critical care notes

1. Recognition/approach of
critically ill patient
Abraham T.
Lecturer, Department of Anesthesia
University of Gondar
1
3/19/2024

2. Assessment
Critically Ill
Patient
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3. Critically Ill Patient (ABCDE Assessment)
o The ABCDE approach
rapid bedside assessment of a deteriorating/ critically ill
patient
designed to provide the initial management of life-threatening
conditions in order of priority
used a structured method to keep the patient alive and to
achieve the first steps to improvement, rather than making a
definitive diagnosis (Smith 2003).
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4. The ABCDE approach: Underlying principles
• Use the ABCDE approach to assess and treat the patient.
• Do a complete initial assessment and re-assess regularly.
• Treat life-threatening problems before moving to the next part of
assessment.
• Assess the effects of treatment
• Recognize when you will need extra help
• Use all members of the team
• Communicate effectively
» The aim of the initial treatment is to keep the patient alive, and achieve
some clinical improvement. This will buy time for further treatment and
making a diagnosis.
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5. The ABCDE approach: Underlying principles
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6. The ABCDE approach: First steps
o Ensure personal safety
o First look at the patient in general
» If the patient is awake, ask “How are you?”. If the patient appears unconscious, shake
him and ask “Are you alright?” If he responds normally he has a patent airway, is
breathing and has brain perfusion.
» If he speaks only in short sentences, he may have breathing problems. Failure of the
patient to respond is a clear marker of critical illness.
o Rapid ‘Look, Listen and Feel” of the patient should take about 30 s and will
often indicate a patient is critically ill and there is a need for urgent help.
» If the patient is unconscious, unresponsive, and is not breathing normally start CPR
o Monitor the vital signs early.
» Attach a pulse oximeter, ECG and a NIBP m to all critically ill patients, as soon as
possible.
o Insert an intravenous cannula as soon as possible.
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7. The ABCDE approach: First steps
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8. Critically Ill Patient (ABCDE Assessment)
Airway (A)
• Airway obstruction is an emergency. Get expert help immediately.
» Untreated, airway obstruction causes hypoxia and risks damage to the
brain, kidneys and heart, cardiac arrest, and death.
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Immediate Management
A B C D E

9. Airway (A)
o The aim of the airway assessment is to establish the patency of the
airway and assess the risk of deterioration in the patient’s ability to
protect their airways.
patient’s airway can be patent (if the patient is talking),
partially obstructed (if air entry is diminished and often noisy) or
completely obstructed (if there are no breath sounds at the mouth or
nose) (Resuscitation Council 2018).
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10. Airway (A)
o Look for the signs of airway obstruction:
Airway obstruction causes paradoxical chest and abdominal movements (‘see-saw’
respirations) and the use of the accessory muscles of respiration.
Central cyanosis is a late sign of airway obstruction.
In complete airway obstruction, there are no breath sounds at the mouth or
nose. In partial obstruction, air entry is diminished and often noisy.
In the critically ill patient, depressed consciousness often leads to airway
obstruction
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11. Airway (A)
Decreased level of consciousness Patent airway
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12. Airway (A)
o According to Resuscitation Council (2017), Treat airway obstruction as a
medical emergency:
– Obtain expert help immediately. Untreated, airway obstruction causes
hypoxemia (low PaO2) with the risk of hypoxic injury to the brain, kidneys
and heart, cardiac arrest, and even death.
– In most cases, only simple methods of airway clearance are required (e.g.
airway opening maneuvers, airways suction, insertion of an oropharyngeal or
nasopharyngeal airway).
Tracheal intubation may be required when these fail.
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13. Airway (A)
• Give oxygen at high concentration:
– Provide high-concentration oxygen using a mask with oxygen reservoir.
» Ensure that the oxygen flow is sufficient (usually 15 L min-1) to prevent
collapse of the reservoir during inspiration.
» In acute respiratory failure, aim to maintain an oxygen saturation of 94–
98%.
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14. Breathing (B)
o Breathing function should only be assessed and managed after the airway
has been judged as adequate.
 Assessment of breathing is designed to detect signs of respiratory distress or
inadequate ventilation (Smith 2003).
o During the immediate assessment of breathing, it is vital to diagnose and
treat immediately life-threatening conditions
e.g. acute severe asthma, pulmonary edema, tension pneumothorax, and massive
haemothorax.
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15. Breathing (B)
o Look, listen and feel for the general signs of respiratory distress:
Sweating, central cyanosis, use of the accessory muscles of respiration, and
abdominal breathing.
o Count the respiratory rate.
An increasing respiratory rate is a marker of illness and a warning that the
patient may deteriorate suddenly.
o Assess the depth of each breath, the pattern (rhythm) of respiration and
whether chest expansion is equal on both sides.
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16. Breathing (B)
o Note any chest deformity; look for a raised JVP (e.g. in acute severe
asthma or a tension pneumothorax) and note the presence and patency of
any chest drains
o Record the inspired oxygen concentration (%) and the SpO2 reading of
the pulse oximeter.
o Listen to the patient’s breath sounds a short distance from his face:
 Rattling airway noises indicate the presence of airway secretions
 Stridor or wheeze suggests partial, but significant, airway obstruction.
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17. Breathing (B)
o Percuss the chest:
 hyper-resonance may suggest a pneumothorax; dullness usually indicates consolidation or
pleural fluid.
o Auscultate the chest:
 bronchial breathing indicates lung consolidation; absent or reduced sounds suggest a
pneumothorax or pleural fluid or lung consolidation caused by complete obstruction.
o Check the position of the trachea in the suprasternal notch:
 deviation to one side indicates mediastinal shift (e.g. pneumothorax, lung fibrosis or
pleural fluid).
o Feel the chest wall to detect surgical emphysema or crepitus;
 suggesting a pneumothorax until proven otherwise.
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18. Breathing (B)
o The specific treatment of respiratory disorders depends upon the cause.
o Nevertheless, all critically ill patients should be given oxygen.
In a subgroup of patients with COPD, high concentrations of oxygen may
depress breathing (i.e. they are at risk of hypercapnic respiratory failure
- often referred to as type 2 respiratory failure).
These patients will also sustain end-organ damage or cardiac arrest if
their blood oxygen tensions are allowed to decrease.
 In this group, aim for a lower than normal PaO2 and oxygen saturation. Give oxygen via
a Venturi mask (4 L min-1) initially and reassess.
 Aim for target SpO2 range of 88–92% in most COPD patients
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19. Breathing (B)
o If the patient’s depth or rate of breathing is judged to be inadequate, or
absent, use bag-mask ventilation to improve oxygenation and ventilation,
whilst calling immediately for expert help.
 In cooperative patients who do not have airway obstruction consider the use of
non-invasive ventilation (NIV).
 In patients with an acute exacerbation of COPD, the use of NIV is often helpful
and prevents the need for tracheal intubation and invasive ventilation.
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20. Breathing (B)
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21. Circulation (C)
 Assessment of circulation should be
undertaken only once the airway and
breathing have been assessed and
appropriately treated.
 The aim of assessing the circulatory
system is to determine the
effectiveness of the cardiac output.
(Mallet 2013).
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22. Circulation (C)
o Look at the color of the hands and digits
 are they blue, pink, pale or mottled?
o Assess the limb temperature by feeling the patient’s hands
 are they cool or warm?
o Measure the capillary refill time (CRT). Apply cutaneous pressure for 5 s
on a fingertip held at heart level with enough pressure to cause
blanching. The normal value for CRT is usually < 2 s.
 A prolonged CRT suggests poor peripheral perfusion. Other factors (e.g. cold
surroundings, poor lighting, old age) can prolong CRT.
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23. Circulation (C)
o Assess the state of the veins:
they may be underfilled or collapsed when hypovolaemia is present.
o Count the patient’s pulse rate.
Palpate peripheral and central pulses, assessing for presence, rate, quality,
regularity and equality.
Barely palpable central pulses suggest a poor cardiac output, whilst a bounding
pulse may indicate sepsis.
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24. Circulation (C)
o Auscultate the heart.
 Is there a murmur or pericardial rub? Are the heart sounds difficult to hear? Look
for other signs of a poor cardiac output, such as reduced conscious level and, if the
patient has a urinary catheter, oliguria (urine volume < 0.5 mL kg-1 h-1).
o Look thoroughly for external hemorrhage from wounds or drains
(e.g. thoracic, intra-peritoneal, retroperitoneal or into gut). Intra-thoracic,
intra-abdominal or pelvic blood loss may be significant, even if drains are
empty.
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25. Circulation (C)
o The specific treatment of cardiovascular collapse depends on the cause,
should be directed at fluid replacement, hemorrhage control and restoration of
tissue perfusion.
o Seek the signs of conditions that are immediately life threatening
e.g. cardiac tamponade, massive or continuing hemorrhage, septic shock), and
treat them urgently.
o Insert one or more large (14 or 16 G) intravenous cannula. Use short,
wide-bore cannula, because they enable the highest flow.
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26. Circulation (C)
o Give a bolus of 500 mL of warmed crystalloid solution (e.g. Hartmann’s
solution or 0.9% sodium chloride) over less than 15 min if the patient is
hypotensive.
o Use smaller volumes (e.g. 250 mL) for patients with known cardiac failure or
trauma and use closer monitoring.
o Reassess the heart rate and BP regularly (every 5 min), aiming for the
patient’s normal BP or, if this is unknown, a target > 100 mmHg systolic.
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27. Circulation (C)
o If symptoms and signs of cardiac failure (dyspnea, increased HR, raised
JVP, a third heart sound and pulmonary crackles on auscultation) occur,
decrease the fluid infusion rate or stop the fluids altogether.
o Seek alternative means of improving tissue perfusion (e.g. inotropes or
vasopressors).
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28. Circulation (C)
o According to the Resuscitation Council 2011, the specific treatment for
circulation problems depends on the cause
fluid replacement, restoration of tissue perfusion and hemorrhage control will
usually be necessary.
o Remember to continuously reassess the patient’s HR and BP, with the
target of restoring them to the patient’s normal physiological state, or,
if this is not known, aim for >100mmHg systolic
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29. Disability (D)
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o This assessment involves reviewing the patient’s neurological status, and should only be
undertaken once A, B and C above have been optimized, as these parameters can all
affect the patient’s neurological condition.
o Level of consciousness: conduct a rapid assessment of the patient’s level of
consciousness using the AVPU system (Mallet 2013)

30. Disability (D)
o If you’re concerned about the patient’s level of consciousness, then use a
more in-depth assessment, such as GCS, and seek further help
(Resuscitation Council 2017).
 Pupil reaction: examine the patient’s pupils for size, shape and reaction to light.
 Blood glucose levels: a blood glucose measurement should be taken to exclude
hypoglycemia. (Resuscitation Council UK 2017).
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31. Disability (D)
o Common causes of unconsciousness include
 profound hypoxia, hypercapnia, cerebral hypoperfusion, or the recent administration
of sedatives or analgesic drugs.
o Check the patient’s drug chart for reversible drug-induced causes of
depressed consciousness.
 Give an antagonist where appropriate (e.g. naloxone for opioid toxicity).
 Examine the pupils (size, equality and reaction to light).
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32. Disability (D)
o Measure the blood glucose to exclude hypoglycemia and follow local
protocols for management of hypoglycemia.
o For example, if the blood sugar is less than 4.0 mmol L-1 in an unconscious patient, give
an initial dose of 50 mL of 10% glucose solution intravenously. If necessary, give
further doses of intravenous 10% glucose every minute until the patient has fully
regained consciousness, or a total of 250 mL of 10% glucose has been given.
o Unconscious patients whose airways are not protected should be nursed
in the lateral position (Resuscitation Council 2011).
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33. Exposure (E)
o To examine the patient properly full exposure of the body may be
necessary.
Respect the patient’s dignity and minimize heat loss.
o By the time the assessment reaches this stage (exposure), there should
be a good understanding of the patient’s problems (Mallet 2013).
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34. Exposure (E)
o Conduct a thorough examination of the patient’s body for abnormalities,
checking the patient’s skin for the presence of rashes, swelling, bleeding
or any excessive losses from drains.
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35. Exposure (E)
o Look at the patient’s medical notes, medicine charts, observation charts
and results from investigations for any additional evidence that can
inform the assessment and ongoing plan of care for the patient.
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36. Exposure (E)
o Remember to document all the assessments, treatments and responses to
treatment in the patient’s clinical notes.
o Always seek help from more senior or experienced practitioners if the
patient is continuing to deteriorate.
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37. 3/19/2024 Critical care, Year II MSc Anesthesia, Jan 2019 37
Immediate Management
A B C D E
Full patient assessment
Chart review
History and systematic examination
Available results

38. Chart review
CIRCULATION Heart rate, rhythm, BP
HYDRATION IV fluids, Urine output, fluid balance
ALERTNESS Glasgow Coma Score
RESPIRATORY Respiratory rate, Inspired oxygen
concentration, SaO2
TEMPERATURE Temperature
SPECIAL FEATURES Drains, special aspects of patients
disease
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39. Review medication chart
• Has their chronic medication been prescribed and given
• Have prescribed antibiotics and fluids been given
• Are they taking any medications with side effects that might be
influencing the current state
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40. History
o Take history from referring staff but do not rely completely on it –
review the notes and talk to the relatives
o Many critically ill patients have co-morbidities which affect their
chances of survival
 eg: COPD or IHD – an exercise tolerance history is important and may not be documented
o Diabetes – how well is it controlled, what systems are involved
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41. AMPLE history
o Allergies
o Medication
o Past medical history
o Last meal
o Events
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42. Examination
o Full examination
– Vital signs
– Systems
o Focused examination on systems/regions involved
surgical site
underlying disease
identify problem areas
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43. Available results
o Results
– Biochemistry – U & Es, LFTs, glucose, ABGs
– Haematology – FBC and coagulation
– Microbiology
– Radiology – reports and films
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44. 3/19/2024 Critical care, Year II MSc Anesthesia, Jan 2019 44
Immediate Management
A B C D E
Full patient assessment
Chart review
History and systematic examination
Available results
Decide and plan

45. Decide
o Is the patient stable or unstable?
o Do you have a diagnosis?
o Which organ systems are involved?
o Which organ systems need support? - eg.
– Ventilation
– Inotropic support
– Dialysis/haemofiltration
o What specific investigations do you need?
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46. Categories of organ support
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47. Categories of organ support …
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48. 3/19/2024 Critical care, Year II MSc Anesthesia, Jan 2019 48
Immediate Management
A B C D E
Full patient assessment
Chart review
History and systematic examination
Available results
Decide and plan
Stable patient
Daily management plan

49. Stable patients
o Daily management plan
o Fluids & nutrition
o Drugs
 Therapeutic and prophylactic
o Physiotherapy
o What level of care do they require?
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50. 3/19/2024 Critical care, Year II MSc Anesthesia, Jan 2019 50
Immediate Management
A B C D E
Full patient assessment
Chart review
History and systematic examination
Available results
Decide and plan
Stable patient
Daily management plan
Unstable / Unsure
Diagnosis required
Specific investigations
Definitive treatment

51. Unstable patient (or unsure)
o Investigations
targeted not blind
supports clinical assessment
o Definitive treatment
start as soon as possible
medical, surgical, radiological
o Co-ordinate and communicate
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52. Communication
o Case notes – problem orientated approach
o Record plan and check progress
o Nursing staff - set parameters and agree plan
o Colleagues
o Patient and relatives
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53. 3/19/2024 Critical care, Year II MSc Anesthesia, Jan 2019 53

54. FAST HUGS BID
o Objective:
To introduce the Fast Hug mnemonic (Feeding, Analgesia, Sedation,
Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer
prevention, and Glucose control) as a means of identifying and
checking some of the key aspects in the general care of all
critically ill patients.
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55. FAST HUGS BID
o Bowels
o Indwelling catheters removal
o De-escalation – antibiotics, inotropes, FiO2 etc
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56. The seven components of the Fast Hug approach
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57. FAST HUG
• Why feeding?
– Adequate nutrition is vital for critically ill
• Poor wound healing
• Post operative complications
• Sepsis
– Critically ill patients
• Are often already malnourished on admission
• Mechanically ventilated ICU patients have a malnutrition
rate of 38% to 100%.
• Have greatly increased calorie requirements
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58. FAST HUG …
o 5.6 kJ/kg/day is an acceptable and achievable target
intake
But patients with sepsis or trauma may require almost
twice as much energy during the acute phase of their
illness (Proc Nutr Soc 2004)
o If oral feeding is not possible, enteral nutrition is
preferred to parenteral nutrition and should be
started early, preferably within 24–48 hrs of ICU
admission (Intensive Care Med 2008).
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59. FAST HUG …
o The optimal constituents of feeding solutions remain under
debate, but literatures recommend that;
 solutions containing fish oils, borage oils, and antioxidants
should be considered for patients with ARDS and
 glutamine-enriched formulas should be considered for
patients with severe burns and trauma (JPEN J Parenter Enteral
Nutr 2003).
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60. FAST HUG
o Why Ensure Analgesia?
 Critically ill patients feel pain due to:
• Their primary illness e.g. pancreatitis / surgical wounds
• Routine procedures e.g. turning / suctioning / dressings
 Humanity & Compassion
 Psychological Effects
 Physiological Effects
 Metabolic effects
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61. FAST HUG ..
o Opioids are the most widely used, although they may be
combined with NSAIDS or acetaminophen for certain
patients.
The most commonly used opioids are morphine, fentanyl, and
remifentanil.
o Continuous infusions of analgesic drugs or regularly
administered doses are more effective than bolus doses
given “as needed,”
o Care should be taken to ensure analgesia is adequate
but not excessive.
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62. FAST HUG
o Why Sedate?
Tolerance of invasive and uncomfortable monitoring and treatment
procedures
Reduce oxygen consumption by reducing patient arousal and activity
Promote amnesia for events in the ICU
Specific treatment for conditions:
 Epilepsy / Tetanus
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63. FAST HUG
o No rules governing how much to give and how often, and
sedative administration must be titrated to the individual.
o Increase the dose of sedative to have a calm and quiet
patient, oversedation is associated with harmful effects
o Using the “CCC (calm, comfortable, collaborative) rule” to
help determine whether patients are appropriately
sedated.
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64. FAST HUG
o How to Sedate?
Benzodiazepines (commonly midazolam)
Intravenous anesthetic agents
Major tranquilizers
Analgosedation
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65. FAST HUG
o Oversedation
Increased risk of nosocomial pneumonia
Increased rate of Neurological Investigation (CT)
Prolonged stay in the ICU + Polyneuropathy
Increased incidence of post – traumatic stress disorder and
depression
Increased use of inotropes
o Monitoring Sedation
Ramsay Sedation Score
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66. FAST HUG
o Why Ensure Thromboprophylaxis?
Critically ill patients have numerous risk factors
Without prophylaxis rates of deep-vein thrombosis range
between 13% and 31%
 May be much higher in trauma patients
Must weigh up risks vs bleeding complications
o How Ensure Thromboprophylaxis?
Mechanical
Pharmacological
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67. FAST HUG
o Head of the bed inclined at 45 degrees
Can decrease gastroesophageal reflux in mechanically ventilated
patients
Can reduce rates of nosocomial pneumonia
Is indicated (20 – 30 degrees) in some patients e.g.
raised ICP
o Take care
o Don’t let the patient slide off the bed!
o Cerebral perfusion
o Pressure areas
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68. FAST HUG
o Peptic ulceration is related to protective barrier loss
– Acid or biliary damage of the underlying mucosa
– Barrier loss occurs secondary to critical illness
o Direct damage from feeding tubes
– especially at the lower oesophagus
o Mucosal damage from tissue hypoperfusion
o Highest risk
– Prolonged mechanical ventilation
– Concurrent coagulopathy.
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69. FAST HUG
How to Ensure Ulcer Prophylaxis?
o Small-bore feeding tubes
o Enteral nutrition
o Adequate tissue perfusion (optimal haemodynamics)
o Prophylactic drug therapy (Controversial)
– H2 antagonists (ranitidine)
– Proton pump inhibitors (omeprazole, pantoprazole)
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70. FAST HUG
o Mayo Clinic 2004 Study: “Keeping blood glucose levels < 140
mg/dL “
– 29.3% decrease in hospital mortality
– 10.8% reduction in length of ICU stay
o Care to avoid hypoglycemia – disaster
o Many units now aim to keep blood sugar levels below about
150 mg/dL
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