Management of the ICU Patient

What is FAST HUGS?

“a simple, short mnemonic to highlight some key
aspects in the general care of all critically ill patients,
which should be considered at least once a day during
rounds and, ideally, every time the patient is seen by
any member of the care team”
Obviously, not all parts of the Fast Hug mnemonic will
apply to all patients at all times
In addition, the Fast Hug does not, of course, cover all
aspects of each patient’s care
 Components
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
 Components
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
 feeding
Adequate nutrition is vital for critically ill
Poor wound healing
Post operative complications
Sepsis

Critically ill patients

Are often already malnourished on admission
Have greatly increased calorie requirements – negative
nitrogen balance
Feeding
Absolute calorie requirement (Carbs / Fats)
American College of Chest Physicians: 25 kcal/kg
May be more in e.g. burns patients

Nitrogen (Protein)
14 grams / day

Other
Water / vitamins / trace elements etc.
 Malnutrition
Underfeeding Overfeeding
Loss of muscle mass Increased VO2

 Respiratory function Increased VCO2

 Immune function Hyperglycaemia

Poor wound healing Fatty infiltration of liver

Gut mucosal atrophy

Reduced protein synthesis
 when to Feed?
Studies comparing early nutrition vs. late
Reduced infectious complications on meta analysis
Improved survival in “early” groups (Head injury, pancreatitis)

Current evidence supports feeding within 24-48 hrs of

admission
 Routes of feeding: Enteral Route
Oral
tube feeding
Naso dodenual / Nasogastric / Nasojejunal / Gastrostomy /
jejunostomy
“Physiological”

More complete diet

Maintains structural integrity of the gut

Improves bowel recovery after resection and reduces infection

risk
Complications: Enteral Route
Tube misplacement
Tracheobronchial / intracranial penetration (basal skull
fracture)

Reflux / Pulmonary aspiration / VAP / sinusitis

Nausea and vomiting / Abdominal distension

Diarrhoea / Constipation

Metabolic
Dehydration / Hyperglycaemia / Electrolyte imbalance /
Fine Bore Nasogastric Feeding Tube
NG
Tip
 Parenteral Route:
When adequate Enteral intake delayed / impossible
Short bowel syndrome
Extensive GI surgery / Complications

Central venous line with dedicated lumen

Hyperosmolar solutions providing adequate energy
Reduced volume of infusion
 Complications: Parenteral Route
Catheter related
Misplacement / sepsis / thrombosis

Liver dysfunction – a common problem

Hyperchloraemic metabolic acidosis

Rebound hypoglycaemia

Electrolyte abnormalities & Re – feeding syndrome

 Feeding: Important Concepts
Are they absorbing enteral feed?
4 hourly aspiration of feeding tube
High volume aspirates indicate reduced transit  “not
absorbing”
Prokinetics (metoclopramide / erythromycin)

Trophic feeding
Not absorbing enough calories
Low volume enteral feed (to maintain gut integrity) + parenteral
feed
How much feed should we give?
nitrogen
no benefit from measuring nitrogen balance
nitrogen 0.15-0.2 g/kg/day
protein 1-1.25 g/kg/day
severely hypercatabolic patients (eg burns) may receive
up to 0.3 g nitrogen/kg/day
What should the feed contain?
carbohydrate
 EN: oligo- and polysaccharides
 PN: concentrated glucose

lipid
 EN: long and medium chain triglycerides
 PN: soya bean oil, glycerol, egg phosphatides

nitrogen
 EN: intact proteins
 PN: crystalline amino acid solutions
water and electrolytes
micronutrients
Feeding formula
 Components
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
 Analgesia
Critically ill patients feel pain due to:
Their primary illness e.g. pancreatitis / surgical wounds
 Routine procedures e.g. turning / suctioning / dressings
Psychological Effects
Causes anxiety / Contributes to lack of sleep
Post Traumatic Stress
 Analgesia
Physiological Effects

Worsens delirium

Enhances stress response –  catecholamine levels & O2

consumption

Respiratory – atelectasis and sputum retention

Leads to immobility and gut stasis

 Analgesia
Metabolic effects

Catabolic state (delayed recovery)

Immunosuppression (danger of infection)

Insulin secretion and activation (hyperglycemia &

dehydration)

Hypercoaguability (venous thromboembolism)

 Common Analgesi
Opioid analgesics
The mainstay of analgesia in most Units
Simple analgesics
Should always accompany “stronger stuff”
Local anaesthetic agents
Epidural / paravertebral / peripheral nerve infusions
Supplemental treatments
acupuncture, acupressure / massage
 Components
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
 Sedation
Compassion for the critically ill patient

Tolerance of invasive and uncomfortable monitoring and

treatment procedures

Reduce oxygen consumption by reducing patient arousal

and activity

Promote amnesia for events in the ICU

Specific treatment for conditions:

 Methods of Sedation
Benzodiazepines (commonly midazolam)

Intravenous anaesthetic agents

Propofol
Ketamine (bronchodilatation / analgesia)

Major tranquilizers
Haloperidol (also used in delerium)

Analgosedation
Opiods

Pharmacological considerations: Analgesia
& Sedation
Patient’s fluid volume status

Serum protein levels

Renal & Hepatic function and blood flow

Drug interactions
 Sedation problems
Oversedation
Increased risk of nosocomial pneumonia
Increased rate of Neurological Investigation (CT)
Prolonged stay in the ICU + Polyneuropathy
Increased incidence of post – traumatic stress disorder and
depression
Increased use of inotropes

Monitoring Sedation
Ramsay Sedation Score
Ramsay Sedation Score
 Important Concepts
“Analgosedation”
Agents with both sedating and analgesic properties
“Tube tolerance” for opioids

“Sedation Hold”
Assess mental status / communication / level of sedation /
neurological status
Important Concepts – Delirium
“acute confusional state characterised by
fluctuating mental status
 inattention
and either disorganized thinking or altered level of
consciousness”

Independent predictor of death in intensive care

patients: 2 – 3 times risk of death

3-fold higher re – intubation rate

Delirium: Clinical Features
Acute onset with fluctuating course

Inattention

Disorganized thinking

Altered consciousness

Cognitive deficits

Perceptual disturbance (hallucinations)

Psychomotor disturbance
Hyperactive / Hypoactive / Mixed

Altered sleep – wake cycle


Delirium: Diagnosis

CAM-
ICU

CAM-
ICU
– ICU
Spell “SAVE A HAART” loudly to patient
Ask them to squeeze your hand every time they hear the
letter “A”
Allowed 2 mistakes - squeezing on a non-A, not squeezing
on a A
Pass = Not delirious

If Fail, look for disorganized thinking or decreased level

of consciousness:
4 simple yes/no questions, one simple command
Allowed 1 mistake
 Delirium: Treatment
Where possible, reduce / withdraw deliriogenic drugs e.g.

midazolam
Daily sedation targets and spontaneous awakening trials if

tolerated
Correct biochemical, hypoxic and haemodynamic

derangements
Screen for infection, identify or treat most likely source

For agitated depression - Haloperidol

 Don’t Forget Anything!
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
 Thromboprophylaxis
Critically ill patients have numerous risk factors

Without prophylaxis rates of deep-vein thrombosis range

between 13% and 31%
May be much higher in trauma patients

Must weigh up risks v.s. bleeding complications

E.g. intracranial bleed
 How Ensure Thromboprophylaxis?
Mechanical
TEDS (thromboembolic deterrent stockings)
Intermittent compression devices
Care to ensure peripheral circulation

Pharmacological
Subcutaneous LMW Heparin o.d. (e.g. Tinzaparin)
Intravenous unfractionated Heparin (infusion)
Subcutaneous unfractionated Heparin b.d.
Oral anticoagulants (Warfarin)
 Don’t Forget Anything!
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
 Why Ensure Head Up Position?
Head of the bed inclined at 45 degrees
Can decrease gastroesophageal reflux in mechanically
ventilated patients
Can reduce rates of nosocomial pneumonia
Is indicated (20 – 30 degrees) in some patients e.g. raised
ICP
 Don’t Forget Anything!
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
 Why Ensure Ulcer Prophylaxis?
 Peptic ulceration is related to
 protective barrier loss
Acid or biliary damage of the underlying mucosa
Barrier loss occurs secondary to critical illness

Direct damage from feeding tubes

especially at the lower oesophagus

Mucosal damage from tissue hypoperfusion

Highest risk
Prolonged mechanical ventilation
 How to Ensure Ulcer Prophylaxis?
Small-bore feeding tubes

Enteral nutrition
Reduces incidence of stress ulcer bleeding

Adequate tissue perfusion (optimal haemodynamics)

Prophylactic drug therapy (Contorversial)

H2 antagonists (ranitidine)
Proton pump inhibitors (omeprazole, pantoprazole)
? Predispose to nosocomial infection.?
 Don’t Forget Anything!
Feeding

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control
Why Glycaemic Control?
As current studies stated that: “Keeping blood glucose

levels at 140 mg/dL “

29.3% decrease in hospital mortality

10.8% reduction in length of ICU stay

Care to avoid hypoglycaemia – disaster

Many units now aim to keep blood sugar levels below

about 150 mg/dL

As per surviving sepsis campaign guidelines
 Daily Assessment
Every patient must be assessed by a doctor twice a day –
YOU will be doing this

The basic rules / methods are:

History
Examination
Measurements
Investigations
Chart review
Consultation with Senior

Here follows a personal method…

 The Alphabetical Approach…
 Airway  Microbiology

 Breathing

 Circulation

 Disability / Neuro

 Enteric

 Fluids / Renal

 Glucose / General

 Haematology

 Infusions / Lines
 Airway
Type
COETT (cuffed oral endotracheal tube)
Tracheostomy
NIV (non-invasive ventilation: CPAP or BiPap)
Facemask / Nasal Cannulae

Duration
Time to change it for a new one?
Time to change tube to tracheostomy?
Time to escalate / de-escalate?
 ETT
Tip
Carin
a
 Breathing
What are the ventilation parameters
FiO2 / SaO2 / mode of ventilation / measurements

What is the progress?

Are they weaning?

Examine the chest

Review Investications
CXR: tube position / any pathology
Arterial Blood Gas
 Circulation
What is the haemodynamic status?
Heart rate & rhythm / Blood pressure / CVP

Any inotropic support?

What is peripheral perfusion like?

Examine capillary refill / warmth of arms & legs

Auscultate the heart

 Disability / Neuro
Sedation score / sedative drugs / sedation hold

Pupils / GCS / Neurological examination

Analgesia

Mood

Any delirium?
 Enteric
Examine the abdomen
Any new signs? Any increase in size? Are we monitoring
compartment pressures?
Any surgical wounds?

Review the liver function & bone profile

FAST examination

Feeding
Are they receiving nutrition? Is it time to start?
Is the NG / NJ tube in the right place?
Are they absorbing feed?
 Fluids / Renal
Fluid Balance
Are they positive or negative? What are we aiming for?
What is the urine output
Is the fluid regimen appropriate?

Renal
Any renal replacement therapy?
What are the electrolytes?
Glucose / General
What is the glucose?
Are they on insulin / should they be on insulin?

General Examination
Vascular sufficiency
Wounds
Drain sites
Pressure areas
 Haematology (& Clotting)
What is the latest haemaglobin & WCC?

Do they need transfusion?

Are they going to the OR?

Should we crossmatch some blood?

Do they need platelet cover or clotting products for the

procedure?
 Infusions & Lines
What drugs are infusing?

What lines do they have and where are they located?

CVC / Arterial / peripheral lines

How long have the lines been in situ?

Do they need changing for new ones?

Inspect the vascular access sites

Microbiology
Antibiotics
Which ones / for how long / any adverse effects

Review all cultures and sensitivities

Urine / blood / sputum / swabs / CSF / fluid aspirates
(abdominal, pleural etc)

Discuss with the microbiologist

 References
 Give your patient a fast hug (at least) once a day. Jean-Louis

Vincent. Crit Care Med 2005 Vol. 33, No. 6

 Oh’s Intensive Care Manual, 6 th Ed. Neil Soni & Andrew Bersten.

Elsevier Limited, 2009

 Oxford Handbook of Critical Care 2 nd ed. Singer, Mervyn; Webb,

Andrew R. Oxford University Press, 2005

 http://www.icudelirium.co.uk