ICU PROTOCOLS PDF
MOH Pocket Manual in Critical Care. TABLE OF . Facilitate transfer to the operating room or ICU. . Most guidelines and clinical protocols recommend that. have ventured further and we are now proud to be able to present to you another 11 management protocols and 2 policies that will cover a diverse range of. Intensive Care Topics: common admissions and useful algorithms. UIH Clinical Care Guidelines These are some general rules/guidelines to follow.
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Shyam Sunder Tipparaju, Gopinath Ramachandran, Ravinuthala Venkat Kumar, Muppiri Vijay Kumar. Pages PDF. It is often difficult to know for certain whether a particular patient needs to be nursed postoperatively in the intensive care unit (ICU), if one exists in your hospital. Intensive Care Unit. Guidelines for Clinical Management. (Developed for the Colonial War Memorial Hospital ICU). Compiled by: Dr Lisa Bennett, Consultant.
Tan Cheng Cheng 2. Investigations and Surveillance Dr. Lim Chew Har 3. Tai Li Ling 4. Weaning From Mechanical Ventilation Dr. Khoo Tien Meng 5. Inotropic and Vasopressor Support Dr. Md Ridhwan Md Noor 6. Enteral and Parenteral Nutrition Dr. Ienny Tong May Geok 7. Sedation and Delirium Dr. Shanti Rudra Deva 8.
Venous Thrornboembolism Prophylaxis Dr. Ahmad Shaltut Othman 9. Noor Airini Ibrahim Mohd Basri Mat Nor Early Mobilization Dr.
Lee See Pheng Laila Kamaliah Kamalul Bahrin Tan Cheng Cheng Program Anvwslr-: An intensive care unit ICU provides special expertise and facilities with the aim to restore vital organ function to normal in order to gain time to treat an underlying cause. Principles 1. Critically ill patients with reversible medical conditions with a reasonable prospect of meaningful recoveryshould be admitted to an ICU.
In the event of unavailability of ICU beds in the hospital, an ICU bed should be sourced from another neighbour- ing hospital. Withdrawal of therapy is advocated when continuing intensive care is deemed medically futile.
Triaging is the strategy used to select patients for admission when unit capacity is reached. Admission Policy a. Admission from the Emergency and Trauma Department or from another hospital must have a primary care unit. While in ICU, these patients shall remain under the primary team. Transfer of care to a different unit must be arranged by the primary unit. Admission from other hospitals must be liaised with the ICU specialist before transfer of the patient. Resuscitation for life-threatening condition must be continued pending ICU admission.
The following factors should be taken into consideration in triaging: It is the responsibility of the ICU specialist to decide if a patient is to be discharged refer to appendix 1 for discharge criteria.
Patients are discharged when the reason for admission has resolved. It is the responsibility of the primary team to promptly receive patients who are discharged from ICU and the primary team must be informed of all potential or continuing problems.
The Acute Pain Team should be notified if patients under their care are discharged. A discharge summary must be completed in the case notes prior to discharge. Patients with the following conditions are candidates for admission to the general ICU.
The following conditions include, but are not limited to: Acute respiratory failure requiring Ventilatory support Acute pulmonary embolism with haemodynamic instability Massive haemoptysis Upper airway obstruction Shock states Life-threatening dysrhythmias Dissecting aortic aneurysms Hypertensive emergencies Need for continuous invasive monitoring of cardio- vascular system arterial pressure, central venous pressure, cardiac output B.
Cardiovascular S"'. Brain dead or potentially brain dead patients who are being aggressivelymanaged while determining organ donation status C. Requirement for acute renal replacement therapies in an unstable patient 2. Acute rhabdomyolysis with renal insufficiency Pmgnm Amqi-sinlngi I. Endocrine 1. Diabetic ketoacidosis complicated by haemodynamic instability, altered mental status. Hyperosmolar hyperglycemic state.
Thyroid storm or myxederna coma with haemodynamic instability 4. Adrenal crises with haemodynamic instability. Other severe electrolyte abnormalities, such as: Gastrointestinal 1. Life threatening gastrointestinal bleeding 2. Acute hepatic failure leading to coma, haemodynamic instability 3.
Severe acute pancreatitis G. Haematology 1. Severe complications of sickle cell crisis. Haematological malignancies with multi-organ failure H. End stage cardiac, res 7ll'iII0l'' and liver disease with no 0 itions for trans wlant C.
Patients on low dose inotropic support may be discharged earlier if ICU bed is required. Cardiac dysrhythmias are controlled Neurologic stability with control of seizures Patients who require chronic mechanical ventilation eg motor neuron disease, cervical spine injuries with the acute critical problems improved Plug: KKM ,. Guidelines for intensive care unit admission, discharge, and triage.
Crit Care Med ; 27 3: JAMA ; Evaluation of triage decisions for intensive care admission. Crit Care Med ; 27 6: Rationing in the intensive care unit. Crit Care Med ; 34 4: Evidence Based Practice Guidelines: Nursing Care of the Ventilated Patient.
Some investigations may be ordered on a routine basis to facilitate the overall daily management of the unit. However CXR should be ordered following placement of central venous catheter, endotracheal tube, nasogastric tube, chest drains or when cardiorespiratory pathology is suspected. In, w,. However in an MRSA outbreak, there is strong evidence for active surveillance cultures. Nasal swabs are taken from all ICU patients, wound swabs taken when applicable and nasal swabs from staff only if implicated in transmission.
In an vancomycin-resistant enterococci VRE outbreak, surveillance swabs should include rectal swabs from all ICU patients, wound swabs in applicable patients and rectal swabs from staff only if implicated intransmission. In the setting of a respiratory reservoir outbreak, tracheal aspirate culture should be sent from suspected patients. For this reason facilities that rarely e.
Screen epidemiologically-linked patient contacts e. Consider point prevalence survey of affected unit. During an outbreak, screening cultures of contacts are also important.
Surveillance cultures for endotracheal aspirates may be done weekly to - identify MDR pathogens o predict susceptibility patterns o aid empiric antibiotic therapy Pn-gram An. Routine blood test ordering for patients in intensive care.
Anaesth Intensive Care Oct; 28 5: Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.
Chest ; Nasal swabs collected routinely to screen for colonization by methicillin-resistant Staphylococcus aureus in intensive care units are a sensitive screening test for the organism in clinical cultures.
Surg Infect Larchmt Dec; 11 6: Baba, G. Nirnmo, AM Allworth et al. The role of surveillance cultures in the prediction of susceptibility patterns of Gram-negative bacilli in the intensive care unit.
European Journal of Clinical Microbiology 8: An audit for microbiological surveillance and antimicrobial susceptibility in the intensive care unit.
Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: A role for routine endotracheal aspirate cultures. Chest , Depuydt, D Benoit, D Vogelaers et al. Systematic surveillance cultures as a tool to predict involvement of multidrug antibiotic resistant bacteria in ventilator-associated pneumonia. Role of serial routine microbiologic culture results in the initial management of ventilator-associated pneumonia. Infec- tious disease: Multidrug-resistant Pseudomonas aeruginosa ventilator-associated pneumonia: The role of endotracheal aspirate surveillance cultures.
Ann Pharmacother January, Choosing appropriate goals for mechanical ventilation is more important than the mode. Low tidal volume ventilation should be instituted in all patients on mechanical venti- lation. If necessary, accept physiologic target outside normal range e. The optimal time to initiate Ventilatory rescue therapies in high potential recruiters is within 96 hours of onset of Acute Respiratory Distress Syndrome ARDS when alveolar recruitment potential is the greatest.
The choice of rescue therapy should be based on equipment availability and clinician expertise. If the therapy does not result in improved oxygenation, it should be aban- doned. In PCV, Pplat is equivalent to peak airway pressure. If VCV is used, the Pplat needs to be mea- sured regularly e. Use the lowest FiO2 to achieve adequate oxygenation. Infusion of intravenous NaHCO3 8. Contraindi- cations to permissive hypercapnia include intracranial hyperterwion, concomitant metabolic acidosis, acute coronary syndrome, right heart failure and worsening pulmonary hypertension.
If conventional ventilation fails i. High potential recruit- ers are those who at the end of the trial demonstrate all of the following: Do not perform further recruitment manoeuvres in non-recruiters.
Consider non-Ventilatory strategies to improve PaO2. The following steps are to be performed only in recruiters: Perform recruitment manoeuvre. Additional sedation, paralysis or both may be required during manoeuvre. Monitor for hypotension and desaturation. Different lung recruitment manoeuvres that may be performed are: Re-recruit the lung at the optimal PEEP level.
Reassess in recruiters. Non-Ventilatory rescue strategies to improve oxygenation: Possible complications include pressure ulcers, unplanned extubation, dislodge- ment of catheters, increased use of sedatives. A regime using methylprednisolone for 28 days is as follows: If extubated between D1 - D14, proceed to D15 of therapy. Other non-Ventilatory strategies to improve oxygenation: Exercise caution in patients who are hypovolemic. Severe hypoxemic respiratory failure. Part 1: Part 2: Nonventilatory strategies.
Recommendations for the diagnosis and man- agement of corticosteroid insufficiency in critically ill adult patients: Crit Care Med. Methylprednisolone infusion in early severe ARDS: Chest Lung recruitment in patients with the acute respiratory distress syndrome. N Engl] Med. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome.
Am] RespirCrit Care Med ; A randomized, controlled trial of furosernide with or without albumin in hypoproteinemic patients with acute lung injury. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med.
The process is uneventful in most patients, but may take up half the time on a ventilator in problem- atic patients. Most patients require a period of rest after intubation, but consideration of the wean- ing process should begin very soon after intubation. Delay in clinical judgment that weaning may be possible and delay in assessment of readiness to wean is a common cause of delayed weaning.
The patient must be awake, cooperative, haemodynamically stable and able to cough and protect airway before extubation. It is important to minimize or discontinue sedation for daytime breathing trials. Unless there is evidence for clearly irreversible disease e. Resolution of acute phase of disease for which patient was intubated - Adequate cough Absence of excessive tracheobronchial secretions Pmjgmm 1nl: IIl au.
Respiratory criteria 1. Adequate oxygenation: Neurological criteria i. None of these measurements, when used in isolation, can predict with certainty which patients are ready to breathe spontaneously independently. Once the patient is deemed ready to wean, proceed with spontaneous breathing trial. It is important to communicate with the patient that attempt at discontinuation of ventilation is about to begin. Spontaneous breathing trial SBT The SBT can be conducted while the patient is still connected to the ventilator circuit or the patient can be removed from the ventilator and allowed to breathe through an independent source of oxygen via a T-shaped breathing circuit known as the T-piece.
SBT through the ventilator: The advantage is patient safety as patient is not disconnected from ventilator and back-up ventilation can be provided if the patient is apnoeic.
In addition, tidal volume and respiratory rate can be monitored. SBT through a T-piece: The advantage is the reduced work of breathing with the T-shaped circuit.
Protocol for SBT 1. Allow 30 to minutes for the initial trial of spontaneous breathing. SBT is considered a failure when patient develops respiratory, cardiovascular or neu- rological instability. Criteria for passing spontaneous breathing trial: In, s,. Refer to appendix 1 for explanation of cuff leak test. If a patient fails a SBT: Pn-gram An. NIV can be used as an alternative weaning technique in patients who have failed con- ventional weaning or failed to meet standard extubation criteria.
Role of Tracheostomg o Must be considered: Weaning from Mechanical Ventilation in the Intensive Care Unit Protocol to mean a tracheostomised patient with prolonged wean or prolonged meclaanical ventilation Principle is to utilize daily SBTS of progressively increasing duration after a certain level of ventilatory support reduction has occurred. Firstly, reduce level of PS gradually by 2 cml-I20 q 24h. Once a PS of 10 - 12 cmH2O is reached, perform assessment for readiness to wean.
If deemed ready to wean, perform SBT using a trachymask for eg 2h. Eventual goal is to reach 24h without ventilator support and therefore be completely liberated from ventilator. Appendix 1 Cuff Leak Test 1. Qualitative assessment 2. Measure the difference between inspired and expired tidal volumes. To improve prediction of post-extubation stridor, perform simultaneous assessment of cough and cuff leak: Absence of both audible cough and cuff leak indicates patient is 10 times more likely to develop post-extubation stridor.
Program Ana-sh-siolngi 1. Igv, aan K: Cardiac i. Ischaemic heart disease dysfunction ii. Valvular heart disease iii. Systolic or diastolic dysfunction iv. Increased metabolic demand of weaning imposing an increased cardiac workload v. Respiratory 1. Reduced pulmonary compliance dysfunction i. Pneumonia primary admission diagnosis or ventilator-associated. Cardiogenicornon-cardiogenic pulmonary oedema 11 iv. Pulmonary haemorrhage v. Reduced chest wall compliance eg kyphocoliosis vi.
Splinting eg abdominal distension, obesity and ascites II.
Management protools in icu
Obstructive problems i. Bronchoconstriction Tube obstruction Kinked tube iv. Inappropriate ventilator settings resulting in increased work of breathing v. Post-extubation - glottic oedema, increased airway secretions, sputum retention 3.
N euromuscular I. Depressed Central drive i. Encephalitis ii. Metabolic alkalosis II. Peripheral nervous system dysfunction i.
Guillain-Barre syndrome, myasthenia gravis usually apparent before weaning ii. Critical illness neuromuscular abnormalities important cause! Nutrition i. Obesity Malnutrition Overfeeding 5.
Unresolved systemic disease - sepsis 6. Neuropsychological i. Delirium ii. Depression iii. Anxiety 7. Metabolic i. Hypokalaemia, hypomagnesemia, hypophosphatemia Steroids and hyperglycaemia - controversial 8. Anaemia Controversial P: Weaning Assessment of readiness to wean - is the patient ready for a spontaneous breathing trial SBT? Able to protect airway? Continue mechanical ventilation. Weaning of Mechanical Ventilation. Weaning from mechanical ventilation.
European Respiratory Journal ; What is the optimal approach to weaning and liberation from mechanical ventilation?
A randomized, controlled trial of the role of weaning predictors in clinical decision making. Critical Care Medicine ; Epstein SK. Weaning from ventilator support. Maclntyre NR, et al. Management of patients requiring prolonged mechanical ventila- tion. Chest ; 2 6.
Scheinhorn D], Chao DC, et al. Outcomes in post-ICU mechanical ventilation: A therapist-implemented weaning protocol. Kollef M, Isakow W editors. Extubation management. Identify type of shock whether it is obstructive, distributive, hypovolemic, cardiogenic or mixed. Before the use of inotropic and Vasopressor support, it is important to: Correct hypovolemia ii.
Exclude causes of obstructive shock eg. The selection of the drugs is determined by the cause of shock and the desired thera- peutic activity targeting the underlying pathophysiology.
The dose of inotropes and vasopressors need to be titrated to targeted goals. The route of administration of inotropes and vasopressors is via central venous catheter.
Blood pressure shall be monitored continuously via arterial line. Advanced hemodynamic studies e. Do not delay resuscitation pending ICU admission. Commence IV noradrenaline infusion Dose 0. Adrenaline may worsen acidosis and increase lactate. Hemodynamic Monitoring. Divatia, Ramesh Venkatraman.
Fluid Therapy, Vasopressors, and Inotropes. Cardiorespiratory Arrest. Sheila Nainan Myatra, Amol T. Kothekar, Jigeeshu V. Cardiogenic Shock. Acute Heart Failure. Cardiac Arrhythmias.
Shyam Sunder Tipparaju, Gopinath Ramachandran. Acute Coronary Syndromes. Hypertensive Urgencies and Emergencies. Aortic Dissection. Cerebrovascular Accident. Dedeepiya Devaprasad, Nagarajan Ramakrishnan. Subarachnoid Hemorrhage. Status Epilepticus. Acute Flaccid Paralysis. Intracranial Pressure Monitoring and Management.
Rajagopal Senthilkumar, Nagarajan Ramakrishnan. Acute Febrile Encephalopathy. Sedation and Analgesia. Brain Death. Babu K. Abraham, Nagarajan Ramakrishnan. Upper Gastrointestinal Bleeding. Lower Gastrointestinal Bleeding. Acute Diarrhea. Acute Abdominal Distension. Intra-abdominal Hypertension. Acute Pancreatitis.
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