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![• In the study of Balzer et al.[17] 1,884 patients receiving
mechanical ventilation were grouped as either lightly or
deeply sedated (light sedation: RASS −2 to 0; deep: RASS −3
or below). Deep sedation (27.2%, n = 513) was associated with
an in-hospital mortality hazard ratio of 1.661 (95% CI: 1.074 to
2.567; p = 0.022) and a two-year hazard ratio of 1.866 (95%
CI: 1.351 to 2.576; p < 0.001).
• In summary, deeply sedated patients had longer ventilation
times, increased length of stay and higher rates of mortality.
According to the results of these studies, early deep sedation is
a modifiable risk factor and that the implementation of
sedation protocols to achieve light sedation is feasible and
reproducible in the early phase of ICU treatment.
8/11/2023 A.T.M 17](https://image.slidesharecdn.com/icucarebundlesashenafi-230811160124-5777c3a5/75/ICU-Care-Bundles-Ashenafi-pptx-17-2048.jpg)
![• Delirium prophylaxis with medications is discouraged in the PAD guidelines.
• Recently, a prospective, randomized, multicenter trial compared a low-dose
haloperidol infusion administered for 12 hours (0.5 mg intravenous bolus injection
followed by continuous infusion at a rate of 0.1 mg/h, n=229 patients) against
placebo (n = 228 patients) in the immediate postoperative period. This study
provided evidence that haloperidol could reduce the incidence of delirium within
the first 7 days postoperatively in patients undergone noncardiac surgery (15.3% in
the haloperidol group versus 23.2% in the control group, p=.031).
• By contrast, another ICU study showed no benefit of early administration of
intravenous haloperidol in a mixed population of medical and surgical adult ICU
patients. In this double-blinded, placebo-controlled randomized trial, 142 patients
were randomized to receive haloperidol or placebo intravenously every 8 hours
irrespective of coma or delirium status. Patients in the haloperidol group spent
about the same number of days alive, without delirium or coma, as did patients in
the placebo group (median 5 days [IQR 0–10] versus 6 days [0–11] days; p=0.53)
8/11/2023 A.T.M 47](https://image.slidesharecdn.com/icucarebundlesashenafi-230811160124-5777c3a5/75/ICU-Care-Bundles-Ashenafi-pptx-47-2048.jpg)
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ICU Care Bundles Ashenafi.pptx
- 1. SEMINAR PRESENTATION ON BASICSOF ICU CARE BUNDLES By DR. Ashenafi T.(IMR1) MODERATOR—Dr AMAN (assistant professor in anesthesiology , and critical care and pain medicine) DEC 2021 8/11/2023 A.T.M 1
- 2. Outline ⇰Introduction ⇰ABCDEF bundle ⇰Septic bundle ⇰VAPbundle ⇰Central line insertion bundle ⇰References 8/11/2023 2 A.T.M
- 3. Introduction A care bundleor evidence-based practice protocol is a grouping of care elements for a particular symptom, procedure or treatment (Lagan, 2003). 8/11/2023 A.T.M 3
- 4.
- 5. ABCDEF Bundle Objectives Optimizepain management. Break the cycle of deep sedation and prolonged mechanical ventilation. Reduce the incidence and duration of ICU delirium. Improve short and long-term ICU patient outcomes. Reduce health care costs! 8/11/2023 A.T.M 5
- 6.
- 7. Implementation of theABCDE Bundle to Improve Patient Outcomes in the Intensive Care Unit in a Rural Community Hospital 8/11/2023 A.T.M 7
- 8. A: Assess, Prevent,and Manage Pain Assessment of pain Numerical rating scale (NRS) Behavioral Pain Scale (BPS) Critical-Care Pain Observation Tool (CPOT) Pain medications should be routinely administered in the presence of significant pain and prior to performing painful invasive procedures. 8/11/2023 A.T.M 8
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- 13. Managing pain ♣Parenteral opioidsare considered as the first-line drug of choice for non- neuropathic pain. ♣Non-opioid analgesics considered to decrease the amount of opioids administered, and to decrease opioid related side effects. 8/11/2023 A.T.M 13
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- 16. B: Both SpontaneousAwakening Trials (SAT) and Spontaneous Breathing Trials (SBT) Deep sedation in the first 48 hours of an ICU stay has been associated with Delayed time to extubation, Higher need for tracheostomy, Increased risk of hospital and Long term death. 8/11/2023 A.T.M 16
- 17. • In thestudy of Balzer et al.[17] 1,884 patients receiving mechanical ventilation were grouped as either lightly or deeply sedated (light sedation: RASS −2 to 0; deep: RASS −3 or below). Deep sedation (27.2%, n = 513) was associated with an in-hospital mortality hazard ratio of 1.661 (95% CI: 1.074 to 2.567; p = 0.022) and a two-year hazard ratio of 1.866 (95% CI: 1.351 to 2.576; p < 0.001). • In summary, deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. According to the results of these studies, early deep sedation is a modifiable risk factor and that the implementation of sedation protocols to achieve light sedation is feasible and reproducible in the early phase of ICU treatment. 8/11/2023 A.T.M 17
- 18. ABC TRIAL • Numerousrandomized trials support the use of ventilator weaning protocols that include daily SBTs as their centerpiece. • Girard et al.undertook the Awakening and Breathing Controlled (ABC) trial, a multicenter, RCT to assess the efficacy and safety of a protocol of daily SATs paired with SBTs (intervention group, n = 168) versus a standard SBT protocol in patients receiving patient-targeted sedation as part of usual care (control group, n = 168). • Patients in the intervention group (both SAT and SBT) spent more days breathing without assistance during the 28-day study period (14.7 days versus 11.6 days; mean difference 3.1 days, 95% CI: 0.7-5.6, p = 0.02) and were discharged earlier from the ICU (median time in ICU of 9.1 days versus 12.9 days, p = 0.01) and earlier from the hospital (median hospital time 14.9 days versus 19.2 days, p = 0.04).During the year after enrollment, patients receiving SATs with SBTs (intervention) were less likely to die than were patients receiving only SBTs (control) (hazard ratio = 0.68, 95% CI: 0.50- 0.92, p = 0.01). 8/11/2023 A.T.M 18
- 19. • No sedationhas also been applied as a strategy in ICU patients. • Strøm et al. enrolled 140 critically ill adult patients who were undergoing mechanical ventilation and were expected to need ventilation for more than one day. Patients were randomly assigned in a 1:1 ratio (unblinded) to receive no sedation (n=70 patients) or sedation (n=70, control group). Patients receiving no sedation had significantly more days without ventilation (mean 13.8 days, SD 11.0 vs mean 9.6 days, SD 10.0; mean difference 4.2 days, 95%: CI 0.3– 8·1. p=0.0191) in a 28-day period, and reduced stays in the ICU and hospital. This study did find increased hyperactive delirium in the group receiving no sedation. 8/11/2023 A.T.M 19
- 20.
- 21.
- 22. A—Daily Sedation InterruptionDecreases Duration of Mechanical Ventilation Hold sedation infusion until patient awake, then restart at 50% of prior dose “Awake” defined as any 3 of the following: • Open eyes in response to voice • Use eyes to follow investigator on request • Squeeze hand on request • Stick out tongue on request 8/11/2023 A.T.M 22
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- 27. PAD Depth ofSedation Recommendations ♫ We recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation in adult ICU patients, unless clinically contraindicated. ♫We recommend that either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients. 8/11/2023 A.T.M 27
- 28. SAT/SBT Outcomes Summary ♫Decreaseddays of mechanical ventilation ♫Reduced weaning time ♫Reduced reintubation rates ♫Fewer days with delirium ♫Decreased length of ICU stay ♫Decreased length of hospital stay 8/11/2023 A.T.M 28
- 29. C: Choice ofSedation and Analgesia • Choice of sedation is crucial to patients’ clinical outcomes. • Psychoactive medication administration should be goal-directed to ensure adequate pain control, anxiolysis, and prevention and treatment of delirium. • Benzodiazepines vs Dexmedetomidine 8/11/2023 A.T.M 29
- 30. Choice of Sedationand Analgesia All ICU patients should be routinely assessed for: Pain (Likert self-report, or BPS/CPOT non-self-report) Agitation/depth of sedation (RASS/SAS) Delirium (CAM-ICU/ICDSC) Important factors influence the choice and dose of analgesia and sedative medications Non-pharmacologic strategies play an important role when managing pain and agitation 8/11/2023 A.T.M 30
- 31. Agitation ♣ Avoid deepsedation/coma: Sedative medications should be titrated to maintain lighter levels of sedation, unless clinically contraindicated. Use daily awakening or a titrated sedation strategy to maintain patient wakefulness. ♣ Choice of sedative: Non-benzodiazepines may be preferred over benzodiazepines to improve clinical outcomes in mechanically ventilated ICU patients. ♣ Reduction in sedation requirements: Use of an analgesia-first (i.e., analog-sedation) strategy is recommended in mechanically ventilated patients. 8/11/2023 A.T.M 31
- 32.
- 33. RASS AND SAS 8/11/2023A.T.M 33
- 34. D: Delirium Assessment,Prevention, and Management • Delirium is a disturbance in attention and awareness that develops over a short period of time, hours to days, and fluctuates over time. • Acute disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that fluctuates over time.(DSM 5th Edition) • Delirium is prevalent, under-recognized, and an independent predictor of poor outcomes such as mortality, prolonged mechanical ventilation, increased length of hospital stay, and long-term cognitive impairment. 8/11/2023 A.T.M 34
- 35.
- 36. Delirium: Long-Term Outcomes Mortality ⇰Eachday of delirium in the ICU increases the hazard of 1-year mortality by 10% Cognitive Impairment ⇰ICU delirium is an independent risk factor for long-term cognitive impairment ⇰34% with scores similar to moderate TBI ⇰24% with scores similar to mild Alzheimer disease 8/11/2023 A.T.M 36
- 37. Delirium Assessment ICDSC andCAM-ICU The CAM-ICU is composed by four features 1) acute onset of mental status changes or fluctuating course; 2) inattention; 3) disorganized thinking; and 4) altered level of consciousness. 8/11/2023 A.T.M 37
- 38. Delirium can becategorized into subtypes according to psychomotor behavior. ♣ Hyperactive delirium (CAM positive, RASS positive range) is associated with a better overall prognosis and it is characterized by agitation, restlessness, and emotional lability. ♣ Hypoactive delirium (CAM positive, RASS negative range), which is very common and often more deleterious in the long term, is characterized by decreased responsiveness, withdrawal, and apathy and remains unrecognized in 66 to 84% of hospitalized patients. Another categorization based on the ICDSC score assigns patients ♣ No delirium, ♣ Clinical delirium, and ♣ Subsyndromal delirium. 8/11/2023 A.T.M 38
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- 41.
- 42. Intensive Care DeliriumScreening Checklist (ICDSC)
- 46. Prevention and riskfactors • The only strategy strongly recommended in the PAD Guidelines, to reduce the incidence and duration of ICU delirium and to improve functional outcomes, is promoting sleep hygiene to prevent sleep disruption and the use of early and progressive mobilization and in these patients. 8/11/2023 A.T.M 46
- 47. • Delirium prophylaxiswith medications is discouraged in the PAD guidelines. • Recently, a prospective, randomized, multicenter trial compared a low-dose haloperidol infusion administered for 12 hours (0.5 mg intravenous bolus injection followed by continuous infusion at a rate of 0.1 mg/h, n=229 patients) against placebo (n = 228 patients) in the immediate postoperative period. This study provided evidence that haloperidol could reduce the incidence of delirium within the first 7 days postoperatively in patients undergone noncardiac surgery (15.3% in the haloperidol group versus 23.2% in the control group, p=.031). • By contrast, another ICU study showed no benefit of early administration of intravenous haloperidol in a mixed population of medical and surgical adult ICU patients. In this double-blinded, placebo-controlled randomized trial, 142 patients were randomized to receive haloperidol or placebo intravenously every 8 hours irrespective of coma or delirium status. Patients in the haloperidol group spent about the same number of days alive, without delirium or coma, as did patients in the placebo group (median 5 days [IQR 0–10] versus 6 days [0–11] days; p=0.53) 8/11/2023 A.T.M 47
- 48.
- 49. “Brain road map” Perhapsthe most important element of delirium management in the ICU setting involves communication among the team. To that end, many ICU teams now present on rounds using the “brain road map,” which is a set of data containing 3 elements. At each bedside, the nurse (or another team member such as an intern or a pharmacist) will present the patient’s ⇰ (1)target RASS or SAS; ⇰ (2) actual RASS or SAS, CAM-ICU, or ICDSC result; and ⇰ (3) sedatives and narcotics received. This helps the team discuss the patient’s cognitive status, compare it with the patient’s desired cognitive status for that day, determine adjustments needed, and then explore the causes of delirium if the patient is CAM-ICU or ICDSC positive that day (using, for example, the Dr. DRE tool shown in Fig. 3). 8/11/2023 A.T.M 49
- 50. E: Early Mobilityand Exercise • Early mobility is an integral part of the ABCDEF bundle and has been the only intervention resulting in a decrease in days of delirium. • The consequence of physical dysfunction in critically ill patients can be profound and long-term with significant reduction in functional status being observed even 1 year and 5 years after ICU discharge. • Physical therapy has shown to be feasible, safe, even in the most complicated patients receiving the most advanced medical therapies (e.g., continuous renal replacement therapy, extracorporeal cardiopulmonary support). • Early activity can be done without increases in usual ICU staffing and with a low risk (< 1%) of complications. Schweickert et al. Showed that a daily SAT combined with physical and occupational therapy, versus SAT alone, resulted in an improved return to independent functional status at hospital discharge, shorter duration of ICU-delirium, higher survival, and more days breathing without assistance. 8/11/2023 A.T.M 50
- 51. • During ICUstay critically ill patients can lose up to 25% peripheral muscle weakness within 4 days when mechanically ventilated and 18% in body weight by the time of discharge and this process is higher in the first 2–3 weeks of immobilization. • The consequence of physical dysfunction in critically ill patients can be profound and long-term with significant reduction in functional status being observed even 1 year and 5 years after ICU discharge. 8/11/2023 A.T.M 51
- 52. ICU-acquired weakness, ♥ thedrugs used during its management, and ♥ the consequences of protracted immobility. The diagnosis of ICU-acquired weakness is made by the Medical Research Council (MRC) scale for grading the strength. The scale ranges from 0 (complete tetraplegia) to 60 (normal muscle strength), with a score < 48 is diagnostic of ICU- acquired weakness. Patients with ICU-acquired weakness should undergo serial evaluations, and if persistent deficits are noted, electrophysiological studies, muscle biopsy, or both are warranted 8/11/2023 A.T.M 52
- 53. • Physical therapyhas shown to be feasible, safe, even in the most complicated patients receiving the most advanced medical therapies (e.g., continuous renal replacement therapy, extracorporeal cardiopulmonary support). Early activity can be done without increases in usual ICU staffing and with a low risk (<1%) of complications. Studying patients early in the their course of mechanical ventilation (<3 days), Schweickert et al. showed that a daily SAT combined with physical and occupational therapy, versus SAT alone, resulted in an improved return to independent functional status at hospital discharge, shorter duration of ICU-delirium, higher survival, and more days breathing without assistance. • However, in a study where ICU patients were enrolled 4 days after the initiation of mechanical ventilation (average 8 days), an intensive physical therapy program did not improve long-term physical functioning when compared to a standard of care program. 8/11/2023 A.T.M 53
- 54. F: Family Communicationand Involvement • The ABCDE bundle has evolved to include Family Engagement, as no ICU treatment plan is complete without incorporation of the family’s wishes, concerns, questions, and participation. • Family members should be educated about delirium and its potential deleterious effects on the patient (post-traumatic stress disorder, depression, cognitive impairment) upon discharge from the hospital. Family members themselves may also suffer long-term psychological complications such as anxiety, depression, and posttraumatic stress disorder, commonly persisting for years. 8/11/2023 A.T.M 54
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- 58. Use of subglotticsecretion drainage • Secretions are potentially able to bypass the ETT cuff, especially when it is deflated. Secretions that pool above the ETT but below the vocal cords are a potential source of pathogens that could cause VAP. Since conventional suction methods cannot access this area, ETT tubes that have a designated suction catheter for this space allows this pool to be drained. The benefits of subglottic secretion drainage (SSD) have been analysed in three meta-analyses with a consistent signal of a reduction in VAP and ICU length of stay 8/11/2023 A.T.M 58
- 59. • Cuff pressures Micro-aspirationcan be reduced by maintaining an endotracheal tube cuff pressure between 20 - 30 cmH2O5. Based on recent recommendations, cuff pressure should be checked and adjusted around 25 cmH2O, at least 4 hourly. It is noted that individual assessment is required as there will be cases where a patient’s clinical condition and ventilation may require higher pressures - the rationale for this decision must be documented and the position reviewed as a minimum daily. 8/11/2023 A.T.M 59
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- 81. Central Line Insertion Bundle •CVCs are the leading cause of device-related bacteraemia or catheter related blood stream infection (CRBSI), which are a major cause of morbidity, increased severity of illness and prolonged hospital stay. • Intravascular catheterization is a cornerstone of medical management of the critically ill patient. • BSIs may be either primary or secondary. 8/11/2023 A.T.M 81
- 82. EPIDEMIOLOGY • the incidenceof CR-BSI associated with central lines among patients hospitalized in intensive care units (ICUs) in the United States decreased from 3.64 to 1.65 infections per 1000 central line days between 2001 and 2009. These decreases in the United States have continued through 2015 and appear to be sustained. 8/11/2023 A.T.M 82
- 83. RISK FACTORS • Hostfactors – Chronic illness – Bone marrow transplantation – Immune deficiency, especially neutropenia – Malnutrition – Total parenteral nutrition administration – Previous BSI – Extremes of age – Loss of skin integrity, as with burns Catheter factors – Duration of catheterization – Type of catheter material – Conditions of insertion – Catheter-site care – Skill of the catheter inserter 8/11/2023 A.T.M 83
- 84. Central Line InsertionBundle Insertion Checklist and Documentation Hand Hygiene and Maximal Barrier Precautions Catheter Site Selection Skin Antisepsis Dressing 8/11/2023 A.T.M 84
- 85.
- 86. Catheter Site Selection •The location of CVCs is also important. Catheter-related infection is generally more common with catheters in the femoral and, probably to a lesser degree, internal jugular veins compared with the subclavian vein. • meta-analysis of nine observational studies which included ICU patients with short-term CVC placement. – The pooled catheter-associated infection rate was lower with nontunneled subclavian catheters (1.3 events per 1000 catheter-days) than either internal jugular or femoral catheters (2.6 and 3.6 events per 1000 catheter-days, respectively) 8/11/2023 A.T.M 86
- 87. • In othertrial in which 289 patients were randomly assigned to either the femoral or subclavian sites for central venous catheter placement, – femoral catheterization was associated with a significant increase in overall infection (20 versus 3.7 per 1000 catheter- days), clinical sepsis with or without documented bloodstream infection (4.5 versus 1.2 per 1000 catheter-days), and thrombotic complications 8/11/2023 A.T.M 87
- 88. SITE CARE • Useof antiseptic solution for skin disinfection at the catheter insertion site helps prevent catheter-related infection. • Chlorhexidine-based solutions (>0.5% chlorhexidine preparation with alcohol) are superior to both aqueous and alcohol-based povidone-iodine in reducing the risk for catheter colonization and catheter-related bloodstream infection. • This was illustrated in a meta-analysis of eight randomized trials including 4143 catheter insertions; disinfection with chlorhexidine rather than aqueous povidone-iodine resulted in a 50 percent reduction in catheter-associated bloodstream infections 8/11/2023 A.T.M 88
- 89. Sterile technique ♫Attention tosterile technique is important for minimizing catheter-associated infection. ♫This includes strict adherence to hand washing and aseptic technique and, with central venous catheter (CVC) insertion, sterile gloves, long- sleeved surgical gown, a surgical mask, and a large sterile sheet drape. ♫2006 report of intensive care units in 10 academic tertiary-care hospitals found that less than 30 percent had adopted maximal barrier precautions. 8/11/2023 A.T.M 89
- 90. The effectiveness ofeducating clinicians in- training on infection control practices and procedures was evaluated in a nonrandomized pre-post observational trial of insertion of CVCs. Six months after a one-day course, the perceived need for and documented use of full-size sterile drapes increased from 22 to 73 percent and from 44 to 65 percent, respectively, while the rate of catheter-associated bloodstream infections decreased from 3.3 to 2.4 per 1000 central line days. 8/11/2023 A.T.M 90
- 91.
Editor's Notes
- #4 • The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcome ‘‘Evidence Based Bundle’’ of care, a concept developed by the Institute for Healthcare Improvement(IHI) usually involves 3–5 structured interventions based on scientific evidence, which when carried out consistently improve patient outcomes The care bundle concept was identified initially in the US and introduced into the UK in the summer of 2002. The original underpinning work was carried out at The Johns Hopkins University by Berenholtz et al.(2002). They reviewed 35 years' worth of critical care literature (1965–2000) and critically analysed the strength of evidence of interventions that could prevent avoidable morbidity and mortality in intensive care.
- #7 In addition to HAI, much attention has now been shifted to delirium and sedation practices in ICUs, with recent data showing the untoward effects of delirium with regards to increased ICU lengths of stay, costs, mortality and long-term cognitive impairment, and the realization that our sedation practices may in part contribute to this delirium
- #8 Implementation of the ABCDE Bundle to Improve Patient O u t c o m e s i n t h e I n t e n s i v e Care Unit in a Rural C o m m u n i t y H o s p i t a l
- #9 Because of the high interrelation between delirium and pain, assessing and treating pain could be important in the prevention and/or management of delirium. ICU patients commonly experience pain, with an incidence of up to 50% in surgical and medical patients. It is a major clinical symptom that requires systematic diagnosis and treatment. Assessment of pain is the first step before administering pain relief. Pain assessments are often only performed 35% of the time before ICU procedures. Patient's self-report of pain using a 1–10 numerical rating scale (NRS) is considered the gold standard and is highly recommended by many critical care societies. In the absence of a patient’s self-report, observable behavioral and physiological indicators become important indices for the assessment of pain. The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for ICU patients unable to communicate (Figure 2). The BPS is composed of 3 subscales: facial expression, movement of the upper limbs, and compliance with mechanical ventilation (MV). Each subscale is scored from 1 (no response) to 4 (full response). A BPS score of 5 or higher is considered to reflect unacceptable pain. The CPOT has 4 components: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. Each component is scored from 0 to 2 with a possible total score ranging from 0 to 8. A CPOT ≥ 3 is indicative of significant pain. Both the BPS and the CPOT provide guidance for the selection of pharmacological interventions for pain and in the evaluation of their effectiveness
- #14 Certain classes of opioids are probably best avoided in older patients and others prone to delirium. Meperidine in particular, has been shown in multiple prospective studies to increase the risk for delirium [13-15]. Parenteral opioids are first-line pharmacologic agents for treating non-neuropathic pain in critically ill patients. All opioids have the potential to induce tolerance over time, resulting in the need for escalating doses to achieve the same analgesic effect. For the treatment of neuropathic pain in ICU patient gabapentin or carbamazepine should be administered enterally, in addition to opioids. Non-opioid analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs, or ketamine, should be used as adjunctive pain medications to reduce opioid requirements and opioid-related side effects ill. Use of regional analgesia in ICU patients is limited to the use of epidural analgesia in specific subpopulations of surgical patients, and in patients with traumatic rib fractures. In managing pain in the ICU, non-pharmacological methods are often effective and safe (e.g., injury stabilization, patient repositioning, use of heat/cold) All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective. Either enterally administered gabapentin or carbamazepine, in addition to IV opioids considered for neuropathic pain
- #15 Non-opioid analgesics considered to decrease the amount of opioids administered (or to eliminate the need for IV opioids altogether), and to decrease opioid related side effects (+2C). • Either enterally administered gabapentin or carbamazepine, in addition to IV opioids considered for neuropathic pain Parenteral opioids are first-line pharmacologic agents for treating non-neuropathic pain in critically ill patients. The use of nonopioid medications should be used where possible, as these are less likely to aggravate delirium. Clinicians must balance the benefits of using opioids to treat significant pain with the potential for an opioid-related delirium. Non-opioid analgesics Certain classes of opioids are probably best avoided in older patients and others prone to delirium Either enterally administered gabapentin or carbamazepine, in addition to IV opioids considered for neuropathic pain
- #17 There is a consistent relationship between deeper sedation and worse ICU outcomes. Deep sedation in the first 48 hours of an ICU stay has been associated with
- #30 the 2013 PAD guidelines emphasize the need for goal-directed delivery of psychoactive medications to avoid over-sedation, to promote earlier extubation, and to help the medical team agree on a target sedation level by using sedation scales. Of the available reliable and valid sedation scales, the PAD guidelines recommend the use of the Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS). Figure 4 shows the psychometric properties of both the RASS and SAS. The SAS has 7 individual tiers ranging from “1” (unarousable) to “7” (dangerous agitation). RASS is a 10-point scale, with four levels of escalating agitation (RASS +1 to +4), one level denoting a calm and alert state (RASS 0), three levels of sedation (RASS -1 to –3), and two levels of coma (RASS -4 to -5). A unique feature of RASS is that it relies on the duration of eye contact following verbal stimulation. The RASS takes less than 20 seconds to perform with minimal training, and has been shown highly reliability among multiple types of healthcare providers and an excellent interrater reliability in a broad range of adult medical and surgical ICU patients.
- #31 IV opioids should be considered first-line analgesics for the treatment of nonneuropathic pain. (+1C) • All IV opioids are equally effective when titrated to similar pain scores. (C) Use of non-opioid analgesics: • Non-opioid analgesics should be considered to decrease the amount of opioids administered and to decrease opioidinduced adverse effects. (+2C) For neuropathic pain, enterally administered gabapentin or carbamazepine should be considered, in addition to IV opioids. Opioid tolerance may occur after only 2 days of continuous IV opioid therapy • Think about multimodal analgesic options in a patient with persistent pain when opioid therapy has been maximized
- #32 Analgo-Sedation Strategies • Addressing pain and discomfort first before administering sedatives. • Utilization of one drug for two purposes: Pain relief and sedation • Usually accomplished with an opioid.
- #35 Between 50% and 80% of mechanically ventilated ICU patients develop delirium, and this organ dysfunction is missed 75% of the time if not monitored, which prompted the PAD guidelines ‘recommendation that all ICU patients be screened regularly for delirium with a valid and reliable tool. Over 80% of patients developed delirium during their hospital stay, with the majority of cases occurring in the ICU with an average time of onset between the second and the third day. Three key points to clarifying the syntax surrounding delirium and coma are as follows: First, coma represents the clinical state of a patient who is unarousable to voice (whether this is due to disease or to iatrogenic causes such as deliberate or unintentional overuse of sedation). Second, hallucinations and delusions are not key major components of the diagnosis of delirium. That is, many patients are delirious who do not have either hallucinations or delusions. Third, clinicians need to realize that inattention is the most important diagnostic criterion for delirium.[30]
- #36 The American Psychiatric Association's Diagnostic and Statistical Manual, 5th edition (DSM-V) lists five key features that characterize delirium [2]: Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness. The disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the course of the day. An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception) The disturbances are not better explained by another preexisting, evolving or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect. Additional features that may accompany delirium and confusion include the following: Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with increased sympathetic activity, and impairment in sleep duration and architecture. Variable emotional disturbances, including fear, depression, euphoria, or perplexity.
- #37 Delirium is a disturbance in attention and awareness that develops over a short period of time, hours to days, and fluctuates over time. Acute disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that fluctuates over time.(DSM 5th Edition) Delirium is prevalent, under-recognized, and an independent predictor of poor outcomes such as mortality, prolonged mechanical ventilation, increased length of hospital stay, and long-term cognitive impairment. Between 50% and 80% of mechanically ventilated ICU patients develop delirium, and this organ dysfunction is missed 75% of the time if not monitored, which prompted the PAD guidelines ‘recommendation that all ICU patients be screened regularly for delirium with a valid and reliable tool. Over 80% of patients developed delirium during their hospital stay, with the majority of cases occurring in the ICU with an average time of onset between the second and the third day. Three key points to clarifying the syntax surrounding delirium and coma are as follows: First, coma represents the clinical state of a patient who is unarousable to voice (whether this is due to disease or to iatrogenic causes such as deliberate or unintentional overuse of sedation). Second, hallucinations and delusions are not key major components of the diagnosis of delirium. That is, many patients are delirious who do not have either hallucinations or delusions. Third, clinicians need to realize that inattention is the most important diagnostic criterion for delirium.[30]
- #38 Several methods have been developed and validated to diagnose delirium in ICU patients but the Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) are the most frequently employed tools for this purpose. The ICDSC checklist is an eight-item screening tool (one point for each item) that is based on DSM criteria and applied to data that can be collected through medical records or to information obtained from the multidisciplinary team. The pooled values for the sensitivity and specificity of the ICDSC are 74% and 81.9%, respectively. The CAM-ICU is composed by four features 1) acute onset of mental status changes or fluctuating course; 2) inattention; 3) disorganized thinking; and 4) altered level of consciousness. The patient is considered CAM positive and, so delirious, if he/she manifests both features 1 and 2, plus either feature 3 or 4. Overall accuracy of the CAM-ICU is excellent, with pooled values for sensitivity and specificity of 80% and 95.9%, respectively. The CAM-ICU has been modified and validated in pediatric, emergency department, and neurocritical care populations, as well as translated in over 25 languages
- #39 Delirium can be categorized into subtypes according to psychomotor behavior. Hyperactive delirium (CAM positive, RASS positive range) is associated with a better overall prognosis and it is characterized by agitation, restlessness, and emotional lability. Hypoactive delirium (CAM positive, RASS negative range), which is very common and often more deleterious in the long term, is characterized by decreased responsiveness, withdrawal, and apathy and remains unrecognized in 66 to 84% of hospitalized patients. Another categorization based on the ICDSC score assigns patients with a score of 0 to have no delirium, those with a score ≥ 4 to have clinical delirium, and those with a score of 1–3 to have subsyndromal delirium. Whichever delirium metric is used, the best picture of the patient’s mental status comes from assessing delirium serially throughout the day.
- #43 0-Normal 1-3 sub-syndromal Delirium 4-8 Delrium
- #48 Delirium prophylaxis with medications is discouraged in the PAD guidelines. Recently, a prospective, randomized, multicenter trial compared a low-dose haloperidol infusion administered for 12 hours (0.5 mg intravenous bolus injection followed by continuous infusion at a rate of 0.1 mg/h, n=229 patients) against placebo (n = 228 patients) in the immediate postoperative period. This study provided evidence that haloperidol could reduce the incidence of delirium within the first 7 days postoperatively in patients undergone noncardiac surgery (15.3% in the haloperidol group versus 23.2% in the control group, p=.031). By contrast, another ICU study showed no benefit of early administration of intravenous haloperidol in a mixed population of medical and surgical adult ICU patients. In this double-blinded, placebo-controlled randomized trial, 142 patients were randomized to receive haloperidol or placebo intravenously every 8 hours irrespective of coma or delirium status. Patients in the haloperidol group spent about the same number of days alive, without delirium or coma, as did patients in the placebo group (median 5 days [IQR 0–10] versus 6 days [0–11] days; p=0.53)
- #49 After reversible causes and modifiable risk factors have been addressed and nonpharmacologic strategies have been implemented, then and only then should pharmacologic interventions be considered. 0921250945
- #50 erhaps the most important element of delirium management in the ICU setting involves communication among the team. To that end, many ICU teams now present on rounds using the “brain road map,” which is a set of data containing 3 elements (Fig. 4). At each bedside, the nurse (or another team member such as an intern or a pharmacist) will present the patient’s (1) target RASS or SAS; (2) actual RASS or SAS, CAM-ICU, or ICDSC result; and (3) sedatives and narcotics received. This helps the team discuss the patient’s cognitive status, compare it with the patient’s desired cognitive status for that day, determine adjustments needed, and then explore the causes of delirium if the patient is CAM-ICU or ICDSC positive that day (using, for example, the Dr. DRE tool shown in Fig. 3).
- #51 Early mobility is an integral part of the ABCDEF bundle and has been the only intervention resulting in a decrease in days of delirium.[49] The consequence of physical dysfunction in critically ill patients can be profound and long-term with significant reduction in functional status being observed even 1 year and 5 years after ICU discharge.[50-52] Physical therapy has shown to be feasible, safe, even in the most complicated patients receiving the most advanced medical therapies (e.g., continuous renal replacement therapy, extracorporeal cardiopulmonary support).[53,54] Early activity can be done without increases in usual ICU staffing and with a low risk (< 1%) of complications.[55] Schweickert et al.[56] showed that a daily SAT combined with physical and occupational therapy, versus SAT alone, resulted in an improved return to independent functional status at hospital discharge, shorter duration of ICU-delirium, higher survival, and more days breathing without assistance.
- #53 ICU-acquired weakness is caused by many different pathophysiological mechanisms that are not mutually exclusive given the diverse diseases that precipitate critical illness, the drugs used during its management, and the consequences of protracted immobility. The reported incidence of ICU-acquired weakness ranges from 25 to 100%. The diagnosis of ICU-acquired weakness is made by the Medical Research Council (MRC) scale for grading the strength (i.e., 0, total palsy to 5, normal strength) of various muscle groups in the upper and lower extremities. The scale ranges from 0 (complete tetraplegia) to 60 (normal muscle strength), with a score < 48 is diagnostic of ICU-acquired weakness. Patients with ICU-acquired weakness should undergo serial evaluations, and if persistent deficits are noted, electrophysiological studies, muscle biopsy, or both are warranted
- #66 The association of lactate level with mortality in patients with suspected infection and sepsis is well established (45, 46). Its use is currently recommended as part of the SSC Hour-1 sepsis bundle for those patients with sepsis (47, 48), and an elevated lactate is part of the Sepsis-3 definition of septic shock (49). It has been suggested that lactate can also be used to screen for the presence of sepsis among undifferentiated adult patients with clinically suspected (but not confirmed) sepsis. Several studies have assessed the use of lactate in this context (50–52). Studies showed an association between the use of point-of-care lactate measurements at presentation and reduced mortality; however, the results are inconsistent (53)
- #67 Serum lactate is an important biomarker of tissue hypoxia and dysfunction, but is not a direct measure of tissue perfusion (73). Recent defiitions of septic shock include increases in lactate as evidence of cellular stress to accompany refractory hypotension using lactate levels as a target of resuscitation in the early phases of sepsis and septic shock, based on earlier studies related to goal-directed therapy and meta-analyses of multiple studies targeting reductions in serum lactate in comparison with “standard care” or increases in central venous oxygen saturation
- #68 The panel recognizes that normal serum lactate levels are not achievable in all patients with septic shock, but these studies support resuscitative strategies that decrease lactate toward normal. When advanced hemodynamic monitoring is not available, alternative measures of organ perfusion may be used to evaluate the effctiveness and safety of volume administration. Temperature of the extremities, skin mottling and capillary refil time (CRT) have been validated and shown to be reproducible signs of tissue perfusion
- #69 Fluid therapy is a key part of the resuscitation of sepsis and septic shock. Crystalloids have the advantage of being inexpensive and widely available. Th absence of clear benefi following the administration of colloids compared to crystalloid solutions supports the use of crystalloid solutions in the resuscitation of patients with sepsis and septic shock (324). Th optimal flid remains a subject of debate. For decades, the administration of normal saline solution (0.9% sodium chloride) has been common practice (325), but potential adverse effcts that include hyperchloremic metabolic acidosis, renal vasoconstriction, increased cytokine secretion and concern about acute kidney injury (AKI) have led to increased interest in chloride-restrictive solutions, known as balanced or buffred solutions (326–330). Subsequently, a network meta-analysis of 14 RCTs of patients with sepsis showed in an indirect comparison that balanced crystalloids were associated with decreased mortality, compared to saline
- #82 Intravascular catheterization is a cornerstone of medical management of the critically ill patient, and these catheters are required for fluid administration, invasive monitoring, laboratory work, blood transfusions, transvenous cardiac pacing, medication administration, and dialysis access. BSIs may be either primary or secondary. Secondary infections are related to infections at other sites, such as the urinary tract, lung, postoperative wounds, and skin. Most nosocomial BSIs are primary, as illustrated by the United States Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance system, in which 64 percent of the nosocomial BSIs reported were primary BSIs [3]. While some primary BSIs have no identifiable source, most are associated with intravascular catheters, and central venous catheters (CVCs) in particular
- #84 Host factors — Host factors commonly associated with nosocomial bloodstream infections (BSIs) include the following [13,14]: ●Duration of catheterization (although there is no indication for routine line changing based on number of catheter days)
- #85 There are five key aspects to this bundle which if addressed together should minimise the risk of catheter related bloodstream infection.
- #88 Experience is usually greater with insertion at the internal jugular site and therefore can be safer. The subclavian, or internal jugular route, are undoubtedly the preferred sites for preventing avoidable infections.