This document summarizes a seminar presentation on ICU care bundles. The presentation outlines several care bundles including the ABCDEF bundle. The ABCDEF bundle focuses on assessing, preventing, and managing pain; both spontaneous awakening trials and spontaneous breathing trials; choice of sedation and analgesia; assessing, preventing, and managing delirium; and early mobility and exercise. Implementing bundles like the ABCDEF bundle can help optimize patient outcomes by reducing ICU delirium and the duration of mechanical ventilation and ICU stays.
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
ICU Care Bundles Seminar: Optimizing Patient Outcomes
1. SEMINAR PRESENTATION ON
BASICS OF ICU CARE BUNDLES
By DR. Ashenafi T.(IMR1)
MODERATOR—Dr AMAN (assistant professor in anesthesiology , and critical care and pain
medicine)
DEC 2021
8/11/2023 A.T.M 1
3. Introduction
A care bundle or evidence-based practice
protocol is a grouping of care elements for a
particular symptom, procedure or treatment
(Lagan, 2003).
8/11/2023 A.T.M 3
5. ABCDEF Bundle Objectives
Optimize pain management.
Break the cycle of deep sedation and prolonged
mechanical ventilation.
Reduce the incidence and duration of ICU
delirium.
Improve short and long-term ICU patient
outcomes.
Reduce health care costs!
8/11/2023 A.T.M 5
7. Implementation of the ABCDE Bundle to Improve Patient Outcomes in the
Intensive Care Unit in a Rural
Community Hospital
8/11/2023 A.T.M 7
8. A: Assess, Prevent, and Manage Pain
Assessment of pain
Numerical rating scale (NRS)
Behavioral Pain Scale (BPS)
Critical-Care Pain Observation Tool (CPOT)
Pain medications should be routinely
administered in the presence of significant
pain and prior to performing painful
invasive procedures.
8/11/2023 A.T.M 8
13. Managing pain
♣Parenteral opioids are considered as
the first-line drug of choice for non-
neuropathic pain.
♣Non-opioid analgesics considered to
decrease the amount of opioids
administered, and to decrease opioid
related side effects.
8/11/2023 A.T.M 13
16. B: Both Spontaneous Awakening Trials (SAT) and
Spontaneous Breathing Trials (SBT)
Deep sedation in the first 48 hours of
an ICU stay has been associated with
Delayed time to extubation,
Higher need for tracheostomy,
Increased risk of hospital and Long term
death.
8/11/2023 A.T.M 16
17. • In the study of Balzer et al.[17] 1,884 patients receiving
mechanical ventilation were grouped as either lightly or
deeply sedated (light sedation: RASS −2 to 0; deep: RASS −3
or below). Deep sedation (27.2%, n = 513) was associated with
an in-hospital mortality hazard ratio of 1.661 (95% CI: 1.074 to
2.567; p = 0.022) and a two-year hazard ratio of 1.866 (95%
CI: 1.351 to 2.576; p < 0.001).
• In summary, deeply sedated patients had longer ventilation
times, increased length of stay and higher rates of mortality.
According to the results of these studies, early deep sedation is
a modifiable risk factor and that the implementation of
sedation protocols to achieve light sedation is feasible and
reproducible in the early phase of ICU treatment.
8/11/2023 A.T.M 17
18. ABC TRIAL
• Numerous randomized trials support the use of ventilator weaning
protocols that include daily SBTs as their centerpiece.
• Girard et al.undertook the Awakening and Breathing Controlled (ABC) trial,
a multicenter, RCT to assess the efficacy and safety of a protocol of daily
SATs paired with SBTs (intervention group, n = 168) versus a standard SBT
protocol in patients receiving patient-targeted sedation as part of usual care
(control group, n = 168).
• Patients in the intervention group (both SAT and SBT) spent more days
breathing without assistance during the 28-day study period (14.7 days
versus 11.6 days; mean difference 3.1 days, 95% CI: 0.7-5.6, p = 0.02) and
were discharged earlier from the ICU (median time in ICU of 9.1 days versus
12.9 days, p = 0.01) and earlier from the hospital (median hospital time 14.9
days versus 19.2 days, p = 0.04).During the year after enrollment, patients
receiving SATs with SBTs (intervention) were less likely to die than were
patients receiving only SBTs (control) (hazard ratio = 0.68, 95% CI: 0.50-
0.92, p = 0.01).
8/11/2023 A.T.M 18
19. • No sedation has also been applied as a strategy in ICU
patients.
• Strøm et al. enrolled 140 critically ill adult
patients who were undergoing mechanical ventilation and
were expected to need ventilation for more than
one day. Patients were randomly assigned in a 1:1 ratio
(unblinded) to receive no sedation (n=70 patients)
or sedation (n=70, control group). Patients receiving no
sedation had significantly more days without
ventilation (mean 13.8 days, SD 11.0 vs mean 9.6 days, SD
10.0; mean difference 4.2 days, 95%: CI 0.3–
8·1. p=0.0191) in a 28-day period, and reduced stays in the
ICU and hospital. This study did find increased
hyperactive delirium in the group receiving no sedation.
8/11/2023 A.T.M 19
22. A—Daily Sedation Interruption Decreases
Duration of Mechanical Ventilation
Hold sedation infusion until patient awake, then
restart at 50% of prior dose
“Awake” defined as any 3 of the following:
• Open eyes in response to voice
• Use eyes to follow investigator
on request
• Squeeze hand on request
• Stick out tongue on request
8/11/2023 A.T.M 22
27. PAD Depth of Sedation
Recommendations
♫ We recommend that sedative medications be
titrated to maintain a light rather than a deep level
of sedation in adult ICU patients, unless clinically
contraindicated.
♫We recommend that either daily sedation
interruption or a light target level of sedation be
routinely used in mechanically ventilated adult ICU
patients.
8/11/2023 A.T.M 27
28. SAT/SBT Outcomes Summary
♫Decreased days of mechanical ventilation
♫Reduced weaning time
♫Reduced reintubation rates
♫Fewer days with delirium
♫Decreased length of ICU stay
♫Decreased length of hospital stay
8/11/2023 A.T.M 28
29. C: Choice of Sedation and Analgesia
• Choice of sedation is crucial to patients’ clinical
outcomes.
• Psychoactive medication administration should
be goal-directed to ensure adequate pain control,
anxiolysis, and prevention and treatment of
delirium.
• Benzodiazepines vs Dexmedetomidine
8/11/2023 A.T.M 29
30. Choice of Sedation and Analgesia
All ICU patients should be routinely
assessed for:
Pain (Likert self-report, or
BPS/CPOT non-self-report)
Agitation/depth of sedation
(RASS/SAS)
Delirium (CAM-ICU/ICDSC)
Important factors influence the
choice and dose of analgesia and
sedative medications
Non-pharmacologic strategies play
an important role when managing
pain and agitation
8/11/2023 A.T.M 30
31. Agitation
♣ Avoid deep sedation/coma:
Sedative medications should be titrated to maintain lighter
levels of sedation, unless clinically contraindicated.
Use daily awakening or a titrated sedation strategy to maintain
patient wakefulness.
♣ Choice of sedative:
Non-benzodiazepines may be preferred over benzodiazepines to
improve clinical outcomes in mechanically ventilated ICU
patients.
♣ Reduction in sedation requirements:
Use of an analgesia-first (i.e., analog-sedation) strategy is
recommended in mechanically ventilated patients.
8/11/2023 A.T.M 31
34. D: Delirium Assessment, Prevention, and
Management
• Delirium is a disturbance in attention and
awareness that develops over a short period of
time, hours to days, and fluctuates over time.
• Acute disturbance of consciousness with
inattention accompanied by a change in
cognition or perceptual disturbance that
fluctuates over time.(DSM 5th Edition)
• Delirium is prevalent, under-recognized, and an
independent predictor of poor outcomes such as
mortality, prolonged mechanical ventilation,
increased length of hospital stay, and long-term
cognitive impairment.
8/11/2023 A.T.M 34
36. Delirium: Long-Term Outcomes
Mortality
⇰Each day of delirium in the ICU increases the
hazard of 1-year mortality by 10%
Cognitive Impairment
⇰ICU delirium is an independent risk factor for
long-term cognitive impairment
⇰34% with scores similar to moderate TBI
⇰24% with scores similar to mild Alzheimer disease
8/11/2023 A.T.M 36
37. Delirium Assessment
ICDSC and CAM-ICU
The CAM-ICU is composed by four features
1) acute onset of mental status changes or fluctuating course;
2) inattention;
3) disorganized thinking; and
4) altered level of consciousness.
8/11/2023 A.T.M 37
38. Delirium can be categorized into subtypes according to psychomotor
behavior.
♣ Hyperactive delirium (CAM positive, RASS positive range) is
associated with a better overall prognosis and it is characterized by
agitation, restlessness, and emotional lability.
♣ Hypoactive delirium (CAM positive, RASS negative
range), which is very common and often more deleterious in the long
term, is characterized by decreased responsiveness, withdrawal, and
apathy and remains unrecognized in 66 to 84% of hospitalized patients.
Another categorization based on the ICDSC score assigns patients
♣ No delirium,
♣ Clinical delirium, and
♣ Subsyndromal delirium.
8/11/2023 A.T.M 38
46. Prevention and risk factors
• The only strategy strongly recommended in the PAD
Guidelines, to reduce the incidence and duration of
ICU delirium and to improve functional outcomes, is
promoting sleep hygiene to prevent sleep disruption
and the use of early and progressive mobilization and in
these patients.
8/11/2023 A.T.M 46
47. • Delirium prophylaxis with medications is discouraged in the PAD guidelines.
• Recently, a prospective, randomized, multicenter trial compared a low-dose
haloperidol infusion administered for 12 hours (0.5 mg intravenous bolus injection
followed by continuous infusion at a rate of 0.1 mg/h, n=229 patients) against
placebo (n = 228 patients) in the immediate postoperative period. This study
provided evidence that haloperidol could reduce the incidence of delirium within
the first 7 days postoperatively in patients undergone noncardiac surgery (15.3% in
the haloperidol group versus 23.2% in the control group, p=.031).
• By contrast, another ICU study showed no benefit of early administration of
intravenous haloperidol in a mixed population of medical and surgical adult ICU
patients. In this double-blinded, placebo-controlled randomized trial, 142 patients
were randomized to receive haloperidol or placebo intravenously every 8 hours
irrespective of coma or delirium status. Patients in the haloperidol group spent
about the same number of days alive, without delirium or coma, as did patients in
the placebo group (median 5 days [IQR 0–10] versus 6 days [0–11] days; p=0.53)
8/11/2023 A.T.M 47
49. “Brain road map”
Perhaps the most important element of delirium management in the
ICU setting involves communication among the team.
To that end, many ICU teams now present on rounds using the
“brain road map,” which is a set of data containing 3 elements.
At each bedside, the nurse (or another team member such as an
intern or a pharmacist) will present the patient’s
⇰ (1)target RASS or SAS;
⇰ (2) actual RASS or SAS, CAM-ICU, or ICDSC result; and
⇰ (3) sedatives and narcotics received.
This helps the team discuss the patient’s cognitive status, compare it
with the patient’s desired cognitive status for that day, determine
adjustments needed, and then explore the causes of delirium if the
patient is CAM-ICU or ICDSC positive that day (using, for
example, the Dr. DRE tool shown in Fig. 3).
8/11/2023 A.T.M 49
50. E: Early Mobility and Exercise
• Early mobility is an integral part of the ABCDEF bundle and has been the
only intervention resulting in a decrease in days of delirium.
• The consequence of physical dysfunction in critically ill patients can be
profound and long-term with significant reduction in functional status
being observed even 1 year and 5 years after ICU discharge.
• Physical therapy has shown to be feasible, safe, even in the most
complicated patients receiving the most advanced medical therapies (e.g.,
continuous renal replacement therapy, extracorporeal cardiopulmonary
support).
• Early activity can be done without increases in usual ICU staffing and with a
low risk (< 1%) of complications. Schweickert et al. Showed that a daily SAT
combined with physical and occupational therapy, versus SAT alone,
resulted in an improved return to independent functional status at hospital
discharge, shorter duration of ICU-delirium, higher survival, and more days
breathing without assistance.
8/11/2023 A.T.M 50
51. • During ICU stay critically ill patients can lose up to
25% peripheral muscle weakness within 4 days
when mechanically ventilated and 18% in body
weight by the time of discharge and this process is
higher in the first 2–3 weeks of immobilization.
• The consequence of physical dysfunction in
critically ill patients can be profound and long-term
with significant reduction in functional status being
observed even 1 year and 5 years after ICU
discharge.
8/11/2023 A.T.M 51
52. ICU-acquired weakness,
♥ the drugs used during its management, and
♥ the consequences of protracted immobility.
The diagnosis of ICU-acquired weakness is made by the
Medical Research Council (MRC) scale for grading the
strength.
The scale ranges from 0 (complete tetraplegia) to 60 (normal
muscle strength), with a score < 48 is diagnostic of ICU-
acquired weakness.
Patients with ICU-acquired weakness should undergo serial
evaluations, and if persistent deficits are noted,
electrophysiological studies, muscle biopsy, or both are
warranted
8/11/2023 A.T.M 52
53. • Physical therapy has shown to be feasible, safe, even in the most
complicated patients receiving the most advanced medical therapies
(e.g., continuous renal replacement therapy, extracorporeal
cardiopulmonary support). Early activity can be done without
increases in usual ICU staffing and with a low risk (<1%) of
complications. Studying patients early in the their course of
mechanical ventilation (<3 days), Schweickert et al. showed that a
daily SAT combined with physical and occupational therapy, versus
SAT alone, resulted in an improved return to independent functional
status at hospital discharge, shorter duration of ICU-delirium, higher
survival, and more days breathing without assistance.
• However, in a study where ICU patients were enrolled 4 days after
the initiation of mechanical ventilation (average 8 days), an intensive
physical therapy program did not improve long-term physical
functioning when compared to a standard of care program.
8/11/2023 A.T.M 53
54. F: Family Communication and
Involvement
• The ABCDE bundle has evolved to include Family
Engagement, as no ICU treatment plan is complete without
incorporation of the family’s wishes, concerns, questions, and
participation.
• Family members should be educated about delirium and its
potential deleterious effects on the patient (post-traumatic
stress disorder, depression, cognitive impairment) upon
discharge from the hospital. Family members themselves may
also suffer long-term psychological complications such as
anxiety, depression, and posttraumatic stress disorder,
commonly persisting for years.
8/11/2023 A.T.M 54
58. Use of subglottic secretion
drainage
• Secretions are potentially able to bypass the ETT cuff,
especially when it is deflated.
Secretions that pool above the ETT but below the vocal
cords are a potential source of
pathogens that could cause VAP. Since conventional suction
methods cannot access this
area, ETT tubes that have a designated suction catheter for
this space allows this pool to be
drained. The benefits of subglottic secretion drainage (SSD)
have been analysed in three
meta-analyses with a consistent signal of a reduction in VAP
and ICU length of stay
8/11/2023 A.T.M 58
59. • Cuff pressures
Micro-aspiration can be reduced by maintaining an endotracheal
tube cuff pressure between
20 - 30 cmH2O5. Based on recent recommendations, cuff pressure
should be checked and
adjusted around 25 cmH2O, at least 4 hourly. It is noted that
individual assessment is
required as there will be cases where a patient’s clinical condition
and ventilation may require higher pressures - the rationale for this
decision must be documented and the position reviewed as a
minimum daily.
8/11/2023 A.T.M 59
81. Central Line
Insertion Bundle
• CVCs are the leading cause of device-related
bacteraemia or catheter related blood stream
infection (CRBSI), which are a major cause of
morbidity, increased severity of illness and
prolonged hospital stay.
• Intravascular catheterization is a cornerstone
of medical management of the critically ill
patient.
• BSIs may be either primary or secondary.
8/11/2023 A.T.M 81
82. EPIDEMIOLOGY
• the incidence of CR-BSI associated with
central lines among patients
hospitalized in intensive care units
(ICUs) in the United States decreased
from 3.64 to 1.65 infections per 1000
central line days between 2001 and
2009. These decreases in the United
States have continued through 2015 and
appear to be sustained.
8/11/2023 A.T.M 82
83. RISK FACTORS
• Host factors
– Chronic illness
– Bone marrow
transplantation
– Immune deficiency,
especially neutropenia
– Malnutrition
– Total parenteral nutrition
administration
– Previous BSI
– Extremes of age
– Loss of skin integrity, as
with burns
Catheter factors
– Duration of catheterization
– Type of catheter material
– Conditions of insertion
– Catheter-site care
– Skill of the catheter inserter
8/11/2023 A.T.M 83
84. Central Line Insertion Bundle
Insertion Checklist and Documentation
Hand Hygiene and Maximal Barrier
Precautions
Catheter Site Selection
Skin Antisepsis
Dressing
8/11/2023 A.T.M 84
86. Catheter Site Selection
• The location of CVCs is also important.
Catheter-related infection is generally more
common with catheters in the femoral and,
probably to a lesser degree, internal jugular
veins compared with the subclavian vein.
• meta-analysis of nine observational studies
which included ICU patients with short-term
CVC placement.
– The pooled catheter-associated infection rate was
lower with nontunneled subclavian catheters (1.3
events per 1000 catheter-days) than either internal
jugular or femoral catheters (2.6 and 3.6 events per
1000 catheter-days, respectively)
8/11/2023 A.T.M 86
87. • In other trial in which 289 patients were randomly
assigned to either the femoral or subclavian sites for
central venous catheter placement,
– femoral catheterization was associated with a significant
increase in overall infection (20 versus 3.7 per 1000 catheter-
days), clinical sepsis with or without documented bloodstream
infection (4.5 versus 1.2 per 1000 catheter-days), and
thrombotic complications
8/11/2023 A.T.M 87
88. SITE CARE
• Use of antiseptic solution for skin disinfection at the
catheter insertion site helps prevent catheter-related
infection.
• Chlorhexidine-based solutions (>0.5% chlorhexidine
preparation with alcohol) are superior to both aqueous
and alcohol-based povidone-iodine in reducing the risk
for catheter colonization and catheter-related
bloodstream infection.
• This was illustrated in a meta-analysis of eight
randomized trials including 4143 catheter insertions;
disinfection with chlorhexidine rather than aqueous
povidone-iodine resulted in a 50 percent reduction in
catheter-associated bloodstream infections
8/11/2023 A.T.M 88
89. Sterile technique
♫Attention to sterile technique is important for
minimizing catheter-associated infection.
♫This includes strict adherence to hand washing
and aseptic technique and, with central venous
catheter (CVC) insertion, sterile gloves, long-
sleeved surgical gown, a surgical mask, and a
large sterile sheet drape.
♫2006 report of intensive care units in 10 academic
tertiary-care hospitals found that less than 30
percent had adopted maximal barrier precautions.
8/11/2023 A.T.M 89
90. The effectiveness of educating clinicians in-
training on infection control practices and
procedures was evaluated in a nonrandomized
pre-post observational trial of insertion of CVCs.
Six months after a one-day course, the perceived
need for and documented use of full-size sterile
drapes increased from 22 to 73 percent and from
44 to 65 percent, respectively, while the rate of
catheter-associated bloodstream infections
decreased from 3.3 to 2.4 per 1000 central line
days.
8/11/2023 A.T.M 90
• The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcome‘‘Evidence Based Bundle’’ of care, a concept developed by the Institute for Healthcare Improvement(IHI) usually involves 3–5 structured interventions based on scientific evidence, which when carried out consistently improve patient outcomesThe care bundle concept was identified initially in the US and introduced into the UK in the summer of 2002. The original underpinning work was carried out at The Johns Hopkins University by Berenholtz et al.(2002). They reviewed 35 years' worth of critical care literature (1965–2000) and critically analysed the strength of evidence of interventions that could prevent avoidable morbidity and mortality in intensive care.
In addition to HAI, much attention has now been shifted to delirium and sedation practices in ICUs, with recent data showing the untoward effects ofdelirium with regards to increased ICU lengths of stay, costs, mortality and long-term cognitive impairment, and the realization that our sedation practices may in part contribute to this delirium
Implementation of theABCDE Bundle toImprove PatientO u t c o m e s i n t h e I n t e n s i v eCare Unit in a RuralC o m m u n i t y H o s p i t a l
Because of the high interrelation between delirium and pain, assessing and treating pain could be important in the prevention and/or management of delirium.ICU patients commonly experience pain, with an incidence of up to 50% in surgical and medical patients. It is a major clinical symptom that requires systematic diagnosis and treatment.Assessment of pain is the first step before administering pain relief. Pain assessments are often only performed 35% of the time before ICU procedures. Patient's self-report of pain using a 1–10 numerical rating scale (NRS) is considered the gold standard and is highly recommended by many critical care societies. In the absence of a patient’s self-report, observable behavioral and physiological indicators become important indices for the assessment of pain.
The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for ICU patients unable to communicate (Figure 2). The BPS is composed of 3 subscales: facial expression, movement of the upper limbs, and compliance with mechanical ventilation (MV). Each subscale is scored from 1 (no response) to 4 (full response). A BPS score of 5 or higher is considered to reflect unacceptable pain.
The CPOT has 4 components: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. Each component is scored from 0 to 2 with a possible total score ranging from 0 to 8. A CPOT ≥ 3 is indicative of significant pain. Both the BPS and the CPOT provide guidance for the selection of pharmacological interventions for pain and in the evaluation of their effectiveness
Certain classes of opioids are probably best avoided in older patients and others prone to delirium. Meperidine in particular, has been shown in multiple prospective studies to increase the risk for delirium [13-15].Parenteral opioids are first-line pharmacologic agents for treating non-neuropathic pain in critically illpatients.
All opioids have the potential to induce tolerance over time, resulting in the need for escalatingdoses to achieve the same analgesic effect. For the treatment of neuropathic pain in ICU patient gabapentinor carbamazepine should be administered enterally, in addition to opioids. Non-opioid analgesics, such asacetaminophen, nonsteroidal anti-inflammatory drugs, or ketamine, should be used as adjunctive painmedications to reduce opioid requirements and opioid-related side effects ill. Use of regional analgesia inICU patients is limited to the use of epidural analgesia in specific subpopulations of surgical patients, andin patients with traumatic rib fractures. In managing pain in the ICU, non-pharmacological methods areoften effective and safe (e.g., injury stabilization, patient repositioning, use of heat/cold)
All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective.
Either enterally administered gabapentin orcarbamazepine, in addition to IV opioids considered for neuropathic pain
Non-opioid analgesics considered to decrease theamount of opioids administered (or to eliminate theneed for IV opioids altogether), and to decrease opioid related side effects (+2C).• Either enterally administered gabapentin or carbamazepine, in addition to IV opioids considered for neuropathic pain
Parenteral opioids are first-line pharmacologic agents for treating non-neuropathic pain in critically ill patients.
The use of nonopioid medications should be used where possible, as these are less likely to aggravate delirium.
Clinicians must balance the benefits of using opioids to treat significant pain with the potential for an opioid-related delirium.
Non-opioid analgesics
Certain classes of opioids are probably best avoided in older patients and others prone to delirium
Either enterally administered gabapentin orcarbamazepine, in addition to IV opioids considered for neuropathic pain
There is a consistent relationship between deeper sedation and worse ICU outcomes. Deep sedation in the first 48 hours of an ICU stay has been associated with
the 2013 PAD guidelines emphasize the need for goal-directed delivery of psychoactive medications to avoid over-sedation, topromote earlier extubation, and to help the medical team agree on a target sedation level by using sedationscales. Of the available reliable and valid sedation scales, the PAD guidelines recommend the use of theRichmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS). Figure 4shows the psychometric properties of both the RASS and SAS. The SAS has 7 individual tiers rangingfrom “1” (unarousable) to “7” (dangerous agitation). RASS is a 10-point scale, with four levels ofescalating agitation (RASS +1 to +4), one level denoting a calm and alert state (RASS 0), three levels ofsedation (RASS -1 to –3), and two levels of coma (RASS -4 to -5). A unique feature of RASS is that itrelies on the duration of eye contact following verbal stimulation. The RASS takes less than 20 seconds toperform with minimal training, and has been shown highly reliability among multiple types of healthcareproviders and an excellent interrater reliability in a broad range of adult medical and surgical ICUpatients.
IV opioids should be considered first-line analgesics for the treatment of nonneuropathic pain. (+1C)• All IV opioids are equally effective when titrated to similar pain scores. (C)Use of non-opioid analgesics:• Non-opioid analgesics should be considered to decrease the amount of opioids administered and to decrease opioidinduced adverse effects. (+2C)For neuropathic pain, enterally administered gabapentin or carbamazepine should be considered, in addition to IV opioids.Opioid tolerance may occur after only 2 days of continuous IV opioid therapy• Think about multimodal analgesic options in a patient with persistent pain when opioid therapy has been maximized
Analgo-Sedation Strategies• Addressing pain and discomfort first beforeadministering sedatives.• Utilization of one drug for two purposes: Pain relief and sedation• Usually accomplished with an opioid.
Between 50% and 80% of mechanically ventilated ICU patients develop delirium, and this organ dysfunction is missed 75% of the time if not monitored, which prompted the PAD guidelines ‘recommendation that all ICU patients be screened regularly for delirium with a valid and reliable tool.
Over 80% of patients developed delirium during their hospital stay, with themajority of cases occurring in the ICU with an average time of onset between the second and the third day.
Three key points to clarifying the syntax surrounding delirium and coma are as follows: First, coma represents theclinical state of a patient who is unarousable to voice (whether this is due to disease or to iatrogenic causes such as deliberateor unintentional overuse of sedation). Second, hallucinations and delusions are not key major components of the diagnosis ofdelirium. That is, many patients are delirious who do not have either hallucinations or delusions. Third, clinicians need torealize that inattention is the most important diagnostic criterion for delirium.[30]
The American Psychiatric Association's Diagnostic and Statistical Manual, 5th edition (DSM-V) lists five key features that characterize delirium [2]:
Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness.
The disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the course of the day.
An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception)
The disturbances are not better explained by another preexisting, evolving or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma
There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.
Additional features that may accompany delirium and confusion include the following:
Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with increased sympathetic activity, and impairment in sleep duration and architecture.
Variable emotional disturbances, including fear, depression, euphoria, or perplexity.
Delirium is a disturbance in attention and awareness that develops over a short period of time, hours to days, and fluctuates over time.
Acute disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that fluctuates over time.(DSM 5th Edition)
Delirium is prevalent, under-recognized, and an independent predictor of poor outcomes such as mortality, prolonged mechanical ventilation, increased length of hospital stay, and long-term cognitive impairment.
Between 50% and 80% of mechanically ventilated ICU patients develop delirium, and this organ dysfunction is missed 75% of the time if not monitored, which prompted the PAD guidelines ‘recommendation that all ICU patients be screened regularly for delirium with a valid and reliable tool.
Over 80% of patients developed delirium during their hospital stay, with themajority of cases occurring in the ICU with an average time of onset between the second and the third day.
Three key points to clarifying the syntax surrounding delirium and coma are as follows: First, coma represents theclinical state of a patient who is unarousable to voice (whether this is due to disease or to iatrogenic causes such as deliberateor unintentional overuse of sedation). Second, hallucinations and delusions are not key major components of the diagnosis ofdelirium. That is, many patients are delirious who do not have either hallucinations or delusions. Third, clinicians need torealize that inattention is the most important diagnostic criterion for delirium.[30]
Several methods have been developed and validated to diagnose delirium in ICU patients but the Intensive Care DeliriumScreening Checklist (ICDSC) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) are the mostfrequently employed tools for this purpose.
The ICDSC checklist is an eight-item screening tool (one point for each item) that is based onDSM criteria and applied to data that can be collected through medical records or to information obtainedfrom the multidisciplinary team. The pooled values for the sensitivity and specificity of the ICDSC are74% and 81.9%, respectively.
The CAM-ICU is composed by four features 1) acute onset of mentalstatus changes or fluctuating course; 2) inattention; 3) disorganized thinking; and 4) altered level ofconsciousness. The patient is considered CAM positive and, so delirious, if he/she manifests both features1 and 2, plus either feature 3 or 4. Overall accuracy of the CAM-ICU is excellent, with pooled values forsensitivity and specificity of 80% and 95.9%, respectively. The CAM-ICU has been modified andvalidated in pediatric, emergency department, and neurocritical care populations, as well as translated inover 25 languages
Delirium can be categorized into subtypes according to psychomotor behavior. Hyperactive delirium (CAM positive, RASS positive range) is associated with a better overall prognosis and it is characterized by agitation, restlessness, and emotional lability. Hypoactive delirium (CAM positive, RASS negative range), which is very common and often more deleterious in the long term, is characterized by decreased responsiveness, withdrawal, and apathy and remains unrecognized in 66 to 84% of hospitalized patients. Another categorization based on the ICDSC score assigns patients with a score of 0 to have no delirium,those with a score ≥ 4 to have clinical delirium, and those with a score of 1–3 to have subsyndromal delirium. Whichever delirium metric is used, the best picture of the patient’s mental status comes from assessing delirium serially throughout the day.
0-Normal
1-3 sub-syndromal Delirium
4-8 Delrium
Delirium prophylaxis with medications is discouraged in the PAD guidelines. Recently, a prospective,randomized, multicenter trial compared a low-dose haloperidol infusion administered for 12 hours (0.5 mgintravenous bolus injection followed by continuous infusion at a rate of 0.1 mg/h, n=229 patients) againstplacebo (n = 228 patients) in the immediate postoperative period. This study provided evidence thathaloperidol could reduce the incidence of delirium within the first 7 days postoperatively in patientsundergone noncardiac surgery (15.3% in the haloperidol group versus 23.2% in the control group,p=.031). By contrast, another ICU study showed no benefit of early administration of intravenoushaloperidol in a mixed population of medical and surgical adult ICU patients. In this double-blinded,placebo-controlled randomized trial, 142 patients were randomized to receive haloperidol or placebointravenously every 8 hours irrespective of coma or delirium status. Patients in the haloperidol group spentabout the same number of days alive, without delirium or coma, as did patients in the placebo group(median 5 days [IQR 0–10] versus 6 days [0–11] days; p=0.53)
After reversible causes and modifiable risk factors have been addressed and nonpharmacologic strategies have beenimplemented, then and only then should pharmacologic interventions be considered.0921250945
erhaps the most important element of delirium management in the ICU setting involves communication among the team.To that end, many ICU teams now present on rounds using the “brain road map,” which is a set of data containing 3 elements(Fig. 4). At each bedside, the nurse (or another team member such as an intern or a pharmacist) will present the patient’s (1)target RASS or SAS; (2) actual RASS or SAS, CAM-ICU, or ICDSC result; and (3) sedatives and narcotics received. This helpsthe team discuss the patient’s cognitive status, compare it with the patient’s desired cognitive status for that day, determineadjustments needed, and then explore the causes of delirium if the patient is CAM-ICU or ICDSC positive that day (using, forexample, the Dr. DRE tool shown in Fig. 3).
Early mobility is an integral part of the ABCDEF bundle and has been the only intervention resulting in a decrease in days ofdelirium.[49]The consequence of physical dysfunction in critically ill patients can be profound and long-term with significant reduction infunctional status being observed even 1 year and 5 years after ICU discharge.[50-52]Physical therapy has shown to be feasible, safe, even in the most complicated patients receiving the most advanced medicaltherapies (e.g., continuous renal replacement therapy, extracorporeal cardiopulmonary support).[53,54] Early activity can bedone without increases in usual ICU staffing and with a low risk (< 1%) of complications.[55] Schweickert et al.[56] showedthat a daily SAT combined with physical and occupational therapy, versus SAT alone, resulted in an improved return toindependent functional status at hospital discharge, shorter duration of ICU-delirium, higher survival, and more daysbreathing without assistance.
ICU-acquired weakness is caused by many different pathophysiological mechanisms that are not mutuallyexclusive given the diverse diseases that precipitate critical illness, the drugs used during its management,and the consequences of protracted immobility. The reported incidence of ICU-acquired weakness rangesfrom 25 to 100%. The diagnosis of ICU-acquired weakness is made by the Medical Research Council(MRC) scale for grading the strength (i.e., 0, total palsy to 5, normal strength) of various muscle groups inthe upper and lower extremities. The scale ranges from 0 (complete tetraplegia) to 60 (normal musclestrength), with a score < 48 is diagnostic of ICU-acquired weakness. Patients with ICU-acquiredweakness should undergo serial evaluations, and if persistent deficits are noted, electrophysiologicalstudies, muscle biopsy, or both are warranted
The association of lactate level with mortality in patients with suspected infection and sepsis is wellestablished (45, 46). Its use is currently recommended as part of the SSC Hour-1 sepsis bundle forthose patients with sepsis (47, 48), and an elevated lactate is part of the Sepsis-3 definition of septicshock (49).
It has been suggested that lactate can also be used to screen for the presence of sepsisamong undifferentiated adult patients with clinically suspected (but not confirmed) sepsis.
Several studies have assessed the use of lactate in this context (50–52).Studies showed an association between the use of point-of-care lactate measurements at presentation and reduced mortality; however, the results are inconsistent (53)
Serum lactate is an important biomarker of tissuehypoxia and dysfunction, but is not a direct measureof tissue perfusion (73). Recent defiitions of septicshock include increases in lactate as evidence of cellular stress to accompany refractory hypotensionusing lactate levels as a target of resuscitation in theearly phases of sepsis and septic shock, based on earlierstudies related to goal-directed therapy and meta-analyses of multiple studies targeting reductions in serumlactate in comparison with “standard care” or increasesin central venous oxygen saturation
The panel recognizes that normal serum lactate levels are not achievable in all patients with septic shock, but thesestudies support resuscitative strategies that decrease lactate toward normal. When advanced hemodynamic monitoring is notavailable, alternative measures of organ perfusionmay be used to evaluate the effctiveness and safety ofvolume administration. Temperature of the extremities, skin mottling and capillary refil time (CRT) havebeen validated and shown to be reproducible signs oftissue perfusion
Fluid therapy is a key part of the resuscitation of sepsis and septic shock. Crystalloids have the advantage of being inexpensive and widely available. Thabsence of clear benefi following the administration of colloids compared to crystalloid solutions supportsthe use of crystalloid solutions in the resuscitation of patients with sepsis and septic shock (324). Th optimal flid remains a subject of debate. For decades,the administration of normal saline solution (0.9% sodium chloride) has been common practice (325),but potential adverse effcts that include hyperchloremic metabolic acidosis, renal vasoconstriction,increased cytokine secretion and concern about acute kidney injury (AKI) have led to increased interest inchloride-restrictive solutions, known as balanced or buffred solutions (326–330). Subsequently, a network meta-analysis of 14 RCTs of patients with sepsisshowed in an indirect comparison that balanced crystalloids were associated with decreased mortality, compared to saline
Intravascular catheterization is a cornerstone of medicalmanagement of the critically ill patient, and these cathetersare required for fluid administration, invasive monitoring,laboratory work, blood transfusions, transvenous cardiacpacing, medication administration, and dialysis access.BSIs may be either primary or secondary. Secondary infections are related to infections at other sites, such as the urinary tract, lung, postoperative wounds, and skin. Most nosocomial BSIs are primary, as illustrated by the United States Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance system, in which 64 percent of the nosocomial BSIs reported were primary BSIs [3]. While some primary BSIs have no identifiable source, most are associated with intravascular catheters, and central venous catheters (CVCs) in particular
Host factors — Host factors commonly associated with nosocomial bloodstream infections (BSIs) include the following [13,14]:
●Duration of catheterization (although there is no indication for routine line changing based on number of catheter days)
There are five key aspects to this bundle which if addressed together should minimise the risk ofcatheter related bloodstream infection.
Experience is usually greater with insertion at the internal jugular site and therefore can be safer.The subclavian, or internal jugular route, are undoubtedly the preferred sites for preventingavoidable infections.