ICU Survival Guide - Upstate Medical University

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2018SUNY Upstate Medical UniversityICU SURVIVALGUIDERavi Doobay, Subrat Khanal, Lauren Krowl, RyanDean, Prathik Krishnan, Hassan Al-Khalisy BrianPratt, Ioana Amzuta, Carlos Martinez-Balzano,Amit S. Dhamoon1 Page

The ICU can be an intimidating and stressfulenvironment. This manual is intended to help supportmedical students, interns, and residents working in theICU.Please be mindful that this manual is a guide for care inthe ICU. Clinical treatment decisions are variable andnuanced depending on patient, nursing, and attendingfactors.2 Page

Table of Contents:Day MICU ExpectationsPage 4Night MICU ExpectationsPage 5SepsisPage 6Respiratory FailurePage 12Mechanical VentilationPage 14Liberation from Mechanical VentilationPage 15COPDPage 17AsthmaPage 19GI BleedingPage 20DKA/HHSPage 23Acid Base DisordersPage 24SedationPage 25DeliriumPage 29ICU DripsPage 323 Page

-Day MICU Expectations:When a service asks for a consultation, confirm that an EPICconsult order is placed.Consults should be seen within 30 minutes.Consults should be presented to either the Fellow orAttending.If a patient is readmitted to the ICU, it is considered a bounceback if the same Attending or Fellow is on service.If a patient is admitted to the ICU, an H&P note should bewritten.If a patient does not require MICU admission, a consult note iswritten.Transfers from outside hospitals should be admitted under theaccepting physician.If a patient is stable for transfer to the hospitalist service, theMAR needs to be contacted to determine the team/attending.The Fellow directly contacts accepting hospitalists.The ICU Resident signs out to the team resident.Transfer summaries should be written when there is more than48 hours of ICU level careDeath Note should be written in EPIC by pronouncingphysician along with prompt EDRS completionThe Fellow or Attending should be notified with changes ingoals of care, new hemodynamic compromise, procedurecomplications, or death followed by a family updateThere should be timeouts before every procedure. Theplacement of CVCs should be confirmed via manometry ortransducing before dilating, it is an institutional policy.Procedural consent is mandatory unless it is an emergency.All procedures require a note.MICU interdisciplinary conference is mandatory unlessattending to patient care.4 Page

--Night MICU Expectations:Confirm a Consult was placed in EPIC from the service askingfor consultationResidents should present the consult to the fellow aftercompletion (irrespective of the diagnosis)Any significant events such as: change in goals of care,hemodynamic compromise, procedure complication, or deathshould be notified to the fellow immediately with a familyupdateBounce backs apply at night as wellMICU on call get the majority of admissions, however can giveto the non-call team to make sure the difference in team size isnot more than two patientsChanges to ventilator should be notified to the Fellow and RTNEVER CHANGE THE VENTILATOR WITHOUTINFORMING THE RESPIRATORY THERAPIST AND ICUFELLOW!5 Page

Sepsis:Key Terms:a. Systemic Inflammatory Response Syndrome (SIRS),need 2/4 positivea. Leukocytosis ( 12,000 ), BANDEMIA,Leukopenia or ( 4,000)b. Fever 100.4F OR Hypothermia 96.8Fc. Tachypnea 20 breaths per minuted. Tachycardia 90bpmb. Sepsis: SIRS Suspected Infectionc. Severe Sepsis: Sepsis Evidence of Organ Dysfunctiond. Septic Shock: Severe sepsis hypotension DESPITEadequate resuscitation (20-30cc/kg, 2L of IVF over30min) or Pressor requirement is neededSofa Criteria:Reference: Singer, M., Deutschman, C. S., Seymour, C. W.,Shankar-Hari, M., Annane, D., Bauer, M., & Hotchkiss, R. S.6 Page

(2016). The third international consensus definitions for sepsisand septic shock (sepsis-3). JAMA, 315(8), 801-810.Reference: Singer, M., Deutschman, C. S., Seymour, C. W.,Shankar-Hari, M., Annane, D., Bauer, M., . & Hotchkiss, R. S.(2016). The third international consensus definitions for sepsisand septic shock (sepsis-3). JAMA, 315(8), 801-810.Treatment:1)Fluid resuscitation is essential!a. Administer intravenous fluids aggressively. Ingeneral, give 30 mL/Kg of BW for fluidadministrationb. Consider central line placement if needed for pressorsupport. Consider arterial line if significanthemodynamic instability.c. Give 3 L of crystalloid fluids immediatelyd. Will need on average 5L in the first six hours7 Page

e. Crystalloids such as NS ( 2 per bag) are as effectiveas colloids ( 40 per bag) such as Albumin2)Antibiotic administration early!a. Give appropriate broad-spectrum antibiotics early.Consider Vancomycin and Zosyn, if concern forESBL can use Carbapenem such as Meropenem.Consider double pseudomonas coverage whenmortality is over 25%. Mortality can be calculatedwith Apache II Score.b. ICU Mortality increases by 7% per hour of noantibiotics in hypotensive patients. Culture beforeantibiotic administration with blood, sputum, andurine cultures. In particular situations considermeninges and bone as sources of infection.c. Lactic Acid is recommended, the rate of decreasewith treatment is a better predictor than the absolutevalue.3) Vasopressorsa. Start Pressors early if after adequate fluidresuscitation. MAP remains 65 mmHg. Pressors canbe started and continued peripherally until patient isstabilized. There is NO policy against startingpressors peripherally.b. Start with norepinephrine first. Consider addingvasopressin next. Agents that can be used as thirdpressors: epinephrine, dobutamine, phenylephrine.Dopamine increases the rates of arrhythmias andshould be used judiciously.8 Page

Vasopressors: Used for Shock when MAP 65Causes of Shock:1) Septic Shock2) Cardiogenic Shock3) Neurogenic Shock4) Anaphylactic ShockGoal Mean Arterial Pressure is generally 65 mm Hg.However this goal can vary in the setting of neurological injurysuch as stroke or intracranial hemorrhage. There is sufficientevidence that Norepinephrine should be the first vasopressorused in all situations even if used peripherally. If bloodpressure does not increase appropriately with norepinephrine,either vasopressin or epinephrine can be next. Dopamine hasshown an increase in mortality and arrhythmias, and should beused cautiously. Phenylephrine is most commonly used forneurosurgical or spinal injury. In severe Congestive HeartFailure exacerbations ionotropic agents such as Dobutamineand Milnirone can be used, however due to their Beta-2receptor stimulation, hypotension can worsen andconcominant use of norepinephrine may be needed. Below arethe specific receptors that these agents work on.VasopressorAlpha 1Norepinephrine Beta 1Beta 2 9 Page

VasopressinEpinephrine Phenylephrine Dopamine (High Dose)DobutamineMilrinone Vasopressin works on V2 receptors stimulating the RAASsystem, which increases blood volume, cardiac output, andarterial pressure. Milrinone is a phoshodiesterase-3 inhibitorand should be used with caution in patients with renaldysfunction.Suggested order for Vasopressor Support for Septic Shock1) Norepinephrine2) Vasopressin3) Epinephrine4) Phenylephrine5) Dopamine (If there is bradycardia, keep in mindDopamine can increase mortality)* Vasopressin and or Epinephrine can be interchanged at 2/3Reference: Singer, M., Deutschman, C. S., Seymour, C. W.,Shankar-Hari, M., Annane, D., Bauer, M. & Hotchkiss, R. S.10 P a g e

(2016). The third international consensus definitions for sepsisand septic shock (sepsis-3). JAMA, 315(8), 801-810.Vitamin C, Steroids, and ThiamineThe early use of IV Vitamin C, Hydrocortisone, andThiamine has been shown to decrease mortality in septicshock, along with preventing organ dysfunction.However these findings are recent and more data needs tobe collected to validate these claims.Refernce: Marik, P. E., Khangoora, V., Rivera, R., Hooper, M.H., & Catravas, J. (2017). Hydrocortisone, vitamin C, andthiamine for the treatment of severe sepsis and septic shock: aretrospective before-after study. Chest, 151(6), 1229-1238.Steroids in Septic Shock:There is a thought that it is actually the steroids that result inthe mortality benefit. Annane et al which is a 1241 personstudy showed that 50 mg of IV Hydrocortisone q6h andFludrocortisone 50 ug daily via an NG tube reduced 90 daymortality in septic shock patients compared to a placebo group,along with vasopressor free days and organ failure free days.However once again there is more data that needs to becollected on these new intervention for sepsis.Reference:Annane, D., Renault, A., Brun-Buisson, C., Megarbane, B.,Quenot, J. P., Siami, S, & Timsit, J. F. (2018). Hydrocortisoneplus fludrocortisone for adults with septic shock. New EnglandJournal of Medicine, 378(9), 809-818.11 P a g e

Respiratory Failure:Hypoxemia - PaO2 60 mmHgO2 controlled with PEEP and FiO2Hypercapnia – PaCO2 45 mmHg (however in COPD baselinePaCO2 is often higher)CO2 controlled with Respiratory Rate and Tidal VolumeDiagnostic Tests to order in Acute Respiratory Failure: CXRand ABG STATTherapies to Consider: Lasix if hypervolemic, ChestPhysiotherapy and suctioning if excessive secretions presentAcute Respiratory Distress Syndrome (ARDS)Berlin Criteria:1) PaO2/FiO2 300-200 (mild), 200-100 (moderate), 100(severe)2) Respiratory insult within seven days3) Bilateral infiltrates on chest xray4) Cardiogenic cause ruled out (echocardiogram appropriate)12 P a g e

5) A minimum PEEP of 5 cm H2O being usedMainstay treatment is low tidal volume ventilation (4-6 mL/kgof IBW) to target a plateau pressure 30 cm H2OThe goal of therapy is not to normalize pH or PaCO2.Permissive respiratory acidosis (hypercapnia) improvesoutcomes.PaO2 of 55 mmHg is appropriateConsider:1) Paralytic therapy if PaO2/FiO2 1502) Prone positioning if PaO2/FiO2 150 and FiO2 60%If the patient not responding to conventional therapy considerECMOReference: Kallet, R. H., Jasmer, R. M., Pittet, J. F., Tang, J. F.,Campbell, A. R., Dicker, R., . & Luce, J. M. (2005). Clinicalimplementation of the ARDS network protocol is associatedwith reduced hospital mortality compared with historicalcontrols. Critical care medicine, 33(5), 925-929.13 P a g e

Mechanical Ventilation:Mechanical Ventilation is one of the more complex entities inthe Intensive Care Unit, this guide provides a brief overviewOxygenation is controlled by PEEP and FiO2CO2 is controlled by RR and TVVolume Assist-Control:Requires the rate and tidal volume to be set. If the patientwants to breathe more than the set rate they can by triggeringthe vent which will then deliver the volume. The plateaupressure is the distending pressure of the alveoli. A safeplateau pressure is less than 30 cm H20.Pressure Assist-Control:Requires the rate and control pressure to be set. All of themodern vents have a combined assist and control mode.Inspiratory time is the time it takes the ventilator to deliver onebreath (expiratory time being the opposite) The ventilator goesup to a set pressure and continues at this pressure until it turnsoff (known as I-time). In spontaneous breathing the ratio of Itime and E-time is (I:E ratio) 1:2 -1:4, and this should bemaintained in ventilated patients. In order to set the I:E ratioconsider the rate of breaths per minute (for instance 20 BPM, 6014 P a g e

sec per min then 3 seconds per breath, if the I-time is 1 secondthen the expiratory time is 2, meaning 1:2 ratio).Pressure Support Ventilation:Requires pressure support and PEEP to be set.This allows a patient to breath spontaneously, therefore itsimperative that a patient has a competent drive to breath.When the patient triggers the ventilator, the machine willdeliver a breath by increasing the pressure in the circuit. Theamount delivered depends on the compliance of the lungs.When a patient triggers the vent, the pressure increases fromthe PEEP to the PEEP Pressure support. Because of thevarying compliance in the lungs, the patient will have variabletidal volumes.Volume Support Ventilation:Requires tidal volume and PEEP to be set.The ventilator will automatically adjust the pressure support toget the desired volume. The mode also allows the patient tospontaneously breath.Airway Pressure Release Ventilation (APRV):Inversed ratio high pressure control mode of mechanicalventilation. It allows for spontaneous breathing at high lungvolumes. Often used as a “rescue” mode if the previous modeson mechanical ventilation failed. Consider should beadequately sedated or else will fight the vent.Common Vent Setting for the various modes:Volume 6-10 mL/kg IBW (non-ARDS)PEEP 5-20Rate 10-25Pressure control: 5-25Phigh 20-30, small changes will have big effects15 P a g e

Plow always is ZERO, don’t change itThigh 3-6 s, change in increments of 0.5s and get ABGTlow 0.4-0.8 s, change in increments of 0.1s and get ABGLiberation from Mechanical Ventilation:Rapid shallow breathing index Respiratory Rate/TidalVolumeWhere RSBI 105 Successful Weaning PredictedWhere RSBI 105 Failure predictedWeaning from the vent or extubation should be consideredwhen the patient is requiring minimal support from the vent,i.e., they are drawing adequate tidal volumes, FIO2 is minimal( 50%) and respiratory rate is 35In order to determine if patient is ready to be weaned from thevent there are four questions that need to be asked: Is the case of respiratory failure reversed? Is there a strong cough? How is the patient mentating? Are there are lot of secretions?Consider doing a spontaneous breathing trial if the answer isyes to all of the above. Patient should be off sedationcompletely, put on pressure support for approximately 30-120min. If they are pulling good tidal volumes, extubation shouldbe attempted.Other considerations are: Being off sedation, no vasopressorsupport, ability to protect airway, secretion burden notexcessive, RSBI 105.16 P a g e

Perform daily withholding of sedation and once dailyspontaneous breathing trials if the patient is ready.SBT should be performed with pressure support of 5-8 cmH2O(preferred) or CPAP of 5 cmH2O.Reference: The ARDS Network Ventilation with lower tidalvolumes as compared with traditional tidal volumes for acutelung injury and the acute respiratory distress syndrome N EnglJ Med. 2000; 324: 1301-1308COPD:Outpatient COPD management:# of exacerbationsCAT 10CAT 10FEWER 2outpatientGROUP AGROUP BSABAGROUP CLABA OR LAMAGROUP DLABA LAMALABA LAMA ICSMORE 2outpatient or 1inpatientConsider Pulmonary Rehabilitation starting at Group BAbbreviations: SABA – Short acting beta agonist, LABA – Longacting beta agonist, LAMA – Long acting muscarinicantagonist, Inhaled corticosteroids, CAT – COPD AssessmentScore17 P a g e

Clinical Features of exacerbation: Increased sputumproduction, shortness of breath, wheezing, increased work ofbreathing, tachypnea, tachycardia, smoking for over 20 years.Labs to order: CBC, CMP, CXR, ABG, and Respiratory PanelMonitor: Continuous monitoring of Oxygen, RR, HR, CardiacMonitoring, and GlucoseCOPD Exacerbation Treatment:---Aggressive bronchodilator therapy (Albuterol 2.5 mgdiluted to 3 mL via nebulizer every 2 hours,Ipratropium 500 micrograms via nebulizer or 4 to 8inhalations from MDI every four hours)Glucocorticoids (eg, methylprednisolone 40 BID orPrednisone 40 mg for five days),Antibiotics (Low Pseudomonas risk – IV Ceftriaxone 1g daily and Azithromycin 250 mg daily for five days)(Pseudomonas Risk – IV/PO Levofloxacin 750 mgdaily, Piperacillin-Tazobactam 3.375 g q8h IV, ORCefepime 1 to 2 grams q8h IV, OR Ceftazidime 1 to 2grams q8h IV). For Influenza Positive patients use.Antiviral therapy (influenza suspected): Oseltamivir 75mg orally every 12 hours.Assess respiratory status, if Hypercapnic and acidemic(7.20-7.35) consider Non-Invasive Ventilation such asBiPap, however if ABG not improving, clinical statusworsening, and pH 7.2 consider mechanicalventilation.Provide Oxygen to keep saturations over 80%References:18 P a g e

1. Dodd JW, Hogg L, Nolan J, et al. The COPD assessment test(CAT): response to pulmonary rehabilitation. A multicentre,prospective study. Thorax 2011; 66:425.2. Dodd JW, Marns PL, Clark AL, Ingram KA, Fowler RP,Canavan JL, et al. The COPD Assessment Test (CAT): shortand medium-term response to pulmonary rehabilitation.COPD 2012; 9:390.Asthma Outpatient Management:Step 1Step 2Step 3Step 4Step 5SABALowDoseICSMediumICS LABAHighDoseICS LABAHigh DoseICS LABA OmalizumabNEVER GIVE LABAs alone in asthma, it increases mortality!The mainstay treatment of chronic asthma is ICS.Labs to order in an exacerbation: CBC, CMP, CXR, ABG, andRespiratory PanelMonitor: Continuous monitoring of Oxygen, RR, HR, CardiacMonitoring, and Glucose19 P a g e

Asthma Exacerbation Treatment:- Aggressive bronchodilator therapy (Albuterol 2.5 mgdiluted to 3 mL via nebulizer every 2 hours,Ipratropium 500 micrograms via nebulizer or 4 to 8inhalations from MDI every four hours),- Glucocorticoids (eg, methylprednisolone 40 BID orPrednisone 40 mg for five days).- Non Invasive Ventilation (for Respiratory Acidosiswith pH 7.20). Intubation if severe acidosis (pH 7.20 or failure of NIV).- Normalization of ABG can suggest severe exacerbation,pay close attention to the clinical statusGI Bleeding in the ICUAny GI bleed with hemodynamic compromise warrants ICUadmission, however it can be warranted by excessive bloodloss alone.Differentials of Upper GI Bleed: Gastric/Duodenal Ulcers Esophageal Varices Mallory Weiss Tears Malignancy: Esophageal, Gastric, Duodenal Gastritis Dieulafoy’s Lesion GAVE HematobiliaDifferentials of Lower GI Bleed: Diverticulosis20 P a g e

Ischemic/Infectious/Radiation ColitisAV MalformationHemorrhoidsMalignancy: Colon and RectalMesenteric IschemiaPost PolypectomyInitial Assessmenta. Check for orthostasis, which suggests significant bloodlossb. Hemoglobin will take hours to reflect acute blood loss,do not follow Hemoglobin in hypovolemic shock,follow vital signs and nursing report of blood lossamountc. Assess what anticoagulation medications the patient ison and if there is reversal agent availabled. Lavage with NG tube to determine if it is an upper orlower GI sourceManagementa. Establish IV access with 2 large bore peripheral lines(size 18 or bigger), give fluids through large bore IVs asfluids will be administered faster, peripheral cathetersare shorter and larger diameter compared to CVC.b. Consults to GI, Interventional Radiology, and GeneralSurgery as warranted depending on the clinicalsituation. If hemodynamically unstable arrange anAngiogram with IR STAT, have Surgery on stand by incase intervention failsc. Resuscitate intravascular volume with IVF and RBCsd. PRBCs transfusion is preferred until hemodynamicstability is achieved and blood loss subsides. If the21 P a g e

e.f.g.h.i.j.k.bleeding is without shock and mild, hemoglobin of 7is the target.Normal Saline is preferred.LR can bind with citrate from PRBCs and form clotsMassive Transfusion Protocol can be used if bleeding issevere, this protocol has to be approved by the MICU orTrauma Attending.Correct bleeding diatheses, patient is losing wholeblood not just PRBC. Rule of thumb is 3:1:1 of PRBC:FFP: PlateletsINR to less than 1.5 with K-Centra (reverses within onehour) or Vitamin K (reverses within 24-48 hours). Anylife threatening bleed should be reversed with KCentra, this includes intracranial hemorrhage or GIbleeds.If hemodynamically unstable suspected UGIB, bolus 80mg of IV Pantoprazole and start a drip at 8 mg/hr.Octreotide is reserved for esophageal varices, 40 mgbolus with drip at 4 mg/hr.EGD/Colonoscopy with intervention 24 hoursReferences:Feinman, M., & Haut, E. R. (2014). Uppergastrointestinal bleeding. Surg Clin North Am, 94(1), 4353.Ghassemi, K. A., & Jensen, D. M. (2013). Lower GIbleeding: epidemiology and management. CurrentGastroenterology Reports, 15(7), 333.22 P a g e

Diabetic Ketoacidosis (DKA)/ HyperosmolarHyperglycemic State (HHS)Diagnostic criter

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