Crit care med give your patient a fast hug (at least) once a day

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Crit care med give your patient a fast hug (at least) once a day

  1. 1. Continuing Medical Education Give your patient a fast hug (at least) once a day* Jean-Louis Vincent, MD, PhD, FCCM LEARNING OBJECTIVES On completion of this article, the reader should be able to: 1. Interpret the mnemonic “Fast Hug.” 2. Explain the elements of “Fast Hug.” 3. Use this knowledge in a clinical setting. The author has disclosed that he has no financial relationships or interests in any commercial companies pertaining to this educational activity. Wolters Kluwer Health has identified and resolved any faculty conflicts of interests regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit. Objective: To introduce the Fast Hug mnemonic (Feeding, An- Interventions: Dependent on the results of applying the Fast Hug. algesia, Sedation, Thromboembolic prophylaxis, Head-of-bed el- Measurements and Main Results: Not applicable. evation, stress Ulcer prevention, and Glucose control) as a means Conclusions: Application of this simple strategy encourages of identifying and checking some of the key aspects in the general teamwork and may help improve the quality of care received by our care of all critically ill patients. intensive care unit patients. (Crit Care Med 2005; 33:1225–1229) Design: Not applicable. KEY WORDS: feeding; sedation; analgesia; stress ulcer preven- Setting: Any intensive care unit at any time. tion; semirecumbent; glucose control; thromboembolism Patients: All intensive care unit patients. E fforts are continually being cols, checklists, and physicians’ rounds. cently published guidelines (13). In addi- made to improve the quality Each of these has its place, and indeed, all tion, although protocols may be of patient care in the intensive three are important. Even though an ICU particularly valuable in ICUs of small pe- care unit (ICU); as elsewhere should optimally be staffed by intensivists ripheral hospitals, they are less efficient in the healthcare system, medical errors (2), the present mnemonic could be use- in large tertiary care institutions (14). are common and considerable variation ful to anybody working in an ICU. An alternative to the protocol is the in clinical practice persists even when checklist, widely employed outside med- evidence-based guidelines are available icine. Some have suggested that the ICU Protocols and Checklists (1). Suggested mechanisms to reduce er- be compared with the aviation cockpit, rors and encourage application of the lat- Protocols have been promoted as en- where checklists are routinely used to est clinical study results include proto- hancing the efficiency, safety, and efficacy improve safety. There are indeed some of care; enabling more rigorous clinical similarities between the airplane cockpit research; and facilitating education (1). and the sophisticated ICU environment in *See also p. 1424. Protocols are increasingly being applied terms of complex instruments, with Head, Department of Intensive Care, Erasme Hos- to specific treatment-management prob- many alarm systems and risks of life- pital, Free University of Brussels, Brussels, Belgium. lems, e.g., weaning from mechanical ven- threatening complications, but there the Presented in part at the 33rd Annual Meeting of comparisons end. Whereas there are rel- tilation (3–5), tight glucose control (6 – the Society of Critical Care Medicine, Orlando, FL, February 2004, and at the 24th International Sympo- 8), and adequate sedation (9 –11). atively few types of planes that any pilot sium on Intensive Care and Emergency Medicine, However, although protocols are easily will be expected to fly, and pilots have Brussels, Belgium, March 2004. applied to these relatively simple pro- very little freedom in their choice of Address requests for reprints to: Jean-Louis Vin- cesses, their usefulness is more debatable route, speed, or timing, intensivists deal cent, MD, Department of Intensive Care Erasme Uni- versity Hospital, Route de Lennik 808 B-1070, Brus- when more complex issues are involved, with an almost infinite combination of sels, Belgium. E-mail: jlvincen@ulb.ac.be for example, the correction of hypovole- disease states (Fig. 1) and have consider- Copyright © 2005 by the Society of Critical Care mia or the treatment of acute lung injury able freedom in the choice and intensity Medicine and Lippincott Williams & Wilkins (12); the treatment of septic shock be- of interventions. In addition, a pilot acts DOI: 10.1097/01.CCM.0000165962.16682.46 comes a real challenge, even with re- alone (or with just one co-pilot), whereas Crit Care Med 2005 Vol. 33, No. 6 1225
  2. 2. the intensivist is the coordinator of a team, unable to act effectively alone. Nev- ertheless, the concept of checklists may indeed be helpful in the ICU, as in the cockpit, and better than the concept of protocols. How often do we realize that a patient has not been fed for 2 or 3 days or another patient has not received heparin prophylaxis? Regular checklists would prevent these oversights. Rounds Rounds at the bedside are important and are part of good care. A number of studies have indicated that daily rounds at the bedside by intensivists may result in better outcomes (15, 16). When con- ducting bedside rounds, it is easy to ques- tion the continued need for ventilatory support for a patient undergoing me- Figure 1. Simplified comparison of the complexities of the intensive care unit (ICU) physician’s options chanical ventilation or the adequacy of and those of the airline pilot. PEEP, positive end-expiratory pressure. nutrition for a patient with a feeding so- lution bag hung above the bed; a protocol is not needed to ensure these questions Table 1. The seven components of the Fast Hug approach are asked and answered, and all members Component Consideration for Intensive Care Unit (ICU) Team of the ICU team—not just the physi- Feeding Can the patient be fed orally, if not enterally? If not, should we cians— can question these aspects of pa- start parenteral feeding? tient care. Likewise, the adequacy of se- Analgesia The patient should not suffer pain, but excessive analgesia should dation and analgesia should be be avoided systematically questioned (and more than Sedation The patient should not experience discomfort, but excessive once or twice a day!). sedation should be avoided; “calm, comfortable, collaborative” is typically the best level Thromboembolic prevention Should we give low-molecular-weight heparin or use mechanical The “Fast Hug” adjuncts? Head of the bed elevated Optimally, 30° to 45°, unless contraindications (e.g., threatened I would like to suggest the concept of cerebral perfusion pressure) the Fast Hug (Table 1), a simple, short Stress Ulcer prophylaxis Usually H2 antagonists; sometimes proton pump inhibitors mnemonic to highlight some key aspects Glucose control Within limits defined in each ICU in the general care of all critically ill patients, which should be considered at least once a day during rounds and, ide- the ICU and need adequate and appropri- debate, but the Canadian guidelines, ally, every time the patient is seen by any ate nutritional support, with daily review based on an extensive literature review, member of the care team. This approach of feeding. Unfortunately, there is no spe- recommend that solutions containing helps involve all members of the critical cific “nutrition” marker, and it is not fish oils, borage oils, and antioxidants care team, including nurses, physiother- practical to perform indirect calorimetry should be considered for patients with apists, and respiratory therapists. Al- on all patients, but a clinical assessment acute respiratory distress syndrome and though the Fast Hug can be vocalized and including weight loss measurement is that glutamine-enriched formulas should each component discussed (for example, probably as reliable as more complex be considered for patients with severe during rounds), it does not need to be tests (18). burns and trauma (21). Further study is practiced out loud but can be used as a Guidelines on nutritional support for needed to define the optimal feeding so- mental checklist when individual staff critically ill patients have been published lutions for different categories of ICU pa- members are attending the patient, thus (19 –21). In general, 5.6 kJ/kg per day is tients. providing all ICU staff with a simple way an acceptable and achievable target in- A for Analgesia. Pain can affect a pa- of ensuring that seven of the essential take, but patients with sepsis or trauma tient’s psychological and physiologic re- aspects of patient care are not forgotten. may require almost twice as much energy covery, and adequate pain relief must As such, it can become a thought process during the acute phase of their illness form an integral part of good intensive that is almost automatic when a patient’s (22). If oral feeding is not possible, en- care management. Critically ill patients bed is approached. teral nutrition is preferred to parenteral feel pain due not only to their illness but F for Feeding. Malnutrition increases nutrition (20, 21, 23) and should be also to routine procedures such as turn- complications and worsens outcomes for started early, preferably within 24 – 48 hrs ing, suctioning, and dressing changes critically ill patients (17). Many patients of ICU admission. The optimal constitu- (24). However, in one study of 5,957 pa- are already malnourished at admission to ents of feeding solutions remain under tients, 63% received no analgesics be- 1226 Crit Care Med 2005 Vol. 33, No. 6
  3. 3. fore a painful procedure (25). Pain is not used (9, 32, 33). However, these scales are antagonists, and the more recently pro- always easy to assess in critically ill pa- really so simple that one may wonder posed proton pump inhibitors; however, tients, who may be unable to express whether they are necessary, if everybody despite several randomized, controlled themselves; for such patients, subjective is aware of the possible problems and has studies and meta-analyses comparing measures of pain-related behavior (e.g., common goals. In our unit, we like using these agents (51–56), the optimal medi- facial expression, movement) and physi- the “CCC (calm, comfortable, collabora- cation is still not clear. In a multicenter ologic indicators (e.g., heart rate, blood tive) rule” to help determine whether pa- study by Cook et al. (55), involving 1,200 pressure) should also be used (26). tients are appropriately sedated. critically ill patients undergoing mechan- Pharmacologic therapies to relieve T for Thromboembolic Prophylaxis. ical ventilation, patients treated with ra- pain include nonsteroidal antiinflamma- Thromboembolic prophylaxis is still un- nitidine had significantly lower rates of tory drugs, acetaminophen, and opioids. derused because it is often forgotten, and clinically significant gastrointestinal Opioids are the most widely used, al- yet the mortality and morbidity rates as- bleeding than patients treated with su- though they may be combined with non- sociated with venous thromboembolism cralfate (relative risk, 0.44; 95% confi- steroidal antiinflammatory drugs or acet- are considerable and can be reduced by dence interval, 0.21– 0.92; p .02), al- aminophen for certain patients (26). The prophylaxis. Among patients who do not though there was no difference in the most commonly used opioids are mor- receive prophylaxis, objectively con- mortality rates between the two groups. phine, fentanyl, and remifentanil (27– firmed rates of deep-vein thrombosis There also was no difference in the rates 29). Continuous infusions of analgesic range between 13% and 31% (34); for of ventilator-associated pneumonia. As drugs or regularly administered doses trauma patients this figure may be con- yet, no large randomized, controlled (with extra boluses when needed) are siderably higher (35). It has thus been studies evaluating proton-pump inhibi- more effective than bolus doses given “as recommended that all patients receive at tors in mechanically ventilated ICU pa- needed,” which can leave the patient least subcutaneous heparin, unless con- tients have been published, but early data without adequate pain relief for a period traindicated (36). Several studies have suggest that they are effective at increas- of time. Intravenous administration al- been conducted comparing various hepa- ing intragastric pH and preventing bleed- lows closer and more rapid titration to rins in specific patient groups (37– 41), ing in ICU patients (57–59). patient needs than intramuscular or sub- but very few have involved general ICU G for Glucose Control. Close glucose cutaneous administration (26). The side patients (42), and the most effective control has been driven primarily by the effects of opioid analgesia should also be method of prophylaxis is still unclear. study of Van den Berghe et al. (6). This remembered when optimizing pain man- Clearly, the benefit of prophylaxis must randomized, controlled study included agement; respiratory depression can be a be weighed against the risk of bleeding primarily surgical patients, many after concern in spontaneously breathing pa- complications. cardiac surgery, with relatively low sever- tients, and constipation, hypotension, H for Head of the Bed Elevated. Sev- ity indexes and mortality rates; neverthe- and hallucinations are not uncommon eral studies have demonstrated that hav- less, the results have led most physicians side effects of opioid therapy. Care should ing the head of the bed inclined at 45 to alter their practices. The strict blood be taken to ensure analgesia is adequate degrees can decrease the incidence of sugar levels of 80 –110 mg/dL in the study but not excessive. gastroesophageal reflux in mechanically by Van den Berghe et al. may be difficult S for Sedation. As with analgesia, se- ventilated patients (43, 44), and one ran- to adhere to in routine patient care, but dation is of fundamental importance for domized, controlled study demonstrated many units now aim to keep blood sugar the ICU patient, but there are no rules reduced rates of nosocomial pneumonia levels below about 150 mg/dL, as recom- governing how much to give and how when patients were nursed semirecum- mended in recently published guidelines often, and sedative administration must bent (45). However, despite the evidence for the management of severe sepsis and be titrated to the individual. Although it and the recommendations, this simple septic shock (13). In a before-and-after may be easier to increase the dose of strategy is still not widely applied (46, study, Krinsley (7) recently reported that sedative to have a calm and quiet patient, 47). Raising the head of the bed alone the institution of a protocol aimed at oversedation is associated with harmful may not be enough, because patients— keeping blood glucose levels at 140 effects, including an increased risk of ve- especially when sedated—might slide mg/dL resulted in a 29.3% decrease in nous thrombosis, decreased intestinal down in the bed. Thus, attempts must be hospital mortality rates (p .002) and a motility, hypotension, reduced tissue ox- made to keep not only the head of the bed 10.8% reduction in length of ICU stay (p ygen extraction capabilities, increased elevated but also the patient’s thorax. .01). risk of ICU polyneuropathy, prolonged U for Stress Ulcer Prevention. Stress ICU stay, and increased costs (30, 31). ulcer prevention is important, notably for Applying the Fast Hug Kress et al. (10) have shown that daily patients with respiratory failure or coag- transient discontinuation of sedation may ulation abnormalities, undergoing ste- Obviously, not all parts of the Fast reduce the length of ICU stay and the roid therapy, or with a history of gas- Hug mnemonic will apply to all patients need for imaging procedures, although troduodenal ulcer, who are at increased at all times. For example, one might not one may argue that if sedation is titrated risk of developing stress-related gastroin- need to feed a patient in the very first continuously, as recommended in cur- testinal hemorrhage (48). There is prob- days after a laparotomy, and one might rent guidelines (26), there should be no ably no need for the routine use of anti- not give heparin to a bleeding patient to need to discontinue it once a day. The use ulcer agents in all ICU patients, including prevent the development of deep-vein of sedation scales has been advocated, after trauma or major surgery (49 –51). thrombosis. In addition, the Fast Hug and we, like others, have shown that they There are several possible treatment op- does not, of course, cover all aspects of may reduce the amounts of sedatives tions, including antacids, sucralfate, H2- each patient’s care; different patients will Crit Care Med 2005 Vol. 33, No. 6 1227
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