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Comprehensive ICU Care

79

 

Tariq Ali, Yatin Mehta, Subhash Todi, and Rajesh Chawla

A 60-year-old male patient with urosepsis and multiple organ failure was admitted to the ICU for 10 days. He was requiring ventilator support, vasopressor, and dialysis support. He was under continuous sedation and not tolerating enteral feeding fully which was being supplemented with partial parenteral nutrition.

ICU management of the multiorgan failure patient is getting increasingly complex due to the availability of the advanced organ support system. A systematic approach to multiple critical-care-related issues encountered by these patients should be initiated by the ICU team to minimize chances of hospital-acquired complications or infections and maximize chances of recovery. For an experienced intensivist, the comprehensive ICU care begins before he/she enters the ICU. Having a plan ready for each patient and modulating it with the current condition drives confidence in both the staff and the patient.

Step 1: Perform a quick overview

Perform a quick overview of ICU occupancy, patient–nurse ratio, and medical staff available for the day. It helps in identifying staffing problems early.

T. Ali, M.D., E.D.I.C.

Critical Care Medicine, Medanta – The Medicity Hospital, Gurgaon, India

Y. Mehta, M.D., F.R.C.A. (*)

Medanta Institute of Critical Care & Anaesthesia, Medanta – The Medicity Hospital, Gurgaon, India

e-mail: yatinmehta@hotmail.com

S. Todi, M.D., M.R.C.P.

Critical Care & Emergency, A.M.R.I. Hospital, Kolkata, India

R. Chawla, M.D., F.C.C.M.

Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,

639

DOI 10.1007/978-81-322-0535-7_79, © Springer India 2012

 

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Check and allocate staff for remote calls (emergency department, wards, highdependency units [HDUs], cardiac arrest).

Planned shifts are best worked up early to accommodate the transfer in timely.

Ensure proper allocation of residents and nurses.

Step 2: Take proper handover

Continuity of patient care in the ICU is dependent on accurate and timely handover. Due to shift work of junior doctors, this may need to be done once or even twice in 24 h and is a common source of medical error.

Structured method of handover has been shown to critically influence the transfer of clinical information, and this process should be implemented for a smooth and correct transfer of information.

Only 2.5% patient information is retained in verbal handover, 85.5% is retained when using the verbal along with note-taking method, and 99% is retained when a printed handout with all clinical information of the patient is used.

Handover should take place in an unhurried manner at a set time and place with minimal interruptions and under senior supervision. Each handover session should last 20–30 min to cover 10–15 patients.

A structured written format like ISBAR should be maintained for all new patient handover. The essentials of this format are as follows:

Identity of the patient—age, gender, and primary consultant.

Situation—symptoms/problems, patient stability/the level of concern.

Background—the date of admission, history on presentation, diagnosis, and relevant past medical history.

Assessment and action—what has been done so far and assessment of situation.

Response and rationale—response to intervention, what needs to be done, investigation, treatment pending, review by whom and when, further plan, and recommendations.

For patients known to the ICU team, ISBAR may be shortened to SAR only.

Step 3: Take relevant history, perform clinical examination, and review investigations, nursing charts, and clinical notes

After taking proper handover, the patients assigned should be thoroughly reviewed and examined afresh rather than relying on previous information.

Enquire about any recent events from the duty nurse.

Observe the patient from the bedside for a minute for any evidence of respiratory distress, restlessness, patient ventilator asynchrony, and paucity of spontaneous movements.

After taking the bedside nurse’s permission, ensuring proper hand hygiene, and maintaining patient privacy, introduce yourself and take patient’s consent before examination. Examine from head to toe in a systematic way without causing any discomfort to the patient. Always thank the patient at the end of your examination and ensure proper covering.

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In the head and neck region, examine for pallor, jaundice, pupils, conjunctival hemorrhage, evidence of exposure keratitis, jugular venous pressure, carotid pulse, carotid bruit, thyromegaly, and cervical lymphadenopathy. Avoid manipulating the neck in trauma patients and ensure proper placement of cervical collar if present.

Examine the conscious level by Glasgow coma scale scoring (see Chap. 30).

In intubated patients, note the length of the endotracheal tube at lips and whether properly secured. Check proper placement of heat and moisture exchanger (HME) filters with dates changed and condition of the filter whether clogged with secretions. Check the ventilator circuit for not causing undue traction on the endotracheal tube, water accumulation, and attachment to heated humidifiers. Ensure proper attachment of nebulizer or metered-dose inhaler devices. Check inline suction assembly and endotracheal tube cuff pressure. In tracheotomized patients, check tracheostomy site for erythema, purulence, proper tying of the tracheostomy tube, and functioning of supraglottic suction, if present, and measure cuff pressure. In the uncuffed tube, check patency by blocking the tube and asking the patient to vocalize. Enquire about the frequency of suctioning and the amount and type of respiratory secretions.

Check placement of orogastric or nasogastric tube position, patency, and attachment to the enteral feeding pump.

In patients with central venous catheters at jugular or subclavian venous sites, ensure proper dressing and inspect the entry site for erythema and purulence. Palpate over the dressing for tenderness. Ensure stopcocks are properly cleaned and securely attached.

Examine the chest systematically. Inspect for proper electrocardiograph lead placement, any skin changes, and flail chest in trauma patients. Palpate for any crepitus and percuss for dullness of effusion and hyperresonance of pneumothorax. Auscultate for breath sounds, cardiac sounds, adventitious breath sounds, and cardiac murmurs.

Examine the abdomen for fullness, tenderness, visceromegaly, ascites, and bowel sounds. Also check the position of the gastrostomy or jejunostomy tube if any.

Rectal examination in all patients and pelvic examination in women should not be ignored. Enquire about bowel movements, consistency, and color of stool.

Check penile area for urinary catheter position and proper tying of the urinary bag at the thigh to avoid traction and reverse drainage. Examine the color and quantity of urine in the drainage bag.

Examine upper extremities for radial and brachial pulse, blood pressure, hand grip, and thrombophlebitis. Check radial artery line if in place for proper functioning by performing a flush test, date of insertion, and capillary refill for ensuring hand perfusion.

Examine lower extremities for edema, calf swelling, muscle strength, proper fitting of anti-embolism stockings, or pneumatic compression. Look for any femoral lines and if present whether properly secured and any evidence of groin hematoma.

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Roll the patient on the side with nurse’s help and examine the back. Feel the back of scalp and ears for pressure areas, auscultate for basal crepitations, or diminished breath sounds. Look for decubitus ulcers at the sacral area, scrotal swelling, and any perineal soiling or evidence of candidiasis.

In postoperative and trauma patients, look at the wound or surgical incision site for erythema and purulence, palpate for induration and tenderness, and check proper dressing. Check the drainage bag for proper labeling, amount, and type of drainage.

Take note of bedside monitor readings of vital signs—cardiac rate and rhythm (print out a rhythm strip), any obvious ST changes, and mean arterial pressure— noninvasive or invasive, and confirm yourself by checking manually if in doubt about correct values. Check pulse oximeter plethysmograph and oxygen saturation, central venous pressure, or pulmonary arterial pressures (after printing out a pressure strip), capnograph, and core temperature readings.

Check ventilator parameters—mode, FiO2, positive end-expiratory pressure (PEEP), tidal volume, pressure limit, ventilator rate, inspiratory–expiratory ratio, and inspiratory flow. Monitor minute ventilation, auto-PEEP, and pause pressure. Measure lung compliance and airway resistance.

Check intravenous infusions, volumetric infusion pumps, and syringe pumps for proper labeling and functioning.

Review recent investigations including hematology, biochemistry, microbiology, and imaging studies and compare it with the previous reports to analyze the trend.

Familiarize with the ICU nursing chart and review it systematically. Examine previous 24-h trend and worst values. Look for records of vital signs, hemodynamic and ventilator parameters, intake and output chart, enteral feed rate and tolerance, hourly urine output, blood or blood product transfusion in previous 24 h, and any untoward transfusion-related reaction.

Review cumulative fluid balance till date and cumulative calories or protein deficit or excess.

Review the medication sheet daily for proper drug dosing and stop any unnecessary medication.

Review clinical notes for any referral input and any new major event described.

Review patient’s code status and therapeutic support level as desired by the patient and family.

Review the payor status of the patient.

Step 4: Participate in a multidisciplinary ward round

ICU care is a teamwork, and a typical ICU round in a tertiary care hospital consists of the ICU consultant, resident doctor, senior sister, duty nurse, physiotherapist/respiratory therapist, dietitian, clinical pharmacist, ICU technician, and social worker.

Rounds in ICUs are different from a general ward round in many aspects. First, substantially more information is exchanged, which is essential. Second, the emphasis is on physiological derangements rather than on specific problems.

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Third, the discussion is always goal-oriented so that when goals are met the patient may be transferred to a lower level of care.

In addition to providing educational value, rounds in ICUs serve two purposes: first to communicate the patient’s present status to the entire team and second to establish goals and plans for each patient.

To ensure that each patient undergoes a comprehensive evaluation each day, think and communicate in terms of systems. These typically include neurological (including analgesia and sedative), pulmonary, cardiovascular, renal, fluid, electrolytes, nutrition, gastrointestinal, metabolic, infectious, and hematologic. Rounds will move more smoothly and efficiently if a structured and uniform format of presentation is adopted by all members.

Each system should be analyzed and presented according to outcome and process variables. For example, in the renal system, urine output, intake/output balance, and electrolyte levels are outcome variables, and supplemental electrolytes administered, volume of intravenous fluid given, and amount of diuretic used are process variables (Table 79.1).

Case presentation should start with identifying the patient, the day of ICU or hospital admission, reason for admission, principal diagnosis, and any significant event in the previous 24 h. For new patients, significant medical background and presenting complaint should be presented. Vital signs, pertinent physical examination findings, hemodynamic, ventilator parameters, intake and output, invasive procedures performed, major investigations done with results, and treatment initiated should be described. Area of major concern needs to be addressed; treatment goals and the plan for the day should be elaborated. A summary capsule of case should be presented at the end. The case presentation should be precise and should not take more than 5 min.

Step 5: Write proper clinical notes

Appropriate documentation whether on paper or electronic is of paramount importance and should be done in a systematic and unhurried manner. Writing should be legible, and the proper date, time, and signature should be recorded.

A uniform format should be maintained during daily case record documentation.

SOAP (subjective, objective, assessment, plan) format may be utilized for case notes in short-stay cases.

A more elaborate and comprehensive daily checklist should be utilized in complex and long-stay cases on multiple organ support (Table 79.2). This ensures that all aspects of case management have been addressed.

Every patient should have a master problem list (active and inactive problems), which needs to be updated periodically.

Documentation of family briefing and end-of-life care decisions should be done meticulously.

Step 6: Perform procedures under supervision

Acquiring technical skills in different procedures is a requisite for any ICU training program.

Table 79.1 Outcome and process variables

 

System

Outcome variables

Process variables

Neurological

Motor function

Type/route of analgesics

 

Pain level

Type/route of sedative, antiseizure medications

 

Sedation level

Intracranial pressure monitors

 

Glasgow coma score

 

 

Intracranial pressure

 

 

Occurrence of seizures

 

Pulmonary

Presence of rales or wheezes

Ventilator settings

 

Appearance of the chest X-ray

Administration of nebulized bronchodilators

 

Oxygen saturation

Administration of supplemental gases such as nitric oxide

 

End-tidal CO2 concentration

Readiness for weaning and extubation daily assessment

 

Arterial blood gas data

 

 

Spontaneous ventilation rate

 

 

Forced vital capacity

 

 

Negative inspiratory pressure

 

Cardiovascular

Blood pressure

Estimates of and interventions to adjust preload, such as central

 

 

venous pressure or pulmonary artery occlusion pressure

 

Heart rate

Estimates of and interventions to adjust afterload, such as

 

 

vasodilator therapy

 

Abnormal rhythm

Estimates of and interventions to adjust contractility, such as

 

 

inotropic therapy

 

Presence of rales

Estimates of (e.g., drug level) and interventions to adjust

 

Peripheral pulses and extremity warmth

antiarrhythmic

 

Cardiac output

 

 

Evidence of ischemia

 

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System

Outcome variables

Process variables

Renal/fluid/electrolytes

Weight

Intravenous fluid composition and rate

 

Net intake and output balance

Supplemental electrolytes

 

Current electrolytes

Sites of unusual loss of volume

 

Blood urea nitrogen, creatinine, ABG

Sites of unexpected loss of specific electrolytes

Gastrointestinal/metabolic/nutrition

Bowel sounds, function

Route/rate/composition of nutritional support

 

Absorption of enteral feedings

Use of prokinetic or antiemetic agents

 

Fraction of caloric goal attained

Prophylaxis against gastrointestinal bleeding

 

Nitrogen balance

Insulin requirements

 

Hyperor hypoglycemia

Hormone replacement therapy (e.g., thyroid)

Hematologic/infections disease

New findings on physical examination suggestive

Transfusion requirements

 

of bleeding

 

 

Hematocrit, platelet count, and coagulation

Deep venous thrombosis prophylaxis

 

parameters

 

 

Temperature; findings suggestive of infection on

Procedures to diagnose and/or control infection

 

physical examination; gram stain and culture data,

 

 

including antimicrobial and sensitivity

 

 

Leukocyte count and differential count

Antimicrobial prescription, including drug levels where

 

 

appropriate

Adapted from www.sccm.org

 

 

Medical students’ guide to intensive care medicine

 

Care ICU Comprehensive 79

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Table 79.2 Daily checklist

 

I Hug Fast

Continuous Quality Improvement (CQI) checklist

I = Infection control

What needs to be done for the patient to be discharged

 

from the ICU?

H = Hand hygiene and head of bed

What is the patient’s greatest safety risk? How can we

elevation

reduce that risk?

U = Ulcer prophylaxis

Pain management/sedation

G = Glycemic control

Cardiac/volume status

F = Feeding

Pulmonary/ventilator (plateau pressure, elevate head

 

of bed 30–45°)

A = Analgesia

Mobilization

S = Sedation

Infectious disease issues, cultures, drug levels

T = Thromboprophylaxis

Gastrointestinal issues, nutrition

 

Medication changes (can any be discontinued?)

 

Tests/procedures

 

Review morning laboratory results and the chest X-ray

 

Consultations

 

Communication with primary service

 

Family communication

 

Can catheters tubes be removed?

Adapted from Vincent (2005) and Pronovost et al. (2003)

Acquire factual knowledge about the common procedures performed in the ICU with indications, contraindications, complications, and steps of procedure (see Sect. XV).

Familiarize yourself with procedures performed by observing seniors in ICUs.

Initial procedures should be performed under elective conditions under proper supervision.

Take informed consent in elective procedure, explain procedure to the patient, and always remember “do no harm.”

Procedure performed should be documented, and any complication should be recorded and countersigned by the supervisor. An individual logbook of procedures should be maintained to acquire sufficient experience to have privileges of unsupervised procedures.

Step 7: Follow infection control practices (see Chap. 48)

Take leadership and exemplary role in maintaining proper infection control practices.

Maintain and teach hand hygiene procedures to juniors and nonmedical members of the ICU team.

Practice isolation practices wherever applicable.

Be vigilant in detecting and reporting nosocomial infection to the infection control nurse.

Practice antibiotic stewardship.

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