Ministry of Health

SKILL BASED COVID 19

ICU TRAINING MANUAL

2021

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Table of Contents
CHAPTER 1: COVID 19 UPDATE ................................................................................................................................. 1
SESSION 1: BACK GROUND OF COVID 19 .......................................................................................................... 2
SESSION 2: CLINICAL SYNDROMES AND PATHOPHYSIOLOGY OF COVID-19 ................................... 3
SESSION 3: COVID 19 CLINICAL MANAGEMENT .......................................................................................... 7
CHAPTER 2: ICU DOCUMENTATION AND POLICY .......................................................................................... 11
SESSION 1: DOCUMENTATION ........................................................................................................................... 12
SESSION 2: ICU POLICY .......................................................................................................................................... 17
CHAPTER 3: IPC PRACTICE IN COVID- 19 ICU SET UP .................................................................................. 24
SESSION 1: ICU DESIGN ......................................................................................................................................... 25
SESSION 2: DONNING AND DOFFING .............................................................................................................. 27
SESSION 3: ENVIRONMENTAL DECONTAMINATION ............................................................................... 34
CHAPTER 4: ICU EQUIPMENT UTILIZATION..................................................................................................... 38
SESSION 1: SUCTION MACHINE ......................................................................................................................... 39
SESSION 2: INFUSION PUMP................................................................................................................................ 42
SESSION 3: MECHANICAL VENTILATION ...................................................................................................... 50
CHAPTER 5: AIRWAY BREATHING, OXYGEN THERAPY AND RESPIRATORY FAILURE ................. 61
SESSION 1: CARE OF STHE AIRWAY ............................................................................................................... 62
SESSION 2: OXYGEN THERAPY ........................................................................................................................... 70
SESSION 3: RESPIRATORY FAILURE ................................................................................................................ 79
CHAPTER 6: CARDIAC CRITICAL CARE............................................................................................................... 85
SESSION 1: ELECTROCARDIOGRAPHY (ECG) AND ARRHYTHMIA ..................................................... 86
SESSION 2: MANAGEMENT OF SHOCK .......................................................................................................... 98
SESSION 3: BASIC LIFE SUPPORT (BLS) AND ADVANCED CARDIAC LIFE SUPPORT (ACLS) 104
CHAPTER 7: APPROACH TO ALTERED MENTAL STATUS, PAIN SADETION AND DELIRIUM IN
ICU...................................................................................................................................................................................... 112
SESSION 1: ALTERED MENTAL STATUS ....................................................................................................... 113
SESSION 2: PAIN AND SEDATION.................................................................................................................... 119
SESSION 3: ICU Delirium ..................................................................................................................................... 124
CHAPTER 8: MONITORING IN ICU ....................................................................................................................... 134
SESSION 1: INTRODUCTION TO PATIENT MONITORING ..................................................................... 135
SESSION 2: PHYSIOLOGIC FUNCTIONS TO BE MONITORED IN ICU ................................................. 136
CHAPTER 9: PRONING-BEDSIDE TEACHING................................................................................................... 140
CHAPTER 10: PEDIATRICS ICU.............................................................................................................................. 147
SESSION 1: PROPER TRIAGE AND ASSESSMENT OF CRITICALLY ILL CHILD .............................. 148

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 SESSION 2: PEDIATRICS AIRWAY AND RESPIRATORY EMERGENCY.............................................. 151
SESSION 3: COVID 19 IN PEDIATRICS ........................................................................................................... 152
SESSION 4: POSITIVE PRESSURE VENTILATION IN PEDIATRICS ..................................................... 154
SESSION 5: PEDIATRICS CIRCULATION AND SHOCK ............................................................................. 156
SESSION 6: PHARMACOTHERAPY OF CHILDREN WITH COVID-19 .................................................. 157
CHAPTER 11: CRITICAL CARE ETHICS............................................................................................................... 161
SESSION 1: ETHICS IN COVID 19 MANAGEMENT ..................................................................................... 162
SESSION 2: COVID-19 PATIENT CARE PRIORITIZATION AND ITS ETHICAL CONSIDERATIONS
........................................................................................................................................................................................ 163
CHAPTER 12: ELECTROLYTE AND FLUID ........................................................................................................ 172
SESSION 1: ELECTROLYTE ABNORMALITIES ............................................................................................ 173
SESSION 2: FLUID BALANCE & FLUID DISTURBANCE ........................................................................... 183
CHAPTER 13: CRITICAL CARE INCIDENT MANAGEMENT ........................................................................ 187
SESSION 1: TYPES OF INCIDENT AND REPORTING OF CRITICAL CARE INCIDENT .................. 188
SESSION 2: CRITICAL CARE INCIDENT MANAGEMENT ........................................................................ 190

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List of Figures
Figure 1: General observation chart .......................................................... Error! Bookmark not defined.
Figure 2: ICU design..................................................................................................................................................... 25
Figure 3: Right time and right technique for hand hygiene in health care ............................................ 29
Figure 4: Steps for donning (Flowchart 1) .......................................................................................................... 30
Figure 5: Upper respiratory tracts ......................................................................................................................... 63
Figure 6: Blocked airways by falling back tongue............................................................................................ 64
Figure 7: A. Head tilt chin lift maneuver B. Jaw thrust maneuver......................................................... 65
Figure 9: Oropharyngeal airway ............................................................................................................................. 65
Figure 10: Nasopharyngeal airway ....................................................................................................................... 66
Figure 11: Nasal prong ................................................................................................................................................ 72
Figure 12: A. Simple face mask B. Non-rebreather mask (NRB) .......................................................... 73
Figure 14: Bag Valve Mask ......................................................................................................................................... 74
Figure 15 : One hand C&E technic and two hands technique using jaw thrust ................................... 75
Figure 16: Oxygen sources......................................................................................................................................... 75
Figure 17: Monitor leads placement ...................................................................................................................... 87
Figure 18: The ECG grid .............................................................................................................................................. 88
Figure 19: Normal ECG wave form ......................................................................................................................... 88
Figure 20: ST segment (red) ,J point(Green) ...................................................................................................... 89
Figure 21: QT interval assessment ......................................................................................................................... 89
Figure 22: Normal R wave progression................................................................................................................ 90
Figure 23: Classification of tachyarrythmia ....................................................................................................... 92
Figure 24: Tachyarrhythmia instability signs and management ............................................................... 94
Figure 25: CPR A. Two Hand Technique B. One Hand Technique .............................................. 106
Figure 26: A. Two finger technique B. The two thumb-encircling hands technique ................... 107
Figure 27: Pain intensity scale ............................................................................................................................... 121
Figure 28: Wong baker faces pain rating scale................................................................................................ 121
Figure 29: Wong- Baker FACES pain rating scale ......................................................................................... 128
Figure 30: Crisis level surge- critical care triage tool ................................................................................... 165

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List of tables
Table 1: Preparations of sodium hypochlorite solution and its conversion to 1% solution .......... 34
Table 2: Medical equipment cleaning.................................................................................................................... 35
Table 3: Hazards and complication of suctioning ............................................................................................ 40
Table 4: Recommended PPE CSS and OSS ........................................................................................................... 41
Table 5: Characteristics of delirium, dementia and psychosis ................................................................. 114
Table 6: Mnemonic “AEIOU-TIPS” for Altered Mental Status.................................................................... 116
Table 7: Glasgow Coma Scale.................................................................................................................................. 118
Table 8: Behavioral Pain Scale (BPS) .................................................................................................................. 120
Table 9: Modified Ramsay Sedation Scale (RASS).......................................................................................... 122
Table 10: Risk factors for delirium in ICU patients ....................................................................................... 124
Table 11: Behavioural Observation Pain Rating Scale (FLAA scale ) ..................................................... 128
Table 12: Clinical symptoms and severity assessment in pediatrics COVID-19 patients.............. 152
Table 13: Positive pressure ventilation in children 0 month to 18 years of age with COVID-19
infection ........................................................................................................................................................................... 154
Table 14: Dosing of Steroid for moderate to severe COVID 19 disease ................................................ 157
Table 15: Antibiotics treatment for children with moderate to critical illness of COVID 19 ....... 158
Table 16: Use of anticoagulant in older and adolescent children............................................................ 159
Table 17: Treatment summary for sodium abnormalities ......................................................................... 178
Table 18: Composition of different fluids in comparison with plasma ................................................. 184
Table 19: Types of colloid fluids ............................................................................................................................ 185
Table 20: Estimated amount of fluid loss .......................................................................................................... 186

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CHAPTER 1: COVID 19 UPDATE
Chapter duration: 1 hour

Chapter Objective

The general objective of this session will help the participant to understand
epidemiological status update, pathogenesis, disease severity classification and general
principle of COVID Clinical case management so as to equip the trainee with a basic
knowledge of COVID 19 diseases before the trainee joins the real practical sessions.

Chapter Methodology

This chapter will be covered in 2 lecture sessions which includes 30 minutes for the
background information and 30 minutes for the general principle of COVID 19 clinical
management and self-reading by participants.

Sessions outline

Session 1: Back ground of COVID 19

Session 2: Clinical syndromes, pathophysiology and Classification of COVID 19 disease

severity

Session 3: COVID 19 clinical management

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SESSION 1: BACK GROUND OF COVID 19

Pneumonia of unusual clinical presentation was first recognized in Wuhan, China in late
December. The etiology was later identified to be an RNA virus that belongs to the
family of CORONA (Latin Crown, from the structure of the virus under electron
microscope) viruses. This new CORONA virus causing acute respiratory disease in
humans since the end of December 2019(2019-nCoV), later labeled as SARS-CoV2 by
World Health Organization is a different strain of CORONA virus from SARS and MERS
CORONA viruses.

The disease has been recognized as global public health emergency by World Health
Organization after cases had started to be seen outside china in less than two-month
period. Between December 31, 2019 and to date, COVID-19 pandemic affected 235
countries/territories causing 161,573,135 cases and 3,352,438 deaths (CFR=2.22%)
globally. In Africa, 57 countries/territories have reported COVID-19 cases and a total of
4,700,347 cases and 125,738 deaths were reported across the continent (CFR=2.58%).
Ethiopia reported the highest number of COVID-19 confirmed cases in East Africa. As of
May 13, 2021 a total of 264,367 confirmed COVID-19 cases and 3,938 deaths were
recorded in the country.

Implementation of strict non pharmacologic preventive methods like universal use of

face mask, frequent hand washing and social distancing are still the available effective
preventive methods.

World Health Organization has registered more than eight COVID 19 vaccines which
undergone trials with encouraging results and most developed countries were rolling
out COVID 19 vaccine to their citizen. Accordingly WHO report, developing countries
are falling dangerously behind in the global race to end the coronavirus pandemic
through vaccinations. The Covax facility aims to get Covid-19 shots to at least 20% of
the populations of the world’s 92 poorest nations by the end of 2021 which was started
last year by the World Health Organization. Ethiopia is one of the countries working on
availing vaccine through the COVAX forum. Currently, three new variants of the virus
(SARS-CoV-2), which includes the U.K(B.1.1.7), South Africa(B.1.351) and Brazil (P1)
that causes coronavirus disease 2019 (COVID-19) are creating concern. These variants
seem to spread more easily and quickly among people, causing more infections with the
COVID-19 virus while it is yet to be seen if there is any change in severity with evolving
new strains. All three variants have now been identified in many other countries. While
routine PCR tests are used to detect the SARS-CoV-2 but viral sequencing is used to
identify any type of new mutant variants. Though vaccine manufacturers are also
looking into creating booster shots to improve protection against variants, in the
meantime all the necessary precautions for avoiding infection with the COVID-19 virus
has to be in place.

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SESSION 2: CLINICAL SYNDROMES AND PATHOPHYSIOLOGY OF COVID-
19

Session description

In this section the pathophysiology, clinical manifestation, diagnostic methods of COVID

19 are described. The teaching methods involve interactive lecture and class works with
small group discussions. There is a summary and self exercise in the end of the session.

Session objectives:

At the end of this session the participant will be able to:

• Identify clinical syndromes related with COVID-19

• Discuss associated features in different clinical syndromes
• Identify different ways of diagnostics to confirm COVID-19 related clinical
syndromes

2.1 Introduction

COVID-19 manifests with a wide clinical spectrum ranging from asymptomatic patients
to hypoxemic respiratory failure, septic shock and multiorgan dysfunction. COVID-19 is
classified based on the severity of the presentation. According to WHO, the disease may
be classified into non severe (asymptomatic, mild and moderate), severe, and critical.
Among the many symptoms, the most common symptoms include fever, fatigue, dry
cough, and shortness of breath (when there is progression to the lung). The majority of
patients present with multiple symptoms but combination of fever, cough, and
shortness of breath, all to be present in one patient, is rare.

2.2 Pathogenesis

• Acute Respiratory Distress syndrome (ARDS): severe inflammatory damage

of alveolar epithelial and endothelial it causes occlusion by exudates. This causes
significant shunting. Such condition is usually significant ventilation-perfusion
mismatch followed by hypoxemic respiratory failure. Vascular obstruction from
thrombosis or destruction associated with inflammation may complicate the
situation causing dead space ventilation.
• Sepsis and septic shock: acute life-threatening organ dysfunction caused by a
dysregulated host response to suspected or proven infection.

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2.3 Clinical syndromes in COVID-19

i. Mild illness

• Patients, uncomplicated upper respiratory tract viral infection may have non-
specific symptoms and these patients may not have any signs of dehydration,
sepsis or shortness of breath and accounts 40% of cases.
• Atypical symptoms: the elderly, immunosuppressed and with Comorbidities may
present with atypical symptoms. Symptoms due to physiologic adaptations of
pregnancy or adverse pregnancy events, such as dyspnea, fever, GI-symptoms or
fatigue, may overlap with COVID-19 symptoms.

ii. Moderate illness (Pneumonia)

• Moderate illness is described as patients having pneumonia using appropriate

criteria in adults or children. This form of illness comprises of 40% of COVID-19
patients.
• Adult patients with respiratory symptoms, fever and RR < 30/min are
categorized here. If there is CT scan these patients have lung infiltrates involving
<50% of the lung field. These patients do and not need supplemental oxygen.
• Child with non-severe pneumonia who has cough or difficulty breathing + fast
breathing: fast breathing (in breaths/min) : < 2 months: ≥ 60; 2–11 months: ≥
50; 1–5 years: ≥ 40, and no signs of severe pneumonia.

iii. Severe illness

• Severe illness is described as patient having severe pneumonia, acute

respiratory Distress Syndrome (ARDS) or sepsis and patients respond to non
invasive management.
• These patients manifest with dyspnea, RR ≥ 30/min, blood oxygen saturation
(SpO2) ≤ 93%, or when there is ABG PaO2/FiO2 ratio < 300 OR when Kigali
definition is used SpO2/FIO2<350, and/or lung infiltrates in CT imaging > 50%
within 24 to 48 hours; this occur in 14% of cases.
• Adult or adolescent: in patients with fever or suspected respiratory infection,
the CURB-65 criteria (Confusion, Urea>7mmol/L or abnormal creatinine value,
Respiratory rate >30, Blood pressure <90/60, Age >65) can be used to
determine severity of pneumonia.
The CURB-65 score should be interpreted in conjunction with clinical judgment.
Patients with a CURB-65 or CURB-65 score of >2 patient should be considered as
severe and admitted.
• Child with cough or difficulty in breathing, plus at least one of the following:
central cyanosis or SpO2 < 90%; severe respiratory distress (e.g. grunting, very
severe chest in drawing); signs of pneumonia with a general danger sign:
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 inability to breastfeed or drink, lethargy or unconsciousness, or convulsions.
Other signs of pneumonia may be present: chest in drawing, fast breathing (in
breaths/min): < 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40 . While the
diagnosis is made on clinical grounds; chest imaging may identify or exclude
some pulmonary complications.

iv. Critical illness

Respiratory failure requiring mechanical ventilation, septic shock, and/or multiple

organ dysfunctions (MOD) or failure (MOF) and it need invasive or special monitoring
ICU management; this occurred in 5% of cases.

2.4 Diagnostic Workup of COVID-19

a) PT-PCR: amplification of the genetic material extracted from the saliva or

mucus sample is through a reverse polymerase chain reaction (RT-PCR), which
involves the synthesis of a double-stranded DNA molecule from an RNA mold.
Because of lower Sensitivity, 70-80% (False negative of about 30%) uses
combination of PCR, epidemiology/cluster distribution, clinical features and CT
if available.
b) Imaging: Chest x ray and CT scan
• In addition to the clinical and laboratory criteria, chest imaging
modalities such as chest X-ray, computed tomography (CT) scan, and
lung ultrasound can be used to support the diagnosis.
• The most frequent finding on CT scan includes ground-glass opacity
(86%), consolidation (29%), crazy paving (19%), bilateral disease
distribution (76%), and peripheral disease distribution (33%) .
• It is important to note that a chest X-ray has a lower sensitivity (59%)
to detect subtle opacities. A CT scan can further detect mediastinal
lymphadenopathy, nodules, cystic changes, and pleural effusion.
c) Laboratory Features
Common laboratory findings in severe patients include Lymphopenia
with relative rise in neutrophils, elevated prothrombin time, LDH (lactate
dehydrogenase), D-dimer, ALT, C-reactive protein (CRP), and creatine
kinase, blood urea, and creatinine levels and ferritin.

2.5 Summary

• In sepsis, infection causes a dysregulated host response leading to widespread

inflammation and altered coagulation which injures the microvasculature,
leading to vasodilation, increased capillary permeability, hypovolaemia,
hypoperfusion, life-threatening organ dysfunction and shock (in most severe
form).

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• In ARDS there is an overwhelming inflammatory process that injures alveoli,
which become flooded with protein-rich edema fluid. Alveolar collapse creates
widespread ventilation perfusion mismatch; clinically, patients present with
severe and refractory hypoxaemia.

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SESSION 3: COVID 19 CLINICAL MANAGEMENT

3.1 Introduction

This session is mainly intended for health care workers taking care of COVID 19 patients
at different set up (HBIC, integrated care, dedicated COVID-19 treatment centers etc).

3.2 General principle of COVID-19 clinical management

• Identify moderate, severe and critical cases and initiate supportive therapy
including oxygen and fluid management as soon as possible. Please measure
oxygen saturation with pulse oximeter in addition to assessment of vital signs.
• Oxygen therapy is effective supportive measure in COVID-19 patients and target
saturation is >92-96%. For pregnant women and children with emergency signs
(airway obstruction, shock, severe respiratory distress, convulsion and
resuscitation) it has to be >94%
• Initiate oxygen therapy when SO2 is < 90% for stable case and < 92% for
unstable cases
• Drug allergies, drug adverse effects, and drug-drug interactions must be
considered during managing the patient with COVID-19.
• Underlying /chronic diseases should be identified as early as possible.
Underlying /chronic diseases such as hypertension, cardiovascular disease,
diabetes, cancer, Chronic respiratory diseases, HIV/AIDS and smoking history
should be identified without delay as they affect the outcome of the disease
• Apply strict IPC measures when managing patients (Refer to IPC
guideline).Apply contact and droplet precautions for all case management while
additional airborne precaution is needed for aerosol generating procedures.
• Use conservative fluid management in patients with COVID-19 patients unless
there is evidence of shock or hypoperfusion. Aggressive fluid administration may
worsen oxygenation, therefore be cautious unless there is justification.
• Initial evaluation includes complete blood count (CBC) with differential, with a
focus on the total lymphocyte and platelet count trend, blood sugar and HbA1C,
serum creatinine, BUN, liver enzymes and function test, electrolytes and HIV
antigen/antibody testing and CXR. PT and PTT for ICU admitted patients.

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3.3 COVID 19 Clinical syndromes and management

i. Management of Mild COVID 19 Illness

All patients in this category will get home care and self-quarantine for 14 days
according to home care guideline

• Transfer Patients whose home condition is not favorable, especially high risk
patients with comorbidities to community COVID-19 centers if available.
• Advice patients to keep hydrated, but not to take too much fluid as this can
worsen oxygenation.
• Provide symptomatic therapies with antipyretic/ analgesic, in adults:
Paracetamol 1gm paracetamol PO every 6–8 hours (maximum 4g/ 24hr) or
Tramadol 50–100 mg PO/IV every 4–6 hours for analgesics purpose as needed,
daily (maximum400 mg/day) can be given alternatively or combined with
paracetamol.

ii. Management of moderate COVID 19 Illness

• The decision to admit depends on clinical presentation, potential risk factors for
presence of severe disease, ability of the patient to self-care at home, and
presence of vulnerable individual at home
• Patients without comorbidities and fulfilling home based care can self-isolate at
home or community isolation facility with follow up based on the home based
guideline
• Patients with risk factors and those without reliable home care should be
admitted to isolation room at health care facility or hospital and closely
monitored for risk of progression especially in the second week after onset of
symptoms
• Admitted patients should have close follow up of vital signs every six hours or
more frequently and avoid IV fluid unless there is a clinical indication.
• Empiric oral antibiotics are given only if there is strong suspicion of bacterial
pneumonia because superimposed pneumonia is rare in confirmed COVID 19.
• In adult: if antibiotics is needed give Amoxicillin 500mg PO tid or Amoxicillin-
clavulanate 1gm PO bid or 625 mg PO tid for 7days
• Provide symptomatic therapy is as described in the mild cases above.
• For admitted patients provide prophylactic anticoagulants(see anticoagulant
section)

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iii. Management of Severe COVID 19 illness

• Provide oxygen supplementation with oxygen flow rates using appropriate

delivery devices (e.g. use nasal cannula for rates up to 5-6 L/min; face mask
with reservoir bag for flow rates 10–15 L/min; and Venturi mask for flow rates
6–10 L/min). For more details about oxygen titration see oxygen section.
• Adults with emergency signs (obstructed or absent breathing, severe
respiratory distress, central cyanosis, shock, coma and/or convulsions) should
receive emergency airway management and oxygen therapy during
resuscitation to target SpO2 ≥ 94%.
• Once the patient is stable, target > 90% SpO2 in non-pregnant adults and ≥ 92–
95% in pregnant women.
• Short of invasive mechanical ventilators, NIPPV can particularly be useful in
patients with chronic respiratory airway obstruction, sleep apnea and
pulmonary oedema. NIPPV shouldn’t be used in unconscious, uncooperative and
patients with excessive secretions.(See NIPPV section for details).
• NIPPV should be used with non-vented masks to avoid room aerosilization.
NIPPV is best used on the ventilator with a closed loop circuit with a viral filter
on the exhaust line.
• In patients whose work of breathing worsens with poor oxygenation a trial of
Bi-level positive airway pressure ventilation (BiPAP), and continuous positive
airway pressure ventilation(CPAP) with high PEEP 10-15 cm H 2 O as tolerated
.If oxygen saturation target fails with NIPPV invasive ventilator support can be
used.
• While managing with NIPPV manage anxiety and coach the patient to be calm
and synchronize his/her breathing with the breath delivered by the machine. If
the patient is clinically deteriorating or if no improvement after 30 minutes of
trial, immediately proceed for steps to intubation for Mechanical Ventilation
(MV). (Refer MV section )
• Close monitoring of vital signs, work of breathing and mental status is advised.
• Awake prone positioning for 16 hrs in a day
• For pregnant: After resuscitation and stabilization of the pregnant woman, fetal
well-being should be monitored. The frequency of fetal heart rate observations
should be individualized based on gestational age, maternal clinical status (e.g.
hypoxia) and fetal conditions.
• Patients hospitalized with COVID-19 require regular monitoring of vital signs
every 6hrs, including oxygen saturation with pulse oximetry.
• Conservative IV fluid management should be instituted.
• Empiric antimicrobials should be started after taking specimen for culture and
sensitivity when superimposed pneumonia is suspected. Alternative choice in
adults:

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 • Ceftriaxone 1gm IV bid for 7 -10 days (in severe pneumonia or sepsis
because of high rate of resistance if there is no response within 24-48 hrs.
change to alternatives below). Add Azithromycin 500 mg PO daily for 5
day.
• In patients who are severe ill and critical, hospital acquired pneumonia,
immunocompromized or with previous structural lung disorder, give
Ceftazidime/Cefepime 2g iv TID +or +/-Vancomycin 1 gm IV BID
• If there is no response with the above antibiotics (when available) or
culture and sensitivity result suggests Meropenem (or other available
carbapenemes) 1g IV q8hours +/- Vancomycin 1g IV q12 hours can be
used.
• When patients improve and are able to take PO switch to Amoxicillin-
clavulanate (look dose at moderate pneumonia section above).
• Dexamethasone 6mg IV/PO once daily for 10 days or until discharge.
When dexamethasone is not available predinisolone 40mg Po stat or
hydrocortisone 100mg IV BID can be used.
• Prophylactic anticoagulants are needed for all admitted patients(see for
choice and doses in anticoagulant section)

iv. Management of critical COVID 19 illness

Admit to Intensive Care Unit (ICU)

• Assess the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) and
act accordingly.
• Antibiotics use (Follow the recommendations of severe cases).
• Oxygen supplementation, non-invasive ventilator support and prone
positioning(Follow recommendations of severe cases)
• Any patient with severe respiratory failure not responding to non-invasive
modes of respiratory support require invasive endotracheal intubation for
Mechanical Ventilation Refer below on management of COVID 19 ARDS section
• Manage sepsis or septic shock.( Refer to sepsis section)
• Anticoagulation: Start on therapeutic dose anticoagulants (Refer to
Anticoagulants section)

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CHAPTER 2: ICU DOCUMENTATION AND POLICY

Chapter duration : 30min lecture 2hr bedside

Teaching method

• Lecture
• Bedside and ICU visit

Teaching materials

• Power point
• Flip chart

Sessions outline

Session 1: ICU documentation

Session 2: ICU policy

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SESSION 1: DOCUMENTATION

Session description

This session describes the general ICU documentation principles, importance and major
documentations in the ICU for the participants.

Session objective

• After completing this session the participants will be able to describe ICU
documentation, its importance and major documentation areas and formats in
the ICU

Enabling objectives

• Discuss why documentation is important in the ICU setup

• Discuss major documentation areas in ICU setup
• Familiarize different ICU formats and documents

Session duration: 15 minutes

1.1Introduction

Standardized, accurate, and accessible documentation is an essential element of safe,

quality, evidence-based clinical care practice. Documentation of the care you provide is
critical as well for effective communication with each other and with other disciplines.
Documentation is a means of create a record of their services for use by facility
management, the legal system, government agencies, accrediting bodies, researchers,
and other groups and individuals directly or indirectly involved with health care.
Documentation sometimes is misunderstood as an additional work and even as a
distraction from patient care. However, high quality documentation is an integral part of
the work of health professionals in COVID 19 ICU and other health care services. This
requires providing ICU staffs with sufficient time and resources to support
documentation activities. In a continuous care operation, it is critical to document each
patient’s condition and history of care.

1.2 Use of documentation

Communication: For communicating within the health care team and providing
information for other professionals

• To ensure the patient receives the best available care, the information
must be passed among all members of the interdisciplinary team of
caregivers.

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 • Incorrect information or no information at all, may result in serious injury
or death of a patient.
• Negative legal repercussions are often avoided because of proper
documentation and appropriate communication of patient information.

Quality process and performance improvement: documentation is the primary

source of evidence used to continuously measure performance outcomes against
predetermined standards of individual health care providers, health care team
members, groups of health care providers and organizations. This information can be
used to analyze variance from established guidelines and measure and improve
processes and performance related to patient care.

Legal evidence: Patient clinical reports, providers’ documentation, administrators’

records, and other documents related to patients and organizations providing and
supporting patient care are important evidence in legal matters. Documentation that is
incomplete, inaccurate, untimely, illegible or inaccessible, or that is false and misleading
can lead to a number of undesirable outcomes, including:

• Impeding legal fact finding

• Jeopardizing the legal rights, claims, and defenses of both patients and health
care providers
• Putting health care organizations and providers at risk of liability

Reimbursement: Documentation is utilized to determine the severity of illness, the

intensity of services, and the quality of care provided upon which payment or
reimbursement of health care services is based.

Research: Evaluation and analysis of documented data are essential for attaining the
goals of evidence-based practice in health care.

1.3 Major documentation in ICU

1. Patient assessment reports: Nursing staff completes the documentation of

• Assessment reports: Perform comprehensive physical assessment per standard

practice and document focused patient assessments result

Focused patient assessment includes the body system related to the presenting problem
or current concern (ex: Pulmonary assessment with care to document accurate
respiratory rate, lung sounds, and oxygen flow/ventilator settings).

• Abnormal findings
• Vital signs
• Clinically relevant intake and output
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 • Key patient information such as height, weight, allergies, and advanced
directives.
• Lines, drains, airway, and wounds (LDAs) are documented upon insertion or
presentation

2. Communications with other health care professionals regarding the patient

3. Communication with and education of the patient, family, and the patient’s
designated support person and other third parties
4. Medication and physician order records (MAR)
5. General observation chart

Figure 1: General observation chart sample

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NB. Timely documentation of the following types of information should be made and
maintained in a patient’s record to support the ability of the health care team to ensure
informed decisions and high-quality care in the continuity of patient care.

1.4 Principles of documentation

Principle 1: High quality documentation: Accessible, accurate, relevant, consistent,

auditable, clear, concise, complete, legible/readable, timely, contemporaneous, and
sequential, reflective of the nursing process, retrievable on a permanent basis

Principle 2: Education and Training: Have skills on the documentation system,

competence in the use of the computer and its supporting hardware, proficiency in the
use of the software systems in which documentation or other relevant patient, nursing
and health care reports, documents, and data are captured

Principle 3: Policies and procedures: The COVID 19 ICU professionals must be

familiar with all organizational policies and procedures related to documentation and
apply these as part of nursing practice.

Principle 4: Protection systems: Availability of paper-based or electronic

documentation, protection of patient identification, confidentiality of patient, clinical
professionals’ information and organizational information

Principle 5: Documentation Entries: Entries into organization documents or the

health record (including but not limited to provider orders) must be:

• Accurate, valid, and complete; Authenticated; that is, the information is truthful,
includes name and signature, and nothing has been added or inserted; Dated and time-
stamped by the persons who created the entry; Legible/readable; and made using
standardized terminology, including acronyms and symbols.

Principle 6: Standardized Terminologies: permit data to be aggregated and analyzed.

These terminologies should include the terms that are used to describe the planning,
delivery, and evaluation of the clinical care of the patient or client in diverse settings

1.5 Documents in the ICU

Different protocols, SOPs, policies, guidelines etc…are prepared and customized based
on the ICU setup at different facilities. These documents includes

• General ICU policy

• Admission /discharge criteria protocols
• Patient transportation protocols
• Patient monitoring formats

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• Communication protocols
• Round protocol
• Handover registry

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SESSION 2: ICU POLICY

Session description

This session describes the general policies and principles to follow for the training
participants. It describes major roles and responsibilities of health care professionals
working in ICU set ups.

Session objective

• After completing this session the participants will be able to define major ICU
polices components related to health professionals and patients

Enabling objectives

• Discuss the major parts of ICU policy

• Familiarize COVID 19 related policies in the ICU

Session duration: 15 minutes

Brain storming: What are the major principles of documentation policy in ICU?

2.1 Introduction

Intensive care units give care to patients with critical or life-threatening illnesses and
injuries, which require constant care than is needed by other patients. In many setups,
ICUs are staffed by specialized personnel and with higher staff to patient ratio than any
other unit. In addition, it has access to advanced medical resources and equipment that
are not routinely available elsewhere. Due to the complexity of the level of care
expected from ICU, all the above combinations need to be handled carefully for an
effective care provision. Therefore, having an ICU policy that is customized based on the
specific facility situation and understood by all professionals working in the ICU set up
is mandatory.

2.2 General ICU policies

i. Allocate duty, arrival and departure times

• Staff will arrive early enough so they can be at the bedside, ready to accept
handover report, at the start time of every shift
• If you are going to be late >5 minutes, you must communicate directly with either
the ICU head or head nurse and provide an explanation.

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• Off-duty nurse must remain with patient until on-duty nurse arrives. If on-duty
nurse does not arrive, the off-duty nurse must report to the charge nurse or
manager who will provide guidance.

Duty Break Times

Staff will take break times according to the rules set at the COVID 19 ICU which
includes

• Who covers before going on a break

• Each unit area in the ICU must have at least 2 nurses who remain monitoring
patients while others go on break.
• Physicians cannot “cover” a patient for a nurse.
• Allocate tea and lunch break time and make sure everyone stick to it

ii. Sick calls/personal days

The following sick call notification rules can be applied

• If you or a family member is sick and you cannot come to work, notify the ICU
head nurse as early as possible. Notifying another nurse is not acceptable. Upon
your return to work, you must submit sick-leave documentation to the head
nurse
• If you get sick while on duty or have family emergency while you are at work,
notify the ICU head nurse hence a decision will be made about what action will
be taken.

iii. Cell Phone Use

In order to maintain consistent patient monitoring, IPC and a quiet ICU environment,
the following rules will apply.

• At no time will physicians or bedside nursing staff use cell phones in the
COVID 19 ICU.
• Staff should provide families the dedicated COVID 19 ICU phone numbers
and COVID 19 center of the hospital.

iv. Donning and doffing (Dress Code and Appearance)

Refer to IPC donning and doffing session

v. Patient Dignity

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At all times, Dignity, Respect, and Modesty will be maintained for all COVID 19 ICU
patients.

Privacy curtains are to be drawn during the following;

• Full Physical Examinations/Assessments

• Bed Baths (in order to optimize comfort and reduce hypothermia, expose
only the area being washed)
• Any Procedure/Action during which patient exposure is probable.

vi. Handover Reporting

Documented handover reporting between shifts for each ICU bed is critical for ensuring
good patient-care continuity.

1. Shift-to-Shift: Between ICU Staff:

• Comprehensive, but brief, review of major systems. Address unusual
events: de-saturation, hypo-hypertension, ventilator issues, unusual lab
results, etc., and what therapy, if any, was initiated.
• Before off-duty nurse departs, check for; new soiling, leaking IV sites,
endotracheal tube issues, and proper infusion pump programs
2. Pt. Transfer into the ICU: Ex. ER to ICU
• See ICU Transfer Report Sheet
• An incomplete handover can lead to serious clinical errors or delayed
therapies.

vii. Responding to Device Alarms

Setting safe alarm limits and quickly responding to alarm sounds is a core nursing
responsibility and patient safety issue.

• After assessing a patient’s condition, nurses will program safe alarm parameters
on:
• Ventilators
• Patient Monitors
• Nurses must adjust alarm settings if a patient’s presentation changes in order to
minimize nuisance or false alarms.
• Alarm Volumes must be set loud enough so they can be clearly heard.

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 viii. Monitoring of Patients

All ICU patients will be monitored and documented according to the nurse to patient
ratio standard set by the specific health facility.

N.B: Refer to ICU patient monitoring for detailed description

ix. Vital Sign Guidelines

Document V.S. as follows

a. BP/HR/SaO2/RR/Vent settings: Q1hr

b. Urine Q2hrs
c. Temp. Q4hrs
d. GCS
• But…if urine trends down <30ml/hr., document Q1hr and notify physician.
• And…Document all VS with increasing frequency if patient begins to
deteriorate.

After your initial physical assessment, re-assess Q4hrs. or PRN, whenever a patient’s
condition has changed.

Notify physician for all significant V.S. or physical changes. Document the
communication.

Except during emergencies, nurses must obtain written orders for:

• Inserting or removing a Foley Catheter

• Inserting or removing an NGT/OGT
• Administering any new Medication or IV fluid
• Ambulating a patient
• Debriding a wound
• Removing a Central or Arterial Line
• Beginning to feed a previously strict NPO patient

x. IV Tubing and IV Site Care

*See Central Line Care Protocol of the facility for specific Central Line Guidelines.

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 xi. Transporting Patients for Procedures

ICU develops patient transport policy which includes the following:

When moving patients onto stretchers or beds:

a. One person, (one voice) must coordinate the move in order to ensure
safety of all lines and tubes. Usually, it’s the staff at the patient’s airway. If
no artificial airway, another nurse or physician can take charge.
b. After a final check of all lines/tubes, that staff member gets attention of
other staff, “Let’s move on 3 hence count 1, 2, 3!”
c. Attendants should not be asked to help, if at all possible.

When moving through corridors:

a. Anticipate problems before you begin transport (lift preparation, corridor

obstacles, crowding, etc.)
b. NEVER RUSH! Transporting should be slow and smooth with extra focus on
artificial airways and IV lines/tubes.
c. The airway and/or all lines/tubes must be carefully watched to prevent pulling
or kinking.

xii. Ventilated Patients Undergoing Dialysis

At times, ICU patients will need dialysis outside the unit. In such circumstances, the
following patient care rules will apply.

• The assigned nurse will accompany the patient to dialysis and remain
for the entire session. The nurse may take her regular breaks but the
patient must be covered by another ICU nurse.

Non-Ventilated Patients Undergoing Dialysis

The assigned nurse will accompany the patient to dialysis, provide a brief report, then
return to the ICU. The dialysis nurse should be given both ICU phone numbers so that
she can contact the ICU with any specific issues.

• Every hour, the ICU nurse will return to re-assess the patient and record
Vital Signs on the ICU flow sheet.
• When dialysis is complete, but before the patient returns to the ICU, the
nurse makes a final visit and receives a handover report from the dialysis
nurse. A final set of VS can then be recorded.

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 xiii. General Behavior & Noise Control

Be Mindful of Your Voices

• Loud voices can be upsetting to patients and to staff trying to perform their
duties
• One loud voice force other to raising their own voices in order to be heard
• Loud atmosphere makes it harder to hear patient conditions
• Except in emergencies, do not call out across distances to get another person’s
attention. Approach the person so that you do not have to yell

xiv. Patient Care Responsibilities and documentations

Assigned nurses will be responsible and accountable for the following patient care
items:

a. At the start of every shift, and every 4 hrs. Thereafter, the assigned nurse(s)
will do a head- to-toe assessment and document findings. This means
completely assessing patients’ entire body surface area for any signs of
change.
b. Documentation of Standard Vital Signs every hour, or more frequently,
depending upon patient status, (temp Q4h. if afebrile)
c. Emptying urine will be the responsibility of the assigned nurse. This will be
done every two hours, if the hourly output is > 30ml. Every hour if less.
Note* Urine collection should be coordinated with repositioning, Q2h, in order
to minimize glove use.
d. The nurse will be expected to check patient diaper at least every 2 hours
(coordinate with patient repositioning). Any sign of soiling (odor or
discolored diaper) will require appropriate intervention.
e. If more than one nurse is assigned to a single patient, both will be expected to
carry equal responsibility for care, monitoring, and documentation
Notify physician for significant V.S. or physical changes.

xv. Doctors’ Orders for Procedures

Except during emergencies, nurses must obtain written orders for the following
procedures:

• Inserting or removing a Foley Catheter

• Inserting or removing an NGT/OGT
• Administering any new or additional Medication or IV fluid (Ex: a
bolus)
• Ambulating a patient

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 • Debriding a wound
• Removing a Central or Arterial Line
• Beginning to feed a previously strict NPO patient
• Discontinuing patient feeding or medication
• Applying patient restraints

xvi. Admitting a Patient

Refer to the annex 1 for admission and discharge of COVID 19 patient in the ICU set up

xvii. Relaying Information to Families

Outline an approach in the policy to provid families, guardians, or next of kin updates
regarding the condition of patients.

Documentation

All formal conversations between clinicians, patients and families, as well as their
reactions and general response, should be documented in the patient chart.

xviii. Cleaners’ Responsibilities

Explicitly define cleaners cleaning duty by shifts, hours and utilities in the ICUC policy

xix. Hygiene and Infection Control policy

ICU related IPC are discussed on IPC hapter

Bedside 2 hours

Objective

• Identify ICU characteristics that need standardized documentation

• Able to register/document patient information appropriately and notify the
responsible person in case of abnormal findings
• Identify major ICU protocols /SOP and observe their implementation

Activities: Observe and practice ICU documentation throughout the clinical practice

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CHAPTER 3: IPC PRACTICE IN COVID- 19 ICU SET
UP
Chapter duration: 30 minute lecture and 1 hour and 15 minutes demonstration

Teaching method

• Lecture
• Demonstration
• Bedside

Chapter description: this module explains the basic principles of IPC practice in COVID
19 ICU set up which can improve the safety of patients, health care workers and the
community at large by applying a Standard set of infection control practices. This
module explain the IPC design requirements of COVID 19 ICU , Donning and Doffing
practices , Hand washing techniques, Environmental decontamination including dead
body management .

Chapter objective: by the end of this module the participants will be able to
understand explain basic principles of IPC practice in COVID 19 ICU set up.

Chapter objectives:

• Describe the basic principles of IPC

• Explain the right time and the right techniques of hand washing
• Apply model for improvement to design and execute an improvement project for
safety
• Describe the steps of proper donning and doffing
• Explain how to properly decontaminate surface , equipment
• Describe the proper management of dead body management

Sessions outline

Session 1: ICU Design

Session 2: Donning and Doffing

Session 3: Environmental Decontamination

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SESSION 1: ICU DESIGN

Introduction

The COVID-19 global pandemic has placed unprecedented strain on healthcare and
critical care services around the world. Generally, all health workers should implement
appropriate personal protective equipment (PPE) regarding contact and droplet
precautions based on recommendations by World Health Organization. For health
workers in ICU, advanced protections are required during routine intensive care and
airborne precautions are considered as airborne transmission may happen during
aerosol-generating procedures.

Most of the ICUs are not designed to deal with airborne viral infections and require
redesigning for the safety of HCWs and patients. Infection control practices related to
the prevention of spread of COVD-19 are unique and are well described. The training of
staff on infection control practices reduces the infection rate among patients and HCWs
significantly.

The ICUs of most hospitals are not designed to deal with airborne viral infections such
as the one seen in this pandemic. In fact, some of the ICU designs may be harmful to the
staff working in these areas during a respiratory virus pandemic and therefore may
require redesigning to minimize the exposure risk to HCWs (Figure 1 depicts a
suggested model of ICU for airborne illness like COVID-19).

Figure 2: ICU design

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1.1 Infrastructure

• The fundamental of ICU design is to ensure safety of both patients and HCWs
• To prevent the spread of infection, “COVID ICU” should preferably be located in a
separate dedicated building designated as COVID hospital/wing. In case this is
not possible, the COVID ICU should be located away from vulnerable areas such
as neonatal ICU (NICU), labor room, dialysis, postoperative surgical unit, etc.
• The COVID ICU should be separated from other ICU patients. At no point,
suspected COVID-19 patients should be allowed to mix with confirmed COVID-19
patients.
• The COVID ICU should have a separate entry, exit and accessible through a
dedicated lift and/or stairs with round-the-clock security to restrict entry into
the ICU.
• At entrance signages for direction and do's/don'ts for isolation area should be
present.
• There should be provision for increase in bed capacity by at least by 20% in case
of surge in patients.
• ICUs must have separate donning and doffing area, preferably located in the
anteroom at the entrance of ICU. There should be a provision of a
washing/bathing area for the HCW to shower after duty before leaving the
premises to prevent transmission of infection.
• There can be a provision for resting chambers for the staff post working hours
for freshening up to prevent burnout syndrome. However, the HCWs should be
allowed to rest only after complete doffing.

1.2 Infection Control Facilities

• Provide appropriate hand washing and hand hygiene facilities in the COVID ICU,
preferably with no touch sensors for hand washing.
• There should be provision of shower facility in changing or doffing area for the
staff.
• The used linen should be disposed either in a water-soluble bag or in a container
filled with 0.5% sodium hypochlorite.
• Provide audio–video communication in ICU patient care areas. This serves as an
information channel for the families and communication with their patients,
avoiding the necessity of physical visits and reduce cross-transmission risk.
• An ultraviolet (UV) light disinfection chamber should be available in the resting
room/change room for disinfection of personal belongings such as keys, cell
phones, etc.
• Alternatively, alcohol-based wet wipes should be available for disinfecting
personal belongings.

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SESSION 2: DONNING AND DOFFING

2.1 Use of PPE in Intensive care unit (ICU)

• Contact and droplet precautions are the minimum protection required for routine
care of patients in ICU, who have confirmed COVID-19, and who:
• Are not ventilated (either invasive or non-invasive), nor on CPAP nor
requiring HRNP or regular nebulisers
• Are intubated with a closed ventilator circuit, from which the risk of
airborne transmission is minimal. However, during routine care when the
circuit is opened (e.g. to change a heat-moisture exchanger) or if risk
assessment indicates that inadvertent disconnection of the ventilator
circuit may occur, use of a P2/N95 respirator should be considered
• Contact, droplet and airborne precautions, including a P2/N95 respirator or
equivalent, should be used for care of COVID-19 patients in ICU requiring or at risk
of AGPs.
• If a health care professional is required to remain in an ICU patient’s room for a long
period (e.g. more than one hour) to perform multiple AGPs, the use of a PAPR may
be considered, as an alternative, for greater comfort and visibility.

ICU staff caring for patients with COVID-19 (or any potentially serious infectious
disease) should be trained in the correct use of PPE, including the use of P2/N95
respirators by an infection prevention and control professional or other suitably
qualified educator.

The following PPE should be put on before entering the patient’s room:

• Long-sleeved, preferably fluid-resistant, gown or apron.

A cloth gown or apron is adequate when direct physical contact is
minimal and/or the risk of splash is low (e.g. specimen collection,
observations, medication delivery).
• Surgical mask. Varying levels of fluid resistant surgical masks are available.
When the likelihood of exposure to body fluid is low, in routine care, a level 1
surgical mask is appropriate. Level 2 or 3 masks should be used when there is a
risk of blood or body fluid exposure and in the operating theatre.
• Eye protection: face shield, wrap-around safety glasses, visor or goggles.
• Disposable non-sterile gloves when in direct contact with patient (use hand
hygiene before donning and after removing gloves). Use of boots or shoe covers
is not recommended unless gross contamination is anticipated or required as
standard attire in operating theatre or trauma room. Long hair should be
securely tied back. Coronavirus disease (COVID-19) 5 Head covering is not
required except as part of standard operating theatre attire or when performing
a sterile/aseptic procedure (e.g. central line insertion).

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*Care should be taken to avoid self-contamination when removing PPE. The principle is
to avoid contamination of clothing, skin or mucous membranes (including the eyes)
with potentially contaminated PPE.

*Do not touch the front of the gown, eye protection or mask and perform hand hygiene
between steps.

The following sequence is recommended and safe but alternative sequences can
be performed safely:

• Remove gloves without touching the outside of the glove and perform hand
hygiene.
• Remove gown/apron, without touching the front of the gown, by folding it so
that the external (exposed) side is inside; perform hand hygiene.
• Remove eye protection and mask outside the patient’s room and perform hand
hygiene. Unsoiled PPE can be discarded into general waste; if visibly soiled e.g.
with blood or faeces, PPE should be disposed of as clinical/infectious waste.
(Note: Local jurisdictional regulations for waste disposal should be followed).

*Only PPE marked as reusable should be reused after decontamination and

reprocessing according to the manufacturer’s instructions. All other PPE must be
disposed of after use.

2.2 Hand Hygiene Procedures

All team members should perform consistent and appropriate hand hygiene
procedures:

• Hand hygiene is the process of removing soil, debris, and microbes by cleansing
hands using soap and water, ABHR, antiseptic agents, or antimicrobial soap.
• Hand washing is the process of mechanically removing soil, debris, and transient
flora from hands using soap and clean water.
• Alcohol-Based Hand Rub (ABHR)is a fast-acting, antiseptic hand rub that does
not require water to reduce resident flora, kills transient flora on the hands, and
has the potential to protect the skin (depending on the ingredients).

The World Health Organization has five recommended points in time when hand
hygiene should occur in order to prevent transmission of HAIs. These recommendations
are called the “My 5 Moments for Hand Hygiene” and focus on the following times:

1. Before making contact with a patient

2. Before performing a clean/aseptic task, including touching invasive devices

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3. After performing a task involving the risk of exposure to a body fluid, including
touching invasive devices
4. After patient contact
5. After touching equipment in the patient’s surrounding areas

Figure 3: Right time and right technique for hand hygiene in health care

• Alcohol-based hand rub products should contain at least 60% alcohol, should be
certified and where supplies are limited or cost prohibitive can be made locally
by carefully following WHO Guide.
• Plain soap is effective at inactivating enveloped viruses such as the COVID-virus
due to the oily surface membrane that is dissolved by soap, killing the virus). In
addition, hand washing removes germs through mechanical action (WHO
Guidelines on Hand Hygiene in Health Care 2009)
• Chlorinated water at 0.05% is not recommended for routine hand hygiene
because it has skin and other toxic effects, and soap is easy to find and can be
used effectively

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2.3 Donning and doffing

Donning and doffing of personal protective equipment (PPE) is a systematic process

involving steps to take on and off PPE

The PPE recommended for AGPs is comprised of goggles or face-shield, head cover, N95
mask, surgical gloves, coverall/gowns, and shoe cover.

i. Donning

Donning Area

Donning area is a “clean filter” equipped with enough disposable PPE. The other
essential items are mirror for donning chairs, surgical scrubs, waste management bin,
and hand wash sink with sanitizer.

There should be a trained observer for review and confirm compliance of the steps of
donning process in the donning area.

Figure 4: Steps for donning (Flowchart 1)

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Page 31 of 202
Steps of donning and doffing

• HCWs should not wear any jewelry in the workplace.

• Scrubs top must be tucked into the scrub pants
• Perform hand wash with soap and water or hand hygiene with alcohol-based
hand rub in case hand wash is not possible.
• Collect all articles of PPE and visually inspect them for any damage.
• The gown should be fluid-resistant, non-sterile, and disposable. Make sure the
forearms are fully covered and gown is secured on the back while donning the
gown.
• Hold the N95 mask in the hands with the straps dangling free. Place the mask
securely at the nose and mouth, followed by straps with top one reaching above
the ear at the crown of head and lower one below the ears. Mold the nose piece
metal to the bridge of nose for a good seal
• The eyes and face are then covered using proper size goggles or a face shield.
• Use surgical gloves made of either latex or nitrile for hands, and pull them till the
sleeves of the gown to ensure no skin is exposed. Make sure that your wrists are
covered and that no skin is visible.

ii. Doffing

The doffing of PPE is very critical process, as chances of self-contamination are high.
The doffing should be done in presence of a trained observer to ensure compliance like
donning.

Doffing Area

Doffing area is a “contaminated filter” equipped with waste management bin as per
hospital infection control policy, mirror, hand wash sink, and washroom. It is
recommended to take shower with soap and water in the hospital premises after
doffing.

Steps for Doffing (Flowchart 1)

• Inspect your PPE for any breach. Hand wash with 70% alcohol after each step
mentioned below.
• Remove your gloves carefully without touching the outer portion of gloves using
the glove-to-glove technique.
• The doffing of gown should be done in front of mirror, with careful untie of strap.
The gown is the pulled off the body with carefully rolling the sleeves without
self-contamination. The gown is then rolled up like a ball before disposal.
• Remove your eye goggles and/or face shield without having a contact with face.

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 • N95 mask is to be removed only after exiting isolation area. Do not touch the
front surface of the mask. Remove the bottom strap first followed by top strap
and discard the mask while holding the straps.
• Clean your hands once again with either soap or water or 70% alcohol.

The ICUs of most hospitals are not designed to deal with airborne viral infections such
as the one seen in this pandemic. In fact, some of the ICU designs may be harmful to the
staff working in these areas during a respiratory virus pandemic and therefore may
require redesigning to minimize the exposure risk to HCWs (Figure 1 depicts a
suggested model of ICU for airborne illness like COVID-19).

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SESSION 3: ENVIRONMENTAL DECONTAMINATION

3.1 Hospital Disinfectants

• As far as possible, single-use or disposable equipment must be used. The non-

disposable equipment can be disinfected with either 70% ethyl alcohol or
quaternary ammonium compounds
• Sodium hypochlorite at 0.5–1% for surface disinfection (Table 1)

Table 1: Preparations of sodium hypochlorite solution and its conversion to 1%

solution

Available
Product chlorine Final concentration (1%)
Sodium hypochlorite-(liquid 3.5% Dilute 1-part bleach and 2.5-parts
bleach) water to get final 1% concentration
Sodium hypochlorite-liquid 5% Dilute 1-part bleach and 4-parts
water
NaDCC (sodium dichloro- 60% Dilute 7 g of powder and one liter
isocyanurate) powder water
NaDCC tablets (sodium 60% 11 tablets are mixed in one-liter
dichloro-isocyanurate) 1.5 water
g/tablet
Chloramine-powder 25% 7 g of powder is mixed to 1-liter of
water
Bleaching powder 70% 7 g of powder is mixed to 1-liter
water
Any other formulation Dilute as per manufacturer's instructions to achieve
final concentration.

i. Surface Cleaning

Surfaces can be divided into two groups depending on the degree of use to either high-
touch surfaces (HTS) or low-touch surfaces (LTS). Wear gloves when handling and
transporting used patient care equipment.9

High-touch Surfaces

These are with frequent hand contact like door knob, bedrails, light switches, wall area
around the toilet and edges of privacy curtains. HTS need to be cleaned and sanitized
more frequently.

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Low-touch Surfaces

These are surfaces like floor, ceilings, walls, curtains, and blinds. LTS require cleaning
less frequently about two times a day and damp mopping is preferred over dry.

Curtains in patient care areas need to be changed when visibly soiled or after each
patient discharge, while blinds must be changed when visibly soiled.

ii. Cleaning and Disinfection of Medical Equipment

• Cleaning and disinfecting of equipment should follow the recommendations of the

manufacturer or relevant WHO guidelines for the disinfection of hospital grade
equipment.
• Equipment should be single use where possible, however where it cannot be,
equipment should be cleaned between patients using 70% ethyl alcohol solutions.
• Any equipment used in the treatment of COVID-19 patients should be dedicated to
COVID-19 treatment areas where possible.
• Medical equipment must also be disinfected before removing equipment from
patient's room.

Noncritical Medical Equipment

The examples of noncritical equipment include stethoscopes, blood pressure cuffs, etc.
They need low to intermediate level of disinfection after cleaning for removal of any
organic matter (Table 2).

Table 2: Medical equipment cleaning

Items Agent used Procedure of cleaning

Stethoscope Alcohol- • Clean with soft detergent water for any
based wipes organic matter, use 70% alcohol wipes for
disinfection before next patient use

Thermometer Detergent • Preferably use new thermometer for each

and water patient
Alcohol rub • After each use should be stored dry in
individual holder.
• In case of nonavailability clean with soft
detergent and tepid water and wipe with
70% alcohol rub between patient use.

Injection and Detergent • To be cleaned daily with detergent and water

dressing trolley and water • After each use should be wiped with

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Items Agent used Procedure of cleaning
disinfectant (70% alcohol or 1%
hypochlorite)

iii. Terminal Cleaning after Discharge of Patients

• Terminal cleaning is complete environmental decontamination of the patient

care area after discharge.
• Terminal cleaning includes cleaning for removal of any organic or nonorganic
matter followed by disinfectant process
• Housekeeping staff should wear full PPE—surgical mask or N95 mask, protective
eyewear, coverall/gown, and gloves—before entering patient-care area
• Clean all surfaces of bed and mattress with 1% sodium hypochlorite.
• Wash the floor with wet mop followed by disinfection with 1% sodium
hypochlorite.
• In case of accidental exposure, disinfection should be done according to area
exposed

3.2 Biomedical Waste Management

• Separate color-coded bins/bags/containers in ICU should be kept for proper

segregation of waste based on hospital infection control policy.
• The bags (using two bags) should be covered in double layers for collection of
waste in ICU to provide adequate strength and to prevent any leaks.
• The waste collected from COVID area should be clearly marked and stored
separately from other BMW, prior to handing over to Biomedical Waste
Treatment or Disposal Facility. In case this is not possible, BMW can be handed
over directly to disposal facility staff.
• For easy identification of BMW from COVID area, they can be labeled “COVID-19
Waste”. This labeling will be helpful for housekeeping staff and BWTFs staff to
identify the waste easily prior to appropriate disposal.
• General waste not having contamination should be disposed as solid waste as
per Solid Waste Management.
• Maintain separate record of waste generated from COVID-19 isolation wards

3.3 Dead Body Management

• The staff responsible for handling dead bodies should be trained by infection
control nurse in IPC practices and safety. This includes the staff in the isolation ICU,
mortuary, ambulance, or those working in the crematorium/burial ground.

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• All personnel responsible for handling dead body should take standard precautions,
including hand hygiene before and after handling, and use appropriate PPE,
including a fluid-resistant apron and surgical gloves.
• Facial protection using a face shield or goggles must be done in case of risk of
splashes of either body fluids or secretions.
• Remove all lines, catheters, or other tubes before packing the body.
• Any body fluids leaking from orifices must be properly contained before packing.
• The body handling should be kept as minimum as possible and by restricted trained
personnel only.
• The dead body must be placed in a leak proof plastic body bag, preferably double
layered; 1% hypochlorite can be used to decontaminate exterior of the body bag.
• It is important to maintain appropriate temperature at the mortuary, as heat and
humidity will cause body decomposition.

Summary

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CHAPTER 4: ICU EQUIPMENT UTILIZATION
Chapter duration: 1 hour lecture 3hour demonstration

Teaching method

• Lecture
• Demonstration
• Bedside

Teaching materials

• Power point
• Flip chart
• Document observations

Chapter objective: At the end of this chapter the participants will be able to

• Utilize common ICU medical equipment

• Apply preventive maintenance on ICU equipments

Sessions outline

Session 1: Suction Machine

Session 2: Infusion Pump

Session 3: Mechanical Ventilation

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SESSION 1: SUCTION MACHINE

1.1 Introduction

Suctioning of a tracheal tube is a frequent and integral activity of airway management in

an adult intensive care unit. Airway suctioning can have deleterious effects on the
patient’s physiological variables. The variability in pathophysiology between patients
requiring mechanical ventilation and the potential adverse effects of the procedure
require that suctioning be customized to individual patients. This guideline has been
developed to provide clinicians with recommendations to guide the development of
local policy/procedures in relation to suction through an artificial airway in critically ill
adult.

collapse appropriate management of the patient with an artificial airway can have an
impact on reducing complications (such as the development of ventilator associated
pneumonia (VAP), length of ICU stays, duration of mechanical ventilation and mortality
and morbidity (Tracheal suction is required to maintain a patent airway and assist with
preventing hypoxia, infection and atelectasis from retention of sputum. Complications
such as hypoxia, cardiac dysrhythmias and mucosal damage have been associated with
tracheal suctioning. Appropriate and competent suctioning technique is important in
minimizing risk and adverse events. The guideline is relevant for practitioners who
perform tracheal suction on patients with artificial airways.

This includes patients who are mechanically ventilated; those being weaned from
mechanical ventilation; and patients with an artificial airway in a ward. Although this
guideline addresses the suctioning requirements of most intubated patients, it does not
address the specific needs of special patient groups such as patients with intra-cranial
hypertension, severe lung injury, or on unconventional modes of ventilation such as
high frequency oscillating ventilation (HFOV) or extra corporeal membranous
oxygenation (ECMO). Consistent high-level evidence exists supporting the practice of
subglottic suctioning as an important component for the prevention of VAP.

1.2 The importance of suctioning a tracheal tube

Tracheal suction through an artificial airway (endotracheal, tracheostomy, or

nasotracheal tube) bypasses the normal protective mechanisms such as the cough reflex
that the upper airways provide. An artificial airway refers to the plastic tube inserted
via the nose, mouth or trachea and located into the trachea of the patient. The major
indications for insertion of an artificial airway include:

• To secure or maintain a patent airway

• To assist in the delivery of mechanical ventilatory support, and where non-
invasive ventilation (NIV) has failed

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 • To facilitate the removal of tracheal secretions
• To aid in the management of multi-organ failure/sepsis
• To reduce the risk of aspiration where patients are unable to protect their own
airway (neurological, unconscious)
• To deliver high concentrations of oxygen

There are a number of potential adverse effects, however, on several body systems
including:

• Respiratory (e.g. reduction in lung volumes, hypoxia, and alveolar collapse,

introduction of infection and trauma to the trachea.
• Cardiovascular (e.g. bradycardia, hypotension, and hypertension)
• Neurological (e.g. increase in intracranial pressure and reduction in cerebral
blood flow).

Table 3: Hazards and complication of suctioning

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Practice point: Suction catheter size

Suction catheter size (Fr) = [ETT size(mm) minus 1] then multiply by 2 (13) or 3FG =
1mm diameter (1FG approx. 0.3mm diameter). For example, for a size 8 ETT: Using the
first formula, {8 minus 1} then multiply by 2 = 14Fr (this formula will give a slightly
larger catheter size), or Using the second formula half the diameter of 8mm = 4mm.
Then multiply this number by 3 = size 12 FG.

1.3 Types of Suctioning

A. Open suction systems (OSS) refer to a single-use catheter inserted into the artificial
airway either by disconnecting the ventilator tubing or via a swivel connector.
B. Closed suction systems (CSS) enable patients to be suctioned by a suction catheter
enclosed within a plastic sleeve, without the need for ventilator disconnection

Table 4: Recommended PPE CSS and OSS

Summary questions
1. What is the optimum suction pressure to minimize adverse effects of alveolar
de-recruitment, hypoxemia and hemodynamic parameters?
2. How far down a tracheal tube should the suction catheter be passed that
minimizes patient complications of tracheal mucosal damage, patient discomfort
and autonomic effects?
3. What size suction catheter should be used to minimize the adverse effects of
alveolar de recruitment, hypoxemia and hemodynamic parameters?
4. What conditions should determine the frequency of suctioning?
5. Which suction method results in the greatest sputum yield? 6. Which suction
methods result in reduced cross contamination?

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SESSION 2: INFUSION PUMP

2.1 Infusion pump Medication Reconstitution and Drug Dosage

Calculation

Learning Objective: After completion of this module trainees will be able to:

• Explain the essence of medication reconstitution.

• Reconstitute a medication.
• Calculate doses from reconstituted medications.
• Demonstrate how to manipulate infusion pump

Calculate drop rate and drops per minute

KEY TERMS

• Concentration: How much solute is dissolved in a certain amount of fluid.

This is going to be a specific amount of drug which is dissolved in a specific
amount of fluid.
• Desired dosage: - is the ordered dosage of the physician
• Diluent: Product added to a solution, powder, ointment, cream or other
product used to reconstitute, dissolve, or dilute another product.
• Drop factor: - is the “drops per milliliter” delivered to the patient and it
depends on the macro drip used for the infusion, commonly 10, 15 and 20.
• Medication Reconstitution: Using the given directions, or recipe, on a
prescription label to reconstitute the powder contained inside to a specific
concentration as indicated.
• Reconstitution: The process of adding a diluent to a dry ingredient to make
it a liquid.
• Shelf Life: The length of time medication can be stored safely and
administered.
• Stock strength: the amount of drug present in the preparation
• Stock volume: is the amount of the solution where the drug is diluted

i. Medication Reconstitution

Medications are available in different forms: tablet, liquid mixture or in a dry form –
powders and crystals. Dry medications available in three common containers: a
glass vial, a glass ampule, and a plastic bottle. medications are packaged in a dry
form so that they can be stored for a longer period of time. 50 ml solute + 50 ml
Solvent = 100ml Solution (reconstituted). A pharmacist or other health professional
will need to reconstitute the medication so that it can be administered to the patient.
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 To guide the reconstitution process, the container containing the powdered
medications will have directions, or recipe, on the label on how to properly
reconstitute the medication. Therefore, before reconstituting a medication, it is
important to thoroughly read the medication label on the container. After a
medication has been reconstituted, it can be stored only for a short time (Shelf life)
before it can no longer be used.

The medication label provides information about

• Name of the medication – Brand and/or generic name

• Quantity of medication in the vial
• Directions on how to properly reconstitute the medication
• Expiration date
• Proper administration – IM, IV, SC, etc.
• Name of the pharmaceutical company who makes the medication
• How long the shelf life is after it has been reconstituted
• Additionally, the medication label will indicate the concentration after
reconstitution. For example, 250 mg/5 mL or 10,000 U/mL.

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 ii. Calculation of drug dosage and flow rate

Calculating Doses from a Reconstituted Medication

Once the medication has been reconstituted, it becomes the responsibility of the health
professional to calculate the correct dose to be given to the patient. The dosage may be
calculated by using dimensional analysis or accepted formulas. As a general rule, follow
the 8 rights of medication administration.

Right Patient

• Right Medication
• Right Dose
• Right Route
• Right Time
• Right Reason
• Right response
• Right Documentation

Summary questions

Example 1: - The nurse practitioner is ready to administer2000mcg intravenously. The

label on the vial says to reconstitute with sterile water for a concentration of 2mg/ml,
then dilute each 2mg in 75ml of normal saline. How many ml will you use to administer
the ordered dose?

• Hint: -In order to come up with the required ml, we should first write the given
and required amounts and use either the dimensional analysis or the formula
shown above.

Given: -

Desired dose = 2000mcg

Dose at hand (Stock strength) = 2mg

Volume at hand (stock volume) = 75ml

Required: -ml/dose (amount to be given)?

Solution 1: Calculating the required amount by using dimensional analysis

2,000𝑚𝑐𝑔 1𝑚𝑔 75𝑚𝑙

Ml/dose = ∗ 1000𝑚𝑐𝑔 ∗ , Cancel out the units of measurement
1𝑑𝑜𝑠𝑒 2𝑚𝑔

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 2,000 1 75𝑚𝑙
= 1𝑑𝑜𝑠𝑒 ∗ 1000 ∗ , multiple everything in the numerator and denominator
2

150,000𝑚𝑙
= = 75ml/dose
2,000𝑑𝑜𝑠𝑒

Solution 2: - Calculating the required amount by using “mixtures and solutions”

formula

𝐷𝑒𝑠𝑖𝑟𝑒𝑑 𝑑𝑜𝑠𝑒
Amount to be given = 𝑆𝑡𝑜𝑐𝑘 𝑠𝑡𝑟𝑒𝑛𝑔𝑡ℎ ∗ 𝑆𝑡𝑜𝑐𝑘 𝑣𝑜𝑙𝑢𝑚𝑒

= (2000mcg) * (75 ml)/ 2mg, convert the mg to mcg

= (2000mcg) * (75 ml)/ 2000mcg, cancel out the units

= 150,000ml/2,000 = 75ml/dose

Example 2: - A patient recovering from accidental fall is about to be given 130 mg drug.
The drug is available in 250 mg per 5 mL preparation. How much should you give to
your patient?

Given: - Desired dose = 130mg, Stock strength = 250mg, Stock volume = 5ml

Required: - Amount of solution to be given

𝐷𝑒𝑠𝑖𝑟𝑒𝑑 𝑑𝑜𝑠𝑒
Amount to be given = ∗ 𝑆𝑡𝑜𝑐𝑘 𝑣𝑜𝑙𝑢𝑚𝑒
𝑆𝑡𝑜𝑐𝑘 𝑠𝑡𝑟𝑒𝑛𝑔𝑡ℎ

= [130 mg ÷ 250 mg] x 5 mL= 0.52 x 5 mL = 2.6 mL

NB. When drawing up medication, always use the smallest syringe possible. This will allow you
to draw up the correct amount of liquid needed more accurately.

Calculating IV rate

The drop rate, also known as IV rate, is a measure of how fast the Iv fluid is being
administered. It is expressed as ml/hr or ml/min.

To calculate this rate, use the following formula

𝑇𝑜𝑡𝑎𝑙 𝐼𝑣 𝑣𝑜𝑙𝑢𝑚𝑒
Drop rate = 𝑇𝑖𝑚𝑒 (ℎ𝑟 𝑜𝑟 𝑚𝑖𝑛𝑢𝑡𝑒)
Example1: - Your patient has dopamine ordered at 15 mcg/kg/min. The patient weighs
50 kg. The 250 mL IV bag has 500 mg of dobutamine in it. At what drop rate will you
infuse it?

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Given:- Desired dose = 15mcg/kg/min

Stock strength = 500mg

Stock volume = 250 ml

Required:- Infusion rate?

Solution 1: - using the dimensional analysis technique

15𝑚𝑐𝑔 60𝑚𝑖𝑛 250𝑚𝑙 1𝑚𝑔 50𝑘𝑔

= ∗ ∗ ∗ ∗
1𝑘𝑔 1𝑚𝑖𝑛 ℎ𝑟 1,000𝑚𝑐𝑔 500𝑚𝑔

= 22.5ml/hr

Solution 2: - Using the Iv rate formula

𝑇𝑜𝑡𝑎𝑙 𝐼𝑣 𝑣𝑜𝑙𝑢𝑚𝑒
Drop rate = 𝑇𝑖𝑚𝑒 (ℎ𝑟 𝑜𝑟 𝑚𝑖𝑛𝑢𝑡𝑒)

First let’s calculate the total IV volume (amount of solution to be given)

Amount of solution = (Desired dose * Stock volume) ÷ Stock strength

= (15mcg/kg/min * 250ml)/500mg, Change the mcg to mg

= ((0.015mg * 50/min) * 250ml)/500mg

= 0.35ml/minute, multiplying by 60

= 22.5 ml/hr

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2.2 Infusion pump

i. Introduction

An infusion pump is a medical device that delivers fluids, such as nutrients and
medications, insulin or other hormones, antibiotics, chemotherapy drugs, and pain
relievers, into a patient’s body (circulatory system) in controlled amounts. Infusion
pumps offer significant advantages over manual administration of fluids, including the
ability to deliver fluids in very small volumes, at precisely programmed rates or
automated intervals. They can administer as little as 0.1 ml. per hour injections (too
small for a drip), injections every minute, injections with repeated boluses requested by
the patient, up to maximum number per hour (e.g. in patient-controlled analgesia), or
fluids whose volumes vary by the time of day.

ii. Infusion Pump Types

• Enteral pump: A pump used to deliver liquid nutrients and medications to a

patient’s digestive tract.
• Patient-controlled analgesia (PCA) pump: A pump used to deliver pain
medication, which is equipped with a feature that allows patients to self-
administer a controlled amount of medication, as needed.
• Insulin pump: A pump typically used to deliver insulin to patients with
diabetes. Insulin pumps are frequently used in the home.

Anatomy of an infusion Pump: an infusion system consists of three main components

• A Container of the substance to be infused.

• A Tubing system to transfer the substance to the delivery site and into the
patient.
• A Device for controlling and delivering the substance

Device for controlling and delivering the substance (The pump itself)

Let’s take a look at the layout of the B. Braun infusion pump.

• Power supply
• LCD screen
• User interface-- for programming
• Alarm to alert user of failures and other issues that need attention
• 2 power distribution boards
• Memory capabilities
• Records doses, rates, and settings

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 • Commonly used buttons

The commonly used buttons at B. Braun infusion pump are: -

• Power Key: On and off, Standby

• Door open key: To open and close the pump door
• Start/stop Button: to start or stop infusion
• “Bol” Key: To program/initiate the bolus
• C key: to reset single values to zero and to switch back to previous screen or menu
• “Up and Down arrows”: - to Scroll between menus, change settings of numbers, answer
Yes/No questions
• “Left and right arrows”: - To select data from a scale and switch between digits when
numbers are entered
• Blue Arrow Key: for biomedical and barcode scanning
• Ok key: to confirm entries

Summary questions

Setting vasopressor infusion

Your patient has dopamine ordered at 10 mcg/kg/min. The package insert tells you that
the 500 mL IV bag has 500 mg of dopamine in it. The patient weighs 60 kg. At what
drop rate will you infuse this drug via a Per fuser and how do you set it on the infusion
pump?

Solution: -

Given:- Desired dose = 10mcg/kg/minute

Dose at hand (Stock strength) = 500mg

Volume at hand (Stock volume) = 500ml

Required= drop rate?

To calculate the drop rate first, we should get

Desired dose x Stock volume / stock strength

= (10mcgx60/min) x 500ml/500mg

Then convert the mg to mcg

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= (10mcg/kg X 60kg/min) X 500ml/500 X 1000mcg

= 600mcg/min X 1ml/1000mcg

= 0.6ml/min

Convert it to ml/hr (Since infusion pumps are set based on ml/hr rate)

= 0.6mlX60 = 36ml/h

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SESSION 3: MECHANICAL VENTILATION

3.1 Introduction

Mechanical ventilator is a machine that helps to breathe air in and out of the lungs
either partially or completely.

Mechanics of breathing

Air moves in and out of the lungs in response to differences in pressure.

During inspiration:

• The intercostal muscles contract and the diaphragm goes down leading to an
increase in lung volume. Therefore, less air per unit of volume in the lungs
and pressure falls. When the air pressure within the alveolar spaces falls
below atmospheric pressure, air enters the lungs.

During exhalation:

• The intercostal muscles relax and the diaphragm goes back up leading to
decrease in lung volume, pressure rises above atmospheric pressure, and air
flows into the atmosphere until pressure equilibrium is reached at the
original lung volume

Indications:

• The major indications for mechanical ventilator include type 1 respiratory

failure (Hypoxemic respiratory failure) and type 2 (hypersonic
respiratory failure).
• It may also be indicated for airway protection in patients with depressed
mental status resulting from intracranial process, metabolic causes, drug
overdose (poisoning) or anesthesia.
• Patients with septic shock and severe metabolic acidosis requiring
increased ventilator demand may also benefit mechanical ventilation
which would serve to conserve energy delivery to the respiratory
muscles.

3.2 Clinically important external parts of mechanical ventilator

Composed of four main parts:

1. The power sources

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 2. The controls

• A gas blender
• A gas accumulator
• Inspiratory flow regulator
• Humidification equipment is

The circuit:

Expiratory pressure regulator (i.e PEEP valve)

3. The monitors are means of sensing and presenting the characteristics of gas
delivery so that one might be able to assess the ventilator’s performance (and
probably also the patient’s condition).
• Gas concentration
• Flow
• Pressure
• Volume

4. The safety features are some devices and measures which ensure that the patient
does not come to any additional harm from being ventilated. These consist of filters
and alarms.

• Inspiratory filters
• Expiratory filters
• Alarms.

Types: several versions and series of mechanical ventilators have evolved over the
past few decades. The commonly used types found in our country include Dragger,
Philips, Mind ray, Shangri-La, GE, etc. Mechanical ventilators would vary based on their
external appearances and the interface displayed on their screens.

• Health professionals using those machines should be familiar with

the machines they have. This document would help in the general
overview and minor details.

3.3 Basics terminologies of mechanical ventilator

Modes: describes the interplay between the patient and the ventilator.

There are different types of modes individually characterized by the kind and level of
support they render to the patient. Assist Control (AC), Synchronized Intermittent

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 Mandatory Ventilation (SIMV), Continuous Positive Airway Pressure (CPAP) and
Pressure Support Ventilation (PSV) are the commonly used modes in clinical practice.

Trigger: is what causes the machine to start inspiration (signals to open the inspiratory
valve).

• Machine triggered: The machine will trigger regular breaths at a frequency

which will depend on the set respiratory rate, i.e. Time triggered. Such
breathes are called mandatory or controlled breaths.
• Patient triggered: If the patient does make an effort to breathe and the
ventilator can sense it (by either sensing a negative inspiratory pressure,
pressure triggered or an inspiratory flow, flow triggered) and deliver a
breath. Such breathes are called patient triggered or assisted breathes.
• Cycle: is a signal that stops inspiration and starts expiration. This may be
volume-, time-, or flow-related.

Modes:

• Assist Control: Every breath is supported regardless of trigger, whether

patient or machine triggered. Let’s say we set at a rate (frequency) of 12 on
the machine. If the patient breathes less than 12, the machine will give the
extra mandatory breathes to a total rate of 12. However, if the patient
breathes more than 12 the machine will fully assist all the extra breathes
above 12. All breathes will be either fully assisted (patient triggered) or
mandatory.
• Synchronized Intermittent Mandatory Ventilation (SIMV): In this mode
the machine will provide a synchronized support, synchronized with the
patient’s effort. Let’s say we set at a rate (frequency) of 12 on the machine. If
the patient breathes less than 12, the machine will give the extra mandatory
breathes to a total rate of 12. However, if the patient breathes more than 12
the machine will only pressure assist the entire extra breathes above 12. The
breath could be either fully assisted (patient triggered), mandatory or
spontaneous-pressure-supported.

3.4 Putting new patient on mechanical ventilator

i. Patient-Ventilator System Checks

• Turn ventilator on and securely attach an appropriate patient circuit

• An operational verification procedure (OVP, as described in the appropriate
department's policy and procedure manual) must be performed prior to
applying ventilator to the patient.

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 • May be accomplished manually by occluding the patient connection and
observing airway pressure rise on a pressure monitor or may be a self-
test performed by the ventilator to assure proper internal function. Check
on artificial lung as well
• Check patient information including patient name, patient hospital number,
age, weight, height, diagnosis, endotracheal or tracheostomy tube size and
position
• Set appropriate mechanical ventilator setting and alarms

ii. Initial ventilator set-up key decisions

• Mode: CMV/AC/SIMV / PS, PRVC- Pressure/Volume control

• Vt (in volume control) : 6 -8 ml/kg IBW (maintain Pplat< 30cmH2O)
• PIP(in pressure control): 10-20cmH2O( maintain adequate tidal volume)
• Freq/ RR: 10 - 16 bpm, (maintain minute ventilation but minimize auto
PEEP)
• FiO2: 100 then reduce for SpO2>90%
• PEEP: 5 cmH20 and above (Recruitment maneuver in ARDS)
• PSV: 10-15 cmH20
• (I:E) Ratio: (1: >2 )
• Insp time: 0.6 – 2.0 sec (maintain adequate I:E ratio)
• Flow rate: 50 - 80 lpm, to achieve optimal Insp time [I:E ratio]
• Trigger/ Sensitivity: 0.5 - 2 cmh2o or 1-3 L/m [pressure/flow]

iii. Alarm Settings

Always set the alarm according to each patient

Never ignore an alarm when it is set off

High Pressure alarm

• 35-40 cmH2O
• Coughing
• Biting, kinking, mal positioning of ET tube(endobronchial)
• Increased airway resistance (secretions, edema, bronchospasm)
• Decreased compliance (pneumothorax, pulmonary effusion)
• Patient – ventilator asynchrony
• Accumulation of water in circuit
• Kinking in inspiratory circuit
• Malfunction with inspiratory/expiratory valves

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Low pressure alarm

• 5-8cmH20
• Disconnections- circuit, humidifiers, filters, water traps, nebulizers, closed
circuit catheter
• Circuit leaks
• Exhalation valve leak
• Airway leaks- Improper endotracheal tube cuff inflation
• Migration of ET tube/extubation or esophageal
• Chest tube leaks

Low tidal volume

• 100ml below set/actual tidal volume

• Disconnections, leaks
• Decreased compliance, increased resistance
• malfunctioning

Low minute ventilation

• 2l/min below set minute ventilation

• Disconnections, leaks, malfunctioning

High minute ventilation

• 5l/min above set minute ventilation

Apnea

• 20 seconds
• patient apneic or disconnection, low sensitivity setting
• Set Vt and freq for full ventilator support in the event of apnea

3.5 Troubleshooting mechanical ventilation

1. High airway pressure

• High airway pressure may cause barotrauma
• It signifies a deterioration in the patient's clinical state
• It may result in hypoventilation of the patient (many ventilators cycle
from inspiration to expiration immediately if the upper pressure alarm
limit is reached. As a result, inspiration is terminated early and the tidal
volume is reduced)

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 Causes

i. Ventilator causes: Inappropriate settings- Excessive tidal volume, excessive inspiratory

flow, short inspiratory time, excessive PEEP. Obstruction in the ventilatory circuit- water
pooling in the circuit, filter that is filled with water, malfunction with inspiratory/expiratory
valves
ii. Patient causes:
o Coughing, Biting, kinking, mal-positioning of ET tube(endobronchial)
o Increased airway resistance (secretions, edema, bronchospasm)
o Decreased compliance (pneumothorax, pulmonary effusion)
o Patient – ventilator asynchrony

Management

2. Assess patient
3. Disconnect patient from ventilator and manually ventilate using ambu bag.
Assess the "feel" of the lungs. Is the patient difficult to ventilate? If the patient is
not difficult to ventilate the problem is a problem with the ventilator or the
circuit. If the patient is difficult to ventilate it is a problem with the endotracheal
tube or the respiratory system.
4. For ventilator and circuit problems check ventilator settings and function, and
check circuit for obstruction or kinking. For patient or ETT problems examine
the patient looking particularly for wheeze, asymmetrical chest expansion and
evidence of collapse. Pass a suction catheter through the ETT to check its
patency.
5. CXR

If the cause is still not clear measure inspiratory pause pressure (approximates to
alveolar pressure). If both airway and alveolar pressure are high the problem is due to
poor compliance. If only the airway pressure is high the problem is one of high
resistance.

2. High respiratory rate

• Patient anxiety or pain
• Secretions in ETT/ airway
• Hypoxia/ hypercapnia
3. Low Oxygen
• Oxygen cylinder has run out
• Oxygen tubing disconnected
• Defective built in oxygen analyzer
4. Hypotension

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The most important causes of hypotension occurring soon after the initiation of
mechanical ventilation are:

• Relative hypovolemia
• Reduction in venous return exacerbated by positive intrathoracic pressure
• Drug induced vasodilation and myocardial depression (all anesthetic
induction agents have some short lived vasodilatory and myocardial
depressant effects)
• Gas trapping (dynamic hyperinflation)/ auto PEEP
• Tension pneumothorax
• Myocardial infarction
5. Desaturation
• Endobronchial intubation
• Accidental extubation
• ET tube blockage
• Pneumothorax
• Pulmonary embolus
• Atelectasis
• Acute pulmonary edema
• Any cause of increased intrapulmonary shunt
• Any cause of hypoxic respiratory failure
• Ventilator malfunction

3.6 Bed side care of a mechanically ventilated patient

Ventilator-associated pneumonia is not uncommon, and it adds significant morbidity to

the patient. Guidelines to prevent ventilator-associated pneumonia include the
following:

• Maintain the head of the bed elevation between 30 and 45 degrees if there
are no contraindications
• Assess the patient daily for readiness to extubate and give a break from
sedation- sedation vacation. This also depends on the vital signs, arterial
blood gas, and hemodynamic instability. Assess the patient's own ability to
breathe. The shorter the time on the ventilator, the lower the risk of
ventilator-associated pneumonia
• All patients on the ventilator need to have prophylaxis against peptic ulcer
disease. Use a proton pump inhibitor or a histamine 2-blocker.
• All patients on a mechanical ventilator should receive deep vein thrombosis
prophylaxis. The use of either heparin and/or sequential compression
stockings may be appropriate

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 • Oral cavity hygiene should be maintained. The teeth should be brushed, and
the mouth should regularly be rinsed. The use of chlorhexidine has been the
standard of care for many years
• Perform passive range of motions to avoid contractures; turn and reposition
the patient to prevent muscle disuse and pressure sores. Having the patient
sit up helps in improving lung compliance and gas exchange
• Provide enteral nutrition if the patient has a functioning gut, and there are no
contraindications. Nutrition prevents a catabolic state and also helps build up
the immune system
• Suction any visible secretions as per need only

3.7 Weaning from Mechanical Ventilation

Mechanical ventilation should only continue when needed. Spontaneous breathing

trials and readiness for extubation should be assessed daily in all those patients. We
need to monitor variables on the patient, on the ventilator and the patient monitor.
The initial indication for mechanical ventilation should improve before complete
weaning is considered.

The following are some of the criteria for weaning:

a. Medical stability: Patient should not be in shock state or should at least be on

low dose of pressor. There should also not be clinically significant uncontrolled
acidosis or alkalosis.
b. Mental status: Patient should be having good mental status (GCS > 8) while off
sedative.
c. Oxygenation: Patient should be on the lowest ventilator support with FiO2
≤40, PEEP 5, P:F (or S:F) >200.
d. Lung mechanics: Check the Rapid Shallow Breathing Index (RSBI), which
would reflect the lung mechanics. Generally, RSBI >105 is likely to be
associated with success of extubation and it mostly means patient is not ready
for extubation.
e. Endurance: With daily spontaneous breathing trial make sure that the patient
is tolerating with RR < 35bpm, HR <140bpm, good tidal and minute ventilation,
and no diaphoresis.
f. Secretions: Patient should not be requiring suctioning more frequent than
every two hourly, and he should be having good cough impulse to expectorate
secretions ven if assumed to be small.
g. Cuff-leak test: Check this in all patients intubated for over 48 hours. This can
be checked quantitatively using the percentage of the difference in expiratory
and inspiratory tidal volumes while the cuff is deflated. If the percentage

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 difference is above 25%, it means post-extubation strider is less likely. This can
also be done qualitatively by deflating the

Cuff and auscultation over the neck: If you hear turbulence of air, post-extubation
strider is unlikely. If the leak percentage is less than 25% or there is no turbulence upon
neck auscultation, give steroid (hydrocortisone 200mg Iv stat then 100mg tid or
dexamethasone 8mg iv bid) for 24 hours before extubation

When all those criteria are met, extubation shall be considered. Be ready to re-intubate
(intubation kit should be prepared and be complete; personnel with intubation skill
should be around). Try to have the habit of extubating patients on working hours and
early in the morning than on duty hours and weekends/holidays.

3.8 Prevention of complications

Common complications in ICU to prevent includes

Catheter associated blood stream infection

• Subclavian site preferred

• Wash hand wash, use hair cap, face shield
• Wear sterile gown and sterile gloves
• Cover entire patient with full sterile sheet
• Use chlorhexidine to clean skin
• Sterile technique while using it.
• Daily reminder to remove if no longer needed

Ventilator associated pneumonia

• Oral intubation preferable to nasal.

• Use a new ventilator circuit for each patient.
• Keep patient in semi-recumbent position: head of bed 30°to 45°
• Perform regular antiseptic oral care:
• Chlorhexidine mouthwash or gel preferred.
• Once patient is ventilated, change circuit if it is soiled or damaged but not routinely.
• Periodically drain and discard condensate in tubing.
• Use in-line closed suction system.
• In adults, change heat and moisture exchanger when malfunctions, soiled, wet or
every 5–7 days.
• Consider specialized endotracheal with subglottic suctioning devices:
• Limit aspiration of oropharyngeal secretions.

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• Preform daily, coordinated SBT.

Gastric ulcer bleeding: Critically ill patients are at increased risk for gastric mucosal
injury:

• Impaired blood flow to the mucosa

• Accumulation of gastric acid.

Two independent risk factors:

• IMV for more than 48 hours

• Presence of coagulopathy or thrombocytopenia.
• Reduce risk factors:
• maintain hemodynamics (e.g. early resuscitation)
• liberate from IMV as soon as possible (e.g. SBT)
• Start early enteral nutrition for mucosal protection.
• Pharmacologic reduction of acid production:
• histamine-2 receptor blockers (H2R)
• proton pump inhibitor (PPI):
• More effective in preventing clinically important GI bleed but may be associated
with increased risk of pneumonia and Clostridium difficile infection.

ICU acquired weakness

● ICU-acquired weakness is characterized by neuromuscular weakness and physical

limitation:
● 1-year outcome of ARDS survivors found all with persistent loss of muscle
mass, proximal muscle weakness and fatigue, and only 50% back at work:
● Weakness due to:
● direct damage to nerves or muscles
● inflammatory states
● drugs (e.g. NMB or steroids)
● metabolic (e.g. hyperglycemia, malnutrition)
● Immobility and atrophy.

Early mobility and exercise protocol

● Step 1: Recognize readiness to exercise

● Step 2: Conduct appropriate level of activity based on RASS score (protocol from
ACT-ICU trial, 2012, see Toolkit for details)
● Step 3: Evaluate performance
● Step 4: Rest for next day

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 ● It is safe and feasible to do in critically ill patients on mechanical ventilation.
● Improves patient outcomes:
● increases muscle strength, functional mobility and independence
● reduces delirium
● reduces days of IMV
● reduces ICU length of stay

UTI

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CHAPTER 5: AIRWAY BREATHING, OXYGEN
THERAPY AND RESPIRATORY FAILURE
Chapter duration: 2hours lecture and 2hours demonstration

Chapter objective:

• The participant will be able to understand care of air way and breathing , oxygen
therapy and demonstrate the skills of airway care.

Methodology

• Will be covered by interactive lecture, demonstration and bedside clinical

practice

Sessions Outline

Session 1: Care of Airway and Breathing

Session 2: Oxygen Therapy

Session 3: Respiratory failure

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SESSION 1: CARE OF STHE AIRWAY

Teaching methodology:

• Interactive lecture

Session description: This session introduces the participants to airway management in

the critical care settings. It consists of ……minutes interactive lecture and…..hours of
practical sessions.

Session objective: By the end of this session, participants will be able to understand
and describe basic airway care to the critical patient with demonstration of basic airway
skills and be able to develop an airway management plan with a reasonable alternative.

Enabling objectives:

• Describe basic anatomy and physiology of the airway

• Describe assessment of the airway
• Demonstrate basic airway management skills
• Understand the principles and preparation of intubation
• Describe the physiologic function to be monitored
• Explain the benefits of proper respiratory monitoring
• Conduct proper respiratory patient monitoring
• List the respiratory parameters to be monitored in critically ill patients

1.1 Introduction

Case scenario: You are called to see a patient in COVID 19 ICU who is un-
responsive and making a loud snoring noise. He is on 4 l/min intra-nasal oxygen
and his saturation is 79%.
a. Is his airway patent?
b. Does he require any airway intervention?
c. Does he have a potential difficult airway?
d. Does he need intubation?
e. Does he need a surgical airway?

1.2 Airway management

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 i. Noninvasive Airway management

Introduction to airway management: Airway obstruction affects people of all ages

and sex and almost 99% is acquired.

It requires proper history taking and use of proper diagnostic methods.

Anatomy and physiology of the airways: Airway tract starts from the nose and mouse
down to the pharynx, larynx, (upper airway) and below the trachea (lower airway).

Figure 5: Upper respiratory tracts

The main function of the airways is to deliver oxygen to the body during inspiration
(oxygenation) and to remove carbon dioxide during expiration (ventilation). To
maintain this functions the airway should be patent or clear of obstruction.

Aims of airway assessment and management are:

1. To open or to bypass the airway obstruction,

2. To assist breathing or ventilation and
3. To protect the lungs from contamination or aspiration.

In unconscious patients: the most common cause is the tongue is falling back and
secretions

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Figure 6: Blocked airways by falling back tongue

Assessement

1. Determine unconsciousness, and assess the airway

2. Hear for the presence of breathing effort
3. Hear for abnormal sounds such as stridor, hoarse sounds
4. Look for Increased secretions, quality of chest movement and increase work of
breath
5. Feel for gas movement around the mouth and nose; if one or more of
abnormality is detected

Action

1. Open the airway using head tilt chin lift for none trauma and jaw thrust
maneuvers for trauma cases and see for presence of secretions, any foreign
materials and the position of the tongue.
2. Remove secretions using large bore suction tube, or swab with your finger any
accessible foreign materials
3. Reposition the tongue using adjuvant equipment (oropharyngeal or
nasopharyngeal airways)

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Figure 7: A. Head tilt chin lift maneuver B. Jaw thrust maneuver

1. In children nearly 50% of the total airway resistance comes from nose .Infants
younger than 2 month are obligate nasal breathers. Clearing the nasal passages
by suctioning can significantly improve an infant’s respiration.
2. Place infant nose pointing towards the roof (neutral position) and for child till
the chin pointing to the roof (sniffing position). You can also aid this by putting
small towel under the shoulder for infant or under the neck for child.

Suctioning: suck the mouth and nose. Appropriate size catheter is required especially
to sack the ETT and tracheostomy tube. Excessively deep suctioning of any patient
should be avoided to minimize the risk of vomiting and aspiration, laryngospasm, and
bradycardia. If vomiting occurs, patients head is first turned down and to one side, and
suctioning is continued until the emesis is cleared.

Insert oropharyngeal airway in deeply comatose patients (GCS<8) OR Nasopharyngeal

airways for patients GCS of >8, and position on lateral side, and monitor with pulse
oximeter continuously (see pictures below)

Figure 8: Oropharyngeal airway

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Nasophargeal airway: is used both in conscious and unconscious patients to facilitate
deep suctioning. It should be avoided in patients with a mid -facial injury, coagulation
disorder.

Size: measure from Nostril to Tragus Make sure you have chosen appropriate size of the
tubes and lubricate with water soluble jell before insertion

Figure 9: Nasopharyngeal airway

Insert the oropharyngeal airway in convex side up or using a tongue depressor, insert
the airway upside down (concave side up) until the tip reaches the soft palate. Rotate
through180° and slide back over the tongue

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1.3 Breathing management

After opening of the airway see for breathing. If patient has adequate breathing effort
start o2 administration using appropriate device, if there is no chest movement or
breathing give two rescue breaths with bag valve mask (Ambubag) and see for chest
movement. If the chest is moving when you squeeze the bag that means, there is
passage of air continue bagging and consider definitive or invasive airway management.

Technics of ventilation using ambubag

1. Have functional and appropriate size of ambubag and 3different size face mask.
2. Position patient supine
3. Open the airway using head tilt chine lift or jaw thrust (trauma patient)
4. Connect the ambubag to o2 source
5. Use C&E method or use two hands with jaw thrust to fix the ambubag to the face
of the patient
6. Squeeze gently the bag carefully to avoid over expansion of the lungs and to
avoid gastric distension. Give 10-12 breaths per minute
7. if the air is going more to the stomach rather than to the lung reposition the
patient or insert oral airway or apply cricoid pressure and decrease the amount
of gas you are pushing from the bag

Ventilation using LMA (Laryngeal Mask Airway)

If bag valve mask ventilation is difficult and you don’t have a skill to intubate the patient
and the patient condition is deteriorating use Laryngeal Mask Airway (LMA) as
temporary airway to rescue the patient and continue ventilation by attaching the BVM.
For the technique of insertion see picture below.

Patient Respiration monitoring

Respiratory rate (RR):

• The normal range for adults is 10-24/min. An increase of even three to five
breaths per minute is an early and important sign of respiratory distress and
potential sign of hypoxemia.
• Respiratory rate should be counted for a full minute, rather than 30 seconds.
• In ICU it can be counted or followed continuously using the monitors.
• Respiratory effort which is depth of inspiration, use of accessory muscles,
and symmetry of chest expansion should also be evaluated to detect
respiratory distress.

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Oxygen saturation (SaO2): it is measured using pulse-oximetry and measures what
percentage of the hemoglobin in the blood is saturated with oxygen.

• To work effectively, a pulse oximeter requires an adequate peripheral blood

flow.
• This flow may be affected by patient movement, tremor or shivering,
hypovolemia, hypothermia, pain, arrhythmias, vasoconstriction or heart
failure, nail polish, pain, and improper size of the probe and high altitude.
• It may be falsely normal anemia, and one you should not rely only on SaO2.

Capnognogram: non-invasive monitoring of CO2 concentration of the expired and

inspired gases.

• The gas is detected at the connector-end of the ETT, the mask or nasal prongs
and measures the end-tidal CO2 (EtCO2), and displayed in graph and in
number.
• This is particularly important in neurocritical and patients on mechanical
ventilator to know how far the ventilation of the patient is.
• Normal value is 35-45mm/Hg.

1.4 Demonstration sessions: airway opening maneuvers and

ventilation techniques using Ambubag and LMA

Session objective: By the end of this session, participants will be able to understand
and demonstration of basic airway skills and be able to develop an airway management
and ventilation plan with a reasonable alternative.

Enabling objectives:

• Demonstrate basic airway management (head tilt chin lift jaw thrust, recovery
positioning, airway insertion maneuvers ,oral airway, nasal airway )
• Demonstrate ventilation skills using ambubag and LMA

Introduction This session introduces the participants to airway management in the

critical care settings. It consists of …..hours of demonstration sessions.

Learning activities
No Topic Airway opening Activities Time
maneuvers

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1. Head tilting chin lift Review the objective

Jaw thrust Tell to the participant the first case

and brain storm

2. Recovery positioning

3. Airway insertions : Display the PPT

Oral and Demonstrate none invasive air way

equipment
nasal air way
Allow participants to practice on the
equipment

Demonstrate on none invasive air way

opening maneuvers
4. Breathing management Demonstrate AMBU bag and LMA
devise

Allow each of the participants to

practice for breathing
5. Summary Summarize the session

Introduction of the session

• Start session by briefing objective of demonstration

Facilitation of the session

• Group participants into 3 small groups and demonstrate the practical session.
• Allow the participants to practice on mannequins

Concluding the Session

The session will be concluded by Q & A and discussing on the summary

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SESSION 2: OXYGEN THERAPY

Session description

This is a 20 minutes session that describes the various indications for oxygen therapy
and the different methods of oxygen delivery.

Session objective

At the end of the session participants will be able to discuss the indications for oxygen
therapy and elaborate the various methods of oxygen therapy.

Enabling objectives

• List the causes of hypoxia

• Describe the indications for oxygen therapy
• Discuss the oxygen delivery methods

Session duration: 45 minutes

2.1 Introduction

Case study

A 65 year old female patient presented with cough, shortness of breath, and high grade
fever of one day duration. On exam, she is anxious, BP 150/100 mm Hg, RR 32/min, P
120 beats/min, T 38.9 0C, O2 Sat 75%. Respiratory exam revealed use of accessory
muscles, decreased air entry in lower one third of chest.

What is the diagnosis?

1. How do you like to approach patient?

2. What supportive therapy do you recommend?
3. What should be the target Oxygen saturation in the management of this case?

Hypoxemia is a major cause of morbidity and mortality in both adults and children.
Oxygen therapy is used not only for primary lung diseases, but also for many other
conditions that result in hypoxemia, such as sepsis, different types of shock, severe
malaria, status epilepticus, trauma; and obstetric and neonatal conditions.

2.2 Causes of hypoxia

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 1. Central: CNS depression due to trauma, space occupying lesion (SOL), infections,
status epilepticus,
2. Neuromuscular diseases:
3. Chest and lung injuries or infections
4. CVS: shock, anemia
5. Infections: sepsis, severe malaria

2.3 Indications for Instituting Oxygen Therapy in Adults

1. Cardio respiratory arrest

2. Respiratory distress (respiratory rate >24/min) in adult; in pediatrics according
the age
3. Hypoxia with pulse oximeter measurement (saturation of oxygen <90%) except
for COPD patients and infants
4. Hypotension (systolic blood pressure <90 mm Hg)
5. Low cardiac output and metabolic acidosis (bicarbonate<18 mmol/l)

Methods to Improve Oxygenation

1. Increase FiO2- initiate supplemental administration of oxygen with nasal prong,

different type of face mask and start to treat the causes
2. Increase minute ventilation (MV)- assist breathing with bag valve mask(BVM),
non-invasive CPAP, invasive mechanical ventilation
3. Increase Cardiac Output- treat causes of hypotension and shock
4. Increase oxygen carrying capacity – blood transfusion when there is
symptomatic anemia
5. Optimize V/Q relationship – treat pulmonary edema, with drugs and when
necessary with PEEP/CPAP
6. Decrease oxygen consumption from- pain, shivering or fever – optimal use of
analgesics

2.4 Oxygen Administration Devices and Techniques

Oxygen is a drug and has to be prescribed and the prescription has to indicate:

1. Flow rate, 5. When to change the device

2. Delivery system, 6. When and how to stop oxygen
3. Monitoring administration
4. When to report
Methods of Oxygen Administration

i. Nasal cannula, nasal prongs

ii. Face mask – simple, partial rebreathing, non-rebreathing;
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iii. Ambubag or Bag Valve Mask (BVM) – assist breathing;

i. Nasal prongs or catheter

a) Used for correction of mild hypoxia and when there is no marked tachypnea;
b) Oxygen administration via nasal prongs range 1-5 liter/minute.
c) Can deliver FIO2 of 0.25-0.4
d) Position the patient on semi seating position where applicable
e) Use humidifier
f) Oxygen administration has to be started from 5L/minute, monitor the patient’s
response,
g) If the saturation is above 93% and other vital signs are stabilized titrate down
ward gradually.
h) If the saturation is not improving change to the next step which is facemask with
high-flow rate

Figure 10: Nasal prong

a. Care should be taken to keep the nostrils clear of mucus, which could block the
flow of oxygen.
b. Clean the nasal prong at least twice to avoid blockade
c. Children: set a flow rate of 0.5-1 liters/min in infants and 1-2 litres/min if older
in order to deliver 30-35% oxygen concentration in the inspired airusing nasal
prongs.

ii. Face Mask

a) They could be with reservoir or without, none rebreathing or simple.

b) A flow rate of 6-15 liters/minute provides a rise in inspired oxygen
concentration(FIO2) up to 60-70 percent, when the mask is simple or above 80%
when face mask is with reservoir and non- rebreathing.
c) The flow rate shouldn’t be less than 6 liters/minute to avoid rebreathing, i.e.
breathing of their own exhaled gas which is rich on CO2.

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 d) Start from the higher flow, which is 10-15L/m, and titrate down ward according
the patients response.
e) Non-rebreather mask (NRB) allows for the delivery of higher concentrations
of oxygen. Before attaching to the patient the reservoir bag has to be full of O2, at
least 2/3 of the bag
f) Exhaled air is directed through a one-way valve around the connection of the
mask, which prevents the inhalation of room air and the re-inhalation of exhaled
air. The valve, along with a sufficient seal of the mask around the patient's nose
and mouth, allows for the administration of high concentrations of oxygen,
approximately 60% - 80% oxygen.
g) Before a NRB is placed to the patient,
h) Children: Face Mask- rate of 0.5-1 litres for infants and 1-2 litres/min for older
children,
i) The reservoir bag is inflated with oxygen to greater than two-thirds of its
volume, at a rate of 15 liters per minute.
j) It has to be connected continuously to the oxygen source with high-flow.
k) Make sure the reservoir bag is always inflated with oxygen.

Figure 11: A. Simple face mask B. Non-rebreather

mask (NRB)

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l. If patients oxygenation and general conditions is not improving and signs of
hypoxia or hypercarbia are persisting consider the next technique of oxygen
administration, which is non-invasive respiratory support (CPAP) if the patient has
adequate breathing effort and conscious and cooperative or invasive (intubation
and ventilation with mechanical ventilator) respiratory support.
m. Children:

iii. Bag Valve Mask (BVM)/Ambubag

a) BVM is used for temporary assist breathing and oxygenation during respiratory
arrest, bradypnea or low breathing rate<10b/m, preoxygenation
b) This device is lifesaving and the techniques on how to use them has to be practiced
by all professionals.

Bag Valve Mask (BVM) has three parts:

a) Bag with oxygen connector

b) Unidirectional valve between the face mask and the bag
c) Face mask

Figure 12: Bag Valve Mask

BVM implementation technique

1. Check the functionality of the BVM;

2. Position the patient supine;
3. Make head tilt and chine lift if patient is medical or non-trauma or jaw thrust for
all trauma patients;
4. Choose appropriate size of face mask that covers the patients nose and mouth
only;
5. Connect the BVM with the oxygen source with high-flow, 10-15L/M;
6. Fix the facemask covering the nose and the mouth using C&E method( see
picture below)

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 7. Squeeze the bag just to raise or inflate the lungs. But remember do not over
inflate, this creates injury to the lungs and decrease the venous return;
8. Give a rate of 10-12breaths/minute, and according the age of the child in
pediatrics
9. If the chest is not moving when you squeeze the bag reposition the head and
neck and insert oro-pharyngeal airway.

Figure 13 : One hand C&E technic and two hands technique using jaw thrust

Figure 14: Oxygen sources

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Summary

1. Oxygen is a drug so you have to prescribe properly indicating the flow rate,
device, monitoring and when to change device and the flow rate
2. BVM ventilation is a lifesaving management of patients with poor breathing
drive or for patients who have stopped breathing
3. O2 therapy is not a one-time prescription and it has to be revised periodically
according the patients response
4. During o2 therapy use appropriate device (nasal prong or face mask)
appropriate flow for the device and proper monitoring of patients response

Bedside clinical practice

Session objective: By the end of this session, participants will be able to demonstrate
basic airway skills and be able to manage patients airway and breathing, develop an
airway management, ventilation, and respirator monitoring plan with a reasonable
alternative.

Enabling objectives:

• Describe assessment of the airway, breathing

• Demonstrate basic airway, and ventilation management skills
• Understand the principles and preparation of intubation
• Describe the physiologic function to be monitored
• Explain the benefits of proper respiratory monitoring
• Conduct proper respiratory patient monitoring
• List the respiratory parameters to be monitored in critically ill patients
• Understand oxygen administration, suctioning, flow meter cylinder assembling

Introduction: This session planned to enable the participants to hands on practice on

airway and ventilation management in the critical care settings, It consists of …..hours of
practice sessions.

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Learning activities
No Topic Airway opening Activities Time
maneuvers

1. Approaches to ABC of life Participant hands on practice at bed

side ,round
2. Airway and breathing Participant hands on practice at bed
management side ,round
3. Patient Recovery Participant hands on practice at bed
positioning side ,round
4. Airway insertions :

Oral and Demonstrate none invasive air way

equipment
nasal air way
Allow participants to practice on the
equipment

Demonstrate on none invasive air way

opening maneuvers
5. Breathing management Demonstrate AMBU bag and LMA
devise

Allow each of the participants to

practice for breathing
6. Oxygen administration Participant hands on practice at bed
side ,round
7. Patients respiratory Participant hands on practice at bed
monitoring side ,round
8. Summary Summarize the session

Introduction of the session

• Start session by briefing objective of clinical practice

Facilitation of the session

• Allow the participants to practice on patients.

Concluding the Session

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The session will be concluded by Q & A and discussing on the summary

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SESSION 3: RESPIRATORY FAILURE

Session description

This session introduces the participant to the approach and management of acute
respiratory failure (ARF). It deals with the types and causes of ARF, diagnosis and
general principles of management.

Session objective

• Following completion of this session, participant will be able to define the types
and causes of acute respiratory failure, diagnose and manage ARF.

Enabling objectives

• Discuss the types and causes of ARF

• Diagnose ARF
• Propose treatment plan

Session duration: 60 minutes

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3.1 Introduction to ARF
Introductory case:

A 36 years man who has had a recent viral illness now is admitted to the ICU with
rapidly progressive ascending paralysis (diagnosed as Guillain-Barre Syndrome). He is
breathing shallowly at 36/min and complains of shortness of breath. His lungs are clear
on exam. CXR shows small lung volumes without infiltrates. With the patient breathing
room air, ABG are obtained.

PH = 7.18

PaCO2= 68 mm Hg

PaO2 =49 mm Hg

HCO3=14mmol/l

What is the diagnosis?

Definition

Acute respiratory failure (ARF) is defined as clinical conditions in which partial

pressure of arterial oxygen (PaO2) < 60 mmHg while breathing room air or a partial
pressure of arterial carbon dioxide (PaCO2) > 50 mmHg. It is failure of oxygenation and
carbon dioxide elimination.

3.2 Classification of ARF

Type 1 ARF (hypoxemic respiratory failure) is defined as hypoxemia without

hypercapnia, and indeed the PaCO2 may be normal or low.

The basic defect in type 1 ARF is failure of oxygenation characterized by:

• PaO2 low (< 60 mmHg (8.0 kPa) on room air

• PaCO2 normal or low

Causes of Type 1 ARF: is caused by conditions that affect oxygenation such as:

• Parenchymal disease (V/Q mismatch)

• Diseases of vasculature and shunts: right-to-left shunt, pulmonary embolism
• Interstitial lung diseases: ARDS, pneumonia, emphysema.

Type 2 ARF (hypercapnic respiratory failure)

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Type 2 respiratory failure occurs as a result of alveolar hypoventilation and results in
inability to effectively eliminate carbon dioxide.

The basic defect in Type 2 ARF is characterized by:

• PaO2 decreased
• PaCO2 increased

Causes of Type 2 ARF

1. Impaired central nervous system drive to breathe

• Drug over dose

• Brain stem injury
• Sleep disordered breathing
• Hypothyroidism
2. Impaired strength with failure of neuromuscular function in the respiratory
system

• Myasthenia Gravis
• GuillianBarre Syndrome
• Amyotrophic Lateral Sclerosis
• Phrenic nerve injury
• Respiratory muscle weakness secondary to myopathy, electrolyte imbalance,
fatigue

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3. Increased loads on the respiratory system

• Resistive-bronchospasm (Asthma ,Emphysema, Chronic Obstructive Pulmonary

Disease)
• Decreased lung compliance-Alveolar edema, Atelectasis, Auto peep
• Decreased chest wall compliance- Pneumothorax, Pleural effusion, Abdominal
distension
• Increased minute ventilation requirement- pulmonary embolism by increase in
dead space ventilation, sepsis and in any patient with type I respiratory failure
with fatigue.

Type 3 and 4 ARF occurs in setting of perioperative period due to atelectasis and
muscle hypoperfusion respectively.

3.3 Diagnosis of ARF

Clinical (symptoms, signs)

Hypoxemia: Dyspnea, Cyanosis, Confusion, somnolence, fits, Tachycardia, arrhythmia,

Tachypnea (good sign), Use of accessory muscles, Nasal flaring, Recession of intercostal
muscles, Polycythemia, Pulmonary hypertension, Corpulmonale, Rt. Sided heart failure.

Hypercapnia: Increased Cerebral blood flow, and CSF Pressure, Headache, Asterixis,
Papilloedema, Warm extremities, collapsing pulse , Acidosis (respiratory, and
metabolic), low pH, raised lactic acid.

Investigations

• Pulse oxymetric assessment of SpO2 to assess blood oxygen content / hypoxia.

• Arterial blood gas (ABG) analysis: Acute hypercapnic respiratory failure (
Type 2 ARF) is diagnosed on ABG analysis by the demonstration of an elevated
PaCO2>45 mmHg with an accompanying appropriate respiratory acidosis.
• Chest x-ray: Details regarding evidence of consolidation, pulmonary edema,
COPD and various other pathology
• Complete blood count, electrolytes
• Electrocardiogram
• Lung Function test (Spirometry)
• CT scan of Chest
• Other investigations to look for underlying cause of respiratory failure

3.4 Management of ARF

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Acute Respiratory failure is managed by combined supportive and specific therapies.

A. Type 1 ARF (hypoxemic respiratory failure)

• If the mechanism is low V/Q mismatch, supplemental oxygen will prove

effective.
• If the disease process involves a diffuse pulmonary intraparenchymal shunt,
as in the acute respiratory distress syndrome, mechanical ventilation with
positive end-expiratory pressure may be required in addition to supplemental
oxygen.
• If the problem is a right-to-left cardiac or pulmonary vascular shunt,
supplemental oxygen alone will be of limited benefit; emphasis is on specific
therapy (i.e., surgical or minimally invasive repair of an atrial septal defect,
obliteration of a pulmonary arteriovenous fistula)

B. Type 2 ARF (hypercapnic respiratory failure)

• The key initial decision in hypercapnic respiratory failure is whether or not

the patient requires ventilator support in the form of noninvasive positive-
pressure ventilation or intubation and mechanical ventilation.
• In general, intubation should be strongly considered for patients with acute
respiratory acidosis that has not rapidly responded to medical therapy or one
to two hours of noninvasive ventilation in patients who can maintain their
own airway effectively.

C. Specific therapy: Examples of potential specific therapy include:

• Naloxone to reverse respiratory center depression from narcotic overdose

• Inhaled bronchodilators and systemic corticosteroids for asthma and an
acute exacerbation of COPD
• Nasal continuous positive airway pressure for obstructive sleep apnea.

Summary

• Early identification and diagnosis of acute respiratory failure has an effect on

treatment outcome
• Acute respiratory failure could be either oxygenation or ventilation failure
• Proper mechanical ventilator management and care is important

Bedside 5hrs divided into 5 sessions

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Objective

• Identify acute respiratory failure

• Evaluate patient with acute respiratory failure
• Manage and care patient with acute respiratory failure
• Monitor a patient with acute respiratory failure
• Able to use equipment and devices for management of acute respiratory failure

Activities

Session 1-How to identify acute respiratory failure

Session 2-How to evaluate patient with respiratory failure
Session 3-Management of acute respiratory failure
Session 4-Monitoring of patient with acute respiratory failure
Session 5-Use of devices for acute respiratory failure according to the clinical condition

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CHAPTER 6: CARDIAC CRITICAL CARE
Chapter duration: 1hour lecture and 2 hours demonstration

Teaching methodology

• Lecture
• Demonstration
• Bedside

Chapter description: This 2.5 days course is designed to provide participants with the
skills required to care competently and safely for critically ill patient with acute cardiac
disorder. It focuses on having participants expand their knowledge base and master
critical care psychomotor skills associated with assessment and provision of critical
care for patient with acute life threatening cardiac conditions and attitudes through
reflection in and on action in clinical settings.

Chapter objective: The participant will be able to understand normal ECG, arrhythmia,
acute coronary syndrome, management of shock including inotropes and vasopressors
and BLS/ACLS.

Enabling objectives

• Analyze ECG
• Describe arrhythmia, acute coronary syndrome
• Explain shock and inotropes/vasopressors
• Demonstrate the skills of BLS/ACLS
• Demonstrate use of cardiac monitor and defibrillator

Session outline

Session 1: ECG

Session 2: Management of shock

Session 3: Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS)

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SESSION 1: ELECTROCARDIOGRAPHY (ECG) AND ARRHYTHMIA

1.1 Normal Electrocardiography

i. Introduction

Basic Electrocardiography (ECG)

Description of normal electrocardiogram (ECG)

• The electrocardiogram (ECG) is a surface representation of the electrical

events of the cardiac cycle. Electrical events are depolarization and
repolarization. Depolarization is characterized by influx of Na ion which
causes the normal intracellular negative electrical tendency to be briefly
transformed to positive, while repolarization happens with K efflux from the
cell after the Na gates are closed and the intracellular negative state returns
back.
• Each event has a distinctive waveform in the ECG, and its abnormality is
important to evaluate cardiac & non cardiac problems like renal, pulmonary
and electrolyte abnormalities.
• The normal electrical conduction starts from SA node then to AV node and
then to bundle of His.

ii. ECG leads

During ECG procedure we attach the electrodes at different parts of the boady. The
electrical potential difference between two places create the lead. Ordinary ECG has 12
leads(recorded through 4 electrodes at the four limbs-one attached to each limb) from
which 6 limb leads are derived.Limb leads are categorized into :standard leads includes
3 bipolar leads : I, II,III and 3 unipolar or augumented leads: aVR, aVL and aVF There are
also 6 precordial or chest electrodes creating leads : V1-V6.

• V1 - R sternal margin, 4th • V5 - Anterio axiallary line, 5th

intercostal space interconstal space
• V2 - Left sternal margin, 4th • V6 - Midaxillary line, 5th
intercostal space intercostal space
• V3 - midpoint between V2 and
V4
• V4 - Left midclavicular line, 5th
intercostal space

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The Monitor leads

In the application of cardiac monitor electrodes or leads are attached at 4

places,namely: The right upper trunk(white color),the left upper trunk(black),the lower
R lower trunk(green) and the Right lower trunk for grounding. The monitor leads
usually give information of the limb leads but not the chest leads. Currently with
advancement cardiac monitors are giving information of multiple leads.

Figure 15: Monitor leads placement

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iii. ECG Paper

ECG tracing is recorded on a graph where the horizontal axis represents time and
Vertical axis represents voltage.

The ECG is recorded on to standard paper travelling at a rate of 25 mm/s. The paper is
divided into large squares, each measuring 5 mm wide and equivalent to 0.2 s. Each
large square is five small squares in width, and each small square is 1 mm wide and
equivalent to 0.04 s. Vertically one big square vis 1 mv.

Figure 16: The ECG grid

The Normal ECG forms:

Waves –Upward or downward deflections: P,QRS complex, T ,U wave

Segments-Flat Lines: ST, PR, TP Segments

Intervals –Waves plus segments: PR interval, QT interval

Figure 17: Normal ECG wave form

P wave: represents atrial depolarization. Normal duration is <0.12 sec or < 3 small
squares. Amplitude is <0.25mv (<2.5mm)

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PR interval: represents conduction delay in the AV node. Duration is 0.12-0.2 sec

QRS complex: represents ventricular depolarization. Duration is<0.12 sec.

• Q is the initial downward deflection

• R is the first positive deflection
• S wave is the negative deflection following the R wave
• Not all QRS complexes have all three components

ST segment: begins with J point. Usually it is iso electric like TP segment which is the
reference segment ,and has upward concavity. ST elevation with up ward convexity
occurs in acute MI and suggests transmural injury or infarction.ST elevation might also
occur in pericarditis.

Figure 18: ST segment (red) ,J point(Green)

T wave: represents ventricular repolarization. Polarity is similar to preceding QRS.T-

wave inversion is normal in leads with dominantly negative QRS complexes (aVR, V1,
and sometimes lead III).

QT interval: represents total ventricular activity. Corrected QT interval is calculated as

normally it is < 0.44 sec.

• The END of T wave should be less than halfway between RR

Figure 19: QT interval assessment

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R wave progression:

Below normal ECG ,where R wave is small at V1 and progressively increases and
prominenet at V5 and V6.R at V3 and V4 usually have transitional zone with R voltage
becomes closer to S voltage.

Figure 20: Normal R wave progression

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• II, III, and aVF: inferior surface of • I, aVL, V5, and V6: lateral surface
the heart • V1 and aVR: right atrium and cavity
• V1 to V4: anterio-septal surface of left ventricle

ECG analysis: for better understanding of an ECG, it requires systematic/ stepwise

interpretation of the following parameters.

1. Rhythm 5. Look segments

2. Rate 6. Look intervals

3. Axis 7. Summarize

4. Look waves

Summary

ECG shows electrical activity of the heart. ECG leads show the hear activity from
different direction. Systematic and step wise approach helps to find abnormalities in the
ECG.

Review Questions:

1. Draw the normal ECG and describe it.

2. Describe the ECG paper.
3. List and explain formation of the ECG leads. What is 12 lead ECG and why is
needed?
4. Describe the steps of ECG reading reading/analysis.

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1.2: ARRHYTHMIA

Arrhythmia is classified in to tachycardia (HR>100/min) and Bradycardia (HR<60/min)

i. Tachyarrhythmia

Tachycardia /tachyarrhythmia: Tachycardia is defined when HR >100 bpm. It is

more likely to be due to arrhythmia if ≥ 150 bpm while rates <150 are usually
secondary or compensatory to the underlying conditions

• Hypervolemia, Hypoxemia, pain, fever, and anxiety are common causes,

therefore stabilize it.

Classification of Tachyarrhythmia

Is based on QRS morphology (wide or narrow), rate, rhythm and acuity (stable or
unstable).

Figure 21: Classification of tachyarrythmia

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 1. Narrow QRS complex(<0.12 second) ( supraventricular tachyarrthmias)
• Narrow and Regular : Sinus tachycardia, Supraventricular tachycardias
• Narrow and Irregular : Atrial fibrillation, Atrial Flutter, Multifocal atrial
tachycardia
Types of arrhythmias and examples of ECG tracing

o Supraventricular tachycardia: p waves not seen, buried p waves

Irregular narrow complex tachycardia

• Atrial Fibrillation – note the irregular R-R intervals, and no distinct P wave

• Atrial Flutter – note the saw toothed appearance & regular rate

2. Wide QRS complex(≥0.12 sec)

• Ventricular tachycardia(regular), ventricular fibrillation(irregular)
• Monomorphic ventricular tachycardia

• Torsadepointes

• Ventricular Fibrillation

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Management of Tachyarrhythmias’

Put patients on monitor, have 12 lead ECG, based on QRS/acuity:

The following 4 KEY QUESTIONS should be asked.

1. Is my patient stable or 3. Is the rhythm regular or

unstable? irregular?

2. Is the rhythm narrow or 4. Is there a potential to

wide? degenerate to a more
dangerous rhythm?
Stable patients are ~ asymptomatic

Unstable patients exhibit signs and symptoms of hypoperfusion/circulatory

compromise

• Altered mental status • Dyspnea/Tachypnea

• Ongoing chest pain • Hypotension
Rate-related symptoms uncommon <150 bpm

Figure 22: Tachyarrhythmia instability signs and management

Persistant
Synchronized cardioversion
tacharrhythmia causing
• Conside sedation
• Hapotension?
• if regular marrow
• Acute altered
complex consider
mental status?
adenosine
• Sign of shock?
• Ischemic chest
discomfort?
• Acute heart
failure?

Synchronized cardioversion

Initial recommendede doses

• Narreow regulare 50-100J • Wide regular 100J

• Narreow regulare 120-200J • Wide regular defibrillation dose
biphasic or 200 J monophasic (not synchronized )

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Stable tachyarrythmias therapy

• Regular narrow complex

• Sinus tachycardia= No specific treatment. Identify and treat
underlying cause
• Stable Supraventricular tachycardia (Reentry SVT)

• Vagal manuevers can be used for SVT

• Adenosine 6IU, then 12 IU IV
• Metoprolol2.5-5 mg iv every 2-5 minutes for three doses
• Digoxin0.5 -1.5mg IVslowly
• Amiodarone 150mg IV over 10 minutes
• Calcium channel blockers like verapamil 2.5-5mgIV every 5
minutes

• Irregular narrow complex

• Atrial fibrillation and flutter
• Rate control: IV Beta blockers,Ca- channel blockers like
verapamil
• For concomitant heart failure: digoxin, amiodarone
- Rhythm control – electrical/ pharmacologic

• AF >48hr has a risk of cardioembolism. Therefore; electrical/

pharmacologic cardio version is reserved for un stable patients
• Wide complex
• Stable: IV antiarrythmics
• Amiodarone 150mgover 10 minutes, repeat as needed
followed by maintenance infusion of 1mg/kg for first 6 hours
• Lidocaine 1- 1.5mg/Kg slow Iv bolus over 2-3 minutes
• Magnesium sulfate 1-2g slow IV (diluted in 50- 100 ml D5W)
over 5-60 minutes, then 0.5-1g/hr IV, highly recommended
especially for torsade pointes

ii. Bradycardia
Rate <60, symptomatic usually when below 50bpm.The most common bradycardia are
sinus bradycardia and AV blocks. AV blocks are classified into first second and third
degree blocks. First degree and second degree Mobitz one are benign but second degree
mobitz two and third degree can cause serious symptoms with need of medical
management.

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ECG features of AV blocks:

First degree AV block

Second degree AV block, mobitz one-Wenkebach phenomenon

Second degree AV block, Mobitz two: Constant PR interval with intermittent failure to
conduct

Third degree AV block: No relationship between P waves and QRS complexes,constant

PP intervals and RR intervals

Approach to bradyarhythmia

Bradycardias are usually benign but some can be symptomatic like syncope, shortiness of
breath, chest pain. If patients are symptomatic or unstable management is as follows

Therapy for unstable bradyarrythmia• Assess ABCs and provide Oxygen and IV access–
monitor–fluids

• Vital signs, pulse oximeter, monitor BP

• Obtain and review 12-lead ECG and chest X-ray
• Conduct focused history and physical examination and rule out non cardiac
causes: hyperkaleamia, hypoxia, hypothermia, hypothyroidism, head injury.

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If there is serious signs or symptoms like shock, chest pain heart failure and alteration
in mental status:

• Give Atropine 0.5–1.0 mg,repeat 3x every 5 minutes. If there is no response

Dopamine 5–20 mcg/kg/minute or Epinephrine2–10 mcg/minute can be
sarted. Transcutaneous pacing is also an option if available

If patients have Type II second-degree AV block or Third-degree AV block need

pacemaker.

Summary

Arrythmias are classified as tachy or bradyarrythmia based on rate.

Tachyarythmia is classied based on QRS width and rhythm regularity.
Management of tachy or bradyarrytmia depends on

Review Questions

1. List various types of narrow complex (supraventricular tachyarrythmia)

and describe ECG characteristics.
2. Explain management of different types of narrow complex tachycardia.
3. List various types of wide complex and describe ECG characteristics.
4. Explain management of different types of wide complex tachycardia.
5. Describe ECG features and management of various types of AV blockes

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SESSION 2: MANAGEMENT OF SHOCK

2.1 Introduction

Shock is a physiologic state characterized by an inadequate systemic tissue perfusion,

resulting in decreased oxygen delivery to the tissues, which creates an imbalance
between oxygen delivery and oxygen consumption. In adults: Systolic BP < 90 mmHg, or
DBP<60mmHG, or MAP (DBP+1/3(SBP-DBP),< /= 60 mmHg, or reduction of systolic BP
> 40 mm Hg from the patient’s baseline especially in hypertensive individuals. The
effect of shock is anaerobic respiration of cells.

2.2 Classification of shock

• Hypovolemic - eg. Bleeding, dehydration

• Distributive: Sepsis, anaphylactic, neurogenic, adrenal insuffciency….
• Obstructive: Pneumothrax, Pulmonary Embolism, cardiac tamponade
• Cardiogenic: Acute Myocardial Infarction, cardiomyopathy, arrhythmia

2.3 Evaluation and management

1. In all patients with shock assess and stabilize the Airway, Breathing and
Circulation (ABC).
2. Subsequent evaluation: general evaluation of V/S and perfusion is needed.

a) General hemodynamic status: measure BP, Check for peripheral pluses (Pulse
volume, Pulse rate, pulse rhythm, pulse pressure)
b) Respiratory rate-may rise due to increased sympathetic tone and metabolic
acidosis
b) Systemic perfusion status: urine output, capillary refill time and peripheral
body temperature

3. Other evaluation for etiology and complication-extend evaluation for hypovolemic

shock, cardiogenic shock, septic shock and obstructive shock: it includes, signs of
dehydration, JVP levels, pulmonary crepitation, the skin for color and temperature
,muffled heart sounds, etc
4. Take relevant and short history and perform rapid clinical evaluation while
stabilizing, including past illness, previous medical records to identify the primary
cause of shock. It also includes external/internal blood or volume loss, fever or
other features of infection, CVS symptoms like shortness of breath or acute chest
pain, or questions related with steroid use or discontinuation.
5. In patients with shock immediately administer high flow oxygen by face mask or
nasal prongs and access of IV line at a peripheral larger vein in the forearm or
antecubital veins ;If the flow in one vein appears to be inadequate access second

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 vein in the other arm. If there is active bleeding it has to be stopped. The volume of
fluid to be given in the management of shock in adults depends on etiology
6. Consultation of appropriate units and departments depending on the
manifestation.
Workup:, which help to identify potential causes of shock and end organ failure. It
includes CBC, with differential count, LFT and RFT, Urinalysis, EKG, CXR.With a goal
to complete in an hour.

Monitoring management of shock: follow vital sign especially BP,RR ,PR and mental
status frequently, and insert urinary catheter for urine output follow up.

2.4 Management of septic types of shock

Case scenario: A 20 year old immediate postpartal lady referred from a nearby health
center for a profuse vaginal bleeding following SVD. Pregnancy was unremarkable until
labor. Labor took a total of 6 hours and the vaginal bleeding could not stop after the
third stage. She is now confused, BP = 70/30mmHg, chest clear. How do you manage?

Hypovolemic shock

Aim is re-expansion of circulating blood and control of ongoing loss.

• Ensure adequate ventilation/oxygenation:High flow oxygen(6-10l/min)

with face mask
• Give 2-3 liters of isotonic N/S or R/L over 20-30 minute (i.e. remember:
continuous administration of large quantity of N/S may induce
hyperchloremic metabolic acidosis, hence, give N/S alternatively with
R/L).
• For the above fluid administration open 2 peripheral veins, preferably at
the arm around cubital fossae in order to get larger veins. When
peripheral veins at the arm fail the options are external jugular vein
canulation, cut down and other procedures not routinely used but future
options (central veins and intraosseous administration)
• Continue fluid repletion should be continued depending on ongoing loss,
the hemodynamic status, peripheral perfusion, urine output and mental
status.
• In haemorrhagic shock prepare cross matched blood, and transfuse with
packed RBC if patient is hemodynamically unstable after 2 liters of
crystalloid or Hgb <10mg/dl and ongoing bleeding. In severe traumatic
bleeding in addition to PRBC transfuse FFP and platelets as Well. (N.B.
Massive transfusion protocol is used in severe bleeding, hypotension,

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 tachycardia, mental status alteration-in this protocol patients may need
about 10 liters in 24 hrs and additionally FFP and platelets)
• Provide immediate control of hemorrhage, when possible (e.g, traction for
long bone fracture, direct pressure), or surgical consultation internal
bleeding like Upper Gastrointestinal(UGI) or extensive external bleeding
is there
• If the patient remains hypotensive in spite of fluids exclude other
problems such as sepsis, tension pneumothorax, tamponade, etc and then
commence innotropes such as dopamine.

Case scenario:

A 35 year old man came with fever, productive cough and right pleuritic chest pain of 01
week duration. He is conscious, PR = 135bpm, regular, BP = 65/35mmHg, RR = 28bpm,
To = 38.5oC, SaO2 = 90% with room air, coarse crepts on the right midlung field.

a) What is the diagnosis?

b) What do you do next?

Septic shock

• Support ventilation and oxygenation (remove work of breathing) - Ensure

adequate oxygenation by giving oxygen via face mask,or through nasal
catheter or nasal prongs.
• If tachypnea is significantly large 50% of cardiac out might be shunted to
respiratory muscles, hence,in such conditions may need invasive ventilator
support.
• Aggressive volume expansion with IV fluids is needed with proper
monitoring, as effective volume retained in vascular space is small due to
Vascular leak.
• Give the first bolus of 20ml/kg immediately within 15-20 minutes, then
subsequent boluses depending on hemoynamics, the lung congestion status,
urine output and mental status.. Patient may need large amount of fluid like
6-10 liters of crystalloid over 24 hour, pulmonary congestion after each bolus
of fluid (N.B in better setup invasive monitoring can be done).
• If hemodynamic response after fluid administration in the first hour is poor
vasopressors. The vasopressors commonly used are Norepinephrine and
dopamine. Nor epinephrine is preferred if available. Epinephrine can also be
used when these drugs aren’t available and cardiac problem is not
anticipated.
• The doses of pressors : dopamine, start with 5micg/kg/min and titrated
every 10 – 15 mints up to 40 micg/kg/min until response is achieved,

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 norepinephrine, infused at 2-30 μg/min, and Epinephrine : 2-30 μg/min
titrated based on response.
• For refractory shock, after fluid and pressors, consider corticosteroid-
hydrocortisone 50mg IV qid administration, and if patient respond to this
drug continue it for 7 days.
• Treatment of underlying infection and proper debridement is important.
• Initiate broad spectrum antibiotic therapy early, usually based on the
possible focus of infection/septic focus.
• Surgical drainage or debridement of an abscess or dead and necrotized
tissue.
• Blood transfusion if HCT is < 30% to keep adequate O2 saturation

Cardiogenic shock

Case scenario: A 60 year old man who is a known diabetic came with left anterior chest
pain, squeezing type and radiating to the left shoulder. He has associated with
diaphoresis and vomiting. On physical examination, he is acutely sick looking, in pain,
BP = 60/40mmHg, PR = 60bpm, and wet tongue and buccal mucosa.

a. What do you think is the likely cause of the shock state?

b. How do you manage?
c. Any precautions you should take?
• Assist increased work of breathing: provide oxygen; pain management; CPAP When
the BP improves
First Preload augmentation with boluses of 250ml of NS, repeat if no rise of crepitation,
in centres with PCWP facility <15mmHg you give more fluid, if it is 15-20mmHG small
boluses, and if >15mmHg

• Vasopressors recommended.
• Inotropic support: Dobutamine (5micro gm/kg/min) is common empiric agent
for a borderline BP (SBP between 90 – 100 mmHg), dopamine/norepinephrine
are choices for significantly reduced BP (SBP < 80 mmHg). Titrate the dose of
inotropes and vasopressors based on patients response.
• In unstable tachyarrythmia where the tachyarrythmia is the cause of shock,
apply Synchronized cardio version is needed, and this procedure needs
procedural sedation.
• In AMI, standard management and revascularization with thrombolytic or PCI
are undertaken.
• Right ventricular infarction is a preload dependent condition ,hence give more
fluid boluses
• Diuress after inotropic support if there are signs and symptoms of pulmonary
edema

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 Anaphylactic shock

-Supportive measures (AABC- Adrenaline, Airway, Breathing, circulation) with

emphasis on the airway, IV fluid infusion administer Adrenaline/Epinephrine 0.3 to 0.5
mg IM on anterior lateral thigh, can be repeated after 5 minuses

• If BP is low mix 5 mg of epinephrine in 500 ml of normal saline. Infuse at 10

cc/hr, and titrate to arterial BP response. If there is no perfusor/infusor mix 5
mg of epinephrine in 1000ml of N/S and start with 6dropes per minute and
titrate up on BP response.

Antihistamines- prometazine 25 mg /IM or Dimenhydramine 50mg IV

• Hydrocortisone 100-200mg iv IV
• If patient deteriorated bronchodilators like aminophyline infusion is given

Neurogenic shock

Fluid and vasopressors are used as other types of shock Vassopressors can be
considered

The primary neurological disorders have to be addressed

Hypoadrenergic shock/adrenal crisis: basal hormonal test can be done but management
should be started immediately.Fluid management is similar other distributive shock
followed by

• vasopressors( see septic/anaphylactic shock above)

• Administer 100 mg hydrocortisone IV followed by 100 mg every 6 hrs for 24
hours. The dosage can be reduced to 50mg every 6 hours when patient is stable.
• If hypoglycemia is present, give 40% glucose IV stat can be given.

Treat precipitating factors.

• For patient with tension pnemothorax perform needle decompression

at 2nd ICS/5thICs.
• If your patient develops massive PE, start anticoagulation and consider
thrombolytic if available.
• If the patient has pericardial tamponade ,immediate pericardiocentesis
should be done

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Summary

• Early identification and management of shock is crucial for better outcome

Treatment depends on the type of shock and quick effort should be taken to identify the
type

• Norepinephrine is the pressor of choice for most type of shocks unless there are
specific indications or contraindications to prefer one over the other

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SESSION 3: BASIC LIFE SUPPORT (BLS) AND ADVANCED CARDIAC LIFE
SUPPORT (ACLS)

3.1 Introduction

Cardiac arrest is a common problem in intensive care setup and it needs prompt
recognition and immediate resuscitation. It is cessation of circulation of blood because
of absent or ineffective cardiac mechanical activity. Cessation of circulation and
resulting organ ischemia can cause cell, organ and patient death if not rapidly reversed.
In adults the main cause of cardiac arrest is underlying cardiac problem, where as in
70% pediatric age respiratory failure cause cardiac arrest. If cardiac arrest occurs
immediate detection and cardiopulmonary resuscitation (CPR) is needed, and this
chapter will enable the trainee to do the procedure with a good confidence. CPR is
categorized into Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS)
depending on the set up available and it’s discussed below.

3.2 BLS and ACLS

It is a skill, which includes chest compression and artificial ventilation to provide blood
flow and oxygen to preserve the brain function until measures are taken to restore
spontaneous blood circulation. Its Components are:

A. Basic Life Support (BLS): It is chest compression and artificial ventilation that is
initiated anywhere by a person who is trained to do so, and most of the time it doesn’t
need special equipment. It has to be followed by ACLS for restoration of cardiac activity.

B. Advanced cardiac Life Support (ACLS) and Pediatric Advanced Life Support
(PALS)–it is a continuation of BLS with better setup and expertise, and hence practiced
in hospital setup like ICU, and it is immediately started after cardiac arrest. In addition
to the basic CPR, defibrillation, pharmacologic treatment and advanced airway
management is included. Survival from cardiac arrest is highly dependent on high
quality CPR, ACLS or PALS &Post cardiac arrest care. These steps and care are also
described as chain of survival.

Chain of survival:

For effective result of resuscitation there should be: early access to the patient or victim,
early CPR initiation, early defibrillation, and early & effective post resuscitation care.

A. Basic Life Support (BLS)

Basic life support is given for cardiac arrest or respiratory arrest.Therefore assess if
there is arrest scenario through the following steps:
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 • Is the patient unresponsive? Call the patient by name or common names and if
no reponse go to next steps.
• Is there breathing? Check for chest rise and breathing sound or pressure.
• How is circulation? Check for central pulse palpating carotid pulse.

Unresponsive person who doesn’t have breathing effort and absent central pulse is in
cardiorespiratory arrest and go to CPR.

When patient is unresponsive or suspected to have cardiac arrest call for help, Position
the victim and start CPR. During resuscitation function as a team and have a team leader
that guides the quality of the CPR. The recommendation in single rescuer resuscitation
is to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C)
to reduce delay.

Different scenarios of CPR

Witnessed and un witnessed arrest: in un witnessed collapse perform 2 minutes of

CPR and call the emergency response team and bring an defibrillator/AED to the patient
but if collapse is witnessed call the emergency response team and bring an AED first
then start CPR

Pulse is palpable or pulseless arrest: if there is central pulse (palpate carotid artery )
present and no breathing, provide rescue breathing - every 3 seconds for infants, and
every 5 - 6 seconds older children and adults. If there is no carotid pulse in adult, or no
femoral or brachial pulse in pediatrics (carotid are not choice for pediatrics because of
short neck) - start chest compression and artificial ventilation on hard flat surface, if
possible.

CAB steps in CPR

Circulation/chest compression

• There is continued emphasis on the characteristics of high-quality CPR.

• Chest compression: press the heels of the hands straight dawn on the center of
the chest.
• Push hard: depress the chest at least 5cm(2 inches) but not greater than
6cm(2.4inches) depth in adults or 1/3rd -1/5th of chest antero-posterior diameter
in infants and older children
• Push fast: give compressions at a rate of 100 -120 per min.
• Compression breathing ratio: give 30 compressions to 2 breaths with one or
two rescuer CPR in adult. But in pediatrics 30:2 ratios in single rescuer and 15:2
ratios in two or more rescuers.

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 • Allow complete chest recoil - release completely, allowing the chest completely
recoil in each compression. This allows the heart to refill with blood.
• Minimize interruptions -try to limit interruptions in chest compressions to 10
seconds or as needed for interventions like rhythm check, defibrillation and for
ventilation. Once an advanced airway is in place, provide continuous
compression and without pause.
• Avoid excessive ventilation–each rescue breath should be given over 1 second
and each rescue breath should result in visible chest raise.

• After every 5 cycle/2min. or sooner when tired check for spontaneous

breathing and circulation for 5 sec
• Rapid identification and intervention of shock is an essential component of
pediatric resuscitation.

Some peculiarities of compression in different age groups:

• Adults - compressions should be performed over the lower half of the sternum
with the heel of two hands as depicted below in Figure
• Older Children- In addition to the above method, the heel of one hand can be
applied over the lower half of the sternum during CPR in older children.

Figure 23: CPR A. Two Hand Technique B. One Hand Technique

• Infant:

• One Hand technique- This technique is recommended when there is

a single rescuer. Compressions are performed with index and middle
fingers, placed on the sternum just below the nipple see figure X .
• The two thumb-encircling hands technique- is suggested when
there are two rescuers. The thorax is encircled with both hands and

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 cardiac compressions are performed with the thumbs. The thumbs
compress over the lower half of the
• sternum, avoiding the xiphoid process, while the fingers are spread
around the thorax

Figure 24: A. Two finger technique B. The two thumb-encircling hands

technique

Air way
• To open the air way, use head tilt and chin lift maneuver
• In suspected trauma stabilize the neck before airway opening maneuver.
• Use jaw thrust in patients with suspicion of cervical spine injury

Breathing

• In cardiac arrest give 30 chest compressions immediately before any rescue

breaths are attempted and give two rescue breaths with bag valve mask (BVM)
for adult for both single or two rescuer but for pediatric 30:2 for single rescue
and 15:2 for two rescuer. Do not over inflate the chest, connect the BVM with O 2
source. After advanced airway is in place, deliver 10 breathe per minute while
continues compression are given.

B. Advanced cardiac Life Support (ACLS)

A Protocol to continue CPR in advanced level when skilled human resource, defibrillator
and other facility are available.

• Defibrillation and cardio version: It is passage of an electrical current of

sufficient magnitude to depolarize a critical mass of myocardium and restoration
of coordinated electrical activity from the SA node.
• Defibrillation non-synchronized delivery of energy, and the shock is delivered
randomly during the cardiac cycle .It is used in pulseless states like Vfib, V tac
and unstable torsade de pointes.
• Cardio version refers to delivery of energy that is synchronized to the QRS
complex to eliminate the risk of VF (in Unstable SVT/AF or monomorphic VT).In

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 this condition the patient is responsive and hence, ask for consent and consider
sedation, prepare the machine and attach monitor leads of the defibrillator, and
then touch synchrony button on the defibrillator; before discharge make sure
everybody including your self is clear from the patient (no body is touching the
patient or the bed). Finally, discharge the selected amount of energy which is
smaller in cardioversion.
• In witnessed arrest, defibrillation should be attempted as early as possible
immediately after starting the CPR, and repeated as per the algorithm. In cardiac
arrests there are two category of electrical rhythms:

1. shockable-which is responding to electrical shock and includes V fib, V-

tac with arrest and torsade de pointes.
2. Non-shockable it does not respond and includes asystole and pulseless
electrical activity (PEA).

The steps of ACLS in shockable and non-shockable rhythms:

The Protocol in Shockable rhythms (Ventricular Fibrillation or Pulseless VT)

• While a team is performing CPR prepare a defibrillator

• Immediate defibrillation with 200 J in biphasic machines (most new machines
models are biphasic,in older monophasic defibrillators 360 J is used), then
follow with Immediate effective CPR for 2 min which is 5 cycles of 30:2 , and
Evaluate the rhythm.
• If no carotid pulse detected, and the rhythm is shockable ,defibrillate with 360J,
and continue the CPR .
• Adrenaline 1 mg IV and repeat every 3 – 5 min and Evaluate rhythm
• Continue CPR and defibrillation, after 3 doses adrenaline give either
amiodarone 300 mg I/V push or IV Lidocaine 1mg/kg.[CPR-defibrillation-
Drug cycle].Mg 2 gm IV is used in suspected Torsade de Pointes, alcoholism or
malnutrition.

Steps of defibrillator use:

• Always charge defibrillator in order to be ready

• Select energy and then touch charge button.
• In cardioversion attach defibrillator leads and press synchronous button.
• Proper position of the paddles or electrode pads, and make adequate contact
between paddles and skin.
• Ensure that no contact with anyone other than the victim
• Apply discharge button and make rhythm assessment.

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 (Preparation→selects energy→ charge→ discharge)

Protocol in non shockable rhythms (Asystole or Pulseless Electrical Activity)

1. Continuous CPR ,find and correct any possible causes
2. Adrenaline 1 mg every 3 minutes during the resuscitation
3. If asystole – flat line protocol : Check monitor/ power ,Check leads
4. In addition to CPR and adrenaline try to correct the 20 causes: 5Ts (Toxins,
tamponade, thromboembolism, Tension pneumothorax,
trauma),5Hs(hypoxia, hypovolemia, hypokalemia/ hyperkalemia, hydorgen/
acidosis,hypothermia).

Post Cardiac arrest care

• Recent guidelines state that it is reasonable to give epinephrine during cardiac

arrest. However, the use of this drug is downgraded slightly in class of
recommendation. Although recent studies have shown that epinephrine was
associated with improved ROSC and survival admission, but it didn’t improve
survival to hospital discharge
• For children who are comatose after cardiac arrest either in hospital or out of
hospital providers should monitor temperatures continuously and also treat
temperature aggressively for the first several days.
• For comatose adult patients resuscitated from out of hospital cardiac arrest it is
reasonable for caretakers to maintain core body temperature of 32-36-degree c.
which should bestarted within 4-6 hours after ROSC, for 12-24 hours and for
comatose children either 5 days of normothermia(36—37.5-degree c) or 2 days
of initial continuous hypothermia(32 to 34-degree c) is recommendedfollowed
by 3 days of normothermia.
• Once ROSC is achieved, it is recommended that caregivers use fluids and
vasopressors to maintain Mean arterial pressure>60mmHg for Adults, orsystolic
pressure above the fifth percentile for children.To identify the fifth percentile for
systolic blood pressure, use the formula 70mmhg + (age x2).
• After ROSC it may reasonable for rescuer to titrate oxygen administration to a
normoxemia which is oxygen saturation of 94% or above.
• when possible oxygen should be weaned to a target of oxyhemoglobin saturation
to the range of 94% or above.The goal should be to strongly avoid hypoxemia.
And the carbon dioxide tension(PaCO2) should be in a range of 40-45mmHg (or
end-tidal CO2 of35-40mmHg).

Deciding to Terminating Resuscitative Efforts:

• Pediatric cardiopulmonary arrest lasting >20 minutes or with no response to

two doses of epinephrine and good CPR is associated with a poor outcome. If

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 hypothermia is thought to be responsible for the arrest, and cardiac electrical
activity is present, continue resuscitation until a core temperature of 30°C (86°F)
is reached.
• The likelihood of survival and intact neurologic function diminish as the duration
of the resuscitation attempt increases. Unfortunately, no single factor is
predictive of outcome, so integrate all the circumstances of the arrest and the
patient’s premorbid condition before terminating resuscitative efforts.
• Neurologically intact survival can occur after very prolonged ED resuscitations
with high-quality CPR, so developing a strict time for termination of resuscitation
efforts is not possible.

Summary

Key review Questions:

1. What is the difference between BLS and ACLS?

2. Describe the steps of one rescuer and two rescuer adult BLS and pediatric BLS?
3. Describe the difference between adult BLS and pediatrics BLS.
4. What is the difference between cardioversion and defibrillation? Describe the
steps of both conditions. Describe the peculiarities of defibrillation in children.
5. Describe the difference between manual defibrilaos and AED.describe the steps
of AED.
6. Describe non shockable rhythms and how do you manage it?
7. What are the indication and dosages of Adrenaline, amiodarone, magnesium,an
dlidocaine?

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BLS/ACLS (Demonstration)

Introduction:

Components of BLS/ACLS:

BLS CPR consists of 3 main components:

1. Compressions
2. Airway
3. Breathing
ACLS: is a continuation of BLS with early advanced care. It includes defibrillation, IV
medications, advanced airway management and post resuscitation care.

Indication: Cardiac arrest manifested by unresponsiveness and pulslessnes (CENTRAL)

with no breathing efforts.

Contraindications:

Consent: in sudden arrest consent can’t be obtained, but while procedure is going on
team members should explain it to family members or parents.

Preparation

1. Equipment preparation

• Defibrilator, cardiac monitor

• IV infusion equipment
• Bag mask valve (ambubag), laryngoscope, endotracheal tube
• ACLS drugs: epinephrine, amiodarone, lidocaine, atropine, magnesium
sulphate, adenosine, etc
• A sterile 5-ml syringe filled with normal saline for inflation of ETT.
• Backboard

Procedure: See the manual and the following table for BLS and CALS steps.

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CHAPTER 7: APPROACH TO ALTERED MENTAL
STATUS, PAIN SADETION AND DELIRIUM IN ICU
Chapter duration: 1 hour lecture

Teaching method

• Lecture
• Bedside

Chapter objective

• The participant will be able to understand approaches to patient with altered mental
status, and principle of management ,manage acute pain in ICU

Chapter description

This session introduces the participants to approaches to altered metal status. It

consists of 1 hour interactive lecture and practical sessions.

Session outline

Session 1: Altered mental status

Session 2: Pain and sedation

Session 3: Delirium in ICU

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SESSION 1: ALTERED MENTAL STATUS

Case scenario

While you are on your duty the nurse lets you know about the new patient that was just
sent over from the local nursing home with a chief complaint of “AMS ”. She’s 87 years
old, bed-bound and minimally verbal. A quick review of the EMS sheet and nursing
home paperwork show a history of diabetes, multi-infarct dementia, seizure disorder
and chronic abdominal pain. Discuss the case.

1.1 Definition

Altered Mental status is the clinical state of emotional and intellectual functioning of an
individual. Disorders of consciousness may be divided into processes that affect either
arousal or content of consciousness, or a combination of both. Arousal behaviors include
wakefulness and basic alerting. Anatomically, neurons responsible for these arousal
functions reside in the RAS (Reticular activating system). The neuronal structures
responsible for the content of consciousness reside in the cerebral cortex. Content of
consciousness includes self-awareness, language, reasoning, spatial relationship
integration, emotions, and the myriad complex integration processes that make us
human.

Dementia: is failure of the content portions of the consciousness with relatively

preserved alerting functions. It is arousal system dysfunction with the content of
consciousness affected as well.

Delirium: is defined as a transient, usually reversible, cause of mental

dysfunction and manifests clinically with a wide range of neuropsychiatric
abnormalities

Psychosis: Psychosis can be defined as the presence of hallucinations and/or

delusions without insight often with intact orientation

Coma: is a failure of both arousal and content functions. It is a state of reduced

alertness and responsiveness from which the patient cannot be aroused. The Glasgow
coma scale is widely used and also the FOUR (Full Outline of Unresponsiveness) score is
used widely in ICU and it the advantages of assessing simple brainstem functions and
respiratory patterns, as well as eye and motor responses.

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Table 5: Characteristics of delirium, dementia and psychosis

Characteristics Delirium Dementia Psychosis

Onset Rapid Onset Slow Onset Variable Onset
Course Fluctuating Course Progressive Course Variable Course
Vital Signs Often abnormal Usually normal Usually normal
vital signs vital signs vital signs
Level of Altered level of Normal level of Variable level of
Consciousness consciousness consciousness consciousness
Hallucinations Visual Rare hallucinations Auditory
hallucinations hallucinations
Physical Exam Often abnormal Often Normal Often Normal
Prognosis Poor if not treated Progressive decline Variable

1.2 Clinical feature

History

• Exploit all available historical sources (EMS personnel, caregivers, family,

witnesses, medical records, etc.)
• Onset of symptoms
• Any history of fever, medication, seizure

Physical examination

• Vital signs including RBS

• Look for signs of trauma
• Neurologic examination (cranial nerves, motor examination, posturing or
meningeal signs)

The clinical features of coma vary with the depth of coma and the cause.

Based on the clinical findings the cause of coma can be categorized in to two:

1. Toxic-Metabolic coma – characterized by diffuse CNS dysfunction and no focal

neurologic findings
2. Structural Coma- characterized by focal CNS dysfunction further classified to

• Hemispheric (supratentorial)

• Progressive hemiparesis or asymmetric muscle tone and reflex

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 • On the contrary coma without lateralizing sign may result from
increased ICP

• Posterior fossa (infratentorial)

• An expanding lesion, such as cerebellar hemorrhage or infarction, may
cause abrupt coma, abnormal extensor posturing, loss of papillary reflexes,
and loss of extraocular movements.

1.3 Investigations

• CBC, RBS, serum electrolytes, renal and liver function tests, blood film etc.
• Brain CT, CXR, ECG, Brain MRI
• Lumbar puncture

Contraindications- although no absolute contraindication, caution should be taken in

patients with:

• Focal neurologic deficits

• Possible raised intracranial pressure
• Thrombocytopenia
• Suspected spinal epidural abscess

1.4 Differential Diagnosis

1. Coma from causes affecting the brain diffusely

• Encephalopathies

i. Hypoxic encephalopathy
ii. Metabolic encephalopathy (hypoglycemia, hyperosmolar state,
electrolyte abnormalities e.g. hyper/hyponatremia)
iii. Hypertensive encephalophathy
iv. Organ system failure (hepatic encephalopathy, uremia/renal failure,
endocrine (addison disease, hypothyroidism), hypoxia, carbondioxide
narcosis)

• Toxins
• Drug reactions ( e.g neuroleptic malignant syndrome)
• Environmental causes (e.g hypothermia / hyperthermia)
• Sepsis

2. Coma from primary CNS disease or trauma

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 • Direct CNS Trauma

i. Diffuse axonal injury

ii. Subdural hematoma
iii. Epidural hematoma

• Vascular disease
• CNS infections
• Neoplasm
• Seizures

i. Non convulsive status epilepticus

ii. Postictal state

Table 6: Mnemonic “AEIOU-TIPS” for Altered Mental Status

Mnemonic Things to consider

Alcohol Alcohol levels, serum osmoles
Epilepsy/ Endocrine/ EEG, referral to neurology, TFTs, cortisol, chemistry
Electrolytes/ Encephalopathy panel, LFTs
Insulin Glucose
Oxygen/ Opiates SatO2%, ABG, hypoxia makes agitation, hypercarbia
makes somnolence
Look for needle marks
Uremia BUN/Cr
Things changing serum osmolarity affect mental status.
Uremia, Sugar, Alcohol are common ones
Trauma/ Temperature CT Head, C-Collar, CT C-Spine
Infection CBC, BCx, UA, UCx, CXR, LP/CSF
Sepsis and CNS infections are more important. But, even
simple fever may cause AMS in elderly and kids
Poisoning/ Psychosis Drug Levels (e.g. lithium, digoxin)
Shock/ Stroke/ SAH/ Space ECG, Troponin, CT Head, LP
occupying lesion

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1.5 Approach to the patient

Treatment of coma involves identification of the cause and initiation of specific therapy
directed at the underlying cause. Evaluation for readily reversible causes of coma, such
as hypoglycemia and opioid toxicity, demands priority.

1. ABC of life

Secure airway, breathing and circulation, take vital signs including RBS, secure IV line

• Indication for intubation

i. Deep coma - GCS<9

ii. Status epilepticus

iii. Anticipated clinical worsening or rapidly deteriorating GCS despite initial

management

iv. If suspected poisoning and gastric lavage is planned.

2. Immobilization of C-spine if there is any concern of trauma

3. Coma cocktail

• Thiamine 100mg IV prior to dextrose in alcoholic patients

• Dextrose 50gm IV push
• Naloxone 0.01
• mg/kg if opiates suspected
• Flumazenil 0.2mg IV if benzodiazepine suspected (routine use in coma of
unknown etiology is not recommended)

4. If concern for increased ICP and herniation

• Elevate head 30degrees

• Consider mannitol 0.5-1gm/kg bolus
• If mass lesion- consider dexamethasone

5. Send lab examinations and do LP if no contraindication. If patient is febrile

give empiric antibiotic ceftriaxone 2gm IV stat with dexamethasone without
waiting for result.
6. Send the patient for investigation after stabilization

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Table 7: Glasgow Coma Scale

Eyes Verbal Motor

4 – Spontaneous 5 – Oriented 6 – Follows commands

3 – Loud voice 4 – Confused 5 – Localizes to pain
2 – To Pain 3 – Inappropriate words 4 – Withdraws to pain
1 – None 2 – Incomprehensible 3 – Abnormal flexion
sounds posturing
1 – No Sounds 2 – Abnormal extension
posturing
1 – None

Summary

• AMS is among the usual ED chief complaints

• Get a Grip on the Diagnosis through systematic” clue finding”
• Every patient with AMS should be approached with ABC
• Early diagnosis and intervention prevents permanent damage to CNS
• Re-evaluate patient frequently and do frequent” hypothesis-testing” in your
mind

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 SESSION 2: PAIN AND SEDATION

Session objective: The participant will be able to manage pain and understand basic
principles of sedation ICU

Enabling objectives:

• Describe and assess pain

• Demonstrate basic sedation skill
• Understand the assessment and management of delirium
• Describe the physiologic function to be monitored
• Explain the benefits of proper respiratory monitoring
• Conduct proper patient monitoring

2.1 Acute Pain

i. Introduction

Acute pain is unpleasant experience with emotional, cognitive and sensory futures that
occur in response to tissue injury. Whenever patients are in pain all sympathetic
outflow increases and patients manifest with increased pulse rate, and blood pressure,
increased work of breathing and they may manifest also with some metabolic and
endocrine derangement such as increased cortisol release with subsequent
development of hyper glycaemia, electrolyte imbalances and increased risk for
infections.

ii. Assessment

The assessment modalities used may be different with the condition of patient or on
intubated and none-intu bated or level of consciousness.

The Behavioral Pain Scale (BPS) in combination with vital signs as far as the motor
function is intact is frequently used to assess pain in ICU patients.

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Table 8: Behavioral Pain Scale (BPS)

Item Description Score

Facial expression Relaxed 1

Partially tightened ( eg. Brow lowering, ) 2

Fully tightened (eg. Eyelid closing 3

Grimacing 4
Upper limb No movement 1
movement
Partially bent 2

Fully bent with finger flexion 3

Permanently retracted 4

Compliance with Tolerating movement 1

MV
Coughing but tolerating 2

Most of the time fighting ventilator 3

BPS Score ranges from 3 no pain to 12 maximum pains

For those conscious and not on MV the visual analog numeric pain intensity scale are
used.

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 Figure 25: Pain intensity scale

Wong-Baker FACES Pain Rating Scale- particularly useful for children who may not have
verbal skills to express their pain level. Six faces are used that are numbered 0 to 10

Figure 26: Wong baker faces pain rating scale

iii. Principle of pain management

1. All patients need to have pain intensity assessments and documented on the
patient chart before treatment and after.
2. Significant pain which is 7-10 according the numeric pain intensity score or
more than 7 according the BPS score requires Intravenous (IV) opoids
3. Add none-opioid analgesics to decrease the amount of opioids administered and
to decrease opioid-related side effect.
4. PO administered gabapentine or carbamazepine, in addition to IV opioids, be
considered for treatment of neuropathic pain.
5. The preferable opioid drug for significant pain in ICU patients is Fentanyl (0.35-
0.5mic/kg, 2-4 hourly, and the infusion rate is 0.7-10mic/kg/hr.), and morphine,(

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 IV 2-4mg/q 2-4 hrs according the response of the patient and the infusion rate is
2-30mg/hr).
6. Use of Pethidine is not recommended because its metabolite is neuro toxic
especially when renal impairment is identified or expected. When there is no
other drug of choice the dose is 0.5-1mg/kg/4-6hrs.
7. Ketamine can be used as analgesic, sedative and bronchodilator in asthmatic
patients. Loading dose is 0.1-0.5/kg bolus, Followed by 0.05-0.4mg/kg/hr.
8. Acetaminophen 325-1000mg/4-6hrs and the daily maximum dose is less than
4gram.

iv. Adult ICU Sedation

1. Guidelines recommend the Richmond Agitation –Sedation Scale (RASS) as an

important and effective sedation assessment tool for measuring quality and
depth of sedation in adult ICU patients.
2. Sedation should be titrated to a RASS score of 2-3 for most mechanically
ventilated patients.
3. Patients on ventilator requiring aggressive ventilator settings (e.g. ARDS)
may require RASS 3- 4.

Table 9: Modified Ramsay Sedation Scale (RASS)

Description Score
Awake, Anxious, agitated, restless 1
Awake Cooperative, accepting ventilation orientated, or tranquil 2
Awake responds only to command 3
Asleep Brisk response to light, glabella tap or loud noise 4
Asleep, Sluggish response to light glabellas tap or loud auditory stimulus 5
Asleep No response to light glabellar tap or loud auditory stimulus or pain 6

v. Principle of Sedation

1. All patients need to have sedation level assessments and documented on the
patient chart before treatment and after.
2. Analgesia-first sedation is used in mechanically ventilated adult ICU patients.
3. Promoting sleep in adult ICU patients by optimizing patients’ environments,
using strategies to control light and noise, and decreasing stimuli at night to
protect patients’ sleep cycles has to be practiced.
4. Maintaining light levels of sedation which is RSS of 2-3 in adult ICU patients is
associated with improved clinical outcomes and shorter duration of mechanical
ventilation and decreased ICU length of stay.

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5. Sedation Vacations: The Pain Agitation Delirium (PAD) guidelines recommend
daily sedation interruption or a light target level of sedation to minimize
sedation drugs side effect, to facilitate patient assessment, to start weaning and
to facilitate removal from the ventilator machine.
6. Combining of daily sedation interruption with a spontaneous breathing trial,
helps to evaluate the progress of the patient’s condition and to shorten length of
stay.
7. When available the drug of choice for sedation has to be nonbenzodiazepine
sedatives such as propofol or dexmedetomidine to improve clinical outcomes
and to minimize delirium.
8. Propofol, 4-5 mg/kg/hr and titrated down according the patient response. When
diazepam is used the doses is 0.2-0.6mg/IV/8hrs and titrate down according the
patients response.

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SESSION 3: ICU Delirium

3.1Introduction

Is a disturbance of consciousness and cognition that develops over a short period of

time (hours to days) and fluctuates over time. It is a common manifestation of acute
brain dysfunction in critically ill patients.

1. 50-80% ventilated patients and 20-50% of lower severity ICU patients develop
delirium
2. Patients with delirium have longer hospital stays and lower 6-month survival
than do patients without delirium
3. delirium is associated with multiple complications and adverse outcomes,
including self-extubation and removal of catheters, failed extubation, prolonged
hospital stay, increased health care costs and increased mortality
4. Delirium may be a predictor of long-term cognitive impairment in survivors of
critical illness.

3.2 Types

1. Hypoactive delirium is characterized by decreased responsiveness, withdrawal,

and apathy, is responsible for 43.5%
2. hyperactive delirium is characterized by agitation, restlessness, and emotional
instability and the prevalence is f1.6%
3. Mixed -54.1%

3.3 Risk factors

1. Risk factors for delirium can be divided into predisposing factors (host factors)
and precipitating factors

Table 10: Risk factors for delirium in ICU patients

Host factors Factors of critical illness Iatrogenic factors

Age (older) Acidosis Immobilization (for
example, catheters,
restraints)
Alcoholism Anemia Medications (for example,
opioids, benzodiazepines)
APOE4 Fever/infection/sepsis Sleep disturbances
polymorphism
Cognitive Hypotension

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impairment
Depression Metabolic disturbances (for
example, sodium, calcium, BUN,
bilirubin)
Hypertension
Smoking Respiratory disease
Vision/hearing High severity of illness
impairment

3.4 Confusion Assessment Method for ICU (CAM-ICU)

1. The CAM-ICU has a high sensitivity (93% to 100%) and specificity (89% to 100%) for
delirium
2. A comatose patient cannot be assessed for delirium. All other patients, whether
moderately sedated (RASS score -3) or more alert, should be evaluated for delirium. The
CAM-ICU assesses patients for four features of delirium; three out of four features are
required for a diagnosis of delirium

Steep 1 to assess the level of sedation (RASS*)

+4-overtly combateive, violete, immidate danger to staff

+3-pulls or remove tube(s) or catheter(s); aggressive

+2-frequent nonpurposeful movment, fights ventilator

+1-anxious but movments not aggressive or vigorous

0-alert and calm

-1- not fully alert ,but has sustained awakening (eye-opening )

-2-briefly awakens with eye contact to voice (<10 secondes)

-3-movment or eye opening to voice, but no eye control

-4-no response to voice, but movment or eye opening to physical stimulation

-5-no response to voice or physical stimulation

If RASS is -4 or -5 then stop and response patient later

If RASS is above -4(-3through+4) then procced to steep 2

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Steep 2 Assess for delirium (CAM-ICU+ or -)

1: Acute onset of mental status changes or a fluctuating

course

And

2: inattention

And

Or

3: disorganized 4: altered level of consciousness

thinking

=Delirium

Figure .

3.5 Prevention and treatment of ICU delirium

None pharmacologic

1. Repeated reorientation of the patient and provision of cognitively stimulating

activities;
2. Restoration of sleep/wake cycles, minimization of unnecessary noise/stimuli
3. Early mobilization activities and range of motion exercises;
4. Timely removal of catheters and physical restraints; use of eyeglasses,
magnifying lenses, and hearing aids; and early correction of dehydration.
5. Prevention and prompt treatment of electrolyte abnormalities, infection,
6. Avoid over-sedation by administering the drugs only as necessary. emphasizing
intermittent boluses rather than continuous infusions and promoting daily
interruption of sedatives and analgesics

Pharmacologic

1. Sedative agents that are GABA receptor sparing, such as opioids and
dexmedetomidine (a novel α2-receptor agonist), may reduce the risk for delirium
in ICU patients

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 2. Benzodiazepines are not recommended for the management of delirium because
these medications are themselves risk factors for delirium
3. SCCM guidelines suggest that patients with hyperactive delirium should be
treated with Haloperidol 2 mg intravenously, followed by repeated doses
(doubling the previous dose) every 15 to 20 minutes while agitation persists.
Once the agitation subsides, every 4 to 6 hours may be continued for a few days,
followed by tapered doses for several days. Common doses for ICU patients
range from 4 to 20 mg/day,
4. Monitor for adverse effects, including hypotension, dystonia, extra pyramidal
effects, laryngeal spasm, malignant hyperthermia, glucose and lipid deregulation,
and ant cholinergic effects such as dry mouth, constipation, and urinary
retention. Torsades de pointes and these medications should be avoided in
patients with prolonged QT intervals.

3.6 Pain and sedation in Pediatric

Pain Assessment: there are three fundamental pain assessment tools used in pediatrics

1. Physiological: primarily measuring physiological arousal consequent to pain eg

heart rate, blood pressure ).This method is not specific but need to be used in non-
communicating patients as indirect assessment of pain .

2. Self-report (measuring expressed experience of pain) this is the best and golden
standard as much we could we try to get the pain level from the patient itself. It can be
assessed using meter or verbal. It is good for adult and children. It is difficult to use for
age less than 5 year

3. Observational behavioral: measuring behavioral distress associated with pain,

measure behavioral distress: e.g. crying, not moving etc

3.1. Use Flacc scale for neonate and age up to 3 years

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Table 11: Behavioural Observation Pain Rating Scale (FLAA scale )

Scoring
0 1 2
Face No particular Occasional grimace or Frequent to
expression or smile; frown, withdrawn constant frown
disinterested clenched jaw,
quivering chin
Leg No position or relaxed Uneasy, restless, tense Kicking or legs
drawn up
Activity Lying,quietly,normal Squirming, shifting back and Arched,rigid,or
position, moves easily forth, tense jerking
Cry No crying(awake or Moans or whimpers, Crying steadily,
asleep) occasional complaint screams or sobs
frequent complaints
consol Content, relaxed Reassured by occasional Difficult to console
ability touching, hugging or talking or comfort
to distractible
Each of the five categories (f) faces ;( l) legs; (a) activity ;( c) console ability is scored
from 0-2, which results in a total score between 0 and 10.

Scoring minld; 0-3; moderate 4-7; severe 8-10.

3.2. For children between 3-8 years: they can quantify their pain and re able to
translate it to visual representation. Therefore, we use the visual analog
which quantifies pain based up on a series of faces in different phases of
happiness and crying. Wong Baker FACES Pain Rating Scale.

Figure 27: Wong- Baker FACES pain rating scale

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Pain Management

Non –pharmacologic:

For new born and infants kangaroo mother care, swadling, of use pacifiers with or without
glucose will help in the pain management.

Glucose analgesia:- 2 ml of 25 %Sucrose (glucose ) solution administered orally by

allowing the infant to suck on a pacifier or using a syringe and apply 1 ml. orally to each
cheek 2 minutes before the painful procedure. Safe and effective in managing
procedural pain, such as heel sticks and injections. It has strongest effect in newborns
and decreases gradually over the first 6 months of life.

Pharmacologic Treatments of pain:

WHO recommend for child in two pains in two steps:

1. Step 1 is for mild pain. The medicines used are non-opioid analgesics like Paracetamol
and Ibuprofen.
2. Step 2 is for moderate to severe pain. Strong opioids are used, e.g. morphine.

In general, Opioids should be administered at regular intervals and not on an “as-

needed” basis. Oral administration of opioids is preferred. The SC could be a valuable
alternative. Treatment with strong opioids needs to be individually adjusted and
there is no fixed maximum dosage.

NB. Codeine no longer is used for children. The effects of codeine are unpredicted,
because of intra-individual metabolic differences and therefore pose a safety risk

Sedation and analgesics in intubated pediatrics

Sedation assessment

1. The goal of sedation is to establish comfort (analgesia, anxiolytic and amnesia)

and safety (avoid fighting of ventilation).In sedated child the usual pain scores
cannot be used.
2. Use state behavior scale on the score is from -2 to 0 .With the goal is to keep
patient in -2 to -1 score unless during weaning
3. Ramsay scoring system is also can be used because of its simplicity .A score of
around 4 targeted in ventilated patient and around 3 in non-ventilated patient.
4. Assess the sedation level every 4 hour and before and after intervention .If you
give extra sedation repeat the assessment after 1 hour.
5. Look the patient in neutral state and then see him /her with stimulation.

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 6. Other measures to keep the child comfortable in the pediatric patient keep light
and sound in room low use non pharmacologic technique and also address
reversible cause which cause uncomfortable e.g. treatment of hypercarbinia ,
urinary retention , prevent skin break down ,

Sedation Medication

1. Combination strategy is used than single drug which allows lower dose of each
drug and avoids complication of higher dose of a single drug.
2. It can be administered bolus dose or continuous dose. The continuous doses give
more consistent level of sedation with greater levels of patients comfort.
3. The dose administered depend on the plan of sedation e.g. short for post
operative who will be extubated next day needs low sedation verses for the
disease needs more days of sedation e.g. the patient with severe trauma.
4. The patient status also affect the need of sedation e.g. acutely sick on
resuscitation need to consider less sedative drug complication .There are patient
who need more sedation for the disease condition or less sedation. Example
patient who need increase sedation with increased ICP, pulmonary hypertension,
patients with difficult airway. Unlike neuromuscular disease patient may not
need that much deep sedation.
5. Combination narcotic and benzodiazepm is used and popular for our setting
used is morphine and diazepam.
6. Increase in vital sign with milled manipulation is a sign to increase the
medication dose.
7. If goal is short term intubation bolus of narcotic is used. If patient need to be
intubated for >2 days we use combination narcotic and benzodiazepam
combination continuous infusion may or may need extra boluses e.g. if they have
procedures or increase dose of the continuous infusions.

Diazepam Midazolam Lorazepam

0.04-0.3mg/kg/dose
Q2-4hour
Not a continuous infusion
0.03 -0.1mg/kg/dose
Q 2-4hrs
Can cause line to precipitate
and potentially lose iv access
0.02-0.1mg/kg/dose
Q4-8hrs
Not continuous infusion
Preservative can be harmful

1. Morphine in neonate and infants because of the immature liver enzyme and
renal filtration higher doses should be avoided in patients <3 month. If it is used>
5 days weaning is recommended. Because of its effect on sphincter urinary
retention and constipation is common problem so patient on higher dose need
catheterization and laxative e.g. bisacody.

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 2. Therefore it is important to frequently assess the need of comfort of the patient
for the sedation. If dose is too low it can cause risk of fighting ventilator and
excessive dose increases staying in ventilator which will cause increase ICU stay.

Weaning from sedation

1. Daily sedation interruption or a light target level of sedation to minimize

sedation drugs side effect, to facilitate patient assessment, to start weaning and
to facilitate removal from the ventilator machine.
2. If the patient intubated for <5-7 days narcotic and benzodiazepim can be
discontinued all at once if they are ready for extubation.
3. If it was given>7 days there is risk of withdrawal symptoms but some patients
may have withdrawal symptom even getting <7 days so wean
4. Opoid and benzodiazepam used for 3-5 days reduce dose of by 20% of pre taper
dose every day .If it is used >10days decrease slowly by 10%
5. Sign and symptom of withdrawal : can be excessive sweating ,can be yawning
,tremor ,retching and vomiting, agitation and easily startled
6. Withdrawal symptom can be assessed by withdrawal assessment tool WAT- it is
>4-5 score need slow tapering or weaning of dose or may need dose replacement
or rescue medication .

Summary

1. Pain sensation, agitation and delirium are more common in ICU patients even
without any intervention done. This could be due to their untreated chronic or
acute illness, or drug induced, or the environment in the ICU increases their
sensitivity
2. Uncontrolled pain and anxiety contributes for complication of the patient’s illness
outcome and increase length of stay in the ICU.
3. Whenever patients are in pain, anxious and restless all sympathetic outflow
increases and patients manifest with increased pulse rate, and blood pressure,
increased work of breathing and they may manifest also with some metabolic and
endocrine derangement leading to increased cortisol release with subsequent
development of hyper glycaemia, electrolyte imbalances and increased risk for
infections.
4. Proper pain and anxiety assessment before treatment, following treatment
according to the half-life of the given and subsequent periodical monitoring is
crucial for effective pain and anxiety Intravenous (IV) opoids to be considered as
the first-line drug choice to treat sever non- neuropathic pain in critically ill
patients. Non –opoid analgesics are considered to decrease the dose of opoids
administered and to decrease oiod related side effect.

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5. Delirium incidence and duration can be prevented by early mobilization of patients
whenever feasible.
6. Daily sedation interruption or a light target level of sedation is used in mechanically
ventilated adult ICU patients.

Analgesia-first sedation is used in mechanically ventilated adult ICU patients.

promoting sleep in adult ICU patients by optimizing patients’ environments, using
strategies to control light and noise and decreasing stimuli at night to protect patients’
sleep cycles should be practiced

Bedside clinical practice

Session objective: By the end of this session, participants will be able to demonstrate
approaches altered mental status, and mange pain in ICU.

Enabling objectives:

• Describe approaches to patient with altered mental status

• Demonstrate monitoring of patient with altered mental status
• Understand the principles pain management and sedation in ICU

Introduction This session planned to enable the participants to hands on practice on

approaches to altered mental status in the critical care settings, . It consists of …..hours
of practice sessions.

Learning activities

No Topic Airway opening Activities Time

maneuvers
1. Approaches to ABC of life Participant hands on practice at bed
side ,round
2. Outline Basic history Participant hands on practice at bed
,physical exam, consider side, round
differential diagnoses
and investigation
modality for patient with
altered mental status
3. Have basic skills of Participant hands on practice at bed
Pain and sedation in side ,round
ICU
4. Monitoring Patients Participant hands on practice at bed
with AMS side ,round

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Introduction of the session

• Start session by briefing objective of clinical practice

Facilitation of the session

• Allow the participants to practice on patients.

Concluding the Session

The session will be concluded by Q & A and discussing on the summary

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CHAPTER 8: MONITORING IN ICU
Chapter duration: 30 minutes lecture

Teaching method

• Lecture
• Bedside

Chapter Objective

The general objective of this session will help the participant to identify the purpose of
monitoring, principles of monitoring and develop the skill on proper patient monitoring
in ICU and emergency units.

Chapter Methodology

Within the 3 weeks of training period, this chapter will be covered in 30 minutes lecture
and 15 hrs of bed side and practical sessions.

Session outline

Session 1: Introduction to patient monitoring

Session 2: Physiologic functions to be monitored in ICU

Session Description: This is a 14 hour session is focuses on the different monitoring

parameters, frequency of monitoring and commonly used devices in patient monitoring
in ICU and emergency room

Enabling objectives: After completing this session participants will be able to: -

• Describe the physiologic function to be monitored

• Explain the benefits of proper monitoring
• Conduct proper patient monitoring
• List the parameters to be monitored in critically ill patients

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SESSION 1: INTRODUCTION TO PATIENT MONITORING

What is patient monitoring?

Continuous measurement of patient parameters such as heart rate and rhythm,

respiratory rate, blood pressure, blood-oxygen saturation, and many other parameters
has become a common feature of the care of critically ill patients.

Patient monitoring can be rigorously defined as “repeated or continuous observations

or measurements of the patient, his or her physiological function, and the function of life
support equipment, for the purpose of guiding management decisions, including when
to make therapeutic interventions, and assessment of those interventions” (Hudson,
1985, p. 630)

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SESSION 2: PHYSIOLOGIC FUNCTIONS TO BE MONITORED IN ICU

• ECG monitoring
• Blood pressure monitoring
• Respiration
• Body temperature
• Oxygen Saturation and Mental status

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Physiologic
Monitoring points
Function
• It is a continuous electrocardiography that displays cardiac
electrical activity including P wave representing the atrial
depolarization, QRS complex representing ventricular
depolarization and the T wave representing repolarization of the
ventricles.
• Ischemic events can detect on lead V4 and V5 while Lead II is best
Cardiac rhythm for monitoring P-waves for detecting arrhythmias. Monitoring
using leads II and V5 simultaneously is the most informative
monitoring modalities. .
• Whenever the heart rate is greater than 100/min, close assessment
and management of patients for fluid balance, fever, pain or anxiety
and communicates the treating physician.

• What to assess?

Pulse ✓ Rate, Rhythm, Volume, Symmetry, and Regularity. The

• Pulse is affected by many factors including age, existing medical

conditions such as fever, medications like beta-blockers and fluid
status hyper/hypovolemia.
• Peripheral pulse and heart rate are not always the same therefore it
has to be assessed carefully

• Affected by cardiac output, peripheral vascular resistance, blood

volume, and viscosity
• Indicators of cellular oxygen delivery it can be measured by using

Blood pressure A. Non-invasively: using automated B/P apparatus or manual

sphygmomanometer.

B. Invasively (through an inserted arterial line and displayed with

transducer).
• An increase of even three to five breaths per minute is an early and
important sign of respiratory distress and potential sign of
hypoxemia.
Respiratory • Respiratory rate should be counted for a full minute, rather than 30
rate (RR) seconds.
• In ICU it can be counted or followed continuously using the
monitors.
• Respiratory effort which is depth of inspiration, use of accessory

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 muscles, and symmetry of chest expansion should also be evaluated
to detect respiratory distress.

• To work effectively, a pulse oximeter requires an adequate

peripheral blood flow.
• This flow may be affected by patient movement, tremor or shivering,
Oxygen hypovolemia, hypothermia, pain, arrhythmias, vasoconstriction or
saturation heart failure, nail polish, pain, and improper size of the probe and
(SaO2) high altitude.
• It may be falsely normal in anemia, and one you should not rely only
on SaO2.

• Non-invasive monitoring of CO2 concentration of the expired and

inspired gases.
Capnog-
• The gas is detected at the connector-end of the ETT, the mask or
nogram:
nasal prongs and measures the end-tidal CO2 (EtCO2), and
displayed in graph and in number.
• Normal value is 35-45mm/Hg.

• Regular calibration and accurate documentation of the site of

Body
measurement, using the same site of measurements are used as
temperature:
ways of accurately identifying trends.
• Low and high temperature should be reported.

• Level of consciousness is monitored using GCS or AVPU (A-alert, V-

responds for verbal stimuli, P- responds to painful stimuli, U-
unresponsive).
• This CNS monitoring has to be in place in all comatose patients using
Level of
the neuro chart, and indicates the progress of the patients.
consciousness:
• When available intra cranial pressure (ICP) is monitored using tubes
inserted to the brain with the normal value is 10cm/H20 and during
the measurement the patient has to be 30Ohead elevated.

• To be done in all patients who are admitted in ICU because critically

ill patient may get easily hyperglycemic or hypo due to feeding
Blood glucose: problem and the calorie they are getting is not known
• It should at least be monitored q4 – 6 hrs
• Target level of 140 – 180mg/dl in most ICU patients should be
achieved

Pain level: • Frequent pain assessment using pain assessment scale is mandatory
for all patients in ICUs, and it should be treated promptly.

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 • Successful management of pain is directly related to the quality of
nursing care and good patient prognosis
• Delays between pain assessment and analgesic administration
should be avoided.

• Critical patients are prone for fluid retention and/or deficit,

therefore input output monitoring is mandatory.
• Urine output is an indirect reflection of renal function and fluid
status, therefore, should be monitored closely in all acutely ill
patients.
• Normal urine output is 0.5-1ml/kg/hour. In patients who are
catheterized, an output of less than 0.5 ml/kg/hour for 2consecutive
hours is a marker of renal hypo perfusion and should trigger
assessment and further action.
Fluid balance • To know the fluid balance all intakes oral, IV, and NGT feedings and
outputs; urine, and any other loss from the body including insensible
loss (a loss from the skin and respiration) are considered.
• The balance is as a minimum evaluated and corrected every 6hrs,
but in patients with renal and hemodynamic instability the urine
output has to be measured hourly.
• Insensible loss: For adult patients on mechanical ventilation this
averages 800ml/24hrs and 2.5ml/kg/24hrs for each unit of
temperature above 37oC.

Summary

• Continuous measurement of patient parameters such as heart rate and rhythm,

respiratory rate, blood pressure, blood-oxygen saturation, and many other
parameters is critical for care of ICU patients.
• A patient monitor may not only alert caregivers to potentially life-threatening
events; many also provide physiologic input data used to control directly
connected life-support devices.

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CHAPTER 9: PRONING-BEDSIDE TEACHING
Chapter duration: 4 hours bedside

Teaching method

• Bedside

Objective

• Put patient on prone position

• Apply proning in the management of acute respiratory failure

1. Background information
i. Prone Positioning

• Prone Positioning is beneficial in improving ventilation-perfusion mismatch,

promoting homogenous aeration and decreasing lung injury as well as infection
by facilitating airway secretions drainage. Recent data also indicate mortality
benefit when used early in moderate to severe ARDS. Trials also indicate that
non intubated patients may benefit with prone positioning in patients with
refractory hypoxemia with high flow oxygen.

ii. Indication for Prone Positioning

• It is recommended to use Prone Positioning as we observe poor oxygenation

despite maximal ventilator support
• Taking into consideration the availability of resources, especially optimal
nursing care we advise to pronate the patients for at least 12hours, preferably 16
hours per day in the absence of contraindications.

iii. Contraindication for proning patients:

• Significant hemodynamic instability

• Increased ICP
• Pregnancy
• DVT treated for <2 days
• Facial surgery or severe facial trauma
• Massive hemoptysis
• Life-threatening cardiac arrhythmias within 24 hours
• Bronchopleural fistula
• Unstable fracture, especially pelvic fractures and Spinal instability

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 • Serious burns (> 20% body surface area)
• History of difficult or nasotracheal intubation
• Inability to tolerate face-down position
• Recent sternotomy ,tracheostomy or major abdominal surgery or active
intraabdominal process

2. Prone Ventilation Guide

Human resource and equipment required

• At least 3 providers, 1 of which with airway proficiency (in droplet/contact COVID

PPE; ETT will be clamped during procedure so no aerosolization is anticipated)
• 3-4 pillows
• 2 flat draw sheets
• ETT holder
• Clamp for ETT
• Pack of new EKG leads
• Thin ear-protective foam pillow (white top from blue/white prone tube holder
pillow)
• liquid skin protectant
• 1 supervising provider
• Extra ventilator circuit and ETT suction catheter
• Airway cart with appropriate sized ETT

Preparation before any turn

• Verify absence of contraindications

• Tracheal surgery of sternotomy in previous 15 days
• Unstable spine, pelvic, or femur fractures
• Massive hemoptysis
• Confirm ETT tip in good position (auscultation +/- U/S to rule out main stem
intubation
• Determine whether turn will be rightward or leftward (typically towards
ventilator)
• Secure ETT, central lines, arterial line, and peripheral IVs
• Secure NG and/or feeding tube and Foley catheter
• Hold tube feeding, fully evacuate the stomach, and cap/clamp NG and/or feeding
tubes
• Suction ETT and oral cavity
• Perform anterior surface skin care and any required wound care or dressing
changes
• Empty all ostomy bags; secure all peritoneal catheters and drains

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 • Evaluate adequacy of sedation and/or paralytic; consider single-dose paralytic if
patient not on paralytic infusion; consider viral filter at ETT if no paralytic to be
used
• Prepare all lines and tubes:
• Assure sufficient IV line length; add extensions as needed
• Relocate all drainage bags to the ventilator side of the bed
• Place all chest tube drains and Foley catheter drainage bags between the
legs
• Reposition all IV tubing running towards the head and off the ventilator
side of the bed

Supine-to-prone turning procedure

• Supervising provider performs brief time-out

• Identify turn leader (usually the patient’s primary nurse)
• One provider on each side of the bed to manage turn
• Dedicated provider at the head of bed to manage ETT
• Increase vent FiO2 to 100% and note the pre-turn vent settings and airway
pressures
• Remove patient gown and any orthotic boots or devices
• Place new EKG leads on the patient's back and connect to monitor
• Remove chest EKG leads and any other non-critical skin-adherent material
• Forehead/Cheek – cut Mepilex lite 4” x 4” into x” x 4” strips; place on
cheekbones and forehead
• Anterior Shoulders - 4” x 4” bordered foam on prominent area of shoulder
• Chest – 6” x 6” bordered foam over each breast/chest wall
• Medial Elbows - 4” x 4” bordered foam over medial olecranon
• Iliac crests – 4” x 4” bordered foam on anterior superior iliac spine
• Knees – Small sacral Mepilex over patella
• Eyes with lacrilube gently taped closed prior to turn
• Flatten the bed
• Place amber gel pad under patient's torson with gel pad in direct contact with
mattress
• Place a new, clean draw sheet under the patient
• Place 2 absorbent Dri-Flo pads directly on patient's skin - chest and pelvis
• Place three pillows:

• Across chest
• Across pelvis at level of iliac crest
• Across shins
• Position arms at side with hands behind buttocks
• Place draw sheet overlying pillows

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 • Roll top and bottom sheets together at the patient’s sides
• Lift draw sheet and move the patient to the non-ventilator side of the bed until
arm is hanging off, but the patient remains securely in bed; avoid sliding
• Prepare to unhook ETT from ventilator
• Perform inspiratory hold and clamp ETT with hemostat
• Turn ventilator on standby
• Unhook ventilator from ETT
• Log-roll into the lateral decubitus position, with the dependent arm tucked
under the chest; one side provider pulls straight up on the patient while the
other side provider pushes under to keep patient at edge of bed
• Check all lines and tubes
• Complete the log-roll towards the ventilator and into the prone position
• Simultaneously turn the patient’s head towards the ventilator
• Prepare to hook ETT back to ventilator
• Hook ventilator to ETT
• Turn ventilator back on
• Unclamp ETT
• Remove the flat sheet and expose the patient’s back
• Reassess ETT and all lines/tubes
• Place white offloading foam under head with ear in opening; slide Dri-Flow sheet
under to catch secretions
• Raise the patient’s arm on the same side as the patient is facing
• Be sure the raised arm shoulder is dropped, and elbow is below the level
of the axilla
• Place the opposite arm at the patient’s side, with palm facing up
• Lift draw sheet and roll amber gel pad up under same side as patient is
facing to micro wedge that side up
• Adjust pillows to keep toes, knees, and abdomen floating
• Position penis, testicles and breasts to avoid inappropriate pressure
• Tilt the bed into slight reverse Trendelenburg (head up) - 15 degrees
• Use fluidized positioner as needed to offload any areas needing extra support
because of patient body habitus
• Compete post-turn evaluation (see below)

Head repositioning

• Identify turn leader (usually the patient’s primary nurse)

• At least one provider on each side of the bed
• Dedicated provider (usually RT/CRNA) at the head of bed to manage ETT
• Flatten bed
• Lift patient and unroll amber gel pad on side of raised arm
• Place raised arm down by patient side, palm facing up

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 • Remove white offloading foam ear protector
• Using bottom flat sheet, lift patient and move upward so that head is off bed;
avoid sliding
• Carefully turn the patient’s head to the opposite side
• Resecure ventilator tubing suspended above the patient’s head
• Using bottom flat sheet, slide patient back down onto bed
• Reassess ETT and all lines/tubes
• Place white offloading foam under head with ear in opening
• Reposition ETT in holder towards up-facing side and check for lip and tongue
pressure
• Reposition arms in modified swimmer’s crawl position
• Raise the patient’s arm on the same side as the patient is facing
• Be sure the raised arm shoulder is dropped, and elbow is below the level
of the axilla
• Place the opposite side arm at the patient’s side, with palm facing up
• Lift draw sheet and roll amber gel pad up under same side as patient is
facing to microwedge that side up
• Adjust pillows to keep toes, knees and abdomen floating
• Position penis, testicles and breasts to avoid inappropriate pressure
• Tilt the bed into slight reverse Trendelenburg (head up) - 15 degrees
• Complete post-turn evaluation (see above)

Prone-to-supine repositioning (planned)

• Identify turn leader (usually the patient’s primary nurse)

• At least one provider on each side of the bed
• Dedicated provider (usually RT/CRNA) at the head of bed to manage ETT
• Flatten the bed
• Increase vent FiO2 to 100% and note the pre-turn vent settings and airway
pressures
• Remove patient gown if in place
• Place new EKG leads on the patient's chest and connect to monitor
• Remove back EKG leads and any other non-critical skin-adherent material
• Place sacral Mepilex foam adhesive pad to prevent pressure ulcers (if not already
place)
• Unroll amber gel pad to lay flat on the bed
• Place both arms at the patient’s side with palms up
• Place 2 absorbent Dri-Flo pads directly on patient's skin - across back and pelvis
• Place clean draw sheet on top of patient
• Using the flat sheet under the patient, slide patient towards the side of the bed
that they are facing, keeping the amber gel pad in place on the bed
• Prepare to unhook ETT from ventilator

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 • Perform inspiratory hold and clamp ETT with hemostat
• Turn ventilator on standby
• Unhook ventilator from ETT
• Log-roll the patient into the lateral decubitus position facing the ventilator, and
center the patient’s head
• Place a clean flat sheet on the bed
• Complete the log-roll towards the ventilator and into the supine position
• Prepare to hook ETT back to ventilator
• Hook ventilator to ETT
• Turn ventilator back on
• Unclamp ETT
• Reassess ETT and all lines/tubes
• Reposition ETT in holder to avoid sustained lip and tongue pressure in one
location
• Complete post-turn evaluation (see below)

Prone-to-supine repositioning (emergent)

• Identify turn leader (usually the patient’s primary nurse)

• At least one provider on each side of the bed
• Dedicated provider (usually RT) at the head of bed to manage ETT
• In an emergency, clamp and disconnect the ventilator circuit for the turn
• Place a draw sheet over patient’s back and roll it to join the draw sheet below
• Complete a one-step log-roll towards the ventilator and into the supine position
• Reconnect the ventilator circuit or Ambu bag and unclamp the ETT
• Reassess ETT and all lines/tubes
• Complete post-turn evaluation

Post-turn evaluation

• Consider potential for accidental right main stemming or dislodging of the ETT
and auscultate or U/S if needed
• Reassess ventilator settings, O2 saturation, heart rate, and blood pressure
• Check and adjust all tube and line connections and function
• Check lips and tongue, and reposition ETT holder as needed to avoid recurrent
pressure
• Check that all leads and other devices have been removed from the dependent
surface of patient
• Check all aspects of the patient’s skin in contact with the bed for adequate
Mepilex padding
• Check that toes/heels are floating
• Pad any fixed IV, arterial line, or connector sites at the skin with pink foam

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 • Document a thorough skin assessment, including any non-blanchable erythema
in areas of pressure

Activities

Session 1-Explain steps

Session 2-Observe

Session 3-Assist

Session 4-Perform

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CHAPTER 10: PEDIATRICS ICU
Chapter duration: 1 hour lecture

Teaching method

• Lecture
• Bedside

Chapter Objective

By the end of this session the participant will be able to detect, evaluate and intervene
common pediatric emergency and critical problems of COVID 19 in a systematic way
(ABCDE method) and with team work approach.

Chapter Methodology

The pediatric session basically focuses mainly on the practical sessions while its
peculiar features will be discussed in the main case management section of each COVID
19 ICU training period. The total duration of session for bedside teaching will be 8hr
and depending on the case load coming to ICU the duration of practice will be amended.

Enabling objective

At the end of this training, the participant will be able to:

• Triage critically ill children

• To do pediatrics airway assessment and management
• Access and manage pediatrics respiratory problems
• Early recognition and manage a child with shock
• Mange fluid and electrolyte abnormality
• Management of COVID 19 children with hypoxemia
• Appropriately asses and manage altered level of consciousness

Session outline

Session 1: Proper triage and assessment of critically ill child

Session 2: Pediatrics Airway and respiratory emergency

Session 3: Clinical symptoms and severity assessment in pediatrics COVID-19 patients

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Session 4: Positive pressure ventilation in children 0 month to 18 years of age with
COVID-19 infection

Session 5: Management of Septic Shock in malnourished and Non-Malnourished Child

Session 6: Pharmacotherapy of children with COVID-19

SESSION 1: PROPER TRIAGE AND ASSESSMENT OF CRITICALLY ILL

CHILD

1.1 Pediatric triage

In this session participants will sort out critically ill pediatric patients at the emergency
room.

Triage category: E=Emergency, P= Priority and, Q=Queue (non-urgent)

Triage process: keep in mind the ABCDO steps: (Airway, Breathing,

Circulation/Coma/convulsion, dehydration and Others).

Besides ABCD signs, there are priority signs remembered with the symbols, which
should alert you to a child who needs prompt emergency assessment. These signs can
be:

• 3T: Tiny baby, temperature, Trauma

• 3P: Pain, poison, pallor
• 3R: RR, restless, referral
• MOB: malnutrition, oedema, burn

NB: Triaging should not take much time. For a child who does not have emergency
signs, it takes on average 20 seconds.

1.2 Assessment of critically ill child

The instructor should make sure that participant able to do the following enabling
objectives during demonstration and practical session:

• Recognize the three components of the Pediatric assessment triangle (PAT).

• Assess and intervene problems identified with primary survey (ABCDE)
approach.
• Assess and intervene problems identified with Secondary survey and tertiary
survey

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 • following step is critical whenever there is a very sick child immediate
evaluation is important

Steps critical whenever there is a very sick child immediate

evaluation:

• Detection: using general assessment, history and physical examination activate the
pediatric emergency response team.
• Intervention: treat the diseases or injury to prevent morbidity and mortality.
• Reassessment: this is to check if the treatment provided is adequate or not.
• Effective teamwork: Initiate team work

Discuss components of the Pediatric assessment triangle (PAT-Appearance,

Circulation and Work of breathing) in every demonstration and bedside teaching.

After you do the general assessments activate the emergency team and go the primary
2ndary and Tertiary survey with ABCDE approach and simultaneously resuscitating the
patient.

i. Primary survey with ABCDE

• Air way assessment and management
• Breathing assessment and management
• Circulation assessment and management
• Disability assessment and management
• Exposure assessment and management

ii. Secondary survey

• History: Use SAMPLE mnemonics: Signs/Symptoms, A: allergies, M: Medications
P: Past medical problems, L: Last food or liquid, E: events leading to injury or
illness.
• Physical examination: do head to toe examination and with both history and
physical examination establish a clinical diagnosis.
• Important laboratories like blood group and cross match, Random blood sugar
are part of the secondary survey.
iii. Tertiary survey

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Plan sequence of laboratory testing and imaging depending on the differential diagnose
considered.

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SESSION 2: PEDIATRICS AIRWAY AND RESPIRATORY EMERGENCY

Practical Session description: participants required to identify the difference of

pediatric airway from adult and the common pediatric respiratory problems following
COVID 19 and how to manage.

Recognition of respiratory distress and failure

Respiratory distress: refers to the use of compensatory mechanism to maintain

adequate oxygenation and ventilation .This compensation consist of an increases
respiratory rate and work of breathing (WOB).

Respiratory failure: is defined by inadequate oxygenation or ventilation or the

inability of the pulmonary system to meet the metabolic need of the body. The
respiratory system is involved in two crucial metabolic roles elimination of carbon
dioxide and oxygenation of the blood.

Clinical indicator of Respiratory failure: marked tachypnea RR>60 breaths /in

abnormal at any age Bradypnea/ apnea, cyanosis, worsening saturation despite
intervention, poor or absent distal air movement, Lethargy stupor, and coma.

Be aware that;

• Cyanosis is a very late sign.

• Initially they become agitation, then somnolence like unresponsive for IV

stick.
• Respiratory failure is a pre arrest state

The instructor at different sessions of demonstrations and bed side teaching should
focus on the peculiarities of clinical symptom and severity assessment of COVID 19 in
pediatrics.

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SESSION 3: COVID 19 IN PEDIATRICS

Table 12: Clinical symptoms and severity assessment in pediatrics COVID-19

patients

Severity Clinical symptoms and signs

Mild Upper Non-specific symptoms: fever, fatigue, cough (with or
disease respiratory without sputum production), anorexia, malaise, muscle
tract infection pain, sore throat, nasal congestion, or headache. Rarely,
patients may also present with diarrhea , nausea and
vomiting
Moderate Pneumonia Child with cough or difficulty breathing + fast breathing:

Disease A. fast breathing (in breaths/min): < 2 months: ≥ 60; 2–

11 months: ≥ 50; 1–5 years: ≥ 40, and
B. no signs of severe pneumonia and SaO2 > 90 %
C. Chest imaging (radiograph, CT scan Ultrasound may
assist in diagnosis and identify complications

*Infants < 3months of age with only fast breathing

should always be considered as sever disease ↓
Sever Severe Child with cough or difficulty in breathing, plus at least one
Disease pneumonia of the following:

D. Infants blow 3months of age with fast breathing

E. Central cyanosis or SpO2< 90%;
F. SpO2 <94% if hemodynamically unstable
G. severe respiratory distress (e.g. fast breathing, grunting,
very severe chest indrawing);
H. general danger sign: inability to breastfeed or drink,
lethargy or unconsciousness, or convulsions
I. Chest imaging (as above)

Critical Acute Onset: within 1 week of a known clinical insult or new or

Disease respiratory worsening respiratory symptoms.
distress
syndrome Chest imaging: bilateral opacities, not fully explained by
volume overload, lobar or lung collapse, or nodules.

Origin of pulmonary infiltrates: respiratory failure not fully

explained by cardiac failure or fluid overload if no risk
factor present.

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 Oxygenation impairment in children: OSI = Oxygenation
saturation Index using SpO2:

NB. wean FiO2 to maintain SpO 2≤ 97% to calculate OSI or

SpO2/FiO2ratio:

• Bilevel ( NIV or CPAP) ≥ 5 cmH2O via full face mask:

PaO2/FiO2≤ 300 mmHg or SpO2/FiO2≤ 264
• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤
OSI < 7.5
• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16
or 7.5 ≤ OSI < 12.3

Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥

12.3.
Critical Sepsis Suspected or proven infection and ≥2 age based system
Disease inflammatory response syndrome (SIRS) criteria of which
one must be abnormal temperature or white blood cell
count.

Newborns: fever, lethargy, rhinorrhea, cough, tachypnea,

apnea, increased work of breathing, vomiting, diarrhea,
feeding intolerance or decreased intake and change in
mentation. (signs of neonatal sepsis)
Septic shock Any hypotension (SBP< 5th centile or >2SD below normal
for age ) or two of three of the following altered status;
bradycardia or tachycardia (HR<90bpmor >160 in infants
and heart rate <70bpmor >150bpmin children); Prolonged
capillary refill (>2 sec) or weak pulse ; fast breathing ;
mottled or cool skin or petechial or purpuric rash; high
lactate, reduced urine output; Hyperthermia or
hypothermia

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SESSION 4: POSITIVE PRESSURE VENTILATION IN PEDIATRICS

Table 13: Positive pressure ventilation in children 0 month to 18 years of age with
COVID-19 infection

Indications Contraindication Mode of delivery

Non-invasive Newborns with Surgery, trauma or Continuous Positive Air
ventilation support respiratory deformity of the way pressure(CPAP)
distress and face start at pressure depth
unable to maintain of 5cmH2O and increase
Spo2 of >90% with Total obstruction up to 8 cm H2O, if the
intranasal or head of the upper baby is not improving
box oxygen airways. can go up to 10cm H2O.

Respiratory Failure of airway Oxygenation targets for

distress due to: protective reflex. newborn = 90-95%
spo2
Sever High risk of
pneumonia aspiration (vomit For children above
or upper, GI 1months of age the
Acute lung hemorrhage), target should be above
injury 94%
Undrained
Chronic lung pneumothorax Bilevel Positive airway
disease Pressure (BiPAP) with
Non respiratory maximum of 10 of
Cardiogenic organ failure: driving pressure
pulmonary edema change in mental
status , digestive The interface of
Patient weaned of hemorrhage, administration can be
invasive cardiac, nasal, face masks,
mechanical arrhythmia and helmet
ventilation hemodynamic
instability All precautions should
NB : The child be taken as there is risk
have to be able to of aerosolization.
maintain the
airway open and
handle its’
secretion
Invasive Severe A conscious Use preferably cuffed
mechanicalventilation Hypoxemia: patient who tubes
unable to maintain otherwise can be

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target oxygen treated with NIV A lower level of plateau
saturation with pressure (< 28 cmH2O),
high flow of and lower target of pH is
oxygen permitted (7.15–7.30).

Change in mental Tidal volumes: 3-

status 6mL/kg Predicted Birth
Weight (PBW) in the
Increased work of case of poor respiratory
breathing with system compliance, and
exhaustion 5–8 mL/kg PBW with
better preserved
Patients with compliance
septic shock
unresponsive to Recommended maximal
fluid and inotropes positive end pressure
(PEEP) is 15 cmH20.
Newborns with Watch for hemodynamic
recurrent or stability while escalating
prolonged apnea, the PEEP
in shock needing
more than 2 In patients with
inotropes with ventilator dysynchrony
congenital and severe ARDS:
diaphragmatic consider deep sedation
hernia and neuromuscular
blockage

Institute standard care

for patient on
mechanical care
ventilator: ventilator
pneumonia bundle, use
of proton pump
inhibitor, avoid pressure
ulcer

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SESSION 5: PEDIATRICS CIRCULATION AND SHOCK

In this session participant will be able to recognize a child in shock and be able to
understand how to manage a shock child. The trainer during the practical session
should enable the trainee to assess a child with circulatory problem, identifying the
compensated and uncompensated shock and develop a skill in early fluid management.

Areas a trainee to discuss

Category of Shock: De-compensated and compensated shock

Causes of shock as classified as for types: hypovolemia, distributive, Cardiogenic,

obstructive

Management of Septic Shock

i. Management of Septic Shock in Non-Malnourished Child

• Provide oxygen for all patients with septic shock
• Measure Random Blood Sugar (RBS)
• Start with 20ml/kg aliquots for at least 3 times with assessment for fluid
overload with each bolus: jugular venous distention, crackles on lungs ,
pulmonary oedema or hepatomegaly, if there is fluid over load stop fluid
• Administer Epinephrine0.1-0.3mcg/kg /hour if signs of fluid overload are
apparent or the following persist after two fluid bolus:

• Altered mental state;

• Bradycardia or tachycardia (hr < 90 bpm or > 160 bpm in infants and hr <
70 bpm or > 150 bpm in children);
• Prolonged capillary refill (> 2 seconds) or feeble pulses;
• Tachypnoea; mottled or cool skin or petechial or purpuric rash;
• Increased lactate; oliguria persists after two repeat boluses; or
• Age-appropriate blood pressure targets are not achieved

• Dopamine can be added if shock persists despite optimal dose of epinephrine

• If sepsis refractory to fluid and inotropes: Hydrocortisone 2 mg/kg IV (maximum
100 mg), followed by 1 mg/kg (maximum 50mg) every six hours for a maximum
of seven days or until all vasoactive infusions have been discontinued for at least
12 hours, whichever comes first.
• Consider blood transfusion if hgb <10g/dl
• Take blood culture and initiate appropriate antibiotics with in the first hour
Management of septic shock in severely malnourished patients: Follow the
national guideline

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SESSION 6: PHARMACOTHERAPY OF CHILDREN WITH COVID-19

i. Systemic Corticosteroid

• Routine use of systemic corticosteroid as a treatment for viral pneumonia is

not recommended.
• Recent study showed that Dexamethasone has reduced the death rate of
severe and critically sick patients with COVID 19
• Decisions to initiate glucocorticoids should be made case by case basis;
dosing regimens described on the table below

Table 14: Dosing of Steroid for moderate to severe COVID 19 disease

Mild Moderate Severe critical

No role of NB: Do not delay in giving the first dose of steroid if indicated, if delay is
steroid in expected for admission oral steroids should be given.
mild cases, Dexamethasone 0.1- Dexamethasone 0.2-
it can harm 0.2mg/kg(max6mg)I.V/day for 3-5 days 0.4mg/mg/day(max6mg)I.V
during for 5-7 days
viremia Injection: methyl-prednisolone 0-5- Injection: methyl
phase 1mg/kg(Max 40 to 60mg)for 3-5 days prednisolone 1-
2mg/kg/day(max 80mg)
for 5-7 days
Increase the dos if already
given
In patients with worsening
clinical conditions increase
the dose 80mg q 12 hourly,
then titrate down as
appropriate
Avoid dexamethasone if Remdesevir is
planned
NB: Endocrine experts recommend that if steroids are given for<2 weeks there may not
be a need to plan tapering dose but if there is need for tapering dose should it be as
follows: next five days after the usual treatment dose: give half dose, then next 2 days
give quarter dose, then next 3 days give one eightieth (1/8th), then you can stop.

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 ii. Empiric Antibiotics

Only children with moderate disease in whom we consider bacterial infection and those
with sever and critical disease should receive empiric antibiotics based on the clinical
diagnosis and should be modified depending on the culture and sensitivity result (Refer
to the table below for choice of antibiotics).

Table 15: Antibiotics treatment for children with moderate to critical illness of
COVID 19

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iii. Anticoagulant use

Generally younger pediatrics patients have a tendency to have bleeding rather than
coagulation disorder in sever disease conditions, however, there might need a need to
have anticoagulant therapy for older children and adolescents admitted with COVID-19.

Table 16: Use of anticoagulant in older and adolescent children

Anticoagulants Moderate disease Severe /critical

disease
Contradicted if HAS-BLED score more than Enoxaparin 40mg Enoxaparin 40 mg
3 indicates high risk of bleeding SC/day SC BID or

HAS BLED SCORE: hypertension -1 point Dalteparin 2500 IU 0.5mg/kg in two

SC /day divided doses
Abnormal liver function -1 point
In End stage renal Titrate the dose as
Abnormal Liver function -1point disease per the value of D-
dinner
Stroke -1point ;Labile INR-1 point Unfractionated
Heparin(UFH)5000u
Alcohol-1 point SC BID

• ALSO contraindicated an active

bleeding , if emergency surgery is
planned ,platelets
<20,000/mm:BP>200/120mmg/Hg,
fibrinogen level <0.5 gm/It
• Use D-Dimer and sepsis induced
coagulopathy (SIC)score (sofa score
,INR ,platelet counts )of more than
or equal to 4 portends high
thrombotic risk
• Monitor anti-Xa activity in
underweight and obese patients
,those with chronic renal failure and
in those patients with an increasing
D-Dimer aiming for anti Xa activity
of 0.6 -1.1Uml
• LMWH is given even if coagulation
tests are abnormal i.e prolonged PT
or aPTT is not a contraindication for
LMWH

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• Patient on anti-platelet agents
follow ASA/ESC and ISTH guidelines

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CHAPTER 11: CRITICAL CARE ETHICS
Chapter duration: 1 hour lecture

Teaching method

• Lecture
• Bedside

Session outline

Session 1: Ethics in COVID management

Session 2: covid-19 patient care prioritization and its ethical considerations

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SESSION 1: ETHICS IN COVID 19 MANAGEMENT

Objective

• Identify ethical issues in the case management of COVID-19

• Apply ethical principles in the management of COVID-19 cases
• Able to disclose bad news to clients
• Communicate ethically with colleagues and clients
• Resolve work place conflicts with ethical manner

Introduction

There are a number of issues that may arise during the period of the epidemics not
covered by the existing ethical standards and laws of the country. Relevant ethical
principles included in the WHO guide line are justice (fairness), beneficence (acts that
are done for the benefit of others), utility (actions are right insofar as they promote the
well-being of individuals or communities), respect for persons (treating individuals
with humanity, dignity and inherent rights), liberty (social, religious and political
freedom), reciprocity (making a fitting and proportional return).

Other ethical issues that may arise include prioritization of limited resources,
withdrawal of treatment and termination of care/life support. The Ethiopian Federal
constitution also restricts certain rights during emergency situations. Relevant
provisions on Civil and Penal code also apply in line with Public Health emergency.

Allocating scarce resources

Most of the resources in the health care system need to be diverted to control the
outbreak while giving attention to continuing care to emergency non COVID-19 cases
and chronic conditions that need continuous follow up. Saving the resources for the
outbreak helps to mitigate scarcity of important supplies at the time and places where it
is highly needed to stop the spread of the outbreak and save more lives. Unless planned
in advance, COVID-19 can quickly overwhelm the capacities of government and health-
care systems, requiring them to make difficult decisions about the allocation of limited
resources such as hospital beds, medications, and medical equipment to control the
epidemic.

In case of limited supply of life saving interventions like mechanical ventilators, the
decision of health care provider should be guided by the principle of first come first
served and chances of survival based on the severity and reversibility of organ damage.
This decision to discontinue life support in terminal cases depends on the existing
practice in the country (i.e. brain death confirmed).

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 SESSION 2: COVID-19 PATIENT CARE PRIORITIZATION AND ITS
ETHICAL CONSIDERATIONS

The ICU is committed to the attempt of preserving life while:

1. Respecting individual's dignity.

2. Determining the competent patient's informed acceptance or rejection of

treatment, including cardiopulmonary resuscitation.

3. Recognizing that in certain cases of irreversible and irreparable terminal illness

heroic measures are unwarranted.

4. Need the consideration of justice during shortage of resources

i. Principles used to decide priority access to scarce resource Equality

• Each person’s interest should count equally unless there are good reasons
that justify the differential prioritization of resources.
• Irrelevant characteristics of individuals, such as race, ethnicity, creed, ability
or gender, should not serve arbitrarily as the basis for the differential
allocation of resources. This principle can be used to justify the allocation of
resources by a lottery – that is, randomly by chance – or by a system of first
come, first served.
Best outcomes
• Allocating available resources to ensure best outcomes and saving most
lives generally
Prioritize to Worst
• These principles justify the allocation of recourses to those in greatest
medical need or those most at risk.
• Need professional clinical judgment or consensus based on
appropriate guide for the allocation of resources that are designed or
intended to protect those at risk;
• PPE for health care workers,
• Vaccines for those most at risk of infection severe illness, or those
most in need
• As in the case of provision drugs in short supply to those needing
them most urgently.
• Ventilators to the most expected to derive the most benefit

Prioritize those tasked to help others

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 • Allocation to certain skills or talents that can save many other people, or
because something is owed to them on account of their participation in
helping others
Ethical Values for Ethical judgment

• Transparency- Patients including families and care givers should be

informed about the criteria guiding the decisions.
• Inclusiveness- Patients and families or care providers should be able to
exert at least some influence over the decision-making process as well as
the decision itself
• Consistency - consistent so that all persons in the same categories are
treated in the same way which favors all similarly
• Accountability – decision makers should be accountable for the decision
they made and should justify what they decide.
• Informed consent
• Confidentiality
Patient care prioritization Criteria guidance

Stringent patient care prioritization criteria should be prepared by the respective

health facilities based on the principles put in this guiding protocol.

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 Figure 28: Crisis level surge- critical care triage tool

This tool provides an element of objectivity to help enhance consistency. It is not

considered, however, a complete substitute for the carefully considered judgment of an
experienced intensive care clinician. The presented algorithm is an example and each
institution can decide on which performance score, comorbidities, and organ system
failures to use based on their experience and what their staff ifs most comfortable using.
A triage (prioritization) decision is a complex clinical decision made when ICU beds are
limited. A structured decision-making process is important to maximize transparency
and improve consistency in decision-making. A clinical estimation of likely benefit
(outcomes from ICU admission compared with outcomes expected if the patient
remained on the ward/other care area) is necessary so that patients who will benefit
most from ICU are given priority.

ii. Ethical considerations

a. Restrictions on patient visit by relatives

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Isolation, quarantine, restriction of movement in suspected and confirmed cases should
be in accordance with the principles mentioned in the WHO guideline. Quarantine
Regulations of Ethiopia: Council of Ministers Regulations No. 4/1992, Ensures the legal
ground for quarantine and isolation of ill patients to prevent the spread of infection,
control of hazardous exposure to the community in case of emergencies and disasters
reduction also applies in this situation.

b. Obligations related to medical interventions for the diagnosis,

treatment, and prevention of COVID-19

Individuals offered medical interventions for the diagnosis, treatment, or prevention of

COVID -19 should be informed about the risks, benefits, and alternatives, just as they
would be for other significant medical interventions. The presumption should be that
the final decision about which medical interventions to accept, if any, belongs to the
patient.

In COVID-19 outbreak, owing to its high contagious nature and threat to the public
safety at large, there may be legitimate reasons to override an individual’s refusal of a
new or existing diagnostic, therapeutic, or preventive measure that has proven to be
safe and effective and is part of the accepted medical standard of care unless there is
medical contraindication in that particular patient. Similarly, it is ethically sound to
conduct research including randomized controlled trial that will have an impact in
disease control and improving survival.

c. Emergency use of unproven interventions outside of research

Considering the high mortality of the COVID-19 outbreak in certain group of the
population it is ethical to offer patients experimental intervention provided that:

• No proven effective treatment exists;

• It is not possible to initiate clinical studies immediately;
• Data providing preliminary support of the intervention’s efficacy and safety are
available, at least from laboratory or animal studies.
• The national ethics authorities, as well as an appropriately qualified ethics
committee, have approved such use;
• Adequate resources are available to ensure that risks can be minimized;
• The patient’s informed consent is obtained;
• The emergency use of the intervention is monitored and the results are
documented and shared in a timely manner with the wider medical and scientific
community.

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d. Ethical issues related to access of essential and emergency care,
disclosure and facility responsiveness

During the care of patients with COVID-19 at facilities many ethical issues are expected
to arise in the clinical care process, equitable distribution of scare resources (such as
access to life support equipment, staff time, and termination or withdrawal of care).

• Facilities are obliged to prepare contingency plans to provide screening, isolation

and emergency care for patients with COVID-19.
• Facilities are also expected to develop and implement a COVID-19 facility
preparedness and readiness plan including setting up a pre-triage screening for
COVID-19, isolation areas with access to essential and emergency care.
N.B. Resource allocation of a particular facility will be governed by facility COVID-19
protocol.
• Facilities should put in place processes and structures to ensure care provided
for patients with COVID19 is as safe, effective, proven, equitable and dignified as
possible. Patients should also be allowed to access family members and
significant others through phone.
• For public health measures disclosure of pertinent information on patients with
COVID-19 (or SARS Cov-2 infection) and their contacts is allowed. Disclosing the
infection to contacts does not require obtaining consent.
• Facility should provide adequate and of good quality food/drink/cloth to
patients.
• Information on patient’s condition should be communicated to their family
regularly and upon request by the treating physician.
• Facilities should establish a clinical Ethical Committee (CEC) and put in place
protocol that address difficult clinical decision making in caring for patients with
COVID-19 as well as to ensure safety, equity and quality of care and use of scarce
resources.
• Facilities should put in place necessary resources to ensure safety of patients and
staff alike in dead body handling, disinfection of equipment for reuse and other
ethical issues at the hospital.
• Any COVID-19 patient who requires emergency surgical or other interventions
should not be denied these emergency services at any health facility, denying the
service amounts to stigmatization.

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e. Health care workers (Health Work Force) Responsibilities:

1. Follow established occupational safety and health procedures, avoid exposing

others to health and safety risks and participate in employer-provided
occupational safety and health training
2. Use provided protocols to assess, triage and treat patients
3. Treat patients with respect, compassion and dignity
4. Maintain patient confidentiality
5. Swiftly follow established public health reporting procedures of suspect and
confirmed cases
6. Provide or reinforce accurate infection prevention and control and public health
information, including to concerned people who have neither symptoms nor risk.
7. Put on, use, take off and dispose of personal protective equipment properly
8. Self-monitor for signs of illness and self-isolate or report illness to managers, if it
occurs advise management if they are experiencing signs of undue stress or
mental health challenges that require support interventions
9. Report to their immediate supervisor any situation which they have reasonable
justification to believe presents an imminent and serious danger to life or health
10. Take any responsibility given by the employer
11. Try and use helpful coping strategies such as ensuring sufficient rest and respite
during work or between shifts, eat sufficient and healthy food, engage in physical
activity, and stay in contact with family and friends.
12. Avoid using unhelpful coping strategies such as tobacco, alcohol or other drugs.
13. Staying connected with your loved ones including through digital methods is one
way to maintain contact.

f. Breaking Bad News Protocol

Evidence and Ethos

Patient communication skills may lead to psychological distress including increased

anxiety and depression and poorer psychological adjustment to the diseases. Presenting
'bad' news in an unhurried, honest, balanced and empathic fashion has been shown to
produce greater satisfaction with communication of the news.

Important aspects include exploring the patient's expectations, warning him/her that
the news is bad, giving the news at the patient's own pace, allowing time for the patient
to react and eliciting the patient's concerns. Health workers-patient communication
skills for COVID 19 countered bad news consultations to enhance patient recall of
information and increase patient satisfaction with communication. On the other hand,

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the psychological impact of the news itself, breaking bad news insensitively can cause
patients additional distress.

The aim in addition to increasing their confidence is to prompt the clinician involve the
patient in each step, helping them feel to feel supported, well-informed and able to
participate in decision-making.

When breaking bad news for coronavirus, we need to follow the SPIKES protocol

SPIKES Protocol

S - Setting

• First, Proper donning personal protective equipment (PPE) (if in person)

• Ensure your calling time is appropriate/ comfortable for your client (for call
news)
• Ensure you are in a comfortable and helping mood
• Ensure you are in a comfortable confidential room where you will not be
interrupted
•
P - Perception

• Remember events that have led up to now

• Ask them what they already know/expect
• Spend some time trying to get them to say what the diagnosis is
“Could you tell me what’s happened so far?”

“Do you have any ideas as to what the problem might be?”

“Is there anything you have been worried about?”

I - Invitation

• Check if the patient wants to know the result now

• you need permission to move on from each step
“I do have the result here today; would you like me to explain it to you now?”

K - Knowledge

• As you know, we took a sample for coronavirus test and, unfortunately, “the
result” PAUSE & WAIT:
• Shape up to the result – give a warning shot

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 • Portion the diagnosis (stepped approach) you need permission to move
on from each step
• “Unfortunately the Corona is a problem” pause & wait for patient to ask
• After every statement you say, pause & wait for the patient to ask the next
question (silence is the best thing at this point – there are a million
thoughts going around in their head)
• “Yes, I’m so sorry to have to tell you”
• “I’m afraid / unfortunately the result is not as we hoped.” / I’m sorry to
tell you it is a coronavirus positive result”
• If the silence is very awkward, you can ask a question about how they are
feeling
• Chunk & check any requested explanations
Next: Don’t say anything. It’s difficult but the most effective way to communicate from
now onwards is not to say anything until asked. If it really gets awkward, reflect the fact
that they are quiet/shocked, pause, then as what’s going through their mind.

E – Emotions and Empathy

• Acknowledge and reflect their emotions back (including body language)

• Don’t try to solve their problems or reassure them, just listen and summarize/
bounce their concerns back to them and expand on them (it shows you are
listening and conveys empathy)
• If there is a lot of silence, Patients have concerns in their head and therefore
won’t listen to anything else you say. You need to get the concerns out first you
can ask about their emotions
“I can see this news was a huge shock” PAUSE & WAIT

“You appear very anxious” PAUSE & WAIT

“How are you feeling about hearing the news?”

“You’re very quiet; can I ask what’s going through your mind?”

“What’s upsetting you the most?”

• First, observe for any emotion on the part of the patient. This may be tearfulness,
a look of sadness, silence, or shock.
• Second, identify the emotion experienced by the patient by naming it to oneself.
If a patient appears sad but is silent, use open questions to query the patient as
to what they are thinking or feeling.
• Third, identify the reason for the emotion. This is usually connected to the bad
news. However, if you are not sure, again, ask the patient.

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 • Fourth, after you have given the patient a brief period of time to express his or
her feelings, let the patient know that you have connected the emotion with the
reason for the emotion by making a connecting state-men
S – Strategy and Summary

• Discuss and Agree on next plan

• Summaries concerns
• Ask how they are left feeling

Summary

• Ethical principles: autonomy, beneficence, non malficence and justice should be

applied in critical care practice based on the agreed care prioritization tool
• Bad news should be disclosed with proper ethical manner

Bedside learning –divided in 6 sessions

Objective

• Respect Autonomy-informed consent

• Practice good general Communication skill
• Able to break bad news
• Apply ethical Priority setting tool in decision making
• Resolve work place conflict with ethical manner

Activities

1. Practice taking informed consent on cases (2 sessions)

2. Take history and explain about illness to client and family members
3. Practice communicating decision to intubate, put on MV, death
4. Make decisions in admission, Intubation and putting on mechanical
ventilation when there is resource scarcity
5. Simulated or real conflict resolving exercise

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CHAPTER 12: ELECTROLYTE AND FLUID
Chapter duration: 1hour lecture

Teaching method

• Lecture
• Self-reading
• Bedside

Chapter description: The chapter contains fluid and electrolyte abnormalities and
their management

Chapter objective: By the end of this chapter the participants will be able to manage
COVID 19 patient fluid and electrolyte imbalances

Session outline

Session 1: Electrolyte abnormalities

Session 2: Fluid balance & fluid disturbance

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 SESSION 1: ELECTROLYTE ABNORMALITIES

Introduction

Electrolyte abnormalities are frequent in ICU, and affect patients’ morbidity and
mortality. The most important of these are sodium and potassium abnormalities, and
will be addressed in this document.

1.1 Hyponatremia

It is an electrolyte disturbance in which the sodium ion concentration in the plasma is

lower than normal. It is generally defined as a serum level of less than 135 mEq/L
(Normal range 135 -145 mmol/L).

i. Classification

a. According to Severity

• Mild: serum sodium = 130-135 mEq/L

• Moderate: serum sodium = 125-129 mEq/L
• Severe: serum sodium <125 mEq/L.

b. Time of onset

• Acute hyponatremia
• Hyponatremia that is documented to have occurred over <48 hours. This
usually results in cerebral edema and significant symptoms.
• Chronic hyponatremia:
• Hyponatremia that is documented to have occurred over ≥48 hours.
• Unknown duration: When it cannot be classified by time of onset. Treatment
should be based on symptoms.

c. Serum tonicity

The most common type of hyponatremia is hypotonic hyponatremia, while hypertonic

and isotonic hyponatremia are less common.
Hypotonic hyponatremia:
• Hypovolemic hyponatremia
• Hypervolemichyponatremia
• Euvolemichyponatremia.

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 • Hypertonic hyponatremia: Can be due to intake of hypertonic fluids (e.g.,
mannitol, sorbitol) or hyperglycemia-induced hyponatremia, although
hyperglycemia-induced hyponatremia may also be isotonic or, rarely, hypotonic.
• Euvolemichyponatremia: Pseudohyponatremia

d. Volume status

• Hypovolemic hyponatremia
Occurs when total body water and sodium are both decreased, but total water is
repleted in excess of sodium. Low intravascular volume activates baroreceptors which
lead to vasopressin release and water reabsorption. With subsequent water intake,
hyponatremia develops.

It is associated with significantly low intravascular volume either from fluid losses (e.g.,
diarrhea, bleeding, urinary loss) or third spacing of fluids (e.g., pancreatitis, severe
hypoalbuminemia).

• Hypervolemichyponatremia

Occurs when total body water and sodium both increase, but total body water increases
to a greater extent. It is associated with baroreceptor perception of low intravascular
volume which leads to inappropriate vasopressin release with water retention despite
overall increases in total body water and sodium. It is commonly seen in congestive
heart failure, cirrhosis with ascites, or nephriticsyndrome.

• Euvolemic hyponatremia

Occurs when total body water increases, but total body sodium remains unchanged.
Associated with pathologic vasopressin release, but is not associated with either
intravascular volume depletion or hypervolemia. Can be due to certain medications (e.g.,
selective serotonin-reuptake inhibitors, thiazide diuretics), or syndrome of
inappropriate antidiuretic hormone (SIADH) as a result of pulmonary or central
nervous system disorders or malignancy.

ii. History

• Fluid intake
• Hypovolemic: excessive fluid losses, third spacing of fluids (eg. Pancreatitis and
hypoalbuminemia), diabetes mellitus
• Hypervolemic: congestive heart failure, cirrhosis, nephrotic syndrome, or acute
kidney injury/chronic kidney disease
• Euvolemic: excessive fluid intake, as might occur during high-intensity physical
exercise, potomania (inadequate diets, alcohol use disorder with a high intake of
beer), excessive fluid during surgery or medical testing such as cardiac
catheterization or colonoscopy

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 • Pseudohyponatremia: multiple myeloma (due to high serum protein levels) or
severe hyperlipidemia
• Drug history: desmopressin, oxytocin, selective serotonin-reuptake inhibitors
(SSRIs) and most other antidepressants, morphine and other opioids, thiazide
diuretics, carbamazepine, vincristine, nicotine, antipsychotics, chlorpropamide,
cyclophosphamide, nonsteroidalantiinflammatory drugs, illicit drugs
• SIADH: exclude hypothyroidism and adrenal insufficiency; associated with lung
diseases, CNS diseases, malignancies, drugs, pain, nausea, stress, and general
anesthesia.

iii. Physical examination

• Determine volume status and look for signs of dehydration or volume overload.
• Signs of volume depletion include: low urine output, weight loss, orthostatic
hypotension, decreased jugular venous pressure, poor skin turgor, dry mucus
membranes, absence of axillary sweat, and absence of edema.
• Signs of volume overload include: Edema and/or ascites, rales or crackles on
lung auscultation, significant weight gain, raised jugular venous pressure.

iv. Treatment of hyponatremia

General issues to be addressed before specific treatment:

1. Is it acute or chronic or unknown duration?
2. Is it symptomatic or not?
3. Optimal rate of correction?
4. Fluid status?

Acute, Chronic or Unknown Duration

Acute
• That occurs within 48 hours
• Aim to increase plasma Na+ by 1-2meq/hr to a total of 4-6meq which is enough to
relieve acute symptoms (usually within 4hrs)
• After this, treatment as protocol of chronic hyponatremia applies
• Use 3% hypertonic saline(= 513meq/L of sodium) or table salt
• Na deficit = TBW( Na desired-Na measured)
• Give usually over 4hrs
• Loop diuretics if pulmonary edema
• O2 and ventilatory support if acute pulmonary edema or acute respiratory failure

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Chronic
• Correct at a rate of <10-12meq/24hrs or <18meq/ 48hrs
• Treat underlying causes
• Hypovolemic hyponatremia- isotonic saline
• Treat causes of hypervolemia
• IV saline and resumption of normal diet for low solute intake
• Hypokalemic patients-correction of K corrects Na
• Water restriction <1liter per day
• Pharmacologic Rx( if potassium supplementation, fluid restriction and increased
solute intake fails)
• Furosemide 20mg PO BID( high dose in renal failure) + salt tabs
Unknown Duration: It is not always possible to know the duration of the
hyponatremia. Treatment should be dependent on the presence or absence of
symptoms. It should aim to relieve symptoms with the acute treatment protocol above.
If patient is asymptomatic, treatment should rely on treatment of the causes.

Symptomatic or not

Symptom relief should be targeted in a symptomatic patient. We manage the patient

and not the lab values. Good to have the following principles.
• If there is an acute significant drop in serum Na while patient is
asymptomatic, repeat the lab test.
• If patient is not symptomatic despite a drop to less than 120mmol/l, it is
likely to be chronic and address accordingly.
• Emphasis should be given to treatment of the underlying causes in an
asymptomatic patient with chronic illnesses.

Volume status

Hypovolemic hyponatremia:
• Isotonic intravenous fluids (e.g., normal saline 0.9% or a balanced solution such
as lactated Ringer solution) should be administered in 250-1000 mL boluses to
maintain blood pressure. Boluses can be repeated as necessary, and then
followed by an infusion of 0.5 to 1 mL/kg/hour to repeate intravascular volume
until signs and symptoms are no longer present.
• Rate of correction should follow the same principles as for acute onset.
• Reassess serum sodium levels
• Treat underlying cause (e.g., treating severe nausea/vomiting, stopping diuretics
if possible, treating mineralocorticoid deficiency).

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Hypervolemic or euvolemichyponatremia:
• All patients should be fluid restricted (including all oral and intravenous fluids)
of 1 L/day. This should be adjusted based on measured urine output and set at
500 mL less than daily urine volume (e.g., a patient producing 1200 mL/day of
urine should be placed on 700 mL/day fluid restriction). This conservative
approach should increase the serum sodium concentration gradually (i.e., <8
mEq/L/day) and helps to prevent myelinolysis.
• Treat underlying cause (eg. hypervolemichyponatremia = AKI/CKD, CHF,
cirrhosis, and nephritic syndrome; Euvolemichyponatremia = SIADH, causative
medications, and excess fluid intake (e.g., exercise, surgery, primary polydipsia,
potomania)
• Add a diuretic if hypervolemia is present and the underlying condition warrants
it (eg. Loop diuretics in CHF or nephrotic syndrome, spironolactone in cirrhosis
& ascites).
• Haemofiltration or dialysis may be necessary if renal failure is established.
• The rate of correction of serum sodium should be kept to <8 mEq/L/day to
prevent
myelinolysis.
• If fluid restriction fails, a vasopressin receptor antagonist (also known as a
vaptan) may be considered a second-line option. Failure of fluid restriction can
be predicted if at least one of the following is there: urine output <500 mL/day, if
on fluid restriction of <1 L/day the serum sodium concentration increase is <2
mEq/L over 24 to 48 hours or if the patient has excessive thirst

Rate and Degree of Correction

• Calculate Na Deficit (for men) = Wt. X 0.6 (target Na – current Na)

• Na-Deficit (for women) = Wt. X 0.5 (target Na – current Na)
• Volume of Hypertonic Saline in ml = Na deficit/512 X 1000
• Infusion Rate (L/h) = Volume of hypertonic saline in ml/ target Na – current
Na/desired correction rate
• In chronic hyponatraemia correction should not exceed 0.5 mmol/L/h in the first
24 hr and 0.3 mmol/L/h thereafter.
• In acute hyponatraemia the ideal rate of correction is 1.5 – 2 mEq/h for 4 hours
then slow correction 12 mEq/L over 24 hours.
• The plasma Na+ of 125–130 mmol/L is a reasonable target for initial correction
of both acute and chronic states.
• Attempts to achieve normo- or hypernatraemia rapidly should be avoided.
• Neurological complications, e.g. Central Pontine Myelinolysis, are related to the
degree of correction and the rate. Premenopausal women are more prone to
these complications.

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For example, If you want to manage a non edematous 60kg woman who is mildly
symptomatic from severe hyponatremia, serum Na = 120meq/l,
• Calculate the sodium deficit = TBW x Desired Na correction
= (0.5 x weight) x (Desired Na – Current Na)
= (0.5 x 60) x (130 – 120)
= 300 meq
• Volume of Hypertonic Saline in ml = Na deficit/512 X 1000
= 300/512 x 1000 = about 600ml
• In acute hypernatremia, in the 1st 4 hours, infusion rate
= Volume of the hypertonic saline/ (Desired Na correction/Desired
correction rate)
= 600 / (10/2) = 60ml/hr in the first 4 hours and the rest would be
given over the subsequent 24 hours (360ml/24hrs = 15ml/hr).
• If this is euvolemichyponatremia and less symptomatic, you may give
isotonic infusion (saline which has a Na of 254meq)
= Volume of saline in ml = Na deficit/254 x 1000
= 300/254 x 1000 = about 1200ml
In acute hyponatremia, in 1st 4 hours, infusion rate
= 1200ml/(10/1) = 120ml/hr and the rest would be given over the
subsequent 24 hours (720ml/24hrs = 30ml/hr).
Table 17: Treatment summary for sodium abnormalities

Type Treatment Summary

Acute: Acute onset
and/or 1st Hypertonic saline (3%) infusion Plus
symptomatic supportive care
Plus treat underlying cause
Chronic onset (≥48 hours) or
asymptomatic

Hypovolemic 1st Isotonic fluid infusion Plus treat underlying

cause
Hypervolemic 1st fluid restriction Plus treat underlying cause
Adjunct loop diuretic or spironolactone
2ndvasopression receptor antagonist +
discontinue
fluid restrictionplus treat underlying cause
Euvolemic 1st fluid restriction Plus treat underlying cause
2nd vasopressin receptor antagonist + discontinue
fluid restriction Plus treat underlying cause

Overcorrection of serum sodium 1st stop active treatment + initiate free water
concentration intake and/or desmopressin

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1.2 Hypernatremia (>145meq/L)
It results from water loss (renal, Extrarenal, into cells), hypothalamic lesions impairing
thirst (osmoreceptor function) or sodium overload
Approach
• Urine osmolality <300mosmol/kg → DI
• Administration of desmopressin increases urine osmolality by 50% in
CDI but no or little response in NDI
• Urine osmolality >600mosmol/Kg (could be water loss or iatrogenic)
• Urine Na <125meq/l if water loss and it is >100meq/l if iatrogenic
hypernatremia
• Urine osmolality 300-600mosmol/kg –various causes
• Partial CDI or partial NDI
• Osmotic diuresis
Treatment
• Slowly correct over 48-72hrs by no more than 10meq/day
• Rarely, Na can be corrected by 1meq/hr in acute hypernatremia (<48hrs) due to
Na loading
• How much fluid? Calculate water deficit – replace it, ideally orally
• Water deficit= TBW x ( Na measured- Na desired)/Na desired
• Plus ongoing loss( insensible, others)
• What type of fluid?
• D5W IV can cause hyperglycemia which precipitates hypernatremia
• ¼ or ½ NS if hypotensive or low BP
• NS only if severe hyponatremia of frank hypotension
• if central diabetes insipidus (CDI):
• Restrict salt; give loop diuretics (furosemide).
• Complete CDI: desmopressin (DDAVP) (10μg BD intra-nasally or 1–
2μg BD IV)
• Partial CDI: desmopressin, but often responds to drugs that
increase the rate of ADH secretion or end-organ responsiveness to
ADH, e.g. chlorpropamide, hydrochlorothiazide
• Nephrogenic DI:
• Low salt diet and thiazides.
• High dose desmopressin may be effective.
• Consider removal of causative agents, e.g. lithium, demeclocycline.

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1.3 Hypokalemia (<3.5 meq/l)

Introduction: The causes could be spurious (in vitro uptake by profound leukocytosis),
inadequate intake, redistribution (from insulin, alkalosis, B2 adrenergic agonists,
theophylline, caffeine, hypokalemic paralysis with thyrotoxicosis), extrarenal losses,
renal loss (diuretics, high doses of penicillin related antibiotics, steroids, thephylline,
renal tubular toxins, DKA, Conn’s syndrome, Secondary hyperaldosteronism, Cushing’s
syndrome, metabolic alkalosis, hypomagnesemia) and other causes like
hypoaldosteronism, metabolic acidosis and hypomagnesemia. The severity of the
manifestations of hypokalemia tends to be proportionate to the degree and duration of
the reduction in serum potassium. Symptoms generally do not manifest until the serum
potassium is below 3.0 meq/L, unless the serum potassium falls rapidly or the patient
has a potentiating factor, such as a predisposition to arrhythmia due to the use of
digitalis. Check all chemistry including all electrolytes and blood sugar, ABG, ECG and
cortisol level
Treatment
• Estimate potassium deficit (100meq/L fall in total K+ for 0.27meq/l decrease
in plasma K+, this may not apply in redistributive causes)
• K bicarbonate and its precursors –in metabolic acidosis and diarrhea
• K phosphate- rarely used except in concomitant severe hypophosphatemia
• KCl in all other clinical situations
• IV (via central line) with ECG monitoring when there is a clinically
significant arrhythmia (20 mmol over 30 min, repeated according
to levels)
• Slower intravenous replacement (20 mmol over 1 h) should be
used where there are clinical features without arrhythmias.
• Oral supplementation (a total of 80–120 mmol/day) where there
are no clinical features.
• Mg++ level as adequate Mg++ is necessary for correction.
• Dietary potassium ineffective for treatment ( low content, potassium
available in diet is in citrate and phosphate form which could only retain 40%
of K)
Treatment of mild to moderate hypokalemia( 3-3.4meq/l)
• Po supplementation ( 20-80meq/d in 2-4 divided doses)
• Potassium sparing diuretics for renal wasting and primary aldosteronism
• Non-selective B agonists like propranolol for hypokalemia due to increased
sympathetic activity
Treatment of severe (<2-3meq/l) or symptomatic hypokalemia
• Rapid administration of K ( PO or IV)
• PO KCl 40meq 3-4x/day or IV 20 meq every 2-3hrs
• Monitor serum level every 2-4hrs

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 • Treat as mild to moderate hypokalemia once K level is persistently >3-3.4meq/l
and asymptomatic
Intravenous repletion
• Use saline initially because glucose containing fluids cause insulin stimulation
and transient hypokalemia
• Pain and phlebitis occurs at a rate greater than 10meq/hr or concentration more
than 3meq/l
• If large infusions are needed for severe hyperkalemia, use central vein or
multiple peripheral veins
o 1000ml fluid- maximum 60meq/l of K
o 100-200ml in peripheral vein-maximum 10meq/l
o 100ml in central vein- maximum 40meq/l

1.4 Hyperkalemia (>5.5meq/L)

Introduction: The cause could bePpeudohyperkalemia (fast clenching during

venipuncture, marked thrombocytosis, leukocytosis, and/or erythtrocytosis, cooling of
blood after venipuncture), redistribution hyperkalemia (resulting from acidosis, beta
adrenergic blockers, digitalis overdose, hypertonic states, familial hyperkalemic
periodic paralysis, fluoride, succinylcholine), impaired K excretion, aldosterone
deficiency or tubular non responsiveness to aldosterone, renal failure( GFR<20%),
medications (like ACEis, ARBs, renin inhibitors, cyclosporine, tacrolimus, NSAIDs, COX-2
inhibitors, K sparing diuretics). Clinical features include arrhythmias, ECG changes,
ascending paralysis, metabolic acidosis
Treatment
• Treat reversible causes first e.g. stop medications that increase serum K
• Antagonism of cardiac effects
• Calcium gluconate 10ml of 10% (contains 90mg of elemental calcium) or
3-4ml of 10% calcium chloride ( 10ml of 10% contains 270mg of
elemental calcium) IV over 3-4min without cardiac monitoring
• Onset is over 1-3min and lasts for 30-60min
• Repeat dose if no ECG change or symptoms recur
• Same amount can be given in 100ml of D5W over 20-30min to avoid acute
hyperkalemia
• Redistribution into cells
• 10IU of RI IV + 50ml of 50% dextrose ( 25g glucose)
• Onset in 10-20min, peaks at 30-60min and lasts for 4-6hr
• Should be followed by infusion of 10% dextrose at 50-75ml/hr, but
no need if glucose >200-25omg/dl
• Frequent blood glucose monitoring
• B2 agonists
• Albuterol 10-20mg via nebulizer in 4ml of NS over 10min

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 • Onset in 30min, peak at 90min and lasts 2-6hrs
• Removal of potassium (potassium exchange resins, diuretics, dialysis)
• Sodium polystyrene sulfonate( SPS)
• 15-30g + 33% sorbitol
• Dialysis effective means of removal of k
Summary
• Electrolyte abnormalities are frequent in ICU, and affect morbidity and mortality
• Treatment should include treating the underlying causes and treatment specific
to the type of electrolyte abnormalities
• Over correction of the electrolyte abnormality can be life threatening, and proper
care and monitoring should take place

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SESSION 2: FLUID BALANCE & FLUID DISTURBANCE

Introduction

Total body water makes up 60% of body weight in average male, and approximately
50%in average female. A 70kg lean adult man has a total body water of about 42liters,
which is 60%of total body weight. The distribution is 66% intracellular,
34%extracellularcompartment. The extracellular is further subdivided into
intravascular 25% (3.5L), and an interstitial 75 %( 10.5L)

2.1 Types of fluids

Crystalloid:
• Fluids are mixtures of sodium chloride and other physiologically active solutes.
Sodium is the major component, and only 20% of infused will remain in the
vascular space.
• Guidelines on intravenous fluid therapy in adults currently recommend the use
of crystalloids that contain sodium in the range 130–154 mmol/l for fluid
resuscitation
• Overall, studies suggest that the use of high chloride, unbuffered crystalloid fluid
may be associated with major complications following surgery and increased
mortality in critically ill patients with sepsis.
• The relative risk of in‐hospital mortality was progressively lower among patients
who received a greater proportion of balanced fluid, than 0.9 normal saline
• 0.9 % saline may affect renal function becausesignificantly higher serum chloride
levels, found reduce renal artery blood velocity and reduced renal cortical tissue
perfusion 0.9% saline and Plasma‐Lyte 148 expanded the intravascular volume
to the same degree, 0.9 % saline expanded the extracellular fluid volume
significantly more than did Plasma‐Lyte 148 (balanced fluid) meaning that 0.9 %
saline may be more likely to result in fluid overload and interstitial edema.
• metabolic acidosis produced by infusion of 0.9% saline significantly impaired
gastro pyloric motility by reducing pyloric contraction amplitude, which results
in delayed gastric emptying or gastro paresis. Therefore while resuscitating
patients balanced fluid or using other crystalloids alternatively is advised.

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Table 18: Composition of different fluids in comparison with plasma

Fluids Plasma 0.9% NaCl Lactated Plasma- Albumin

Ringer's Lyte 5%
148a
Sodium, 140 154 131 140 130–160
mmol/1
Potassium, 5 – 5.4 5 ≤2
mmol/l
Chloride, 100 154 111 98 –
mmol/l
Calcium, 2.2 – 2 – –
mmol/l
Magnesium, 1 – 1 1.5 –
mmol/l
Bicarbonate, 24 – – – –b
mmol/l
Lactate, 1 – 29 – –
mmol/l
Acetate, – – – 27 –
mmol/l
Gluconate, – – – 23 –
mmol/l
pH 7.4 5.4 6.5 5.5 7.4

Colloids: high molecular weight substances that do not pass rapidly across capillary
walls. They stay in the vascular space and exert an osmotic force that keeps fluid in the
blood vessels. The most commonly used colloids are: Albumin, hetastarch, and dextran.
Blood products are also considered as colloids.

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Table 19: Types of colloid fluids

Solution Nature Amount Allergic Molecular Remark

of volume reaction weight
expansion
Hetastarch Synthetic 1to 1 Rare
starch
Dextran Polysacharide, 1to2 1% 40,000 Interference
40 with
subsequent
cross
matching ,
when
>1.5gm/kg/d/
is given
bleeding may
occur
Dextran 70,000
70

Goal of fluid therapy

• Maintain an adequate state of • Observation of vital signs
hydration and tissue perfusion • Measurement of input output
with electrolyte balance • Invasive monitoring – CVP
monitoring

Factors to be considered for estimation of fluid requirement

• Maintenance volume- both sensible and insensible
• Fluid deficit – shock, NPO time
• Ongoing loss – bleeding, drainages, any GI loss,
• 3rd space loss- fluid extravasation on the wound side

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Table 20: Estimated amount of fluid lose

Maintenance 4:2:1principle. Eg for a 50kg patient the 0-10kg= 100ml/kg/24hrs

(sencible 1st 10kgx4=40ml/hr; 11-20kg =1000ml+50ml/kg
&incencible 2nd 10kg x2=20ml/hr; for every kg above 10kg
losses, fever 3 rd and above 30x1=30ml/hr. total >20kg- 1500ml + 20ml/kg
90ml/hrx24hrs= 2160ml/24hrs plus for every kg above
insensible loss (300-500ml/24hrs)=2460- 20kg/24hrs
2660ml/24hrs plus
For each degree of fever above 37 , 2-2.5
ml/kg/day
Fluid deficit Maintenance/hrx NPO time

Ongoing loss For 1ml blood loss 3ml crystalloid,

for other losses 1:1
3rd space loss Depends on the size of the wound or
surgical site and ranges from 4-
8ml/kg/24hrs

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CHAPTER 13: CRITICAL CARE INCIDENT
MANAGEMENT
Chapter duration: will be covered in every sessions during critical care practice

Chapter Objective: The general objective of this session will help the participant to
understand the occurrence of critical care incident, categorizing the type of incident,
early identification and reporting, management of incident and communication with
family and are giver.

Chapter Methodology: This will be covered during the practical session and during the
morning briefing. Especially detail discussion by arranging a different session will be
delivered when incident happened.

Sessions outline

Session 1: Types of incident and reporting of critical care incident

Session 2: Critical care incident management

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SESSION 1: TYPES OF INCIDENT AND REPORTING OF CRITICAL CARE
INCIDENT

Introduction

A critical incident: occurs when an incident is the result of care provided and not
related to the patient’s underlying health condition, or usual risk in treating the disease.

• On occasion, something unexpected can happen to a patient causing serious

harm.
• The incident results in unintended consequences, such as death, disability, injury
or harm, unplanned admission to hospital, or unusual extension of a hospital
stay.

1.1 Incident Types

To properly collect and manage incident data, health facilities must be able to identify
types of incidents. It is important to note that, while each incident type group is distinct,
an incident can be classified as more than one incident type. Common aggregated
incident types may include:

• Clinical Process/Procedure
• Documentation
• Healthcare Associated Infection
• Medication/IV fluids
• Blood/Blood Products
• Nutrition
• Medical Device/Equipment

1.2 Reporting a critical incident

• Critical incident reporting should be introduced into the intensive care unit (ICU)
as part of the development of a quality assurance programme.
• Factors relating to causation, detection and prevention of critical incidents
should be sought.
• Detection of a critical incident in over 50% of cases resulted from direct
observation of the patient while monitoring systems accounted for a further
27%.
• No physiological changes were observed in 54% of critical incidents.
• The most common incidents reported are due to human error in 55% of
incidents while violations of standard practice contributed to 28%.
• Therefore reporting an incident is critical and has to be immediate.

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1.3 Stages of incident management

The following are critical steps in managing critical care incidents:

1 Notification
2 Pre-investigation
3 Investigations
4 Analysis of investigation results
5 Conclusions and recommendations for action
6 Implementation of actions
7 Feedback to staff
8 Monitoring of actions

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SESSION 2: CRITICAL CARE INCIDENT MANAGEMENT

2.1 Role of all intensive care staff

• To report any accident or incidents immediately to their line manager or to the

person in charge of the unit at the time.
• To complete an incident report form in accordance with Trust policy.
• To take appropriate remedial action at the time of the incident to prevent further
harm to patients, members of staff.
• To make a contemporary record of events to ensure that details surrounding the
incident are accurate.
• To assist in the investigation of any incident

Role of the ICU manager or other appropriate delegated authority

• To review all incident report forms and, where possible, take appropriate
remedial action, to prevent a recurrence.
• To ensure staff involved in an incident have access to appropriate support
• To be as open as possible about planned actions.
• To record any remedial action taken on the incident form.

2.2 Communication following critical incidents

Communication with the patient and relatives

• Patients and their relatives increasingly wish to participate in their healthcare

and have to be given information about what has happened.
• Being open about what has happened and discussing the problem promptly, fully
and compassionately can help patients cope better with the consequences.
• Openness and honesty can help prevent incidents from becoming formal
complaints and litigation claims
• The three most important elements of being open are:
o Providing an apology and explanation
o A thorough investigation following the incident
o Support in coping with the physical and psychological consequences of
incident happened.

Communication within the ICU team

• Critical incident meetings are an essential method of communication about

critical Incidents.
• Open discussion of critical incidents should help with root cause analysis and
with the identification of actions to avoid future incidents.

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 • Care should, however, be taken to protect patient and staff confidentiality until
legal and ethical communication managed

Working together to improve patient care

To encourage everyone to speak openly and frankly about what occurred, the critical
incident review process is confidential. The goal of the review is to learn where we can
make improvements. Recommendations from the review are focused on ways to
improve care and prevent similar incidents from happening in the future.

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Annex 1: Health Facility Admission and Discharge Protocol for COVID-
19 Cases

Background
In order to avoid unnecessary delay in admission, prioritize the beds available for those
who benefit much, to prevent premature discharge and prolonged hospital stay
standardized admission and discharge criteria will support practitioners and increase
patient satisfaction. But this will not by any means replace individualized decision by
service providing clinician.
Admission
A. Admission administrative processes
Coordination, review and management of electronically and hard copy admission
referral documentation
Provision of assistance to patients in the completion of admission information
requirements, in person or by phone
Provision of a mobile service to a service or department to complete admission
documentation at the point of the patients arrival
Assistance with inter hospital transfers
Administrative functions related to the preparation and maintenance of the
admission records
Assistance with the bed management/ allocation in a healthcare facility
Assistance with the co-ordination of patient arrival and admission to a
healthcare unit
Assistance with the co-ordination of appointments for attendance to a pre
admissions outpatient clinic if available.
B. Clinical Assessment processes
Completion of admission documentation and consent forms
Organization of patient diagnostic tests (pathology, imaging, cardiac)
Organization of patient health records, assessments and diagnostic results
Commencement of discharge planning
C. Severity classification-(general)

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Page 193 of 202
 COVID 19 severity classification of Symptomatic COVID 19 for case management
Purpose
Severity Disease Description
category component
Mild No Symptomatic patients meeting the case definition for
Pneumonia COVID-19 without evidence of viral pneumonia or
hypoxia.
Adolescent or adult with clinical signs of pneumonia
(fever, cough, dyspnea, fast breathing) but no signs of
severe pneumonia, including SpO2 ≥ 90% on room air.

A child with clinical signs of non-severe pneumonia

(cough or difficulty breathing + fast breathing and/or
chest indrawing) and no signs of severe pneumonia.
Fast breathing (in breaths/min): < 2 months: ≥ 60; 2–11
months: ≥ 50;1–5 years: ≥ 40.

While the diagnosis can be made on clinical grounds; chest

Moderate Pneumonia imaging (radiograph, CT scan, and ultrasound) may assist
in the diagnosis and identify or exclude pulmonary
complications.

Caution: The oxygen saturation threshold of 90% to

define severe
COVID-19 was arbitrary and should be interpreted
cautiously. For example, clinicians must use their
judgment to determine whether low oxygen saturation is a
sign of severity or is normal for a given patient with
chronic lung disease. Similarly, a saturation >90–94% on
room air is abnormal (in a patient with normal lungs) and
can be an early sign of severe disease, if the patient is on a
downward trend. Generally, if there is any doubt, the
panel suggested erring on the side of considering the
illness as severe.
Adolescent or adult with clinical signs of pneumonia
(fever, cough, dyspnea, fast breathing) plus one of the
following: respiratory rate > 30 breaths/min; severe
respiratory distress; or SpO2 < 90% on room air.

A child with clinical signs of pneumonia (cough or

difficulty in breathing) + at least one of the following:
• Central cyanosis or SpO2 < 90%; severe respiratory

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 distress (e.g. fast breathing, grunting, very severe chest
indrawing); general danger sign: inability to breastfeed or
drink, lethargy or unconsciousness, or convulsions.
Severe Severe • Fast breathing (in breaths/min): < 2 months: ≥ 60; 2–11
Pneumonia months: ≥ 50; 1–5 years: ≥ 40.

While the diagnosis can be made on clinical grounds; chest

imaging (radiograph, CT scan, ultrasound) may assist in
the diagnosis and identify or exclude pulmonary
complications
Onset: within 1 week of a known clinical insult (i.e.
pneumonia) or new or worsening respiratory symptoms.
Chest imaging: (radiograph, CT scan, or lung ultrasound):
bilateral opacities, not fully explained by volume overload,
lobar or lung collapse, or nodules.
Origin of pulmonary infiltrates respiratory failure not
fully explained by cardiac failure or fluid overload. Need
Acute objective assessment (e.g. echocardiography) to exclude
respiratory hydrostatic cause of infiltrates/edema if no risk factor
distress present.
syndrome Oxygenation impairment in adults:
(ARDS) • Mild ARDS: 200 mmHg < PaO2/FiO2a ≤ 300 mmHg (with
PEEP or CPAP ≥ 5 cmH2O).
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg
(with PEEP≥ 5 cmH2O).
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5
cmH2O).
When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests
ARDS (including in non-ventilated patients)(Kigali
Modification of berlin definition)
Oxygenation impairment in children: note OI
(Oxygenation Index) and OSI (Oxygen saturation index).
Use OI when available. If PaO2 not available, wean FiO2 to
maintain SpO2 ≤ 97% to calculate OSI or SpO2/FiO2 ratio:
• Bilevel (NIV or CPAP) ≥ 5 cmH2O via full face mask:
PaO2/FiO2 ≤ 300mmHg or SpO2/FiO2 ≤ 264.
• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI <
7.5.
• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5
≤ OSI < 12.3.
• Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥
12.3.

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 Adults: acute life-threatening organ dysfunction caused
by a dysregulated host response to suspected or proven
infection. Signs of organ dysfunction include altered
mental status (delirium), difficult or fast breathing, low
Sepsis oxygen saturation, reduced urine output, fast heart rate,
weak pulse, cold extremities or low blood pressure, skin
mottling, laboratory evidence of coagulopathy,
thrombocytopenia, acidosis, high lactate, or
Critical hyperbilirubinemia.
Children: suspected or proven infection and ≥ 2 age-
based systemic inflammatory response syndrome (SIRS)
criteria of which one must be abnormal temperature or
white blood cell count.
Adults: persistent hypotension despite volume
resuscitation, requiring vasopressors to maintain MAP ≥
65 mmHg and serum lactate level > 2 mmol/L.
Septic Shock Children: any hypotension (SBP < 5th centile or > 2 SD
below normal for age) or two or three of the following:
altered mental status; bradycardia or tachycardia (HR <
90 bpm or > 160 bpm in infants and heart rate < 70 bpm
or > 150 bpm in children); prolonged capillary refill (> 2
sec) or weak pulse; fast breathing; mottled or cool skin or
petechial or purpuric rash; high lactate; reduced urine
output; hyperthermia or hypothermia
Acute Acute venous thromboembolism (i.e. pulmonary
thrombosis embolism), acute coronary syndrome, acute stroke.
Preliminary case definition: children and adolescents 0–19
years of age with fever > 3 days AND two of the following:
rash or bilateral non-purulent conjunctivitis or
Multisystem mucocutaneous inflammation signs (oral, hands or feet);
inflammatory hypotension or shock; features of myocardial dysfunction,
Syndrome in pericarditis, valvulitis, or coronary abnormalities
children (including ECHO findings or elevated troponin/NT-
(MIS-SC) proBNP); evidence of coagulopathy (by PT, PTT, elevated
D-dimers), acute gastrointestinal problems (diarrhea,
vomiting, or abdominal pain); AND elevated markers of
inflammation such as ESR, C-reactive protein, or
procalcitonin. AND no other obvious microbial cause of
inflammation, including bacterial sepsis, staphylococcal or
streptococcal shock syndromes. AND evidence of COVID-
19 (RT-PCR, antigen test, or serology positive), or likely
contact with patients with COVID-19.

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 D. Admission criteria
Severe COVID
Moderate COVID with Comorbidities
Moderate COVID with age ≥ 60
Critical COVID
Note:
1. Those who do not qualify for health facility admission but could not be admitted
to HBIC should be admitted to non-health facility isolation site.
2. COVID-19 patients with other severe or critical medical illnesses should be
admitted to COVID-19 care health facility.
3. High risk patients with moderate COVID should be admitted for at least 24 hour
of observation.

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Discharge criteria from treatment facility
For patients with SEVERE/CRITICAL-COVID
Discharge when all of the following criteria are fulfilled
A. Subjectively
Symptoms have subsided
Cough must subside – limited to be either nocturnal or
significantly reduced as to the patient’s description.
No hemoptysis or minimum expectoration (1 ACC/day) for the
past 72 hours.
Patient is able to feed well
B. Objectively
Body temperature remains at a normal range for at least 3 days without
antipyretics.
Patient maintains saturation on atmospheric oxygen (off any support) as
follows:
For patients with no prior lung problem: SpO2 > 92 % off oxygen
for 48hours
For patients with chronic hypoxia: SpO2 88-92 % off oxygen or
baseline oxygen saturation as reported by patient to have achieved
before illness for 48 hours
No comorbidity that needs in-hospital management
Comorbidities that need active management should be treated
before discharge.
For those patients admitted because they were “high-risk” (comorbidities and age
>60years)) and moderate COVID-19
Consider/do all of the following before discharge
Follow the patient for up to 10 days (at least 24 hour observation and then as an
outpatient) from test day
After 7 days, please do CXR and Lab work up and see if there are early signs of
pneumonia. Get the reading on the next day and decide for extra days of
observation according to the result
Make sure to give the patient the appropriate advice for isolation and self-care

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