Avinash B Kumar MD Assistant Professor Anesthesiology and Critical Care Dec 2006
Avinash B Kumar MD Assistant Professor Anesthesiology and Critical Care Dec 2006
Avinash B Kumar MD Assistant Professor Anesthesiology and Critical Care Dec 2006
Disclaimer: This survival guide is meant as an educational resource for Residents, Fellows and Medical students during their SICU rotation. All efforts have been made to accurately depict information. This is just a guideline and you still have to exercise good and safe clinical judgment and discuss management with your Staff on call before you treat critically ill patients. The sources for the information are listed at the bottom of each page.
Acknowledgements: 1. Chad Laurich MD (Resident General Surgery) 2. Dr Joss Thomas MD, PhD, MPH: Associate Critical Care medicine and Anesthesiology 3. Harry Zwez. Computer support 4. Kelly Cowen. Administrative Assistant Format reviews and suggestions: 1. Rebecca Delong MD (Resident in Anesthesiology) 2. Scot Paulsen MD (Resident in Anesthesiology) 3. Jonathan Simmons DO (Associate Fellowship Director) 4. Steven Hata MD (Director SICU)
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Table of Contents
Introduction to the SICU .. Useful Beeper Numbers . Admission Orders Sedation in ICU . Silent Killers in the ICU SOFA Score . Infectious Diseases Primer . BIPAP . Hemodynamic Monitoring . Lidco ABG Analysis Cosyntropin Stim Test Nutrition in ICU Social Work in the SICU . Brain Death/ Organ Donor Protocol .. .. Page 3 Page 4 Page 5 Page 8 Page 10 Page 11 Page 12 Page 14 Page 17 Page 18 Page 20 Page 21 Page 22 Page 26 Page 27
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ICU call begins Fellow Lectures and Journal Clubs Radiology Rounds ( Dept of Radiology) Bedside Rounds in Individual Bays Noon Lecture series SICU "Check out" rounds
Surgical ICU Front Desk SICU Bay 1 SICU Bay 2 SICU Bay 3 SICU Bay 4 SICU Conference Room
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Neurosurgery resident on Call : 3268 Neuro IR resident on call : 4381 Neurology resident on call : 3319 EEG : 1-6733
IPCU: 3262 Medicine Admissions Triage Pager : 4633 ECHO lab : 6-2811 EKG : 6-2328
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Admission Orders
All orders have to be cosigned by the ICU team. Always cross check the admit orders from the primary team. Prophylaxis for Ventilator associated pneumonia, Deep vein thrombosis; ICU insulin protocol should be accounted for. Fever prophylaxis PRN for lytes to be replaced. Pain medicine orders. IV fluid rates Labs and X rays PRN electrolyte orders: Mg Sulfate 2gm IV prn for Mg <2.0 KCl 20-40 mEq IV/PO prn for K<4.0 (unless in renal failure) Do not write for a prn order for phosphate. You have to know the sodium and potassium levels prior to supplementing phosphate as KPhos or Sodium phosphate
Daily Labs: Please be prudent in ordering labs. CBC, lytes (Na, K, Cl, CO2, BUN, Cr, Mg, PO4, Ca), ABG, lactate on admit and q AM; you may want to follow ABG, lactate and/or H/H more frequently in some pts especially those with suspected ongoing blood loss. Anti-emetics: Zofran 4mgIV q4hr prn and or Metoclopramide 10mg IV/PO q6hr prn.
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Commonly used meds/modalities are: Epidural catheters: placed and managed by Anesthesia/Pain service. Please page the Pain service for problems with the epidural pump and medicines. Fentanyl gtt: 25-100mcg/hour. Do not use in NON intubated patients. Morphine PCA: 1mg q 6-15 minutes, no basal rate Morphine 2-4mg q4hr IV prn Dilaudid 2-4mg q4hr PO prn Dilaudid PCA: 0.2 mg Q 8-12 mins No Basal Rate. D o n ot u se P C A s on in tu b ated /sed ated p atien ts. Always turn off the opioid infusions following extubation. Please switch to more appropriate dosing regimes.
Evaluation for management of Acute Pain in the ICU The Anesthesiology Pain Service offers valuable resources to help you better manage pain in ICU patients. Please consult their team after speaking with the Attending SICU Staff for interventions such as Continuous nerve block catheter placements or even advise your team with complex opioid use patients.
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1
2 3 4 5 6 Riker Sedation Score:
Anxious, Agitated, Restless Cooperative, Oriented, Tranquil .Accepts mechanical ventilation. Responds to commands only Brisk response to light glabellar tap or loud noise. Sluggish response to light glabellar tap or loud noise. No Response.
http://www.mit.edu/~gari/papers/cinc2005Janz.pdf
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Commonly used agents for ICU sedation: Please account for analgesia in ICU patients prior to placing them on sedation. Often you may have to use a combination of Analgesics and other classes of sedation medicines. Propofol gtt com m on titrate to R iker 3 Lorazepam: 1mg q6-8hr IV/PO or as a prn. Maybe used as an infusion in certain cases. Haloperidol (Haldol) 5mg IV q6hr prn Dexmedetomidine (the dosing is in mcg/kg/hr) up to 24 hrs only. Morphine gtt: Start at 1 mg/hr. Caution in Renal failure. Fentanyl gtt : Between 25 mcg to 100 mcg/hr
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0
Respiratory P: F ratio Coagulation Platelet count Liver BILIRUBIN mg/dL Cardiovascular Hypotension CNS Glasgow Coma Score Renal Creatinine mg/dL >400 >150 <1.2
1
400 150 1.2-1.9
2
300 100 2.0-5.9
3
200 50 6.0-11.9
4
100 20 >12
None
MAP<70mmHg
Dopamine>5mcg Or NorEpi/Epi
Epi/Norepi>0.1
15
13-14
10-12
6-9
<6
<1.2
1.3-1.9
2.0-3.4
3.5-4.9
>5.0
Reference: Textbook of Critical Care. M Fink, JLVincent. 5th edn. Pg: 1261.
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Infectious Diseases:
Gram positive
Cocci
Gram negative
Neisseria (in pairs) Moraxella (in pairs)
Bacilli
Pseudomonas Haemophilus Bordetella Legionella Campylobacter (spiral) Helicobacter (spiral) Clostridium (anaerobic) Bacteroides (anaerobic)
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This is just an introduction to ICU microbiology and some of the common antibiotics that are available at UIHC. CHOICE of ANTIBIOTICS and SPECTRUM of COVERAGE
Reference: http://www.healthcare.uiowa.edu/pharmacy/formulary/Pocketguide/antiinfectivetherapy.pdf
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Failure of non-invasive ventilation and need for endotracheal intubation: 1. Inability to improve gas exchange or dyspnea. The dyspnea should improve within 30 mins to consider the NIV mode successful. 2. Poor patient compliance. 3. Worsening airway secretions and increasing need for suctioning (more frequent than Q 2 hours). 4. Development of conditions requiring intubation to protect the airways (coma or 5. seizure) 6. Hemodynamic or EKG instability (ischemia or significant ventricular arrhythmias
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Hemodynamic Monitoring:
Systolic Pressure Variation (SPV): Prerequisite conditions:
1. 2. 3. 4. Mechanical ventilation About equal tidal volumes Arterial line present Recording speed <6.5mm/s
Set up as follows
1. Plug in the bedside printer module (usually located near the central core work area in the bays.) 2. Select ABP (arterial line tracing) on the Phillips monitors 3. Select the sampling speed to 6.5 mm/s 4. Start recording the waveform.
Interpretation:
When the Peak to trough of the waveform >10mmHg then the patient is likely to be fluid responsive.
Limited Reliability:
1. Atrial fibrillation 2. Dilated cardiomyopathy
References:
Anesthesiology. 1998 Dec; 89(6): 1313-21 O hs intensive C are M an ual. 5 th edn. Pg 81.
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Key Points: Uses Lithium dilution curves for determining CO/CI Y ou need the p atients height (cm ), w eight (k g), serum N a and H em o globin prior to calibration of the Lidco. Must not have neuromuscular blockade on board as the large molecular size interferes with the Lidco sensors during calibration. Needs to be recalibrated Q 12 hours. Parameters that can be measured and trends followed up to 24 hrs are: Systolic, Diastolic, Mean arterial pressures(MAP) Cardiac index and Cardiac output and Systemic Vascular Resistance (SVR). Pulse pressure variation (PPV) and Systolic pressure variation (SPV) Real time Oxygen Delivery
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Using the Lidco to measure Systolic Pressure Variation (SPV) and Stroke Volume Variation (SVV) as indices for Volume Responsiveness:
Reference: http://www.lidco.com/docs/Brochure.pdf
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Interpretations:
BASELINE Cortisol
<16
NO
Second Cortisol level If the second cortisol increase from the baseline is 9
YES
No Adrenal Insufficiency
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Feeding Routes
Yes
No
Enteral Nutrition
Oral Nutrition
Parenteral Nutrition
Enteral Nutrition Formula Selection o Standard formulas Jevity 1.2 (fiber containing) or Osmolite 1.2 (no fiber) Moderate protein content, 1.2 calorie/cc standard formula Promote with fiber (higher protein content, 1 calorie/cc) Consider using with patients on propofol, use for trauma/surgery o Fluid restricted/ renal formulas: Two Cal HN, Nepro o Partially Predigested Formulas (Perative, Peptinex DT) Ordering and Administering o Once a feeding tube has been placed and confirmed for use, determine the formula type based on diagnosis, needs, and fluid status. Isotonic formula (300-500 mOsm/L) Start at 20-25 cc/hr, increase by 25 cc q 4-8 hours depending on pre-existing malnutrition, hemodynamic stability, or anticipated tolerance Hypertonic formula (>500 mOsm/L)---Start at 15-20 cc/hr, increase by 20 cc q 8 hrs depending on above factors
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Parenteral Nutrition (TPN) Peripheral Nutrition (PVN): Short term Dextrose: 10% surgical Amino Acids 4.25% or 5% fluid restriction Lipids: 500 ml 10% lipids to run over 24 hrs restricted Rate: between 75-100 cc unless FR needed Initiate: at goal rate
Central Nutrition (CVN): Dextrose: 10, 15, 20, 25, 30 or 35% Amino Acids: 4.25, 5, 6, 7.5% Lipids: 10% and 20% concentration, 250 ml or 500 ml. Lipids run over 10 hrs. Rate: Typically <100 cc/hr Initiate: 25 cc/hr, advance 25 cc q 6-8 hours until goal reached. Micronutrients/ Additives Electrolytes standard option (most pts) and electrolyte free option dependent upon individual pt needs. MVI and trace elements daily Selenium trace element formulation does not contain selenium, therefore with pt on PN >2 weeks recommend adding 40 mcg daily. Monitoring Blood glucose q 4 hours with initiation less frequently once stable Electrolytes, BUN, creatinine, Mg, and Phos daily Fluid balance concentration and rate of PN can be adjusted as needed Prealbumin weekly
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Social Work in the Surgical Intensive Care Unit The Department of Social Service provides social work contact on every inpatient unit. We provide patient and family support, and address discharge planning needs. The Surgical Intensive Care Unit has a social worker dedicated to the four SICU bays during the weekdays, 8 a.m. to 5 p.m. An on-call social worker is available at all other times. Please contact the SICU social worker when: 1. The patient has potential discharge planning needs. If you feel your patient may need inpatient rehabilitation, long-term placement for chronic care needs, or some form of home care, early social work involvement is needed to coordinate discharge planning. 2. The patient is from another acute care hospital and is expected to return there. Patients who come to UIHC for specialty care may not need to remain here for the duration of their care, particularly if the patient was transferred a long distance. 3. T h e p a ti e n t o r p a ti e n t s family is in crisis. The social worker is available when patients and families are facing difficult times and need assistance. We often coordinate with other services, including Pastoral Care, Palliative Care, and Psych Nursing when addressing these complex needs. 4. The patient or family is asking about insurance. The social worker can typically address these concerns, especially if the patient has no insurance. 5. The patient appears to have no family or next-of-kin. The social worker may be able to assist in locating family when decisions need to be made. Also, we work with the Iowa Substitute Decision Making Board when legal decision-making power needs to be established. 6. Neglect or abuse of a patient is suspected. We will assist in evaluating and reporting cases to the appropriate entities.
From 8 a.m. to 5 p.m. Monday through Friday: Page 7224 to reach Steve Cummings, LISW, ACSW O th e r ti m e s: D i a l 0 a n d a sk fo r th e o n -call social worker.
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REFERENCES: American Academy of Neurology. Practice Parameters http://aan.com/professionals/practice/pdfs/pdf_1995_thru_1998/1995 .45.1012.pdf http://www.massgeneral.org/stopstroke/pdfs/brain_death.pdf NEJM 2001 APRIL 344. NO 16. Diagnosis of Brain Death. Eelco Wijdicks.
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Practical Points in the SICU: Before doing the Apnea test. Make sure that the ETCO2 is close to 35-40 for at least 10 mins. Paging the resident/fellow on call can help set up the Nuclear medicine study in a timely manner. Speak to the SICU Staff about arterial line and central access for managing the potential donor. Sometimes the Apnea test cannot be completed and we have to go to the confirmatory test. Significant hemodynamic instability can occur during the Apnea Test.