TABLE 17-2 SYSTEM-BASED APPROACH TO THE CRITICALLY ILL PATIENT

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General Set daily goals and formulate an action plan; communicate with members of the team. Review current medications, titrate, and adjust dosages (new renal or liver failure). Elevate head of bed; assess for decubitus ulcers.

Communicate with and update patients and relatives.

Pulmonary Assess for wheezes or crackles, spontaneous respiratory rate, frequency of secretion suctioning, and need for bronchodilator therapy.

Review O2 saturation, arterial blood gas, chest films, endotracheal tube position, and chest tube placement.

Review ventilator settings, level of support, peak and plateau pressures, and auto-PEEP. Consider low tidal volume ventilation in patients with acute respiratory distress syndrome. Consider weaning trial if patient FIO2 is <50%, PEEP is ≤5 with adequate sedation level. Consider early tracheostomy for patients in whom prolonged ventilation is anticipated.

Cardiovascular Assess pulse, blood pressure, rhythm, extremity warmth, CVP, peripheral and sacral edema, and evidence of adequate perfusion (e.g., urine output, lactate).

Evaluate and adjust preload (CVP, pulmonary artery occlusion pressure), afterload, cardiac output, and ischemia.

Consider and titrate vasopressor, inotropic support, and antiarrhythmic therapy. Consider deep vein thrombosis prophylaxis.

Renal Assess weight, net fluid balance, insensible fluid losses, urine output, blood urea nitrogen, creatinine, and electrolytes.

Adjust renally excreted drugs.

Consider early nephrology consultation if dialysis is anticipated.

Consider N-acetylcysteine and hydration if radiocontrast agents will be administered.

Heme/ID Assess temperature, bleeding sites, complete blood cell count with differential, and coagulation times.

Minimize phlebotomy; establish transfusion needs.

Recognize and treat acquired vitamin K deficiency in patients. Wash your hands before and after you examine patients.

Examine site and determine duration of indwelling catheters. Can they be removed? Review cultures and antibiotic sensitivity data.

Gastrointestinal and nutritional

Assess for bowel sounds, distension, diarrhea, and constipation.

Set goals for nutrition support; consider route, rate, and composition of nutritional support. Give gastrointestinal stress ulcer prophylaxis in patients on mechanical ventilation or those with coagulopathy.

Consider the use of prokinetic and antiemetic agents.

Endocrine Consider testing and treating relative adrenal insufficiency in patients with septic shock. Consider aggressive glycemic control with insulin in critically ill patients.

Neurologic Assess neurologic status, sedation level, intracranial pressure, and occurrence of seizures. Titrate sedation and analgesic regimen to goal.

Stop sedation once daily.

Consider induction of hypothermia early after cardiac arrest. CVP, central venous pressure; PEEP, positive end-expiratory pressure.

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IV. BASIC PRINCIPLES AND SAFETY IN THE ICU

1. Computerized or paper-based protocols for complex clinical ICU problems reduce unnecessary interclinician variability and improve patient outcomes.

a. Use of a nursing- and respiratory therapy–driven weaning protocol has been shown to decrease duration of mechanical ventilation.

b. Use of a sedation protocol that incorporates a sedation scale and regular, scheduled trials of sedation withdrawal decreases duration of mechanical ventilation.

c. Use of a protocol to prevent hyperglycemia reduces mortality in surgical patients and medical patients with acute myocardial infarction.

2. Critically ill patients are vulnerable during transportation. Intrahospital and interhospital transportation should include pretransport coordination and communication, trained transport personnel, transport equipment and medications, the patient's chart, continuous monitoring, and secure IV access.[7]

3. Prevention of Complications.

a. Only patients who have a coagulopathy or who are undergoing mechanical ventilation are at significant risk for stress ulcer bleeding. In this population, H2-receptor antagonists, sucralfate, or proton pump inhibitors can be used for acid suppression.

b. For critically ill patients who are not at high risk for bleeding, venous thromboembolism prophylaxis with unfractionated heparin or low molecular weight heparin is recommended. Intermittent

compression devices with stockings can be used in patients at high risk of bleeding or who have other contraindications to heparin.

c. Nosocomial infections are 5 to 10 times more prevalent in the ICU and can significantly increase morbidity, LOS, and mortality. ICU nosocomial infections include catheter-related bloodstream infections, ventilator-associated pneumonia, urinary tract infections, and surgical or wound infections. Prevention requires a systematic approach to prevention, detection, and treatment.

(1) All team members should be familiar with infection control policies including hand washing, use of isolation precautions, and maximal barrier precautions for the insertion of indwelling catheters.

(2) Skin preparation with chlorhexidine reduces catheter-related bloodstream infections by half compared with povidone-iodine solution (see Chapters 2 and 58 ).

(3) Elevating the head of the bed 30 to 45 degrees is an effective means of preventing ventilator-associated pneumonia (see Chapter 55 ).

d. Any new, unexplained fever in the critically ill patient merits a thorough clinical assessment before laboratory and imaging studies are ordered. The initial evaluation includes the following:

(1) Two sets of blood cultures (preferably from two different peripheral sites), urinalysis, and urine cultures. Additional blood cultures should be obtained if the suspicion of bacteremia or fungemia remains high.

(2) Examination of the intravascular catheters. If there is evidence of a tunnel infection, embolic phenomena, or sepsis, the catheter should be removed, the tip cultured, and a new catheter (if needed) inserted at a different site. In the presence of unexplained fever alone, central venous catheters may be exchanged over a wire, with the subcutaneous portion sent for quantitative culture. If the culture is positive, the new catheter should be removed unless the patient has defervesced (see Chapter 58 ).

(3) If ventilator-associated pneumonia is suspected on physical examination or radiographic evaluation, obtaining cultures from lower respiratory secretions is indicated. Quantitative bronchoscopic cultures have much better sensitivity and specificity than suctioned sputum because of the high prevalence of proximal airway colonization in intubated patients (see Chapter 55 ).

(4) If diarrhea (more than two loose stools) is present, Clostridium difficile toxin should be sent. Empiric treatment with metronidazole should be considered unless two assays are negative.

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(5) Less common causes of fever include central nervous system infections and sinusitis (particularly in patients with nasogastric tubes).

V. ETHICAL ISSUES

One in five deaths in the United States occurs in an ICU. Recommendations to improve end-of-life care include the following[7]:

▪

A shared approach to end-of-life decision making involving the caregiver team and patient surrogates. Patients deserve to have their decisions guided by the judgment of their physicians and not merely receive a list of facts and options.

▪ Respect for patient autonomy and the intention to honor decisions to decline unwanted treatments should be conveyed to the family.

▪

The patient must be assured of a pain-free death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this double-effect should not detract from the primary aim to ensure comfort.

Recognition of futility is difficult for caregivers, patients, and families. Palliative care teams can be helpful in guiding families through this transition.

PEARLS AND PITFALLS

▪ Therapeutic decisions in the ICU often must be made in situations of diagnostic uncertainty and clinical instability.

▪ Phlebotomy from a critically ill patient for testing can average greater than or equal to 70 ml/day. The presence of an arterial catheter can further increase this amount by 30%.

▪ A neuromuscular blocking agent should never be used without appropriate sedation and analgesia and should be avoided, if possible, in patients on corticosteroids.

▪ The most valuable ICU monitor is an experienced, thoughtful nurse.

▪ ICU rounds at the bedside can improve outcomes. Questions that should be systematically raised include the following[8]

• Is the head of the bed elevated? • Is stress ulcer prophylaxis indicated?

• Is deep vein thrombosis prophylaxis indicated? • Is pain well controlled and sedation well titrated?

• Can the patient be weaned from mechanical ventilation? :

▪

Pharmacokinetics often are altered in critical illness, and patients typically are on many medications. Drug-patient and drug-drug interactions are responsible for many complications and should be specifically considered in the differential diagnosis of new signs or organ dysfunctions.

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REFERENCES

1. Halpern NA, Pastores SM, Greenstein RJ: Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004; 32(6):1254-1259.

2. Knaus WA, Wagner DP, Zimmerman JE, et al: Variations in mortality and length of stay in intensive care units. Ann Intern Med 1993; 118:753-761.

3. Azoulay E: Determinants of post–intensive care unit mortality: a prospective multicenter study. Crit Care Med 2003; 31(2):428-432.

4. American College of Critical Care Medicine of the Society of Critical Care Medicine : Guidelines for ICU admission, discharge, and triage. Crit Care Med 1999; 27(3):633-638.

5. Marshall JC, Cook DJ, Christou NV, et al: Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995; 10:1638-1652.

6. Pronovost P, Berenholtz S, Dorman T, et al: Improving the communication in the ICU using daily goals. J Crit Care 2003; 18(2):71-75.

7. Warren J, Fromm Jr RE, Orr RA, et al: American College of Critical Care Medicine: guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004; 32(1):256-262.

8. Thompson BT, Cox PN, Antonelli M, et al: Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care

Med 2004; 32(8):1781-1784.

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