Critical care units provide intensive monitoring and treatment to patients with life-threatening health issues. Critically ill patients have single or multiple organ failure due to injury, surgery, or disease. Critical care nursing focuses on caring for critically ill patients requiring mechanical ventilation. The FAST HUGS BID principle provides a systematic checklist for caring for critically ill patients, addressing Feeding/Fluids, Analgesia, Sedation, Thromboembolism Prophylaxis, Head Elevation, Ulcer Prophylaxis, Glycemic Control, Spontaneous Breathing Trials, Bowel Care, Indwelling Catheter Removal, and Drug De-escalation. Using this checklist improves patient care quality and safety

1. Protocolised Care of Critically ill patients
m
Renu Bisht
Registered Nurse

2. Critical Care Unit
Critical care unit is defined as specially designed and equipped
facility , staffed by skilled personnel to provide effective and safe
care for patients with life threatening or potentially life threatening
health problems.
Using advanced therapeutic , monitoring and diagnostic technology
, the objective of critical care is to maintain organ system functioning
and improve the patient’s condition such that his/her underlying
injury can be treated.

3. Critically ill patients
Critically ill patient has life threatening or potentially life threatening
health problems that requires continuous monitoring and
intervention to prevent complication and to restore health .
This could be a result of injury or surgery or disease leading to a
single or multiple organ failure .

5. Critical care nursing
Critical care nursing is the field of nursing with a focus on the utmost
care of the critically ill or unstable patients following extensive injury
, surgery of life threatening diseases.
These specialists generally take care of critically ill patients who
require mechanical ventilation .

6. Criteria for admission in crtical care unit

8. Priority of care
Follow a systematic approach based on Circulation , airway ,
breathing , disability and exposure (CABDE) to assess and treat the
critically ill patient in circulatory compromised state.

9. FAST HUGS BID

10. FAST HUGS BID is a systematic approach to patient care which is
used repeatedly throughout work shifts to prevent errors of omission
in basic domains of intensive care unit management that might
otherwise be forgotten in the setting of more urgent care
requirements.
J L Vincent described and published the FAST HUG mnemonic to
identify and check the key aspects in the general care of critically ill
patients / bed bound patients admitted in ICU.

11. Need of FAST HUGS BID principle
• Improves quality of patient care
• Increases safety and efficacy of patient care
• Encourages teamwork
• Helps in preparation for patient rounds
• Helps to prevent and identify medication errors

13. F --- FEEDING/FLUIDS
• Issue - malnutrition
• Need - to meet nutritive demands of ICU patients
• Our role - a) preservation of lean body mass
b) maintenance of immune function
c) avert metabolic complications

14. Six main components of nutrition bundle
1. Assess patients’ nutrition statusto identify those at risk for
malnutrition .
2. Initiate and maintain enteral nutrition .
3. Reduce risks for aspiration .
4. Implement enteral feeding protocols .
5. Avoid the use of gastric residual volumes as a n assessment of
enteral feeding tolerance
6. Consider parenteral nutrition early , when enteral feedings
cannot be initiated .

17. A --- ANALGESIA
• Need - Analgesics optimise patient comfort and minimise the
acute stress response (hypermetabolism , increased
oxygen consumption)
• Issue - Excessive analgesia should be avoided .
• Our role - a) Pain should be assessed regularly using various
tools like visual analogue scale (VAS) & CCPOT.
b) Timely administration of analgesics.
c) Pre-elective analgesics should be considered for
invasive or potentially painful clinical procedures.

18. Visual Analogue Scale (VAS)

19. Critical Care Pain Observation Tool (CCPOT)

20. S --- SEDATION
• Need - Sedation in critically ill patients is principally used
to control agitation , enable effective care ,
minimise patient ventilator dys-synchrony, reduce
acute stress response
• Issues - Over sedation can lead to respiratory depression,
prolonged ventilation , high risk of nosocomial
infection .
• Our role - a) Ensure intubated patients have adequate
depth of sedation with 3C’s
(calm,comfortable,collaborative)
b) Evaluate depth of sedation by GCS daily.

22. T --- THROMBOEMBOLISM PROPHYLAXIS
• Need - Thromboembolism prophylaxis should be
implemented within the first 24 hours following
admission to prevent life threatening risk of
venous thromboembolism ( DVT / PTE )
• Our role - a) Ensure all patients have appropriate
thromboembolic prophylactic agents
unless contraindicated (thrombocytopenia ,
DIC , within 24 hrs of cranial surgery - raised ICP
)
• b) Serial assessment of prothrombin time and INR.
• c) Informed decision making for appropriate
method of thrombo- prophylaxis.
d) reassessment of risk and monitoring of

23. Types of Thrombosis Prophylaxis

24. H --- HEAD OF END ELEVATION
• Need - Reduces the occurence of gastro intestinal reflux ,
prevents chances of aspiration during enteral
feeding and VAP in mechanically ventilated
patients .
• Our role - a) Ensuring head of bed is elevated at 30-45 drgree
angle .
b) head injury patients should have head of bed
elevated to 30 degrees unless contraindicated.

25. VAP bundle

26. U --- ULCER PROPHYLAXIS
• Incident of overt gastrointestinal bleeding in critical care unit
ranges from 1.5 to 8.5% and may reach 15% in patients without
prophylaxis.
• Need - to prevent gastrointestinal bleeding and to prevent
stress ulcers in ICU patients.
• Our role - a) Ensure patient is receiving a form of stress ulcer
prophylaxis (histamine-2 receptor blockers ,
proton pump inhibitors , sucralfate)
b) identifying risk factors for stress related bleeding
in ICU patients .

28. G --- GLYCAEMIC CONTROL
• Insulin deficiency is associated with diabetic ketoacidosis . Both
hyperglycemia and hypoglycemia can increase mortality , length
of stay and infection in ICU patients.
• Need - Glycemic control is necessary in critically ill patients to
decrease incidence of complications related to
hypo/hyperglycemia .

29. Current AACE recommendations for target blood
glucose levels
• Blood glucose in critically ill patients : < 110mg/dl
• Threshold for initiating insulin therapy : persistent hyperglycemia
of 180mg/dl or greater .
• Insulin infusion preferred over s/c insulin in ICU with frequent
glucose monitoring .

30. • Our role - a) identify elevated blood glucose levels in critically ill
patients.
b) prior history of diabetes or drug therapy that cause
hyperglycemia ( steroids , cyclosporins , atypical
antipsychotics )
c) Educate and implement structured protocols for
control and management of blood glucose in ICU
patients.
d) correct administration of insulin therapy .

31. S --- SPONTANEOUS BREATHING TRIAL
• Spontaneous breathing trials have been shown to improve
outcomes in critically ill patients .
• To avoid prolonged days of intubated patients it is very important
to give intermittent breathing trial to patients of atleast 30-120
minutes.
• Patients who are intubated ( on ET / tracheostomy ) should be
assessed on their ability for spontaneous breathing and put on
weaning plan .

32. Three main strategies to perform SBT
T piece trial
Continuous positive airway pressure
Invasive ventilation with low level
pressure support (5-8cmH2O)

33. Criteria of successful spontaneous breathing trials
• Respiratory rate <35 breaths/min
• heart rate <140/min or heart rate variability >20%
• arterial O2 saturation >90% or PaO2 >60mmHg on fiO2 <40%
• 80mmHg < systolic blood pressure < 180mmHg or <20% change
from baseline
• no signs of distress during breathing

34. B --- BOWEL CARE
Bowel care is a fundamental area of patient care that is frequently
overlooked . Constipation and diarrhoea are not uncommon in
critical care unit and can be due to -
a. immobility
b. effects of ongoing treatment modality
c. infection
d. admitting diagnosis
It is very important to look for abdominal distension , auscultate for
presence of bowel sounds , document passage of flatus , B/O and
nature of faeces.

35. Constipation
1. spinal cord injury
2. neuromuscular
disease
3. abdominal Sx
4. sepsis
5. electrolyte imbalaces
6. inappropriate use of
diuretics
7. underlying dysmotility
Causes
1. early mobilisation
2. adequate fluid and
fibre intake
3. regular stool softeners
and laxtaives
4. osmotic and stimulant
laxatives >>>
5. suppositories and
enemas
Management

36. Diarrhoea
1. enteral nutrition
2. infective causes
3. altered intestinal
function
4. sepsis
5. antibiotic therapy
6. low albumin
7. malabsorption eg:
pancreatitis
Causes 1. review of ongoing
tretment regimen
2. anti diarrhoeal drugs
to reduce propulsive
peristalsis eg :
loperamide
3. fibre rich diet
4. probiotic therapy
5. replace fluid losses
Management

37. I --- INDWELLING CATHETER REMOVAL
Foleys urinary
catheter
Periphery Inserted
central catheter
(PICC)
central venous
catheter (CVC)
arterial line epidural

38. CAUTI bundle

39. CLABSI bundle

40. D --- DRUG DE - ESCALATION
• De - escalation therapy is defined as changing from the broad
spectrum antibiotic to an agent with a narrow focus based on
culture data ; changing the focus from multiple antibiotics to a
single drug when the suspected organism is detected by culture to
reduce overload of antibiotic dosages.
• better explained by antimicrobial stewardship.

42. De-escalating regime

43. CONCLUSION
FAST HUGS BID principle followed for care of critically ill patients as
a checklist is a simple strategy which is used for identifying and
checking the significant aspects in the general care of ICU patients.

44. THANK YOU