A one day ‘basics’ of intensive care course

A Practical Introduction to Intensive Care

ICU Housekeeping

How did your 1st day on the ICU go?

Where do you start?

Does it matter?Topic Author Outcome Recommendation

Steroids in septic shock

Spring, 2008 No effect on 28d or 1 year mortalityFaster time to resoultion of shock

Steroids for those on CV support (inotropes/pressors) may reduce duration of support

Semi-recumbent positioning

Drakulovic, 1999 Reduced ventiator associated pneumonia

All mechanically ventilated patients should be 45 head up

Tight Glycaemic control

NICE-sugar investigators, 2009

Increased hypoglycaemia and mortality with tight control

Keep BM 4-10 but tight control (BM4.5-6) not recommended

Sedation holidays Kress, 2000 Reduced duration of mech ventilationReduced LOS on ICU

Daily sedation holds recommended

Topic Author Outcome Recommendations

Low tidal Volume ventilation(6mls/Kg v 12mls/Kg)

ARDSnet, 2000 Low VT associated with lower in-hospital mortality(NNT 11)

Aim for VT no greater than 6mls/Kg keeping Pplat<30 cmH2O

Transfusion Triggers Herbert, 1999 Restrictive v liberal(<7 vs <10)

Restrictive stratergy is probably better in non-cardiac patients

DVT prophylaxis(Enoxaparin 20/40mg)

Samama, 1999 Reduced DVT incidence

Prophylactic LMWH should be administered unless contraindicated

A Practical Solution …the Handover Sheet

Problem Lists: A Solution

Airway

Breathing (Ventilatory Mode)

PaO2:FiO2 Ratio

Positive End Expiratory Pressure

RR:TV Ratio

Peak Airway Pressure

Secretions

Chest X-Ray

Respiratory & Ventilation

P1: VAP? A1: Start Ceftazidime

Acute Lung Injury Acute Respiratory Distress Syndrome

ALI ARDS

<300 (mmHg) <200 (mmHg)

<40 (kPa) <27 (kPa)

P:F Ratios

PaO2 10 on 21%

≠

PaO2 10 on FiO2 100%

P:F = PaO2 / FiO2

Everything’s fine, doc

“Weanable” Not “Weanable”

RR/TV <80 RR/TV >100

Spontaneous Breathing Trial

Pressure Sup port Ventilation

RR/TV

Weaning

Cardiovascular

Rate and Rhythm

MAP

Inotrope / Vasopressor No. 1

Inotrope / Vasopressor No. 2

Steroids

Hb

Markers of PerfusionClinical – Warm Well PerfusedCentral Venous Oxygen SaturationLactateBase Deficit

Cardiovascular Numbers

MAP 65 mmHg is OK

0.5 mcg/kg/min (Adr / NAd) is A LOT

ScvO2 <70% is TOO LOW

Lactate >2 mmol/l is TOO HIGH

Base deficit < -2 is TOO MUCH

Steroids in Sepsis

ControversialPreviously shown to reduce mortality amongst

those unable to mount a steroid stress response (Synacthen)

CORTICUS study (2008): No effect on mortality but faster time to

resolution of shock (i.e. reduced inotrope/vasopressor duration).

Same for responders and non-responders thus synacthen test no longer indicated

Renal

Target Fluid Balance

Achieved Fluid Balance

Urine Output in 24hrs(= hourly urine output)

Oedema

BiochemistryNaKUreaCreatinineMagnesiumPhosphate

Fluid Balance

ControversialCrispy or Bloated?

Colloids for FillingCrystalloids for Maintenance

+500ml / day is normalAdd if febrile / diarrhoea

Subtract if oedema / bad lungs

Renal Numbers

Normal Mg2+ >0.8Give 10mmol over 1 hour

Normal PO43- > 0.8

<0.5 mmol / kg over 6 hours

Target Nutrition In

Achieved Nutrition In

Nutrition Out

Ulcer prophylaxis

BM - Glycaemia

Bilirubin

GI / Liver

Nutrition

Controversial

Starvation is bad (eventually)30ml/kg/day

TNIN ≠ ANIN?Metoclopramide

Gastric Protection

Controversial

Ranitidine / Sucralfate

Ventilator Associated Pneumonia

Glycaemic Control

NICE-SUGAR (2009)Tight (4.5-6 mmol/L) vs conventional

(4.5-10mmol/L) glycaemic control---------------------------------------------------Increased mortality and hypoglycaemic

episodes for tight control. Conventional range recommended

Bilirubin

Haemoglobin

Platelets

Clotting

DVT Prophylaxis

Haematology

Blood in Critical Care

Controversial

TRICC

Exceptions

DVT Prophylaxis

Don’t forget

Sedation Scores

Hypnotic DoseOpiate Dose

Sedation Holidays

CNS Intact?

PNS Intact?

Neuro & Sedation

Temperature

White Cell CountC-Reactive Protein

Organism Site of infection

Antibiotic 1 DayAntibiotic 2 Day

║(Lines ) Central Arterial Vascath

Micro & Sepsis