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Current Guidelines in Critical Care Session 1: 2014 Critical Care Boot Camp


... lorazepam, midazolam Use clinical judgment when selecting ICU PAD ... Bispectral Index (BIS), Narcotrend Index (NI), Patient State Index (PSI), or State ... – PowerPoint PPT presentation

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Title: Current Guidelines in Critical Care Session 1: 2014 Critical Care Boot Camp

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

Current Guidelines in Critical CareSeptember 8,
  • Ventilator Associated Events
  • Resuscitative Fluid
  • ICU Delirium Bundle
  • Glucose Management in the ICU
  • Antibiotic Rotation in the ICU
  • Ebola Virus Guidelines

  • 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

Ventilator Associated Events in Adults
  • Background
  • Formerly known as VAP (Ventilator Associated
    Pneumonia) last updated in 2002
  • VAEs reported to National Healthcare Safety
    Network (NHSN) the CDCs Healthcare Associated
    Infection (HAI) surveillance system newly
    updated in 2011
  • Prior reporting systems were too subjective
    CDCs Division of Healthcare Quality Promotion
    teamed with CDC Prevention Epicenters to develop
    more objective reporting

Ventilator Associated Events in Adults
  • Background continued
  • Previous reportable data
  • 1) Xray component
  • 2) Signs and Symptoms component
  • 3) Laboratory component
  • - Previous reports too subjective and variable
    across institutions based on resources and lack
    of standardization

Ventilator Associated Events in Adults
  • New Algorithim Created
  • Created in cooperation with critical care
    professionals and organizations involved in the
    care of mechanically ventilated patients
  • More objective
  • Requires engagement across disciplines

Ventilator Associated Events in Adults
  • New Algorithm for Surveillance
  • - Patients gt/ 18 years of age
  • - Patients who have been intubated/mechanic
    ally ventilated for at least 3 calendar days
  • - Include patients in acute and long-term
    acute care hospitals and inpatient
    rehabilitation facilities
  • (ECMO, HFV, Prone patients are excluded)

Ventilator Associated Events in Adults
  • New Algorithim vs Old Algorithm Whats
  • - Xray No radiographic reporting is required
    due to inconsistency in ordering practices and
    variability in resources/techinique. Do not
    adequately identify patients with VAP
  • - Will detect ventilator associated conditions
    and complications
  • - Focuses on readily available, objective
    clinical data
  • - Requires a minimum period of time on the

Ventilator Associated Events in Adults
  • Minimum daily FiO2 increase gt/ .20 over
    baseline gt2 days
  • Minimum PEEP increase gt/ 3 cmH20 over baseline gt
    2 days

Ventilator Associated Events in Adults
  • Infection- Related Ventilator Associated
    Complication (IVAC) Definition
  • On or after calendar day 3 of mechanical
    ventilation within 2 calendar days of onset of
    worsening oxygenation, ONE of the following
    criteria is met
  • Purulent respiratory secretions (gt25 neutrophils
    and lt10 squamous epithelial cells per lpf) or be
    above quantitative thresholds
  • Positive culture of sputum, BAL, lung tissue,
    histopathology, pleural fluid

Ventilator Associated Events in Adults
  • The events on previous slide are reportable
  • Break Down
  • VAC Temp, signs of infection, lab data of
    infection, new antimicrobial agent gt4 days
  • IVAC The above with the addition of positive
    cultures from lungs, lung tissue, purulent
  • More objective data
  • VAP no longer used as the event it is the result
    of the event
  • Reference 2011. Improving surveillance for
    ventilator-associated events in adults. Centers
    for Disease Control and Prevention

Ventilator Associated Events in Adults
  • Prevention
  • Oral chlorhexadine rinse reduces opportunistic
    VAP by 40 when performed consistently by nursing
    and care staff q6-8 hours(1)
  • Elevate the head of the bed at an angle of 30-45
    degrees for a patient at high risk for aspiration
    in the absence of medical contraindications.
  • Use a dedicated suction line for endotracheal
    tube suctioning of respiratory secretions or use
    ETT with subglottic secretion drainage
  • Cuff pressure should be maintained at 20-25 cm
  • Circuit changes should occur when visibly soiled
    rather than routinely.
  • Heat and moisture exchangers should not be
    changed more frequently than every 48 hours or
    when they become visibly soiled or mechanically
  • Assess patient for daily sedation
    reduction/discontinuation and implement per
    institution's guidelines. Reduce or discontinue
    sedation until patient is awake and can follow
    simple commands OR patient becomes agitated.
  • Assess eligibility for daily weaning trials
    unless contraindicated (2)

Ventilator Associated Events in Adults
  • References
  • Shi, et al. 2013. Oral hygiene care for
    critically ill patients to prevent
    ventilator-associated pneumonia. Cochrane
    Database Systematic Review.
  • Sinuff, et al. 2013. Implementation of clinical
    practice guidelines for ventilator-Associated
    pneumonia prospective study. Critical Care
    Medicine. Vol 41-1 15-23
  • 2011, 2014. Prevention of ventilator-associated
    pneumonia. Health care protocol. National
    Guideline Clearinghouse. Agency for Healthcare
    Research and Quality.

Resuscitative Fluid in ICU
  • Background
  • Recent evidence has shown that hyperchloremic
    crystalloid solutions, such as Normal Saline, can
    induce and/or exacerbate hyperchloremia, acute
    kidney injury (causes renal vasoconstriction and
    decreased GFR), and metabolic acidosis in the
    critically ill patient.

Resuscitative Fluid
  • Recommendations
  • In the critically ill adult, it has been shown
    that by using nonchloride-rich fluids, that there
    are significant reductions in rise in SCr, AKI
    (using the RIFLE criteria), and the use of RRT
  • Choosing from the following fluids assist in
    lowering the risk of these conditions
  • Lactated Crystalloid Solution (Cl- 109 mmol/L)
  • Plasma Lyte (Cl- 98 mmol/L)
  • 20 Albumin Solution (Cl- 19 mmol/L). Be
    considerate of costs and availability in your

Resuscitative Fluid
  • References
  • Yunos, et al. 2012. Association between a
    chloride-liberal vs chloride-restrictive
    intravenous fluid administration strategy and
    kidney injury in critically ill adults. JAMA,
    October 17, 2012 Vol 308, No. 15

ICU Pain, Agitation, Delirium (PAD) Bundle
  • Background
  • In 2013, the American College of Critical Care
    Medicine published a revised version of the pain,
    agitation, and delirium guidelines (from 2002) to
    include an ICU pain, agitation, and delirium
    care bundle designed to facilitate implementation
    of said guidelines.
  • Update the ABCDE Bundle (did not address pain
  • Link these guidelines with other evidence-based
    ICU practices including, SBTs, early mobility,
    and sleep hygiene in order to improve ICU patient
    outcomes and reduce costs of care/LOS

PAD Bundle Pain
  • Assessing Pain in the PAD Bundle
  • Use a numeric pain scale for patients who can
    self-report pain use a behavioral pain scale for
    those who cannot
  • Pain is considered gt/4 on a NPS and gt/ 6 on a
  • Pain should be assessed at least 4 times per
    nursing shift and more often if changes in NPS or
    BPS occur

PAD Bundle Agitation
  • Assessing agitation/sedation in the PAD Bundle
  • Assess agitation/sedation with an evidence-based
    scale such as the Richmond Agitation and Sedation
    Scale (RASS) or Sedation-Agitation Scale (SAS).
    This will help avoid over sedation and the
    harmful outcomes that can occur (longer vent
    days, increased risk of ICU delirium and
    neuropsychological sequelae, increased risk of

PAD Bundle Delirium
  • Assessing delirium in the PAD Bundle
  • Assess for delirium using an evidence-based scale
    such as Confusion Assessment Method (CAM-ICU) at
    least once per shift to avoid increasing the risk
    of prolonged vent days, increased LOS,
    postdischarge institutionalization, long-term
    cognitive dysfunction, and increased risk of

ICU PAD Bundle Treatment
  • Treating pain
  • Treat pain FIRST, then consider sedation (only if
    needed). May patients can manage mechanical
    ventilation with effective analgesia only.
  • Options opioids (morphine, fentanyl,
    hydromorphone) for nonneuropathic pain
    nonopioids (acetaminophen) nonsteroidals
    (ketorolac, ibuprofen) adjunctives (ketamine,
    catapres), epidurals (primarily with rib
    fractures), consider gabapentin or carbamazepine
    for neuropathic pain
  • Assess pain within 30 minutes of administering
    the selected pain regimen and adjust as deemed
    necessary based on evidence-based pain scale

ICU PAD Bundle Treatment
  • Treating agitation
  • Use the following guidelines when deciding what
    type of treatment plan is needed
  • Specific indications for sedation and the
    sedative goals for each patient
  • Compatibility between the clinical pharmacology
    of a sedative, its side effect profile, and the
    relative contraindications for its use in the
    critically ill patient
  • Overall costs (not limited to pharmacy costs)
    associated with a particular sedative

ICU PAD Bundle Treatment
  • Treating agitation
  • Benzodiazepines vs Nonbenzodiazepines
  • Some studies (meta-analyses and Fraser, et al)
    suggest that use of nonbenzos over benzos reduce
    length of stay and reduction of ventilator days
    but, no specific data suggests decreased
    prevalence of delirium or decreased short-term
  • Nonbenzo options Dexmedetomidine and diprovan
  • Benzo options most common choices lorazepam,
  • Use clinical judgment when selecting

ICU PAD Bundle Treatment
  • Treating agitation
  • A note about benzos
  • Guidelines do not prohibit use of benzos
  • Still a good choice because of their anxiolytic,
    amnesic, and anticonvulsant properties
  • Still recommended for use of treating ethanol
    and/or benzo withdrawal
  • Recommended for patients needed sedation who have
    intractable seizures
  • Synergistic effects can be achieved with benzos
    when other sedation options have proven

ICU PAD Bundle Treatment
  • Treating agitation
  • Sedate only those patient needing sedation based
    on an evidence-based approach using the lightest
    amount of sedation tolerated by the patient
    (being able to perform 3 of the 5 following
    commands open eyes, maintain eye contact,
    squeeze hand, stick out tongue, wiggle toes)

ICU PAD Bundle Treatment
  • Treating delirium
  • First steps in treating delirium
  • Identify and eliminate potential contributing
  • Sepsis
  • Septic shock
  • Glycemic dysregulation
  • Electrolyte disorders
  • Hypoxia/Hypercarbia
  • Treat untreated pain
  • Treat drug withdrawal
  • Discontinuation of psychiatric medications
  • Decrease exposure to deliriogenic medications
    (ie benzos)
  • Eliminate adverse drug reactions
  • Improve environmental factors (ie sleep
    deprivation, disorientation, prolonged
    immobilization, use of restraints)

ICU PAD Bundle Treatment
  • Treating delirium
  • Nonpharmacologic
  • Frequent reorientation
  • Allowing for eyeglasses and hearing aids
  • Maintaining sleep-wake cycles
  • Minimizing nursing activities at night to
    increase quality sleep
  • Mobilizing patients (even ventilated patients)
  • Pharmacologic
  • Adequate analgesia (opioid/nonopioid infusions
    pca prn)
  • Discontinue benzos (except in patients with
    benzo/alcohol withdrawal)
  • Resumption of patients psychiatric medications
  • Treat withdrawal syndromes
  • Antipsychotics if needed (olanzapine, quetiapine,
    haloperidol) Be careful to monitor Q-T intervals

ICU PAD Bundle Prevention
  • Pain
  • Take specific care to prevent procedural pain,
    especially in the ICU
  • Treat sleep deprivation to decrease long term
    effects such as PTSD
  • Agitation
  • Reduce the need for sedation highest reported
    reason is for mechanical ventilation use SBTs
    SATs DSIs to reduce ventilator days
  • Delirium
  • Improve sleep quality
  • Normalize (increased mobility, remove lines and

ICU PAD Bundle Big Picture
  • Optimize pain management first
  • Make light sedation the norm
  • Move away from routinely using benzodiazepines ,
    especially in ICU patients who are at high risk
    for delirium
  • Implement more effective delirium prevention and
    treatment strategies using both pharmacologic and
    nonpharmacologic methods
  • Use antipsychotics judiciously and be aware of
    clinical effects

ICU PAD Bundle
ICU PAD Bundle
  • References
  • Barr, J., Pandharipande, P. 2013. The pain,
    agitation, and delirium care bundle
    synergistic benefits of implementing the 2013
    pain, agitation, and delirium guidelines in an
    integrated and interdisciplinary fashion.
    Critical Care Medicine 2013 41 S99-115
  • Barr, et al. 2013. Clinical practrice
    guidelines for the management of pain,
    agitation, and delirium in the intensive care
    unit. Critical Care Medicine. 2013 41

Glucose Management in the ICU
  • Background
  • Untreated hyperglycemia and/or hypoglycemia
    contributes to increased mortality in critically
    ill patients with specific research available
    for unstable angina, AMI, CHF, arrhythmia,
    ischemic and hemorrhagic stroke, GIB, ARF,
    pneumonia, PE, and sepsis
  • Morbidity/Mortality can be increased with those
    patients with pre-existing diabetes
  • There was an established need to define a more
    specific glycemic range for target glucose goal.

Glucose Management in the ICU
  • Background General ADA recommendations
  • Patients with diabetes should have their disease
    clearly marked in their chart when entering the
  • Sole use of sliding scale insulin is discouraged
    in the inpatient setting
  • All patients with diabetes should have an order
    to check their blood glucose with results
    reported to their primary healthcare team
  • Consider ordering a HgA1C for patients who are
    suspected to be poorly controlled diabetics or
    who have significant risk factors for diabetes
    when being hospitalized

Glucose Management in the ICU
  • Guidelines (Clinical Practice Guideline Study)
  • A BG gt150 mg/dL should trigger initiation of
    insulin therapy titrated to keep BG lt150 mg/dL
    ADA recommends 140-180 mg/dL for tight glycemic
  • NICE-SUGAR RCT showed higher incidence of
    hypoglycemia in intensive BG target range of
    81-108 mg/dL
  • 2) Maintain BG absolutely lt180 mg/dL
  • 3) Avoid hypoglycemia defined lt70 mg/dL better
    achieved with intravenous insulin infusion with a
    glucose source
  • 4) Avoid or minimize dextrose infusions when
    patient have another source of nutrition such as
    enteral tube feeds or parenteral nutrition

Glucose Management in the ICU
  • Guidelines (Clinical Practice Guideline Study)
  • 5) Avoid BG lt100 mg/dL in patients with brain
    injury (can produce or exacerbate neurological
    deficits, encephalopathy, seizures, permanent
    cognitive dysfunction, death)

Glucose Management in the ICU
  • Guidelines (Clinical Practice GuidelineStudy)
  • 6)Treatment of hypoglycemia stop insulin
    infusion and adminsiter 10-20 grams of hypertonic
    (50) dextrose and recheck BG within 15 minutes
    with a goal BG gt70 mg/dL achievement taking
    effort to avoid iatrogenic hyperglycemia
  • Point of Care testing
  • Care should be taken to realize that glucometers
    have various error rates based on condition of
  • In the critically ill, especially patients on
    vasopressors, in shock, or critically anemic,
    arterial or venous samples should be used for BG

Glucose Management in the ICU
  • Guidelines (Clinical Practice Guideline Study)
  • 8)Transitioning from insulin infusion to SSI
    Patients in the ICU should be started on SSI of a
    protocol-driven basal/bolus regimen before the
    insulin infusion is discontinued to avoid loss of
    glycemic control
  • Calculate the basal/bolus regimen based on the
    patients use of IV insulin in the last 24 hours,
    taking into consideration carbohydrate intake

Glucose Management in the ICU
  • Guidelines Considerations out of the ICU
  • Antihyperglycemics Okay to use once patient is
    stabilized and readied for discharge. May need
    to avoid metformin as increased risk for renal
    insufficiency and hemodynamic instability in the
    hospitalized patient
  • Use inpatient specialized diabetes providers when
    available for hospitalized patients who have
  • Self management may be agreed upon by patient and
    provider is they mutually agree that the patient
    understand the use of his/her insulin pump,
    insulin injections, and treatments for sick day
    management of glucose

Glucose Management in the ICU
  • Guidelines Considerations out of the ICU
  • Note There are more specific recommendation/sugge
    stions in this study, but address metrics and
    calculation formulae of insulin infusion
    protocols that were outside the scope of this
  • References
  • Standards of medical care in diabetes 2014.
    American Diabetes Association. Diabetes Care
    2014 Jan 37 S 14-80
  • Jacobi, et al. 2012. Guidelines for the use of
    an insulin infusion for the management of
    hyperglycemia in critically ill patients.
    Critical Care Medicine. Vol 40, No 12

Antibiotic Rotation in the ICU
  • Background
  • Patients in the ICU are at an increased risk
    for hospital-acquired infections (HAI)
  • Gram-negative pathogen resistance to
    broad-spectrum antibiotics poses increase to
    morbidity and mortality
  • Gram-negative pathogen infections increase
    institutional resource utilization and
  • Use of antibiotic cycling is proposed to reduce
    resistance of gram-negative pathogens

Antibiotic Rotation in the ICU
  • Background Definitions
  • Antibiotic resistant pathogen Any pathogen
    that is resistant to at least one class of
    antibiotics (ie fluoroquinolones)
  • Multidrug resistant pathogen Any pathogen
    that is resistant to 3 or more classes of
    antibiotics (ie aminoglycosides,
    fluroquinolones, carbapenems)

Antibiotic Rotation in the ICU
  • Cycling vs Mixing Antibiotics
  • Cycling antibiotics allows for a resistance
    strain of pathogen to decrease in frequency or
    perhaps even disappear in the off-period
  • Mixing antibiotics (using randomly selected
    antibiotics on different patients)
  • The majority of research favors cycling in large
    populations of patients

Antibiotic Rotation in the ICU
  • Example antibiotic cycling for HAIs based on
    annual quarters
  • Pneumonia (Day 1-3) Pneumonia gt/ Day 4
    a Non-pneumonia b Excluded Class
  • 1st Qtr Ceftriaxone Levofloxacin Piperacillin
    /tazobactam CARB
  • 2nd Qtr Ampicillin/sulbactam Doripenem Cefepime
    /metronidazole FQ
  • Imipenem-cilastatin
  • 3rd Qtr Levofloxacin Cefepime Doripenem BL
  • 4th Qtr Ertapenem Piperacilline/tazobactam Levo
    floxacin/metronidazole ¾ CEPH
  • a Empiric coverage includes vancomycin and
    aminoglycoside until culture data is available
  • b Vancomycin included except in secondary
    peritonitis fluconazole included for high risk
    patients and tertiary peritonitis
  • BLIC beta-lactamase inhibitor combinations
    FQ fluoroquinolones
  • CARB carbapenems ¾ CEPH 3rd and 4th
    generation cephalosporins

Antibiotic Rotation in the ICU
  • Guidelines
  • Incorporate multiple disciplines to reduce
    infection risks (nursing, pharmacy, physician,
    infectious disease, pathology, advanced practice
    nurses/PAs, nutrition, IT). Terminal room cleans
    after discharge of patient with resistant
  • Narrow antibiotics to pathogen-specific drug as
    soon as known (de-escalate)
  • Pneumonia early and late onset
  • Non-pneumonia blood stream, surgical site,
    urinary tract,
  • body fluid
  • Avoid prophylactic antibiotics except in
    certain patient populations (abdominal trauma,
    orthopedic fractures, craniofacial trauma)
  • Rotate antibiotic classes on a quarterly basis
    to reduce resistance and maintain heterogeneity
  • Aggressively empirically treat suspected
    pathogens and de-escalate as cultures are
    speciated (ie suspected necrotizing soft tissue
    infections use of clindamycin)

Antibiotic Rotation in the ICU
  • References
  • Dortch, M., et al. 2011. Infection reduction
    strategies including antibiotic stewardship
    protocols in surgical and trauma intensive care
    units are associated with reduced resistant
    gram-negative healthcare-associated infections.
    Surgical Infections. 2011 12 15-25
  • Kouyos, R., Abel zur Wiesch, P., Bonhoeffer, S.
    2011. Informed switching strongly decreases the
    prevalence of antibiotic resistance in hospital
    wards. PLoS Computational Biology. 7(3)
  • May, A., et al. 2006. Influence of
    broad-spectrum antibiotic prophylaxsis on
    intracranial pressure monitor infecitons and
    subsequent infectious complications in
    head-injured patients. Surgical Infections.
    2006 7 409-417
  • May, A., 2014. Antibiotic stewardship program
    multidisciplinary surgical critical care
    guidelines. Vanderbilt Medical Center. .

Ebola Virus Updates
  • Background
  • Ebola Virus Disease (EVD), formerly known as
    ebola hemorrhagic fever, is rare and deadly
  • Found in several African countries near the Ebola
    river (Guinea, Liberia, Nigeria, Sierra Leone).
  • Current outbreak includes 2,127 persons with a
    54 mortality rate
  • Animal-borne most likely reservoir bats
  • On August 8, 2014, the World Health Organization
    declared the current EVD outbreak in West Africa
    as a public health emergency of international
  • 2 American healthcare workers contracted EVD
    while serving in Africa and were transported to
    Emory University Medical Center for treatment 1
    more has now contracted EBV

Ebola Virus Updates
  • Risks
  • History of travel to affected country in past 3
    weeks OR
  • Direct unprotected contact with blood, body
    fluids, secretions, or excretions of a person
    infected with EVD OR
  • Possible exposure when working in a laboratory
    that handles EVD
  • EVD is NOT airborne

Ebola Virus Updates
  • EVD Basics
  • Incubation period 2-21 days contagious patient
    once symptoms are exhibited
  • Initial Symptoms sudden onset of fever, intense
    weakness, muscle pain, headache, sore throat.
  • Progressive Symptoms vomiting, diarrhea, rash,
    acute renal injury, acute liver failure (rise in
    LFTs), internal/external bleeding
  • EVD only confirmed through lab testing of blood
  • No vaccine
  • Care is supportive only prevent spreading

Ebola Virus Updates
  • Guidelines for Care of those with EVD
  • Surveillance is KEY in diagnosing EVD (begins in
    ED) thorough history of travel and exposure
  • Place patient in private room with door closed
  • Maintain a log of all persons entering the room
  • Nonessential staff and visitors are restricted
    from the room. NO students may enter
  • Use Contact and Droplet precautions (PPE
    gloves, gown, mask). Double gloving recommended

Ebola Virus Updates
  • Guidelines for Care of those with EVD
  • Wear eye protection (prescription glasses not
  • Use Powered Air Purifying Respirator in the event
    of an aerosol-generating procedure
  • Remove all PPE before exiting room and wash hands
    before exiting
  • In the likelihood of blood/body fluid contact,
    additional barriers should be used (plastic
    apron, leg and shoe covers, etc)

Ebola Virus Updates
  • Guidelines for Care of those with EVD
  • Dedicated medical equipment should be used
  • Limit use of needles and sharps
  • Contact institutional lab prior to sending any
    samples for testing so lab personnel can take
  • Virus needs to be undetectable in blood work
    before discharge

Ebola Virus Updates
  • Big Picture
  • Surveillance is key in recognizing symptoms and
    isolating the patient
  • Use PPE with each patient contact
  • EVD is spread with blood/body fluids (and
    infected food) not an airborne illness
  • Patient becomes contagious once symptoms occur,
    not during incubation
  • Care is intensive resuscitation supportive
  • Blood transfusions with EVD antibodies of
    survivors have not been proven research ongoing

Ebola Virus Updates
  • References
  • Disaster and Emergency Resources. Society of
    Critical Care Medicine. disaster/Pa
  • Infection prevention and control recommendations
    for hospitalized patients with known suspected
    ebola hemorrhagic fever in US hospitals. Centers
    for Disease Control. August 2014. retrieved
    8/25/14 at
  • Key Points Ebola Virus Disease, West Africa.
    World Health Organization. August 22, 2014.
    Retrieved 8/26/2014 at
  • Klompas, M., et al (Aug 21, 2014). Ebola fever
    Reconciling ebola planning with ebola risk in US
    hospitals. Annals of Internal Medicine
    10.7326/M14-1918 (electronic update)
  • Kuhar, D. (Aug 20, 2014). Infection prevention
    and control of ebola virus disease in US
    hospitals. Retrieved on 8/25/14 at
  • Safe management of patients with ebola virus
    disease in US hospitals. Centers for Disease
    Control. August 2014. retrieved 8/25/14 at