ventilated pt

1.2-1.4 1.3-1.6 1.5-1.85 1.85-1.95 1.2-.14

V. Estimation of Energy Requirements using Shortcut

VI.

Stress

Calories (kcal/kg/day)

Patient Demographics

Mild

25

Hospitalized pt on ward, COPD, minor infection, minor surgery

Moderate

25-30

Infection, PNA, major surgery, AMI, ischemic stroke, CHF exacerbation

Severe

30-35

Cancer, Multiple trauma, closed head injury, SIRS, shock, pancreatitis

30-40

Burns

25-30

Ventilated pt

20-25

Morbidly obese pt (permissive underfeeding but MUST protein spare)

Metabolic cart / indirect calorimetry a. b.

A measurement of gas exchange to accurately estimate energy requirements. Study performed by respiratory therapist Provides Measured Energy Expenditure (MEE) and Respiratory Quotient (RQ) i. RQ = rate of CO2 inspired to amt of O2 inspired (VCO2/VO2) ii. Ideal RQ between 0.82 – 0.85 iii. Indicates the substrate being utilized as fuel

RQ

Process

0.7 0.8 – 0.82 0.82 – 0.85 1.0

Oxidation of fat (pt being underfed) Oxidation of protein Mixed diet (ideal) Oxidation of CHO (overfeeding)

B. Route of Feeding I.

Enteral is always the preferred route a.

b.

c.

56

Common Enteral feeds: i. Pivot 1.5 – 1.5 kcals / mL, 25% PRO; highest PRO feed, immune enhancing, semielemental; ideal for trauma and wound healing, contraindicated with transplants, benefits / indicated for ~ 5 days ii. Osmolite 1.5 – 1.5 kcals / mL, 16.7% PRO –standard TF, moderate PRO iii. Peptamen 1.5 – 1.5 kcals / mL, 18% PRO; semi-elemental / peptides, ideal for malabsorptive conditions / pancreatitis iv. Nepro – 1.8 kcals / mL, 18% PRO; ideal for hemodialysis pt, moderate in electrolytes v. Two Cal – 2 kcals / mL, 16.7% PRO; ideal for volume restricted pt Tube feed additives i. PROTEIN powder – 25 kcals, 6g PRO per scoop; usually adding about 3 scoops to Osmolite 1.5 will give pt approx 1.5 g/kg, used in the transition of Trauma pts from Pivot 1.5 ii. Glutamine – 10 g packets should be dosed as 30 g/d. Can be flushed 1 pkt TID via tube or mixed with liquids PO. Used for gut integrity / increased absorption and wound healing iii. Salt – now comes from pharmacy. Not available as TF mix. Call unit PharmD. Complications of Enteral feeds i. Diarrhea – commonly from meds; hold stool softeners, check if pt on antibiotics (if so consider adding Lactinex 1 pkt TID), check C. Diff, if concerns of malabsorption, consult RD ii. Abdominal distention – hold TF, check KUB iii. High NG output – check DHT / NG placement, consider motility agents

II. Hyperalimentation (HAL) or Total Parenteral Nutrition (TPN) a.

b.

c.

d.

e.

f.

g.

57

Indications i. Failed enteral nutrition trial (i.e. cont poor tolerance, unable to place tube in correct position)with appropriate tube placement ii. Enteral nutrition is contraindicated or intestinal tract has severely diminished function due to underlying disease or treatment: a. Paralytic ileus b. Mesenteric ischemia c. Small bowel obstruction d. GI fistula when enteral access cannot be placed posterior to fistula Protein / Amino Acids: i. Day One TPN: Give no more than 1 gm / kg. If patient has elevated BUN at baseline, consider giving only 0.8 gm / kg to ensure tolerance. ii. Do not count into total kcals – PRO kcals used to PRO spare Take total calories (as calculated above in 3) and then determine dextrose and lipid components i. Calories per component a. Dextrose IV – 3.4 kcals / gm b. Lipids 20% - 2 kcals / ml Typically, calories are given in the following ratio: 70% dextrose and 30% lipids. However, certain scenarios may warrant 50% dextrose and 50% lipids. (i.e. If patient requiring large amounts of insulin consider decreasing dextrose and increasing % of lipids if TG less than 500) i. Dextrose: 70% of the total calories a. Divide this number by 3.4 to determine the grams of dextrose (which will be used to complete the form) b. Day One TPN: Begin with no more than 150 – 200 gm dextrose. Then increase daily by 25 – 75 grams on subsequent days until at goal ii. Lipids: 30% of the total calories a. Divide this number by 2 to determine the milliliters of lipids which the patient will be administered b. Divide this number by 12 to determine the rate c. You MUST have a triglyceride level before initiating lipids (assuming no change in the patient’s medical history that would warrant a repeat TG) d. If triglycerides are less than 500, you may give the patient their full lipid goal Electrolytes i. Sodium a. In general, it is reasonable to make a TPN which is ½ NS unless compelling reason to do otherwise b. There are 77 mEq of NaCl in one liter of ½ NS c. On the TPN form, you complete mEq per DAY of sodium chloride, thus you must adjust it based on volume of TPN provided ii. Potassium a. A good starting place for KCl is to see how much the patient required the previous day (MIVF, enteral and IV supplements) to maintain K+ within normal limits b. Okay to be conservative: It is always easier to supplement than to waste a TPN because the patient becomes hyperkalemic iii. Bicarbonate iv. If high, give more chloride; If low, give less chloride v. Giving acetate results in a higher bicarbonate Insulin i. 1. Placement into TPN is generally avoided since blood glucoses are managed through our insulin protocol Some additional considerations (not absolutes) i. COPD: Be conservative with DEXTROSE  Increase CO2 production ii. Minimal or no lipids: Hypertriglyceridemia (greater than 500), propofol sedation at very high doses, fungemia iii. If attempting to wean patient from ventilator and having difficulty attempt to decrease dextrose and increase lipids.

iv. If TPN infusion rate is decreased might need to decrease dextrose / protein in solution as may no longer fit in amount desired v. If infusion rate decreased Ca / PO4 product might need to be checked also

C. Nutritional Labs Albumin a. 2 – 3 week half life b. Increased with dehydration, steroids c. Decreased with overhydration, chronic malnutrition, acute phase response, renal / liver damage, cancer, edema d. Not a good marker of nutrition in the ICU II. Prealbumin a. 2 – 3 day half life b. Increased with steroids, chronic renal failure c. Decreased with acute catabolic stress, liver disease, stress, infection, and post-surgery d. Better marker than albumin, but still greatly variable in the ICU. Can follow trends. e. Checked weekly I.

D. Medications effecting Nutrition

Propofol a. 1.1 kcals / ml b. May have to adjust TPN / Enteral kcals provided to prevent overfeeding II. Dilantin a. If given PO, Enteral feeds must be held 1 hr before and 1 hour after administration (i.e. with PO TID Dilantin, feeds can only be given over 18 hrs) b. If possible, change to IV Dilantin for easier TF administration and better glucose control with insulin protocol III. Antibiotics a. Often a source of diarrhea b. Can give Lactinex (Lactobacillus or Culturelle) 1 packet BID – TID to restore gut flora I.

Section 12:

Pain Control and Sedation

GENERAL COMMENTS A. PATIENT ASSESSMENT 1. Prior to initiating sedative therapy, all other causes of anxiety and agitation should be evaluated and appropriately addressed, including all of the following: a) Pain b) Hypoxia c) Hypoglycemia d) Hypotension e) Drug and / or alcohol withdrawal 2. Sedative, analgesic, and neuromuscular therapy must be re-evaluated daily at a minimum. Decisions should be discussed on rounds for continuation and / or titration of each therapeutic modality. 3. Physical and neurological exams may require discontinuation of some or all agents to fully evaluate the patient’s best function. B. WRITING ORDERS 1. The goal of therapy should be included with the order. a) Sedation orders should include desired level on sedation scale. b) Neuromuscular blocker orders should include the desired “train of four” response. 2. All IV infusions require a daily re-order to inform pharmacy of the continued need for the drug. Please re-write these during or after rounds when possible to reflect any changes requested. ANALGESIC AGENTS 58

NOTE: Pain is a common part of the SICU experience, either as a result of obvious sources such as wounds or the not so obvious such as indwelling monitoring devices. Every patient needs to be evaluated and treated frequently and appropriately for pain and discomfort. A. INDICATIONS FOR THE USE OF ANALGESIC AGENTS 1. Invasive procedures 2. Post-op pain control 3. Adjunctive therapy to anxiolytics B. MONITOR THE FOLLOWING DURING USE OF NARCOTIC ANALGESIC AGENTS 1. Mental status 2. Pain control assessment 3. Oxygen saturation and respiratory rate 4. Urinary retention if applicable 5. Nausea / Vomiting 6. Gastric retention / ileus 7. Hypotension 8. Analgesic dose should be decreased by 10% to 20% every 1 to 2 days to re-evaluate dosing needs. C. DOSING OF NARCOTIC ANALGESIC AGENTS (See Table 2) 1. Continuous infusions or PCA using opioids are preferred to intermittent IV boluses. 2. Infusions must be re-ordered daily. 3. The dose of continuous infusion analgesic agents should be decreased by 10% to 20% daily to assess dosing needs and neurological status. Table 1 Pharmacokinetics of narcotic analgesics commonly used in the SICU Agent Morphine Fentanyl Meperidine (Demerol)

Half-life (IV) 1.5-2 hours 30-60 min 3-5 hours

Comments Removed by dialysis 9-16 hr with prolonged administration Liver dysfunction = 7-11 hr Normeperidine (active met.) = 15-20 hr

SEDATIVE AGENTS A. INDICATIONS FOR USE OF SEDATIVE AGENTS IN THE SICU 1. Primary treatment of anxiety and agitation, including that induced by the ICU environment itself. 2. Other potential causes of agitation have been ruled out, such as: a) Uncontrolled pain b) Organic causes c) Metabolic causes 3. Assist with mechanical ventilator management. 4. Facilitate endotracheal intubation and tracheal suctioning. 5. Protect patients from self-inflicted injury. 6. Decrease awareness of noxious stimuli. B. MONITORING AND CONCURRENT TREATMENT OF PATIENTS DURING USE OF SEDATIVE AGENTS 1. Sedation level: a) Use approved sedation scale (Riker Scale). b) RN to perform and document q 2 hrs. c) MD to perform and document at least once daily. d) If sedation level is greater than desired, hold sedative until desired level is obtained. Reinitiate therapy at 50% of previous dose. e) If sedation level is less than desired, consider re-bolus and increase dose by 50%. Reassess sedation level 30 minutes after any dose adjustments are made. Titrate as necessary (either up or down) until desired level of sedation is achieved. 59

f)

Unless contraindicated, Patient should have a sedation holiday daily.

2. CNS function: a) MD to perform and document at least once daily. b) May be necessary to hold infusion to completely assess neurologic function. 3. Serum triglycerides – Propofol infusions: a) Obtain baseline serum triglyceride levels. b) Monitor every 3 to 7 days while on therapy. c) Discontinue therapy if levels exceed 500 mg / dL. 4. Pain management No sedative agent possesses any analgesic properties. C. DOSING OF SEDATIVE AGENTS At initiation of therapy and with daily rewrites, a goal level of sedation must be clearly defined in the written order (e.g. sedate patients to level 3). 1. Sedation agents a) Lorazepam i. Load: 0.03 to 0.05 mg / kg IV (usual does is 2 to 4 mg) Rebolus every 15 min until desired level achieved ii. Maintenance: 0.03 to 0.05 mg / kg / dose IV q 4 hrs Weight Dose 45-60 kg 2 mg IV q 4 hrs 61-80 kg 3 mg IV q 4 hrs 81-100 kg 4 mg IV q 4 hrs iii. Adjust dosing interval for hepatic dysfunction: mild moderate severe

q 6 hrs q 8 hrs q 12 hrs

iv. Intermittent dosing allows for frequent neuro checks. v. Recommended for hemodynamically unstable patients vi. Continuous infusion rates range from 0.5 to 2 mg / hr. If > 2 mg / hr are required, consider adding a second agent such as haloperidol or opiates, and evaluate pain management. vii. With narcotics or other CNS depressants, initiate therapy at 80% of the recommended dose. viii. Poor choice for elderly patients b) Midazolam i. Load: 0.02 to 0.05 mg / kg IV. Usual initial dose is 1 to 5 mg. ii. Maintenance: 0.03 mg / kg / hr IV infusion. iii. Boluses may be used for agitation unresponsive to Lorazepam. Titrate to desired effect. iv. With narcotics or other CNS depressant: If < 65 yrs old – decrease dose by 30% If > 65 yrs old – decrease dose by 50% c) Propofol i. ii. 60

Initiation of sedation

Assess any post-anesthesia level of sedation.

Recommended starting dose: 1 to 3 mg / kg / hr or 2.5 to 5 mcg / kg / min.

iii.

Titrate rapidly in increments of 5 to 10 mcg / kg / min over 5 to 10 minute intervals until desired level of sedation is achieved.

iv.

Use bolus doses of 10 to 20 mg in patients where hypotension is not likely to occur.

i. ii.

Maintenance of sedation

Average of 5 to 50 mcg / kg / min.

Lower doses are required for: patients receiving large doses of narcotics CNS depressants; patients > 55 yrs old; patients recovering from the effects of general anesthesia.

iii. Initiate therapy at 80% of the recommended dose. iv. For patients requiring rapid emergence for neurological evaluation (neurosurgery and liver transplants). 2. Treatment of ICU delirium Before initiation of therapy, hold all sedatives and rule out other causes of delirium, including hypoxemia. The onset of extrapyramidal side effects is not dose-dependent, but will be dose-limiting.

Degree of Agitation Mild Moderate Severe

Starting Dose of Haloperidol IV 0.5-2.0 mg 5.0-10.0 mg 10.0 mg or more

Continuous infusions have been given at rates of 1 to 40 mg / hr, prepared as 100 mg / 100mL D5W. Titration and Maintenance: a) Allow 15 to 20 minutes before next dose. b) If agitation persists, double the dose every 20 minutes until agitation subsides. Dose limit is dependent on clinical judgment. c) If patient is calming down, repeat last dose at the next dosing interval. d) Once the delirium is controlled, 50% to 100% of the dose required to achieve this should be administered in divided doses every 6 hrs over the next 24 hours. e) As the need for haloperidol diminishes, the scheduled dosage may be tapered by 20% to 30% every 24 to 48 hours, as tolerated. f) Watch for prolonged Q-T interval on ECG. g) Use regular dosing intervals and not PRN scheduling. Table 3 The Riker-SICU Sedation Assessment Scale 1. Unarousable 2. Very Sedated 3. Sedated 4. Calm and Cooperative 5. Agitated 6. Very Agitated 7. Dangerously Agitated Sedation level must be indicated— usually want a Riker of 3 to 4— with each order for sedation and reassessed

daily.

NEUROMUSCULAR BLOCKING AGENTS Note: Adequate sedative and analgesic therapy must accompany and precede sustained neuromuscular blockade. 61

A. GENERAL INDICATIONS FOR SUSTAINED USE OF NEUROMUSCULAR BLOCKING AGENTS (NMB) IN THE SICU 1. Ventilatory management of patients with severe ARDS. 2. Patients with open abdominal wounds. 3. Patients with intractable increased intracranial pressure. 4. Patients with increased metabolic needs. B. MONITOR THE FOLLOWING DURING SUSTAINED NMB USE 1. Obtain an ABG 30 minutes after the start of paralysis and then daily to adjust ventilator settings. 2. Daily complete physical exam. 3. If possible, NMB should be allowed to dissipate at least once each day to assess: a) adequacy of sedation and / or analgesia; b) neurologic function; c) need for continued NMB and / or dose adjustment. 4. Ventilator alarms should be checked frequently to assure they are audible. 5. Eye care to prevent corneal ulcers. 6. DVT prophylaxis. 7. Range of motion exercises. 8. Frequent position changes (evaluate for kinetic therapy bed). 9. Peripheral nerve stimulator (“train-of-four”) assessed minimally every hour (usual desired endpoint is 1 out of 4 twitches). 10. A sign must be posted above patient’s bed stating “Neuromuscular Blocking Agent in Use”. C. DOSING OF NMB AGENTS AVAILABLE AT SHANDS AT UF (See Table 2) Infusions must be re-ordered each day. If possible, NMB should be allowed to dissipate daily to assess dosing needs and neurological status. Table 1 Agent Pancuronium Vecuronium Atracurium

Onset 2 – 4 minutes 2.5 – 5 minutes 2 – 5 minutes

Duration 45 – 90 minutes 25 – 40 minutes 20 – 35 minutes

Table 2 Dosing of Neuromuscular Blocking Agents Agent Recommended Use Dose Pancuronium Only for pts with Bolus normal renal function 0.06 – 0.08 mg / kg (not with concomitant steroids) Maintenance 0.02 – 0.03 mg / kg / hr Vecuronium

Atracurium

Renal failure or C-V instability (not with concomitant steroids)

Severe liver failure, C-V instability

Bolus 0.08 – 0.10 mg / kg

No hemodynamic changes. May accumulate in liver failure.

Maintenance 0.8 – 1.2 mcg / kg / min Bolus 0.4 – 0.5 mg / kg

Potential for histamine release (decr. BP), although not considered significant.

Maintenance 5 – 9 mcg / kg / min 62

Side Effects Incr HR, incr / decr BP, histamine release accumulates in renal failure

Table 3: Drug/Disease Interactions Increase NMB Effect Halogenated anesthetics Local anesthetics Antibiotics: Aminoglycosides Clindamycin Vancomycin Antiarrhythmics Procainamide Quinidine Calcium Channel blockers Beta-Blockers Cyclosporine Lithium Mineralocorticoids Acidosis Electrolyte abnormalities: Severe hyponatremia Severe hypocalcemia Severe hypokalemia Hypermagnesemia Neuromuscular diseases: Myasthenia gravis Muscular dystrophy Amyotrophic lateral sclerosis Poliomyelitis Multiple sclerosis Eaton-Lambert syndrome Hypothermia Acute intermittent porphyria Renal failure Liver failure

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Decrease NMB Effect Phenytoin Carbamazepine Anticholinesterase agents: Edrophonium Neostigmine Pyridostigmine Theophyline Azathiprine Ranitidine Hypercalcemia Demyelinating lesions Peripheral neuropathies Diabetes mellitus

Section 13:

Administration

General: 1. You are responsible for the patients and their families. Make sure that contact is made with the patient’s surrogate daily if at all possible. a. Remember, you are supposed to be at your best, the family members of an ICU patient are often not. Do not be surprised to hear the same question several times. Do not be surprised if you think you detect “hostility”. The families are often frightened and feel out of place. Listen to them, answer questions, help them feel that they are part of the solution. 2. The nurses in our unit are excellent. If they have a suggestion for you, consider it strongly. If you have a question as to policy or our “standard way of doing things”, ask them. 3. These are some of the sickest individuals you will have the opportunity to care for. The acuity level is such that when things “fall outside” of the plan made during rounds, you must discuss alterations of the plan with your Fellow or Attending. 4. The model of care in our units and the BICU is a collaborative care model. We and our surgical colleagues have a symbiotic relationship. Make sure all communication lines are open. Keep your surgical colleagues in the loop. a. Any problems should be handled by your Fellow or Faculty Policies and Procedures: 1. All of our patients require a progress note every day. Use the note template we have provided you. 2. All patients require a completed “Patient Goal Sheet” daily; these are located in each Pod. These are to be completed on rounds and should make clear, in a bulleted fashion, our plan for the day. 3. All patients require that their “Central Line” sheet [located in the front of the chart; if not present, ask the unit clerk] be kept up to date. This lists the place and date that the CVL was placed, what type of line it is and, when removed, the date and reason for removal. 4. All antibiotics require a stop date. When you write for the drug, consider placing a stop date, depending upon the infection. Ask your Fellow, Faculty, or Critical Care Pharmacist about this for more detail. 5. The Common Consent Form must be completed when a patient is admitted to our Units: a. The form is placed into the admission paperwork by the unit clerk; b. The consent packet is handed off to the patient / surrogate by the bedside nurse with the instructions to read it and then to bring it back for signature when they are ready; c. When the patient / surrogate is ready to sign, the nurse will call the resident. Your job is to answer any queries about the procedures that the patient / surrogate may have. Then witness the signature along with the nurse. d. Any problems should be handled by your Fellow or Faculty. Protocols: 1. We use a. b. c. d. e. f. g. h. i. j. k. 64

a number of protocols so that common issues are handled in a common manner. These include: Sedation Protocol; Glycemic Control [Insulin] Protocols [IV Insulin Protocol, Subcutaneous (Transitional) Protocol]; Heparin Protocols [for DVT / PE, for Acute Coronary Syndrome, for Patients at high Risk of Bleeding]; Electrolyte Protocol; Recombinant activated Protein C [Xygris] Protocol; Ventilator Initiation and Weaning Protocol; Fever Work-up Protocol; CVL placement Protocol; Arterial Line Placement Protocol; Airway Cannulation Protocol; Adrenal Cortical Insufficiency Evaluation Protocol.

2. Other protocols are in development. Lectures / Didactics: 1. Ask questions on rounds. We will certainly ask YOU questions. 2. Lectures – see the monthly Lecture Schedule: a. Bed Control – 0745 – 0800 daily; b. Case Conference – 0800 – 0830 daily except last Thursday of rotation; c. Resident Lecture – 0830 – 0900 daily except Wednesday; d. Surgical M&M and Grand Rounds - 0645 – 0900 each Wednesday; e. Neuroradiology Conference – 0800 – 0900 last Tuesday of each month; f. Pat Abbitt Radiology Rounds – 1130 – 1230 on the 2nd and 4th Tuesday of each rotation; g. CCM M&M – last Thursday of Each rotation – 1200 – 1300 lunch provided; h. CCM Evaluation Conference – last Friday of each rotation – 1200 – 1300 lunch provided; i. Fellow Lectures – 1200 or 1230 daily for 1st 3 months. See Schedule; j. Journal Club – 1730 at Room 2154 PSB, 2nd Wednesday of each month (see schedule); k. CCM Grand Rounds – 1200 Dragstedt Library. (see schedule). Code Blue Responsibility: 1. Our responsibility for now is the airway. Help the medical resident with ACLS if you think it is needed; 2. Leave a note in the chart after you are no longer needed at the code. If there is no need for an airway, please leave a note. 3. Cardiac arrest airways are not good learning situations. If a resident asks if he / she can do the airway, the wisest answer is “No”. However, you can send the resident to any of the CCM faculty to set up a session on the simulator and in the operating room. 4.

Code Blue Pager Announcements:

a. The way you differentiate South Tower from North Tower Codes is as follows: i. SOUTH TOWER CODES HAVE THE PREFIX: SSC – PO4 –UA and then the ROOM NUMBER 1. SSC = Shands South Campus, PO4 = some numerical designation that means the new SOUTH Tower, unclear what UA means ii. NORTH TOWER CODES HAVE THE PREFIX SUF: SUF then the Room number 5. Airway Boxes: a. We no longer have to go to the Operating Room to restock our airway boxes. b. Respiratory Therapy, using our list of equipment, will keep boxes for us. c. We are responsible for ensuring that there are drug packs in the airway boxes. d. North Tower: i. On the NeuroICU: 1. There will be one (1) box, to which is attached an elevator key. 2. The box is in Room 8414.1 [key pad *0082]. 3. It will be the responsibility of Mr. Kevin Hollen – or if he is on vacation the person taking his place – Monday thru Thursday, or Ms Rene Mathis – or the person taking her place if she is on leave Friday through Sunday – to check with the evening person (Anthony Mussalo / Vivian Murphy) at sign-out top determine if the box has been entered OR if the drug pack is outdated. This MUST be done daily. 4. If the box has been used, it is replaced by going to Room 2401.2 [keypad *078] and taking another one from the stock of 4 boxes. a. The Respiratory Therapist Supervisor (North Tower) must be called [phone number on each box – 494.8178] and informed so the box can be removed and re-stocked. b. Make sure that the supply list – in the top right hand container – has a patient sticker affixed to it, your name is legibly written on the list , and the equipment used is checked or circled. 5. If the drugs HAVE NOT been opened, remove the drug pack from the used box and place it into the top right–hand area on the box. 65

6. If the drugs HAVE been opened, take the unused portion to the ICU STAT Pharmacy [Room 2446, 265.0069] for a replacement pack. a. Hours of operation of the STAT Pharmacy are Monday thru Friday – 0700 to 2300 hours, Friday through Sunday 0700 to 1900 hours b. After hours: Call 265.0069 and trade out the drugs from Room G539 ii. On 25 – SICU: 1. There will be one (1) box, to which is attached an elevator key 2. The box is in Room 2505 [key pad *911]. 3. It will be the responsibility of LONG STAY RESIDENT Monday thru Sunday to check with the evening person at sign-out top determine if the box has been entered OR if the drug pack is outdated. This MUST be done daily. 4. If the box has been used, it is replaced by going to Room 2401.2 [keypad *078] and taking another one from the stock of 4 boxes. a. The Respiratory Therapist Supervisor (North Tower) must be called [phone number on each box – 494.8178] and informed so the box can be removed and re-stocked. b. Make sure that the supply list – in the top right hand container – has a patient sticker affixed to it, your name is legibly written on the list , and the equipment used is checked or circled. 5. If the drugs HAVE NOT been opened, remove the drug pack from the used box and place it into the top right–hand area on the box. 6. If the drugs HAVE been opened, take the unused portion to the ICU STAT Pharmacy [Room 2446, 265.0069] for a replacement pack. a. Hours of operation of the STAT Pharmacy are Monday thru Friday – 0700 to 2300 hours, Friday through Sunday 0700 to 1900 hours b. After hours: Call 265.0069 and trade out the drugs from Room G539 e. South Tower: i. There are two boxes in the Faculty – for now the Fellow and Resident – Sleep Room 4026.1 [key pad # 1-3-5-7-9]. ii. The Code Blue FOBs are presently in the hands of the On shift resident and the Fellow; they will be affixed to the boxes in the next 48 hours. 1. To make these work, you go to the STAFF elevators, wave the FOB in front of the reader [“Code Blue” lights up]; 2. You enter the elevator when it comes and AGAIN wave the Code Blue FOB in front of the reader INSIDE the elevator; 3. Then you push AND HOLD the button signifying the floor to which you wish to go….if you don’t push and hold, nothing happens ! iii. It will be the responsibility of LONG STAY RESIDENT Monday thru Sunday to check with the evening person at sign-out top determine if the box has been entered OR if the drug pack is outdated. This MUST be done daily. 1. If the box has been used, it is replaced by going to Room 4237 on 4-EAST [presently no keypad, it will be *50078] and taking another one from the stock of 4 boxes. a. The Respiratory Therapist Supervisor (South Tower) must be called [phone number on each box – 494.4985] and informed so the box can be removed and re-stocked. b. Make sure that the supply list – in the top right hand container – has a patient sticker affixed to it, your name is legibly written on the list , and the equipment used is checked or circled. 2. If the drugs HAVE NOT been opened, remove the drug pack from the used box and place it into the top right–hand area on the box. 3. If the drugs HAVE been opened, take the unused portion to the ICU STAT Pharmacy (South Tower) [Room 4018, 733.0891] for a replacement pack. a. Hours of operation of the South Tower STAT Pharmacy are 24 / 7 / 365 6.

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Difficult Airway Assistance: a. North Tower – Call 352-260-7220 as soon as you see that you have a problem – this is carried by the Attending Anesthesiologist b. South Tower – Call 352.260.7638 – carried by the on call Attending Anesthesiologist

Problems: 1. Communication / Political / Nursing / Medical – talk to any of the Faculty. You may always speak directly to the Division Chief without fear of recrimination 2. Work hours – speak with Doctor Caruso or Doctor Layon 3. Anything else – speak to either Doctor Layon or Doctor Caruso Thanks and have a good time on the rotation.

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