Strategies to Prevent Complications of ICU Stay

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Strategies to Prevent Complications of ICU Stay

• Current Concepts in Critical Care
• Illinois Hospital Association
• Moraine Valley Community College
• April 2007
• David P. Gurka, Ph.D.-MD
• Director, Critical Care Services

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David P. Gurka, Ph.D.-MD
Disclosure of Financial Relationships

• Has no relationships with any proprietary entity
  producing health care goods or services consumed
  by or used on patients.

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MLAD
CRITICALLY ILL PATIENT
HEAD
WORKING
With apologies to Walt Kelly (1971)
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MLAD
CRITICALLY ILL PATIENT
HEAD
WORKING
With apologies to Walt Kelly (1971)
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Complications

• Catheters, especially blood stream infections
• Ventilator-associated pneumonia
• Thrombosis
• Gastric stress ulceration
• Sedation-related
• Delirium
• Contrast media-induced nephropathy
• Transfusions

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Frequency of Mechanical Complications of Line
Insertion
McGee and Gould (2003) New Eng. J. Med 248, 1127
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Internal Jugular vs. Subclavian

• Complication Relative Risk
• Vessel occlusion 0.29
• Malposition 0.66
• Hemo/pneumothorax 0.76
• Bloodstream infection 2.24
• Arterial puncture 4.70

Ruesch et al (2002) Critical Care Medicine 30, 454
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Catheters and Thrombosis

• Thrombi found by ultrasound in 33 of catheters
• (22 large, 3 occlusive)
• Risk factors for thrombosis
• Age gt 65 (RR 2.4)
• IJ gt subclavian (RR 4.1 42 vs. 10 of lines)
• No therapeutic anticoagulation
• Thrombosis increases relative risk of infectious
  complications
• Catheter colonization 1.64
• Catheter related bacteremia 2.62
• Catheter related sepsis 3.22

Timsit et al (1998) Chest 114, 207
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Femoral vs. Subclavian Catheters

• Infection rates
• Overall 19.8 vs. 4.5 (colonization sepsis)
• Sepsis 4.5 vs. 1.5
• 4.83 Hazard ratio for femoral
• Thrombotic complications
• Overall 21.5 vs. 1.9
• Complete thrombosis of vessel 6 vs. 0
• 14.4 Odds ratio for femoral
• Absolute risk reduction, subclavian vs. femoral
• All complications 33 (NNT 3) Major 6 (NNT 16)

Merrer et al (2001) JAMA 286, 700
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How do catheters get infected?
Sadfar and Maki (2004) Intensive Care Med 30,
62-67
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Risk Factors for Bloodstream Infection
Safdar, Kluger and Maki (2002) Medicine 81, 466
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Making Lines Less DifficultKarakitsos et al
(2006), Critical Care 10R162
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Central Line GuidelinesMMWR (9 August 2002) 51,
RR-10

• Insertion
• Staff and operator education
• ESPECIALLY HAND WASHING
• Chlorhexidine 2 antiseptic
• Maximum barrier precautions
• Minimum number of ports
• Antibiotic-impregnated if gt 5 days expected
• Subclavian preferred over IJ or femoral to
  minimize infection

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Central Line GuidelinesMMWR (9 August 2002) 51,
RR-10

• Changes No routine changes
• NO GUIDEWIRE EXCHANGES IF INFECTION SUSPECTED
• DO NOT CHANGE FOR FEVER ALONE
• GUIDEWIRE CHANGE OK IF NOT INFECTED
• NEW GLOVES FOR NEW CATHETER
• Dressing changes
• Gauze q2d, Transparent q7d (unless soiled)

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Intense Guideline AdherencePronovost et al
(2006), NEJM 3552725

• Guidelines
• Wash hands before procedure
• 2 (not 0.5) Chlorhexadine skin preparation
• Full barrier precautions
• Avoid femoral venous catheterization
• Remove lines when no longer needed

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Intense Guideline AdherencePronovost et al
(2006), NEJM 3552725
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Consensus Recommendations VTE Prophylaxis
Geerts, et al (2004) Chest 126338S

• Grade 1A
• Screen all ICU patients for risks
• Most will receive thromboprophylaxis
• Moderate risk (Medically-ill or post-op)
• EITHER LDUH or LMWH
• High risk (Major trauma or ortho surgery)
• LMWH
• Grade 1C
• High bleeding risk
• Mechanical prophylaxis (graded compression
  stockings or intermittent pneumatic compression)

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Stress Related Mucosal Disease(SRMD)
Mutlu et al (2001).CHEST
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Stress Ulcer Prophylaxis

• 75-100 of patients will have evidence of
  mucosal damage within 24 hours
• 50 of patients will experience erosive
  esophagitis
• 25 of patients will experience a bleeding
  event
• 4.2 million patients required IV acid-suppressive
  therapy
• Low incidence (3-4), but carries a several-fold
  increase in mortality

Abraham (2002). Crit Care Med. Mutlu (2001).Chest
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Risk Stratification for SRMD

• Risk Factors
• 1. Respiratory failure / mechanical ventilation
  (gt 48 hours) Odds ratio 15.6
• 2. Presence of coagulopathy (platelets lt 50,000
  or INR gt 1.5)
• Odds ratio 4.3
• 3. Hypotension / shock (vasopressor support)
• Odds ratio 3.7
• 4. Sepsis
• Odds ratio 2.0

Cook et al (1994).N Engl J Med.
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ASHP Guidelines for SRMD Prophylaxis Indications

• Patient requiring mechanical ventilation gt48
  hours
• Patient presenting with coagulopathy
• (platelets lt 50,000 or INR gt1.5)
• Patient with history of GI ulceration/bleeding or
  receiving hydrocortisone gt250mg/day
• Patient with GCS lt10 or thermal injury gt35 BSA
• Stress Ulcer prophylaxis is NOT recommended for
  adult patients in non-ICU setting

ASHP (1999).Guidelines for Stress Ulcer
Prophylaxis.
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SRMD ProphylaxisWhat to use?

• H2-receptor blockers
• Proton pump inhibitors
• Sucralfate
• ?lower risk of ventilator-associated pneumonia?
• ?less effective in high-risk patients?
• Enteral nutrition
• Probably insufficient as sole therapy

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SRMD ProphylaxisWhat to use?

• Multiple studies, total 2000 patients
• Cimetidine and antacids equally effective
• Sucralfate and antacids equally effective
• Ranitidine better than sucralfate
• Cimetidine, sucralfate and antacids equal

No differences between therapies PPIs not
directly compared to H2-antagonists
Treziak and Dellinger (2004) Critical Care
Medicine 32 S571
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SRMD ProphylaxisWhat is used?

• Famotidine 38
• Ranitidine 23
• Pantoprazole 14
• Sucralfate 12
• Lansoprazole 4
• Omeprazole 4
• Cimetidine 2
• Esomeprazole 1
• Antacids 0.8

H2-antagonists 63 PPIs
23 Sucralfate 12 Antacids lt1 Limited
data on PPI Use in critical illness
Daley et al (2004) Critical Care Medicine 322008
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Enteral Nutrition as prophylaxis

• Current literature is inconclusive
• Lack of randomized-controlled trials
• Enteral nutrition lowers intragastric pH and
  significant bleeding occurs at low pH
• Proven to reduce stress-related damage in rat
  studies
• Cook and colleagues trial in gt1,000 pts
  describing those developing GI bleeding (60 of
  which were receiving enteral nutrition)
• Odds ratio 0.30-0.33 if fed
• Meta-analysis of early versus late enteral
  nutrition
• only decreased infections and length of stay

Ben-Menachem (1994) Ann Intern Med.
Mabogunje (1981) J Pediatr Surg. Fiddian-Green
(1983)Gastroenterology Cook et.al
(1999)Crit Care Med. Stollman and Metz (2005) J.
Critical Care
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Ventilator-associated Pneumonia

• Epidemiology
• 3-4 days after intubation
• 9 prevalence
• Increases
• ICU and hospital length of stay
• Mortality
• Time on ventilator
• Health care cost (double)

Rello et al (2002). Chest 122 2115
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Educational Program

• Extubate AS SOON AS POSSIBLE
• Semi-recumbent positioning
• Reduction of sinusitis risk
• Endotracheal intubation, oro (NOT naso)-gastric
  tubes
• Reduction of aspiration risk
• Subglottic secretion removal, gastric
  overdistention
• Daily oral hygiene program
• Minimize ventilator circuit interruptions
• In-line suction catheters, in-line nebulizers
• Weekly (or prn) tubing circuit changes

Zak et al (2002). Critical Care Medicine 30, 2407
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ATS Guidelines 2005Am. J. Respiratory and
Critical Care Med (2005) 171 388

• Level I Recommendations for all
• Infection control education and isolation
• Avoid intubation (use NIPPV) and reintubation
• Continuous aspiration of subglottic secretions
• Semi-recumbent positioning (30-45)
• Enteral nutrition preferred over parenteral
• GI bleeding prophylaxis, either H2-blockers or
  sucralfate
• Restrictive transfusion policy
• Tight glucose control

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Hilinski AM and Stark ML (2006) Critical Care
Nursing 2679
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ATS Guidelines 2005Am. J. Respiratory and
Critical Care Med (2005) 171 388

• Level I Recommendations for some
• Prophylactic antibiotics (closed head injury)
• Oral chlorhexadine (CABG)
• NO oral decontamination (colonized with MDR)

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ATS Guidelines 2005Am. J. Respiratory and
Critical Care Med (2005) 171 388

• Level II Recommendations
• Infection surveillance and antibiograms
• Oro- rather than naso-gastric tubes
• ET cuff pressure gt 20 cm H20
• Caution with ventilator circuit condensate
• Protocols for sedation and weaning
• Avoid heavy sedation and paralysis
• Daily interruption and awakening
• Adequate ICU staffing

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RUMC ICU RT-RN (MD-independent) Ventilator
Weaning Guidelines
Areas of MD input
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A possible explanatory model of neurocognitive
impairments among ICU survivors
Hopkins, R. O. et al. Chest 2006130869-878
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Sedation

• Prevents self-harm (extubation)
• Decreases risk of post-traumatic stress disorder
• Facilitates nursing care
• Masks neurological changes
• Prolonged intubation due to oversedaton

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PTSD after ARDS
Schelling et al (1998) Critical Care Medicine 26,
651

• 80 ARDS survivors
• Compared to
• German population norms
• ENT surgical patients
• Intubated/trach, no ALI
• UN troops in Cambodia

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PTSD and recall of experiences
Schelling et al (1998) Critical Care Medicine 26,
651
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Sedation to Delirium
Pandharipande P, Jackson J and Ely EW (2005)
Curr. Opin. Crit. Care 11 360-368
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Delirium in the ICULin, et al (2004) Critical
Care Medicine 32 2254

• Common finding
• 22-30 of ventilated patients
• Occurs early
• Associated with increased mortality

• Predictors of mortality
• (Odds ratios)
• Delirium 13.0
• Shock 12.9
• APACHE III 9.6
• CHF 5.8
• Elevated BUN 3.9

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Long-term Effect of Delirium
Pandharipande P, Jackson J and Ely EW (2005)
Curr. Opin. Crit. Care 11 360-368
Oiumet S, Kavanagh B,Gottfried SB and Skrobik Y
(2007) Intensive Care Medicine 3366-73 820
patients
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ICU-Delirium Risk Factors
Pandharipande P, Jackson J and Ely EW (2005)
Curr. Opin. Crit. Care 11 360-368
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ICU-CAM Diagnosis
Pandharipande P, Jackson J and Ely EW (2005)
Curr. Opin. Crit. Care 11 360-368
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Delirium in the ICU Therapy?

• All patients vent gt48 hrs
• Dose-responses
• gt12.5 mg/d 7.7
• 5 - 12.5 mg/d 15.4
• 0.5 - 5 mg/d 35.5
• 0 mg/d 36.1
• Other sedation received?
• Retrospective
• needs controlled trial

Millbrandt et al (2005) Critical Care Medicine
33 226
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Sedation

• Daily awakenings (Kress et al (2000). New Eng. J.
  Med. 342, 1471)
• Decreased time on ventilator (4.9 d vs. 7.3 d)
• Decreased ICU stay (6.4 d vs. 9.9 d)
• Fewer evaluations for mental status changes
• No increase in PTSD
• Use of guidelines
• SCCM ((2002) Critical Care Medicine 30, 119)
• Institutional or unit-specific

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Rush University MICU Guidelines for Sedation
and Analgesia In Mechanically Ventilated Patients
2002-2006
KEY COMPONENT
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Risk Assessment for Contrast Media-Induced
Nephropathy

• Risk Factor Integer Value
• Hypotension 5
• IABP 5
• CHF 5
• Creatinine gt 1.5 mg/dl 4
• Age gt 75 years 4
• Anemia 3
• Diabetes 3
• Volume of contrast (per 100 ml) 1
• Risk categories Score Risk () RRT()
• Low 5 7.5 0.04
• Moderate 6 10 14.0 0.12
• High 11 15 26.1 1.09
• Very High 16 57.3 12.6

Mehran et al (2004) JACC 44 1393
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Strategy for Management of Patients With Risk
Factors for Contrast-Induced Nephropathy
Best option Use radiologist as consultant
Time constraints
Determined by Radiology
Pannu, N. et al. JAMA 20062952765-2779.
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Transfusions and Nosocomial Infections
Increased risk of Nosocomial infection
Risk greatest for those LESS Acutely Ill
Taylor RW et al (2006) Crit Care Med 34 2302
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So in the end..

• Careful attention to catheters
• Insertion procedures
• Site
• Dressing care
• Prophylactic measures for VTE and SRMD
• VAP preventive measures early extubation
• Sedation to prevent PTSD yet avoid snowing
• using established guidelines
• Minimize transfusions
• Caution with radiographic contrast studies
• AND
• WASH YOUR HANDS

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Less is More

• Mies van der Rohe
• R. Buckminster Fuller
• (actually Robert Browning, poet,
• Andrea del Sarto, 1855)