ICU PROTOCOLS

BY
DR AFIA
PROF. JODAT SALEEM
 INFECTION CONTROL PROTOCOL
• Patients requiring intensive care are highly
susceptible to infection due to
o immunosuppressive effects of drugs and
disease,
o the use of invasive monitoring techniques
o severity of the underlying illness requiring
admission.
• The use of broad-spectrum antibiotics may
predispose to infection with resistant
organisms.
• All ICU staff are responsible for ensuring
good infection control policies are adhered
to, in particular good hand hygiene practice.
• Hand Hygiene :
• Hand washing and hand disinfection remain
the most important measures in the
prevention of cross infection.
• Hands should be cleaned before and after
contact with every patient and after
manipulation of the patient environment.
• Either a 15-second handwash with soap and
water, or alternatively the waterless hand gel
may be used if hands are not visibly soiled.
• A longer handwash with antibacterial soap is
required prior to any major invasive
procedures such as insertion of central
venous catheter.
• Standard precautions are used for all
patients:
• Wear gloves for all contact with blood and
body fluids including dressings and wounds.
• Gloves must be changed between patients.
• Hands must be decontaminated after the
removal of gloves.
• Wear a disposable plastic apron or fluid-
resistant gown to protect the skin and
 clothing for procedures likely to generate
splash or cause soiling.
• Wear a mask and eye protection to protect
mucous membranes of the eyes, nose and
mouth during procedures likely to generate
splash or cause soiling.
• Ensure patient-care equipment is cleaned
and disinfected appropriately between
patient use.
• Staff who generate a sharp product (eg:
needle or blade) are responsible for its safe
disposal into an approved puncture resistant
sharps container.
• Isolation and transmission-based precautions
• In addition to standard precautions, isolation
and appropriate transmission-based
precautions are to be used with the patients
infected or colonised with Multi-resistant
organisms
• General measures
• The ICU should be kept tidy and uncluttered.
• Equipment not in use should be stored in a
clean area.
• Movement of people through the unit should
be kept to a minimum. This applies equally to
colleagues and relatives.
• All visitors are to be encouraged to wash
their hands before and after visiting the
patient.
• Staff with communicable diseases should
take sick leave.
 PERIPHERAL IV CATHETERS SOP
• Indications
• Initial IVI access for resuscitation
• Stable or convalescent patients where more
invasive access is not warranted.
• Management
• All lines placed in situations where aseptic
technique was not followed must be removed
(eg. Placement by emergency staff at the
roadside)
• Acceptable aseptic technique must be
followed including:
• Thorough hand-washing
• Skin preparation with alcohol swab
• Occlusive but transparent dressing
• All lines should be removed if not being
actively used, or if > 2 days old. An exception
may be made where venous access is
challenging (eg. paediatric patients)
• Complications
• Infection
• Thrombosis
• Extravasation
 ARTERIAL CANNULAE SOP
• Indications
o Invasive measurement of systemic blood
pressure
o Multiple blood gas sampling and laboratory
analysis
• Site and catheter choice
• 1 st choice: Radial artery
• 2 nd choice: Femoral.
• All catheters should be inserted with full sterile
technique (gown, sterile gloves, topical
antiseptic) ⋅
• The arterial line must be firmly anchored (eg.
sutured) ⋅
• The insertion site and all connectors must be
visible through the applied dressing.
• Complications
• Infection
• Thrombosis
• Digital Ischaemia
• Vessel trauma
• Fistula formation.
 GENERAL NURSING CARE SOP
• No critical care patient will be left without a
nurse in attendance.
• Each nurse will be responsible for the entire
care of his/her patient, and acts to coordinate
care with other health team professionals.
• The nurse must give a full report to another
staff nurse prior to leaving for a break.
• The staff nurse will report any changes in
his/her patient's condition directly to the
physician.
• All critical care patients will have continual
ECG monitoring.
• For a stable, non-acute patient without
invasive monitoring equipment, vital signs will
be done at least every hour.
• Temperatures will be measured on all patients
at least q4h
• All patients admitted for neurological
problems will have hourly neurological
 assessments performed using the Glasgow
Coma Scale.
• The turning of all critically ill patients every
two hours around the clock is done unless
contraindicated.
• All intensive care patients will have chest
physiotherapy q4h
• All critical care patients will have range of
motion exercises q4h unless contraindicated
(i.e. neuromuscular blockers).
• Perineal care will be done every shift .
• All Critical Care patients will have mouth care
done every four hours with inspection for oral
skin sores. Teeth will be brushed every shift
and as needed.
• All dressings unless otherwise indicated will be
changed daily.
• All patients who have not had a bowel
movement will be checked for impaction
q.3. days
• Information and emotional support needs for
the family and patient will be provided by the
nurse and physician
• The environment will be maintained in a
mechanically safe condition through: dry
floors, good repair of furniture, proper
placement of machines and equipment,
cleanliness, freedom from clutter, and good
repair of equipment.
• Labels will be affixed to: all bedside
medications, intravenous bags and bottles, all
wound or bladder irrigations, multidose vials,
multiple drainage bags/bottles, hemodynamic
transducers and monitor.
• The number of visitors will be limited to 2 at a
time; however, the nurse may use
discretion based on patient condition and
room activity
 CENTRAL VENOUS CANNULAE SOP
• Central venous catheterisation may not be
attempted by any member of staff without
adequate training or supervision.
• All staff are expected to view and familiarize
themselves with insertion techniques as
described in standard texts.
• All procedures must be performed under
conditions of strict “asepsis”.
• Where a junior member of staff is familiar with
a certain technique, they should continue to
use that technique.
• If you suspect that you have mistakenly
cannulated an artery rather than a vein, seek
assistance from the senior Registrar or duty
ICU specialist prior to removing the offending
line.
• The internal jugular route represents less risk
than subclavian in un-practised hands.
• Subclavian catheterisation may be the route of
choice from an infective risk perspective,
followed by internal jugular and then femoral.
• Avoid subclavian route in situations where
pneumothorax would be fatal. (i.e. severe
respiratory failure, lung hyperinflation).
• Avoid in patients therapeutically
anticoagulated or coagulopathic ,Platelet
count < 50 000 ,INR > 2.0 ,APTT > 50 sec
• It may be appropriate to attempt to reverse
abnormal clotting prior to insertion of a CV
catheter, however this should be discussed
with the Duty Specialist.
• Always choose side of chest that is least
effective for ventilation, or in which there is
already an intercostal catheter
• Internal Jugular approach is the route of
choice for dialysis catheter insertion, although
femoral access is also acceptable.
• The safety of jugular puncture is improved
with ultra-sound guidance.
• Routine line replacement is not required.
• Lines should be removed as soon as they are
not required any longer.
• CVC Bundle must be followed which has
following components
o hand hygiene
o maximal barrier precautions (both for the
patient and the inserter) when placing a
central line
o chlorhexidine skin antisepsis
o optimal catheter site selection (subclavian
preferred site)
o daily assessment of line necessity with
prompt removal of unnecessary line
• The checklist must be completed for EVERY
line inserted.
• If all bundle components are not followed the
checklist must reflect why.
• Nursing has the power to stop the procedure if
sterility is compromised or if components are
missed ie: hand hygiene not performed
• In a life threatening situation where the
bundle may not be fully implemented a
checklist must still be completed with patient
sticker and reason not followed.
 ENTERAL NUTRITION FEEDING SOP
• Enteral nutrition is preferable to parenteral
nutrition if adequate feeding can be achieved.
• It can be administered by a variety of routes
including oral, nasogastric, orogastric,
nasojejunal, gastrostomy, and jejunostomy
feeding tubes.
• For nasogastric or orogastric feeding, a wide
bore (14 Fr.) ‘nasogastric’ tube is inserted
• Gastrostomy feeding tubes may be placed
surgically, or via an endoscope (Percutaneous
Endoscopic Gastrostomy= PEG).
• If surgically placed, check with surgical team
prior to commencing feeds
• The position of all tubes should be confirmed
by Xray prior to feeds commencing
• The patient should be 15-30 degrees head up
the majority of the time unless there is a
contraindication to being head up (eg unstable
spine).
• The standard feed is prescribed by the
dietician. It is a mixture of blended foods and
feeding supplement
• The content is adjusted so 100mls/hour
supplies daily caloric intake.
• Commence feeding at 40mL per hour. Increase
by 20mL per hour every four hours, up to a
maximum of 100mL per hour.
• Feeding may be as continuous infusion or
hourly boluses.
• The nasogastric tube is aspirated every 4 hours
using multiple syringes if necessary.
• If the gastric aspirate is < 150mL the aspirate is
returned and feeding continues; 150 to 250mL
the aspirate is discarded and feeding
continues; > 250 ml, then feeding should be
stopped for two hours, then restarted at 40
ml/hr
• In the absence of contraindications, a gastric
aspirate > 200 ml should be treated with
 metoclopramide 10 mg IV QID, and
consideration given to adding erythromycin
250 mg IV Q8H if subsequent aspirates are >
200 ml.
• If this does not improve the problem,
consideration should be given to jejeunal
feeding.
• Enteral feeding associated diarrhoea should be
reported to a medical officer and managed as
per guideline
• Signs that a patient is not tolerating feeds
include:
o 1. Progressive abdominal distension
o 2. Reflux of significant volumes of feeds
into the stomach
• If these signs develop then stop feeding and
inform medical officer.
• Feeds should be stopped 4-6 hours prior to
planned extubation.
• In addition NG tube should be aspirated just
prior to ETT removal.
• In a patient with a definitive airway
(endotracheal tube or tracheostomy tube)
there is no indication to stop feeds before a
trip to theatre unless the intended surgery
involves manipulation of the airway or a
procedure related to the face, oropharynx or
neck
 TOTAL PARENTERAL NUTRITION SOP
• TPN should not be started in ICU unless this
has been discussed with the ICU consultant
and surgical team.
• ICU TPN administration regimen will give
approximately 25-30 kCal/kg/24 hours of non-
protein energy, and 1.5g amino acids/kg/24
hours ( =0.2 grams nitrogen/kg/day).
• TPN should be infused via a dedicated lumen
on a central venous catheter.
• TPN can be infused with insulin and intralipid.
TPN prescription involves reviewing the
available solutions and prescribing the correct
volume of these to achieve:
o Target calories as above (usually
carbohydrate: lipids ratio 60-70%;30-40%)
o 1.5 g amino acids/kg/24 hours as above.
o Maintenance water 1.5mls/kg/hr and
electrolytes (Na 1-2mmol/kg/day, K+ 0.5-
1mmol/kg/day, Magnesium and calcium)
 achieved but not exceeded (may need
additional crystalloid solution if large fluids
requirement)
o Vitamins and trace element requirements
met (usually separate prescription needed)
• Clinical situations that may require adjustment
of the standard ICU TPN regimen include renal
failure, hepatic failure, cardiac failure, volume
overload.
• While on TPN, blood glucose should be
measured at least 4 hourly as per Insulin
Protocol.
• Daily blood tests should include an LFTs, full
blood count and coagulation profile.
• Re-feeding syndrome can occur after
prolonged starvation and may cause severe
hypokalaemia, hypomagnesaemia ,
hypophosphataemia and rarely Wernicke’s
encephalopathy.
• If the patient is at risk TPN must be
commenced more slowly with careful
monitoring.
• Patients with large ongoing GI losses such as
diarrhoea or fistulas should receive additional
zinc; 10 mg for each litre of intestinal fluid lost
 DVT AND PE PROPHYLAXIS SOP
• All patients in ICU should be assessed for
venous thromboembolism (DVT/PE) risk on
admission and have appropriate thrombo-
prophylaxis.
• All ICU patients should be considered
moderate to high risk
• All patients in ICU should have TED stockings
or if available sequential calf compression
devices applied on admission.
• Contraindications to the application of TED
stockings and sequential compression devices
are:
o lower limb ischemia or advanced
peripheral vascular disease
o lower limb injury, wound or ulcer.
o If unilateral, TED can be used on the
uninjured limb.
• Established DVT is a contraindication to
sequential compression devices but not to TED
stockings.
• In addition to mechanical prophylaxis, all
patients in ICU should have pharmacological
prophylaxis unless there are specific
contraindications.
• Subcutaneous Heparin 5000u bd is indicated
for elective surgical postoperative patients
having a short stay in ICU.
• Subcutaneous Heparin 5000u tds is indicated
for the remainder of ICU patients.
• For ICU patients having surgical procedures,
subcutaneous heparin should be continued on
the morning of surgery except for specific
high-risk procedures (eg spinal /
neurosurgery).
• Heparin should be withheld 6hr prior to
removal of epidural catheter.
• Use of heparin prior to percutaneous
tracheostomy is at consultant discretion.
• Subcutaneous Enoxaparin 40mg daily is the
preferred alternative to subcutaneous heparin
for:
o patients who have had elective hip or knee
surgery
o patients with spinal cord injury in the post-
acute period (following definitive
stabilisation).
o patients with lower limb or pelvic fracture,
but risk of bleeding from other injuries
must be taken into consideration.
• Use of enoxaparin should involve input from
the ICU consultant and relevant surgical
teams.
• Enoxaparin should not be used in patients with
renal impairment.
 ARDS SOP
• INCLUSION CRITERIA
• Acute onset of
o 1. PaO2/FiO2 ≤ 300 (corrected for altitude)
o 2. Bilateral (patchy, diffuse, or
homogeneous) infiltrates consistent with
pulmonary edema
o 3. No clinical evidence of left atrial
hypertension
• VENTILATOR SETUP AND ADJUSTMENT
✓ 1. Calculate predicted body weight (PBW)
• Males = 50 + 2.3 [height (inches) -
60]
• Females = 45.5 + 2.3 [height
(inches) -60]
✓ 2. Select any ventilator mode
✓ 3. Set ventilator settings to achieve initial
VT = 8 ml/kg PBW
✓ 4. Reduce VT by 1 ml/kg at intervals ≤ 2
hours until VT = 6ml/kg PBW.
✓ 5. Set initial rate to approximate baseline
minute ventilation (not > 35 bpm).
✓ 6. Adjust VT and RR to achieve pH and
plateau pressure goals below
• OXYGENATION GOAL:
o PaO2 55-80 mmHg or SpO2 88-95%
o Use a minimum PEEP of 5 cm H2O.
o Consider use of incremental FiO2/PEEP
combinations to achieve goal.
• PLATEAU PRESSURE GOAL: ≤ 30 cm H2O
• Check Pplat (0.5 second inspiratory pause), at
least q 4h and after each change in PEEP or
VT.
o If Pplat > 30 cm H2O: decrease VT by
1ml/kg steps (minimum = 4 ml/kg).
o If Pplat < 25 cm H2O and VT< 6 ml/kg,
increase VT by 1 ml/kg until Pplat > 25 cm
H2O or VT = 6 ml/kg.
o If Pplat < 30 and breath stacking or dys-
synchrony occurs: may increase VT in
 1ml/kg increments to 7 or 8 ml/kg if Pplat
remains < 30 cm H2O.
• pH GOAL: 7.30-7.45
❖ Acidosis Management: (pH < 7.30)
o If pH 7.15-7.30: Increase RR until pH > 7.30
or PaCO2 < 25 (Maximum set RR = 35). .
o If pH < 7.15: Increase RR to 35.
o If pH remains < 7.15, VT may be increased
in 1 ml/kg steps until pH > 7.15 (Pplat
target of 30 may be exceeded). May give
NaHCO3
❖ Alkalosis Management: (pH > 7.45)
Decrease vent rate if possible.
 MECHANICAL VENTILATION
WEANING/EXTUBATION SOP
• Trial Criteria
• FiO2 < 0.4 with pO2 > 60 and PEEP < 8
• The patient can take spontaneous breaths over
the vent with RR < 20
• SBP > 90 without pressors
• The initial indication for intubation is resolving
• Extubation criteria
• Minute ventilation < 10 L/min.
• Rapid Shallow Breathing Index: spontaneous
RR ÷ TV in L < 105
• Dead space < 50%.
• MIF (maximal inspiratory force) < – 20 (the
more negative, the better)
• Failure to wean:
o F Fluid overload …diurese if indicated.
o A Airway resistance check endotracheal
tube; is it obstructed or too small?
o I Infection ..treat as indicated.
o L Lying down, bad V/Q mismatch ..elevate
head of bed.
o T Thyroid, toxicity of drugs .. check TFT’s,
check med list.
o O Oxygen ..increase FiO2 as patient is
taken off ventilator.
o W Wheezing ..treat with nebs.
o E Electrolytes, eating .. correct
K/Mg/PO4/Ca; provide adequate nutrition.
o A Anti-inflammatory needed? .. consider
steroids in asthma/COPD.
o N Neuromuscular disease, neuro status
compromised .. think of myasthenia
gravis, ALS, steroid/paralytic neuropathy,
etc; assure that patient is in fact awake and
alert.
 SEPSIS SOP
• The ‘Surviving Sepsis Campaign’ (SSC) has
produced evidence based guidelines on
management of severe cases.
• TO BE COMPLETED WITHIN 3 HOURS OF TIME
OF PRESENTATION
o Measure lactate level
o Obtain blood cultures prior to
administration of antibiotics
o Administer broad spectrum antibiotics
o Administer 30ml/kg crystalloid for
hypotension or lactate ≥4mmol/L
• TO BE COMPLETED WITHIN 6 HOURS OF TIME
OF PRESENTATION:
o Apply vasopressors (for hypotension that
does not respond to initial fluid
resuscitation) to maintain a mean arterial
pressure (MAP) ≥65mmHg
o In the event of persistent hypotension
after initial fluid administration (MAP < 65
 mm Hg) or if initial lactate was ≥4 mmol/L,
re-assess volume status and tissue
perfusion
o Re-measure lactate if initial lactate
elevated.
• DOCUMENT REASSESSMENT OF VOLUME
STATUS AND TISSUE PERFUSION WITH: EITHER
• Repeat focused exam (after initial fluid
resuscitation) by licensed independent
practitioner including vital signs,
cardiopulmonary, capillary refill, pulse, and
skin findings.
• OR TWO OF THE FOLLOWING:
o Measure CVP
o Measure ScvO2
o Bedside cardiovascular ultrasound
o Dynamic assessment of fluid
responsiveness with passive leg raise or
fluid challenge
SIGNIFICANT CHANGES IN NEW GUIDELINES
• Fluid Resuscitation
• Initial fluid resuscitation
o Unchanged from 2012 guidelines
o 30ml/kg of IV crystalloid fluid (normal
saline or balanced salt solution) within the
first 3 hours of sepsis presentation.
o Patients may require greater volumes of
fluid as guided by frequent reassessment
of volume responsiveness.
o Consider 4% albumin in refractory
hypotension.
• Static fluid status measurements (i.e. Central
Venous Pressure)
o No longer recommended as lone guiding
principles as they carry limited value for
measuring fluid responsiveness
o 2017 guidelines recommend the use of
dynamic variables over static variables to
predict fluid responsiveness (ie passive leg
 raise, pulse pressure variation, stroke
volume variation)
• Weak suggestion to guide resuscitation to
normal lactate
o Use clinical judgement. For instance, if
patient has adequate BP and urine output
and is down-titrating vasopressors, but has
a persistently elevated lactate, additional
fluid carries the risk of over-resuscitation.
• Antibiotics
o First priority is source control and
obtaining cultures. Cultures should be
obtained prior to administration of
antibiotics when feasible
o Give antibiotics within 1 hour of
identification of septic shock
o Antibiotic Regimen
o Begin with broad spectrum coverage when
the potential pathogen is not immediately
obvious
 o Narrow once pathogen identification and
sensitivities are established
o Vancomycin
▪ Goal to achieve a trough of 15-20mg/L
▪ IV loading dose of 25-30mg/kg in septic
shock
o For β-lactams, achieve higher Time-
Dependent Killing (T>MIC) by increasing
frequency of dosing
o Fluoroquinolones should be given at their
optimal nontoxic dose
o Aminoglycosides should be dosed using
once-daily dosing
o Average duration: 7-10 days is
recommended in most patients
• Consider using procalcitonin to guide de-
escalation of antibiotics
• Other:
• Vasopressors
• Useful in patients who remain hypotensive
despite adequate fluid resuscitation
• Target mean arterial pressure (MAP) of
65mmHg
• First line vasopressor: norepinephrine
o Dose: start 2-12 mcg/min (no true
maximum dose)
• Administer vasopressin (up to 0.03) and
epinephrine as add-on therapies if not at
target MAP or to decrease norepinephrine
dose
• Consider inotropes in low cardiac output
states i.e. septic cardiomyopathy, which can be
common in these patients
• Steroids
• Indicated for patients with septic shock in
which fluids and vasopressors fail to achieve
hemodynamic stability
• Transfusion indicated in majority of patients
only when hemoglobin <7.0g/dL
• Target glucose <180mg/dL
• Bicarb not recommended when pH>7.15
• Mechanical Ventilation (unchanged from 2012
guidelines)
• Lung Protective Ventilation Strategy
o Target a tidal volume of 6mL/kg of ideal
body weight
o Plateau pressure of <30cm H20
o PEEP: increase with FiO2 as per ARDS net
protocol
o Recommend prone over supine position in
patients with sepsis-induced ARDS and
Pa/Fio2 ratio<150
o Recommendation against high frequency
oscillatory ventilation/lung protective
ventilation