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Current Guidelines in Critical Care Session 2: 2014 Critical Care Boot Camp

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Current Guidelines in Critical Care Session 2: 2014 Critical Care Boot Camp Billy Cameron, MSN, ACNP-BC Assistant in Surgery, Dept of Surgery Acute Care Nurse ... – PowerPoint PPT presentation

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Title: Current Guidelines in Critical Care Session 2: 2014 Critical Care Boot Camp


1
Current Guidelines in Critical Care Session 2
2014 Critical Care Boot Camp
  • Billy Cameron, MSN, ACNP-BC
  • Assistant in Surgery, Dept of Surgery
  • Acute Care Nurse Practitioner
  • Surgical Intensive Care Unit

2
Current Guidelines in Critical Care September 9,
2014
  • Rapid Response Teams
  • Use of Corticosteroids in Septic Shock
  • Central Venous Catheter Infection Prevention
  • Critical Care of the Organ Donor
  • Advanced Cardiac Life Support Algorithms

3
Objectives
  • Identify background of previous evidence based
    critical care practice guidelines
  • Identify and apply most recent evidence based
    guidelines for critical care practice
  • Be able to identify areas in which critical care
    practice may be impacted by most recent guidelines

4
Rapid Response Teams
  • Background
  • Literature supports Rapid Response Teams in
    reducing mortality of patients, reducing lengths
    of stay, reducing unplanned transfers to ICUs,
    and increasing patient satisfaction
  • Rapid Response Teams can intervene prior to an
    acute cardiac event, or other deterioration of
    clinical status (ie early intervention for
    sepsis)

5
Rapid Response Teams
  • Goals of Rapid Response Teams
  • Increase early intervention and stabilization to
    prevent clinical deterioration prior to cardiac
    arrest or other life-threatening event
  • Decrease the number of cardiopulmonary arrests
    that occur outside of the ICU and ED
  • Decrease hospital mortality
  • Increase patient, family, and staff satisfaction

6
Rapid Response Teams
  • Guideline Develop an Early Warning System
  • Something isnt right
  • Heart rate lt40/gt160 (some systems use 120) new
    onset chest pain
  • Blood pressure Consider range of SBP lt80/gt180
  • or DBP gt100
  • Respiratory status Consider rate lt8/gt28 bpm
  • consider SpO2 lt85-90 for more than 5 minutes
  • increasing O2 demand to maintain baseline
    SpO2 evidenced
  • by increased work of breathing or change
    in breathing
  • pattern
  • Neurological status Acute change in baseline
    neuro status
  • Alteration in LOC AMS
  • Unexplained lethargy and/or agitation new
    delirium
  • Seizure
  • Symptoms of stroke change in speech,
    facial/extremity weakness, numbness/tingling

7
Rapid Response Teams
  • Guideline Develop an Early Warning System
  • Some institutions use Early Warning Score 3 or
    more institutes activation of RRT

8
Rapid Response Teams
  • Guideline Other Considerations
  • RRT should consist of qualified individual
    providers with excellent assessment,
    communication, and clinical skills
  • Have a means by which to active an ACS protocol
    with qualified cardiopulmonary providers should
    the event be an ACS event have an algorithm that
    drives activity
  • Encourage family members to be educated and feel
    comfortable activating the RRT
  • Bedside report upon arrival of the RRT should
    include SBAR (situation, background, assessment,
    recommendation) in a concise, brief exchange in
    order to give the providers on the RRT enough
    information to begin piecing the events together

9
Rapid Response Teams
  • Guideline Other Considerations
  • Provide ongoing simulation training to the RRT
    members
  • Provide ongoing evaluation of RRT events and
    problems that arise
  • Post early warning signs for activation of the
    RRT with clear visibility for patients, their
    family members, and healthcare staff (ie posters)

10
Rapid Response Teams
11
Rapid Response Teams
  • Algorithm example at
  • https//www.icsi.org/_asset/8snj28/rrt.pdf

12
Rapid Response Teams
  • References
  • Health care protocol rapid response teams.
    Institute for Clinical Systems Improvement.
    Retrieved from internet on 8/11/2014 at
    https//www.icsi.org/_asset/8snj28/rrt.pdf
  • Romero-Brufau, S., et al. (2014). Widely used
    track and trigger scores Are they ready for
    automation in practice? Resuscitation 85 (2014)
    549-552.
  • Pliego, J., Sheather, S., Villamaria, F.
    Wehbe-Janek, H., (2014). System-based
    interprofessional simulation-based training
    program increases awareness and use of rapid
    response teams. The Joint Commission on Quality
    and Patient Safety. Vol 40 No 6.

13
Use of Corticosteroids in Septic Shock
  • Background
  • The use of corticosteroids as an adjunctive
    therapy has been used for decades, controversial
    and often misunderstood.
  • High-dose corticosteroids have been shown to
    provide no real benefit in septic shock
  • Hypothetically, severely prolonged systemic
    inflammation can lead to adrenal insufficiency
    resulting in critical illness-related
    corticosteroid insufficiency which, can be
    treated with physiologic doses of corticosteroid
    (hydrocortisone 200mg 300 mg per day)
  • Studies have shown reduction in mortality in
    patients with relative adrenal insufficiency when
    treated with physiologic doses of corticosteroid
  • The 2012 Surviving Sepsis Guidelines attempted to
    clarify often misunderstood guidelines from 2008.

14
Use of Corticosteroids in Septic Shock
  • Barriers to Guideline Implementation
  • No specific dosing recommendations beyond stating
    a limit of 300mg/day
  • Intensivists individualizing treatment
  • Different interpretations of the guidelines
  • Discrepancy between a clinicians interpretation
    of guidelines and the reality of their clinical
    practice
  • Lack of support from institution to implement
    prevention and treatment bundles based on
    evidence

15
Use of Corticosteroids in Septic Shock
  • 2008 Surviving Sepsis Guidelines for
    Corticosteroids
  • Hydrocortisone IV should be given only to adult
    patients in septic shock after it has been
    confirmed that their blood pressure is poorly
    responsive to fluid resuscitation and vasopressor
    therapy.
  • ACTH stimulation test should not be used to
    identify the subset of adults with septic shock,
    who should receive hydrocortisone
  • Steroids need to be weaned by the clinician when
    vasopressors are no long required

16
Use of Corticosteroids in Septic Shock
  • 2012 Surviving Sepsis Guidelines for
    Corticosteroids
  • Do not administer IV hydrocortisone to treat
    adult septic shock patients if adequate fluid
    resuscitation and vasopressor therapy are able to
    restore hemodynamic stability. If this is not
    achievable, the suggestion is IV hydrocortisone
    alone at a dose of 200mg per day
  • RATIONALE Several studies have shown benefit on
    mortality with the use of hydrocortisone in
    patients who exhibit shock, as well as low
    results. Because of study design and patient
    population differences, disparity continues in
    the research. So, it is best to use fluid
    resuscitation and vasopressors when the patient
    is responsive to such treatments.

17
Use of Corticosteroids in Septic Shock
  • 2012 Surviving Sepsis Guidelines for
    Corticosteroids
  • Do not use the ACTH stimulation test to identify
    the subset of adults with septic shock who should
    receive hydrocortisone
  • RATIONALE Observations have been made in
    multicenter trials regarding responders and
    nonresponders to hydrocortisone in septic shock
    and ACTH stimulation tests are not significant
    predictors of adrenal insufficiency. Random
    cortisol tests may still be useful for absolute
    adrenal insufficiency , but not relative adrenal
    insufficiency (no absolute stress response). A
    random cortisol level of less than 15 µg/dl in
    critical illness is where most literature sets
    the limit to treat relative adrenal
    insufficiency some studies suggest as high as 20
    25 µg/dl Of note, etomidate when used for
    intubation, can suppress the hypothalamic-pituitar
    y-adrenal axis therefore, reducing levels of
    cortisol.

18
Use of Corticosteroids in Septic Shock
  • 2012 Surviving Sepsis Guidelines for
    Corticosteroids
  • 3) Taper treated patients from steroid therapy
    when vasopressors are no longer being used
  • RATIONALE There has been no comparative study
    between fixed-duration and clinically guided
    regimen or between tapering and abrupt cessation
    of steroids. There have been randomized
    controlled trials that have shown good results in
    a weaning regimen, abrupt cessation (however, one
    study showed hemodynamic and immunologic rebound
    effects after abrupt cessation), and no
    difference in outcome with regimens of low dose
    steroids for 3 or 7 days.
  • ? This leads to a barrier in practice giving rise
    of clinicians to implement their own practice
    biases. More large center trials are needed.

19
Use of Corticosteroids in Septic Shock
  • 2012 Surviving Sepsis Guidelines for
    Corticosteroids
  • 4) Do not administer steroids for the treatment
    of sepsis in the absence of shock
  • RATIONALE There is no sufficient evidence to
    show that steroid treatment has benefit in
    treating patients who have sepsis but, who do
    not have shock. In this case, steroids may be
    considered for adrenal dysfunction, but no
    evidence supports steroid treatment for a
    preventive potency in reducing the incidence of
    severe sepsis and shock in critically ill
    patients.
  • When low-dose hydrocortisone is given, use
    continuous infusion rather than bolus injections
  • RATIONALE Several randomized trials show an
    increase in hyperglycemia and hypernatremia with
    the use of bolus high-dose steroids.

20
Use of Corticosteroids in Septic Shock
  • References
  • Contrael, K., et al. (2013). Prescribing
    patterns of hydrocortisone in septic shock a
    single-center experience of how surviving sepsis
    guidelines are interpreted and translated into
    bedside practice. Critical Care Medicine.
    4110.
  • Dellinger, R., et al. (2013). Surviving sepsis
    campaign international guidelines for
    management of severe sepsis and septic shock
    2012. Critical Care Medicine. 412.
  • Pastores, S., Rajendram, P., (2013). Prescribing
    patterns for corticosteroids in septic shock
    translating guidelines into bedside practice.
    Critical Care Medicine. 4110.

21
Central Venous Catheter Infection Prevention
  • Background
  • Central venous catheters (CVC) are routinely used
    in the ICU and bloodstream infections are a major
    complication in those patients with indwelling
    CVC.
  • CVC tubing may contribute to bacteremia and other
    infections.
  • Healthcare associated infections can contribute
    to increased mortality and morbidity when
    hospital staff do not adhere to proper aseptic
    technique when inserting CVCs and caring for them
  • Over 80,000 CVC-related blood stream infections
    occur annually in ICUs and increase LOS.

22
Central Venous Catheter Infection Prevention
  • Current 2011 CDC Guidelines Summary
  • 1) Educate clinicians regarding the indications
    of CVC use, proper procedures to insertion and
    maintenance, and appropriate infection control
    measures
  • 2) Periodically assess knowledge of and
    adherence to guidelines for all involved with
    insertion and care of CVCs.
  • 3) Designate only trained personnel who
    demonstrate competence for insertion and
    maintenance of CVCs
  • 4) Ensure appropriate nursing staff levels in
    ICUs. Studies suggest that a higher proportion
    of pool nurses or elevated patient-to-nurse
    ratio is associated in increased occurrence of
    CVC-related infections

23
Central Venous Catheter Infection Prevention
  • Current 2011 CDC Guidelines
  • Use maximal sterile barriers during CVC insertion
  • Use gt0.5 chlorhexidine skin preparation with
    alcohol for skin antisepsis
  • Avoid routine placement of CVC as a strategy to
    prevent infection
  • Avoid femoral vein placement of CVC (higher risk
    for infection due to location)
  • Change dressings using aseptic technique
  • Perform daily audits to assess whether central
    line is still needed
  • Promote hand hygiene

24
Central Venous Catheter Infection Prevention
  • Current 2011 CDC Guidelines
  • Promote evidence based bundles for prevention of
    CVC infections
  • Avoid subclavian site in patients receiving
    hemodialysis to avoid subclavian vein stenosis
  • Use ultrasound guidance to place CVCs to reduce
    number of cannulation attempts and mechanical
    complications
  • Promptly remove any CVC that is no longer deemed
    necessary
  • When adherence to aseptic technique cannot be
    ensured, replace catheter as soon as possible
    (outside hospital admisisons)

25
Central Venous Catheter Infection Prevention
  • Current 2011 CDC Guidelines
  • Do not remove CVCs or PICCs on the basis of fever
    alone. Use clinical judgement
  • Do not use guidewire exchange routinely for
    non-tunneled CVCs to prevent infection, or for
    CVC that is suspicious of infection
  • Replace administration tubing no more frequently
    than 96 hours for those sets not infusing blood,
    blood products, or fat emulsions (ie TPN,
    propofol, lipids), but at least every 7 days
  • Replace administration tubing for blood, blood
    products, and fat emulsions every 24 hours
  • Replace tubing for propofol every 6-12 hours or
    with each new bottle of medication

26
Central Venous Catheter Infection Prevention
  • Suggested Updates to Guidelines
  • Use antimicrobial CVCs (no significant difference
    between non-impregnated or impregnated) to reduce
    line infections, especially in ICUs, where the
    primary evidence shows to be most effective. Use
    caution outside the ICU where nursing staff may
    be less aware of CVC-related infection
    precautions.
  • Provide ongoing education to hospital staff
    regarding infection prevention in order to assess
    knowledge and adherence to guidelines
  • When introducing bundles for prevention of
    infection, introduce one new intervention at a
    time to decrease confusion and/or overwhelming
    the hospital staff to increase adherence

27
Central Venous Catheter Infection Prevention
  • References
  • Flodgren, G., et al. (2013). Interventions to
    improve professional adherence to
    guidelines for prevention of device-related
    infections. Cochrane Database of Systematic
    Reviews, Issue 3. CD 006559
  • OGrady, N., et al. (2011). Guidelines for the
    prevention of intravascular catheter-related
    infections. Centers for Disease Control.
    http//www.cdc.gov/hicpac/pdf/guidelines/bsi-g
    uidelines-2011.pdf
  • Lai, NM., et al. (2013). Catheter impregnation,
    coating or bonding for reducing central venous
    catheter-related infections in adults. Cochrane
    Database of Systematic Reviews, Issue 6. CD
    007878
  • Ullman, AJ., et al. (2013). Optimal timing for
    intravascular administration set replacement.
    Cochrane Database of Systematic Reviews, Issue 9.
    CD 003588

28
Critical Care of the Organ Donor
  • Background
  • Organ donation is often surrounded by ethical and
    policy issues that require strict adherence
  • Donation after circulatory determination of death
    (DCDD Formerly known as donation after cardiac
    death) has the potential to increase the number
    of organs available for transplantation.
  • Consent and management of potential donors must
    occur before death therefore, unique ethical
    considerations exist

29
Critical Care of the Organ Donor
  • Background
  • DCDD organs are accounting for more available
    organs across the Organ Procurement Organizations
    (OPO), allowing for more policies to be enacted
    in hospitals to consider ethical principles and
    advanced directives regarding organ donation
  • Care of the DCDD donor/patient requires dedicated
    and informed hospital staff along with OPO staff

30
Critical Care of the Organ Donor
  • Underlying Ethical Principles
  • Acts that promote the opportunity to donate
    viable organs respect the patients potential
    interest in becoming an organ donor.
  • RATIONALE In controlled DCDD, actions must be
    taken on living persons which are more for the
    intent of organ preservation for donation. It
    becomes imperative to promote the donors
    legitimate interests in what becomes of their
    bodies after death

31
Critical Care of the Organ Donor
  • Underlying Ethical Principles
  • The legitimacy of surrogate decision making for
    critically ill patients whose wishes are unknown
    extends to decisions regarding organ donation
  • RATIONALE Critically ill patients are often
    incapacitated of decision making. Surrogates are
    viable decision makers however, care must be
    taken that the wishes of the surrogate do not
    overshadow the wishes of the donor prior to
    critical illness

32
Critical Care of the Organ Donor
  • Underlying Ethical Principles
  • 3) If real or perceived conflicts arise between
    the goals of providing optimal end-of-life care
    and the goals of procuring organs, delivery of
    quality end-of-life care should take priority
  • RATIONALE Patients or their surrogates must be
    well informed of how certain end-of-life
    treatment strategies may impact opportunities for
    donation before they are initiated.

33
Critical Care of the Organ Donor
  • Treatment Guidelines for Organ Optimization with
    DCDD
  • Hemodynamics Immediate attention should be
    given to correcting hypotension resulting in
    maximized organ perfusion.
  • - Use volume
  • - Use vasoactive drugs cautiously vasopressin
    has become the drug of choice in lieu of high
    dose vasopressors

34
Critical Care of the Organ Donor
  • Treatment Guidelines for Organ Optimization with
    DCDD
  • Pulmonary Lungs are transplanted most rarely
    (15-25 of donors) therefore, care should be
    taken to optimize if viable
  • - Adequate gas exchange is imperative
  • - Mechanical ventilation should focus short
    periods of PEEP of 15 cm H2O for 2 hours
    followed by lower PEEP of 5 cm H2O to prevent
    atelectasis and open alveoli.
  • - Avoid excess fluid administration

35
Critical Care of the Organ Donor
  • Treatment Guidelines for Organ Optimization with
    DCDD
  • 3) Hormonal Therapy
  • - Catecholamine surges following DCDD are
    common. These need to be avoided by doing the
    following
  • Exogenous replacement of ADH following posterior
    pituitary insufficiency this has been shown to
    improve graft function of kidneys, liver, and
    cardiac recipients
  • Volume replacement is essential to treat Diabetes
    Incipidus
  • Correct Hypernatremia
  • Deficiencies of pituitary hormones need to be
    corrected TSH, T4, HGH. UNOS has done research
    hormone replacement and has been shown to
    increase donation of organs by 22.5
  • Correct hyperglycemia using insulin infusion, if
    needed

36
Critical Care of the Organ Donor
  • Guidelines for Organ Optimization with DCDD
  • Organ procurement can only occur once death has
    been certified by a physician
  • To decrease warm ischemic time, withdrawal of
    life support should occur in the OR where
    procurement can begin immediately thereafter.
  • Consideration for Extracorporeal Membrane
    Oxygenation (ECMO) to increase oxygenation and
    organ preservation is controversial and an
    extreme measure that must be understood by those
    involved in premortem care

37
Critical Care of the Organ Donor
  • References
  • Baumann, A., et al. (2013). Elective
    non-therapeutic intensive care and the four
    principles of medical ethics. Journal of
    Medical Ethics. 39 139-142
  • Dare, A., Bartlett, A., Fraser, J. (2012).
    Critical care of the potential organ donor.
    Curr Neurol Neurosci Rep. 12 456-465
  • Gries, C., et al. (2013). An official American
    Thoracic Society/International Society for Heart
    and Lung Transplantation/Society of Critical Care
    Medicine/Association of Organ and Procurement
    Organizations/United Network of Organ Sharing
    Statement Ethical and policy considerations in
    organ donation after circulatory determination of
    death. American Journal of Respiratory Critical
    Care. 188 1, 103-109

38
Advanced Cardiac Life Support
  • Simplified Algorithms for Easy Memorization and
    Use in Acute Events
  • TOO FAST VT, VF
  • Determine whether stable or unstable
  • Stable
  • Narrow complex (SVT) Wide complex (VT)
  • Vagal
  • Drugs
  • Adenosine 6mg ? 12mg/12 Amiodarone 150mg bolus
    Sotalol
  • Then, consider betablocker, CCB
  • Unstable (hypotension/shock/ACS/AMS/CP) ?
    Cardioversion

39
Advanced Cardiac Life Support
  • Simplified Algorithms for Easy Memorization and
    Use in Acute Events
  • TOO SLOW sinus brady/heart blocks
  • Determine whether symptomatic (unstable) or
    asymptomatic
  • Symptomatic
  • Atropine 0.5mg q3-5 mins (max 3mg)only use for
    atropine now
  • Call for TCP
  • Epinephrine/domamine infusion
  • Asymptomatic
  • 1) Monitor causes

40
Advanced Cardiac Life Support
  • Simplified Algorithms for Easy Memorization and
    Use in Acute Events
  • Pulseless VT/VF
  • SHOCK (Defib VF) _at_ 200 J
  • ? CPR 2 mins. (prep meds)
  • ? Rhythm check
  • SHOCK if still no pulse VF/VT
  • ? CPR 2 mins. (give meds epi call for amio)
  • ? Rhythm check
  • Consider Hs/Ts (hypoxia, hypothermia,
    hypovolemia, hypo/hyperK, Hydrogen ion acidosis)
    (Toxins, Thromboses (cardiac/pulmonary),
    Tamponade Mg, Tension pthx)
  • ? Continue cycles of CPR

41
Advanced Cardiac Life Support
  • Simplified Algorithms for Easy Memorization and
    Use in Acute Events
  • Pulseless Electrical Activity/Asystole
  • CPR
  • Epinephrine 1mg q3-5 mins
  • H/Ts
  • Return of Spontaneous Circulation
  • V VS, values (labs)
  • O O2 ETT with capnography
  • M Mentation (candidate for hypothermia?)
  • I IVs, ICE
  • T Twelve lead transport (either cath lab for
    STEMI ICU for NSTEMI)
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