Dummies Guide to ICU

Dummies Guide to ICU


This is a non-expert opinion from an ED Reg, especially for those who haven’t done anaesthetics.
 
The following applies to adolescents and adults. Most of it applies to kids as well – but get a big person to help you.
 
Listen to the senior nurses - they are invaluable.
 
Let the boss nurse know if you are leaving the unit eg going to a ward, ED or just to lunch - they need to know where you are.

A good website is ccmtutorials.com

If in doubt call the boss day or night. They expect to be called several times a night. 

Start your phone call with "I just need some advice ..." or "I think you need to come in" or "We need you here now ..."  so the boss knows how urgent the problem is.


Airway


Don’t intubate anyone with GCS> 3 unless there is a consultant or experienced ICU or anaesthetics reg at the bedside.

Don’t hesitate to call an anesthetics reg overnight. Usually they are very helpful (much easier to get them to come and help for a tube than trying to get them to ED for a transport).

ICU airways are almost all high risk.

Most should be RSI.

Preparation is the key.


RSI

Preparation

SABI MALE SOD (?the not so sweet transsexual)

Staff: Assign roles so everyone knows what they need to do

  • Ensure boss nurse knows

  • You

  • Your assistant: drugs / passer of suction/tube / attacher of ambibag

  • Cricoid person: tell them not to release until told to

  • Scribe

  • Neck immobilizer for traumas

  • Goffer/chest auscultator (needs stethoscope)

Assess and position airway

  • Assess

    • Mouth opening

    • Neck mobility (not trauma)

    • Dentition

    • Jaw length

    • Neck length

    • Obesity

    • Modified Mallampati: how much of the oropharynx can you see

      • Whole uvula: good

      • Tongue and palate only: badness

    • If any of these look bad move you supervisor a bit closer

  • Position

    • Fatties: “ramping” shoulders on pillows, head on more pillows. Tragus above level of manubrium.

    • Trauma: in line manual stabilization, collar off

    • Otherwise: “sniffing” head on one thick pillow.

Bougie = get out of jail card #1. Unopened but within reach.

IV access x 2, IV fluid running

Monitoring x 4

  • Oxymetry – audible “the beeps”

  • BP

  • ECG

  • Capnography – attached to filter ready to attach to ETT

Airways

  • Oropharyngeal airway (guedel)(unopened on tray)

  • Nasopharyngeal airway (know where to find one quickly)

Laryngoscope x2 working, usually use a size 3 in adult female, size 4 adult male.

LMA = get out of jail card #2. Size 4 for adult female, size 4-5 adult male.

ETT correct size open, lubed, balloon checked. Another one, 1/2 size smaller, unopened.

Suction working, under the pillow

Scalpel for cric = get out of jail free card 3#. Don’t use a cric kit: takes 5 minutes in expert hands

 

Oxygen – check it’s flowing and reservoir bag reservoir fills

Drugs

  • Intubation

    • Etomidate 0.3mg/kg = 20mg = 1 ampoule (0.2mg/kg if shocked, very elderly, chronic renal failure)

    • Suxamethonium (= succinylcholine) 1-2mg/kg = 100mg = 1 ampoule

    • Or Rocuronium (1mg/kg = more than one ampoule for RSI) instead of sux if:

      • Hyperkalaemia including

        • renal failure where is K not known to be normal

        • severe crush injuries

      • Severe burns more than 5 days old, until burns completely healed

      • Neuromuscular disorders

        • Paralysis (eg CVA, trauma) more than 5 days old

        • Other denervation eg Guillain Barre, Myasthenia Gravis, MS amytrophic lateral sclerosis

        • Myopathies

      • Malignant hyperthermia

    • Pressor drawn up eg ephedrine see below

    • Atropine available esp 4 kids

  • Post intubation

    • Rocuronium 50mg (if not used for intubation) to keep patient immobile till everything is stabilized (not all patients need this but to start with just paralyse them all)

    • Propofol infusion15ml/hour initially until long term sedation started. Watch for hypotension. If it occurs stop infusion temporarily and given ephedrine 10mg (3.3ml of 30mg (1 ampoule) made up to 10ml with saline)

    • If BP dodgy use midazolam 5mg rather than propofol

    • If patient in pain add an opiate eg fentanyl 50-100µg depending on pain and age.


Preoxygenation

Washes nitrogen out of lungs giving a bigger reservoir of oxygen in lungs

At least 3 minutes on ambibag – but get sats as high as they will go


(Pretreatment

Don’t do it. No proven benefit. KISS = less chance of error).

Paralysis and Induction

Rapid push of etomidate immediately followed by rapid push of sux or roc (in that order to avoid a paralysed awake patient if anything goes wrong) then large flush.


Protection

Cricoid on. Remind cricoid person not to let go until asked to.


Placement

When fasciculation stops (or 45 seconds after roc) open mouth with fingers, remove false teeth, hold laryngoscope in left hand and slide it down right side of tongue, pushing tongue to left.

When you see the epiglottis, ensure the laryngoscope passes anterior to it (posterior if less than say 8 years old) and gently advance as far as it will go. Lift the laryngoscope up and away from you, pulling in the direction of the laryngoscope handle until you get a good view of the cords (= most of the time).

If poor view try repositioning, adjusting cricoid pressure (cricoid off if necessary) or bougie.

Suction if necessary (keep looking in the hole, ask your assistant to pass the suction to your right hand).

Keep looking in the hole, ask assistant to pass ETT to your R hand.

Pass the ETT from the R corner of mouth (ask your assistant to pull the corner of the mouth out if necessary).

Pass tube through cords until 24cm at the teeth.

Hold the tube.

Get your assistant to attach ambibag (+ filter + capnography) and start bagging. Ask the goffer to inflate the cuff until the leak stops.


Proof

Look for fogging of the tube.

Look at the capnography trace.

Get the goffer to auscultate lateral upper chest bilaterally.

If you’re happy “cricoid off” and get someone to tie the tube in.


Post intubation management

Sedate and paralyse as above (“Drugs”)

Attach to ventilator (see “Breathing” below)

NG tube.

Urinary catheter early.

Check cuff pressure with manometer (lives on main airway trolley): get pressure in the green zone.


Other Airway Issues

Tracheostomies

If one falls out

  • Occlude trache hole and bag and mask then you have plenty of time to:

  • Trache less than a week old: reintubate orally with ETT as above. Then someone can redo the trache later.

  • Trache more than a week old: sedate eg Infuserite (see Sedation later) or propofol 15ml/hour and insert a new trache through the hole.


Bleeding from trache: fresh blood may = tracheo-inominate fistula = huge mortality. D/w boss even if bleeding stopped. If actively bleeding incr pressure in trache cuff to attempt to tamponade.

Suctioning

Get the nurses to show you how to suction ETTs and traches. An important skill we need to be comfortable with.


Extubation

Generally done during day shift, unless immediately post-op, FIO2 0.3, able to lift head off pillow, squeeze your hand x3 and keep eyes open.

Incr FIO2 to 1.0 for a few minutes.

Airway trolley handy.

Part of challenge is stinky secretions above cuff.

Sit pt up at least 30° (if spine allows). Put "bluey" on chest for stinky tube and secretions to go on.

Suction down ETT. Suction mouth.

Attach syringe to cuff balloon.

Undo tube holder/tape.

Turn PEEP up to 15cm (to help blow crud out).

Get pt to take deep breath in, deflate cuff, pull ETT out.

Suction mouth.

Turn ventilator off.

O2 via hudson mask (occassionally CPAP used post extubation (if needed more than 5cm PEEP prior to extubation)

Breathing

They seldom listen to backs of chests in ICU.
 
One approach to ventilation is to consider oxygneation; ventilation and lung mechanics separately:
 
Oxyenation: FIO2 + PEEP determines oxygneation.  "The patient is able to maintain an O2 sat of 97% with an FIO2 of 0.35 and a PEEP of 5: they are oxygenating well"
 
Ventilation: What is the minute ventilation (L air moved per minute) and what CO2 does this achieve.  "We are only getting a minute ventilation of 4L/minute and the PCO2 is 50: we are underventilating the patient.
 
Lung mechanics:  "We are requiring 20 of pressure support and causing plateau pressures of 34cmH20.  The patient has stiff lungs and at the moment our airway pressures are too high"


 

Respiratory rate

Important marker of lung badness.

Know the RR of all patients.

Starting rate for ventilator: 16. Go as low as 6 for an asthmatic.  Patients breathing at 25+/minute, even if supported, will fatigue.  You either need to increase their manditory ventilation or sedate +/- paralyse to allow them to tolerate a higher CO2.

FIO2

A good marker of lung health.

Generally, if the patient has a high FIO2 it means lung badness eg pneumonia; ARDS.

In ICU they don’t generally drop the FIO2 below 0.3 (for no good reason).

The patient generally won’t be ready to extubate till FIO2 is 0.30 or 0.35.

Generally start at 0.6 and titrate down to the lowest that will keep the patient at “normoxyia” for them. Tolerate SaO2s as low as 88-89% in ARDS

ARDS

Generalised lung badness not due to the heart.

Stiff wet lungs.

Definition: bilateral infiltrates on CXR. PaO2/FIO2 < 200mmHg with normal pulmonary artery and left atrial pressures (in practice the vascular pressures are a clinical guess).

Managed with low tidal volume ventilation. See below.

Acute Lung Injury

Like ARDS but not quite so bad. Definition: as for ARDS but PaO2/FIO2 < 300mmHg.

PEEP

Positive end expiratory pressure.

Like CPAP.

Pressure maintained in lungs at the end of expiration to keep airways open.

Usually start off with 5cm H20.

NB PEEP can reduce venous return, so if BP low may need to reduce PEEP.

PEEP is good for CCF, ARDS, atalectasis. Not good for localised pneumonia.

For ARDS use 15 cm H20.

Peak Airway Pressure and Plateau Pressure

Too higher pressures are believed to do a lot of damage to lungs and cause/exacerbate ARDS.
 
Generally we like to have both the peak pressure and the plateau pressure (the airway pressure during most of inhalation) < 30cmH20
 
d/w boss if getting above 30. Often intial management is to reduce tidal volume.  Sometimes a pressure limited mode of ventilation is used

Pressure Support

When the patient breathes in, the ventilator helps push air in under pressure.

Pressure support is the extra pressure above the patient inspiratory pressure.

More pressure support generally results in deeper breaths ie greater tidal volume.

Always set to a minimum of 5cm H20 to overcome the resistance of the circuit.

Tidal Volume

Generally start with 500ml for an adult male, 400-450ml for a adult female.

For someone with dodgy lungs, eg ARDS; asthma, use a “lung protective strategy” of 6-8ml/kg ideal body weight (based on height). You will need a table/calculator, eg Archimedes, to work this out)

SIMV

Synchronised intermittent mandatory ventilation.

The ventilator breathes for the patient at a set rate. If the patient breathes faster than the set rate, the machine will assist the spontaneous breaths.

Use this initially for all patients and all patients who are paralysed.


ASB

Assisted Spontaneous Breathing.

Incorrectly called CPAP by many of the nurses, and lablelled CPAP on some of the ventilators, just to confuse you.

The patient is breathing spontaneously and the ventilator is just giving a bit of help with each breath.

Initial settings

SIMV, 500 by 16, on 60% with 5 and 5”

NB notes on Tidal volume above.

This applies to portable vents as well as the ones in the unit.

BiPAP

As in ED.

Initial settings

  • Asthma: 13/5. Seton likes 8/5

  • CCF: 20/15

  • COPD: 15/5. BPM (back up rate) 15. I time 1. Target SpO2 85-90.

CPAP

Seldom used.

10cm H20 to start with.


Breathing up” / “Poor synchronisation with the ventilator” / "fighting the ventilator

Patients with losts of rapid irregular spontaneous breaths need there ventilator settings adjusted, there sedation increased &/or to be paralysed. d/w boss.   Also check for bronchospasm.


Adjusting Ventilator Settings

For the first few months speak to the boss before fiddling with the vent. Vent generally shouldn’t be adjusted overnight.
 
Shuffling Secretions”

Looks like a pneumothorax but it aint.  During/immediately after being turned in bed, ICU patients often drop their sats, and may have decr air entry on the new dependent side. This is probably due to lung secretions moving to the new dependent side.

Often just need suctioning and an increased FIO2 for a few minutes till they sort themselves out.

Occasionally need increased PEEP or hand-bagging to reinflate them.

Sometimes need a bronchoscopy to suck the snot out of the bronchi. These ones will have a lobe or lung whited out on CXR. d/w boss.

Pneumothoraces do happen but are rare (usually post trauma).

If in doubt get urgent CXR.

Unlikely to need “stat” needle decompression in ICU - but tension pneumothoraces do happen.  If you get the above picture + falling BP treat as tesnion penumothorax


Circulation

Swing in the art line”

This beastie is a believed to be a marker that the patient needs more volume. The arterial line blood pressure trace swings with ventilation. In an under-filled patient a high intrathoracic pressure decreases venous return and decreases cardiac output and therefore blood pressure.

Art lines and central lines.

One of those skills that just takes time, and many failed attempts, to master. Be patient with yourself. Use the ultrasound. It’s great when you get the hang of it.


Volume

This unit likes volume = Normal Saline (sometimes plasmalyte is used if the patient has a hyperchloraemic acidosis)

Patient is normally on maintenance fluid (male 80ml/hr, female 60ml/hr, cardiothoracic surgery 20ml/hr).

If the patient may be under-filled eg

  • Swing in art line

  • MAP < 65

  • Urine output < 0.5 ml/kg/hr (0.3ml/kg/hr for cardiothoracic surgery)

  • Cool peripheries

  • Cardiac index < 2.5

We usually give 1L normal saline stat for any adult (no matter how old and crumbly) and monitor the results.

If still looks under-filled repeat.

Patients occassionally get 15 litres of fluid over 4 hours but NB Pressors below.



Colloid

Used sparingly after cardiothoracic surgery.

Otherwise considered evil.


Blood products

Used sparingly. Transfuse if Hb < 70 (or patient is exsanguinating).

With massive transfusions have a low threshold for giving FFP and platelets as urgent coag results take an hour to come back. d/w with the boss. Recommendations vary: 1 FFP:1 RBC; 1FFP:2RBC


Pressors

If you think your patient is well filled, eg 3 litres of crystalloid, but still they look like they are under-perfused (partly given by the indices under volume above) or you are getting no response from your fluid boluses d/w the boss. They will usually be given noradrenaline 2mg made up to 50ml with D5W starting at 2ml/hour. When they get to 20ml/hr they change to 4mg/50ml = “double strength norad” and will often have vasopressin added.

The volume vs pressor balance is part of the fine art of ICU, ie we don’t know which approach works better.

If you are in ED or on the wards use the “poor man's pressor” 1 mg of adrenaline in 1 L normal saline and run it at about 120ml/hr (= 8 hour bag) till you get a response (do 2 minutely BP) then titrate up or down.

Or use ephedrine (alpha and B agonist) 30mg (1 ampoule) made up to 10ml with normal saline. 10mg boluses prn every few minutes. Lasts about about 10 minutes.

In Australia: metaraminol (alpha>Beta) 0.5-1mg prn q 3 minutes

(another, less often used, pressor in phenylephrine (pure alpha) but KISS)

Inotropes

Many cardiac surgery patients come back from theatre on milrinone. It is a long acting phospodiesterase inhibitor => incr levels of cAMP. d/w boss when to stop it.

Non-cardiacs will sometimes have dobutamine added to their cocktail when norad and vasopressin aren’t working.

Cardiac surgery patients

Often precarious. Keep the ICU Registrar Guidelines handy and follow them. Call the bosses early and often.

Know how to use the defib – you’ll be using it lots.

Know how to drive a pacemaker – get someone to talk you through the control box.

“Reopens”

= cardiac surgery in CICU, not theatre. This happens fairly frequently. Don’t take it personally. When the boss decides to reopen you call the operator “reopen please”. Keep the patient alive (may require every blood product, CPR, adrenaline infusions) till the anaesthetist comes to take over from you.

PICCO

A very expensive, unproven, cardiac function monitor.

Arterial pressure and temperature sensing cathether.

Different sized catheters for brachial vs femoral.

Uses thermodilution to work out cardiac output. Cold saline is injected into central venous line. The temperature drop at near-central arterial line tells you how much blood the cold saline has been diluted in. Then with some magical assumptions the machine will tell you from the shape of the pressure and temperature change curves whether the patient needs more volume, more squeeze or some frusemide.

Put the lines in. Nurses do the cold saline bit. Machine spits out numbers which you tell the boss. He scratches his chin and says give more fluids.

CCF

Treated with BiPAP or invasive ventilation and nitrates.

Frusemide is not used acutely for CCF.

Frusemide is sometimes used to dry out an overloaded patient who is over the acute phase of an illness.


DVT Prophylaxis

Short stay, eg overdose: TEDS

Post op: TEDS, enoxaparin as directed by surgeon

Other: TEDS, enoxaprin 40mg od, or 20mg od if moderate renal impairment (arbitrary cut off)


Antiarrhythmics

First line: correct K and Mag. Give Mag even if Mag in normal range – often helps.

Second line: Amiodarone for just about everything.



D

Sedation

Sedation is required so patients can tolerate ETTs.

Different ICU have different methods.  Commonly infusions of midazolam and fentanyl are used for long term intubations and propofol if the patient will be intubated for < 24H


After long periods of sedation it may take hours or days to clear body stores of sedative.

Use fentanyl 600µg rather than morphine in renal failure.

Watch for hypotension with propofol.

For procedural sedation give 2ml boluses of propofol or an infusion as above, but ICU patients are often extremely sensitve to sedatives/analgesics and will drop their BP. If BP dodgy safer to use midazolam 1-5mg depending on how nasty the procdure is and whether they’re being ventilated or not.

Delerium/agitation

Most of the long term oldies wake up delirious and agitated. Rx haloperidol 0.5 – 5 mg prn. Nurses will often tie the patients’ hands to stop the patient removing tubes and lines.


E

Fever

Nurses will take blood, sputum and urine cultures.

Antibiotics seldom started empirically. D/w boss before starting Abs – they’re very particular about them.

Over 39°: paracetamol, actively cool: damp sheet, fan.

Over 40°: may need paralysis to reduce heat generation.


Therapeutic hypothermia

Unconscious post cardiac arrest: Sedate with propofol (they are unconscious now, but they potentially could wake in a hurry and pull their ETT out. Cool: 24 hours @ 32-34° (international guidelines are vague): 2 litres cold normal saline (out of fridge in ED or ICU), damp sheet, fan.


G

Glycaemic control.

Aim for BSL 8-10 for all ICU patients

NG feeding (Glucerna (Jevity if diabetic/hyperglycaemic) 0-80ml/hour adjusted by the nurse) starts on admission to ICU unless very short stay eg overdose.

If 2 blood sugars > 10 the patient will have blood sugar controlled with an insulin infusion as per the ICU protocol


Renal

Dialysis

Consultant decision.

Insert a vas cath or niagra as directed by the boss. Same technique as central line, just scary bigger catheter. Make a big skin incision. Have lots of gauze ready as they bleed ++ when you pull the dilator out.

Dialysis has some heparin in the filter which shouldn’t affect the patients coags too much, but often does.

Dialysis may or not remove volume from the patient – the boss decides.

We don’t prescribe dialysis enough to know what we’re doing – admit defeat and ask the boss what to write down.

A sample standard prescription enclosed.










XRay

Chest XRay after insertion of central line, ETT or NG tube. Further chest XRays only if clinically indicated. Radiographers do a round about 7am each day, so nightshift docs need to think about who needs an XRay that day.

Transfers/Retrievals

Retrievals from wards or ED, transporting patients to CT.

Potential disaster around every corner.

To start with take a budy and boss nurse with you.

Get someone to show you how to drive the portable ventilator

Take every drug you think you may need (intubation drugs, post intubation drugs, ephedrine and adrenaline) and one of the red airway bags (ambibag, airways, PEEP valve for doing CPAP) (on the wall opposite the loos the reg room) with you. You have to ask nurses to get etomidate for you especially cos it’s not in the transport box for some stupid reason.

If the patient isn't tubed take some good sedatives with you eg haloperidol + midazolam for agitation clasutrophobia (especially in the CT) and antiemetics if flying or travelling by road.

Usually leave art lines and central lines till you get back to ICU. Any drugs can be given peripherally for a short time – just watch for extravasation of pressors.

OK to tube people in ED, otherwise, where possible, bring patients back to ICU to be tubed.

Don’t move patients till you are happy with them. Don’t let any one rush you. It’s better to stabilise where you are rather than have a disaster in the lift or CT.

Have full monitoring (sats, ECG, art line or BP cuff set to go q5min, capnography if tubed) on before you move.

For tubed patients paralyse for transport to decrease risk of patient pulling out tubes or lines en route.

Beware of propofol and morphine for anyone with a dodgy BP. Safer to use midazolam (and fentanyl if analgesia needed).

Resist taking unstable traumas to CT if they need to go theatre.

Be assertive during trauma resuscitations.


Admission note

Brief.

ICU admission from ED/Ward/Theatre

Background

76 male, mentally sharp, lives alone at home, independent with ADLs but has to stop every 100 metres on flat due to SOB

Problems

  1. 7 days of productive cough. Started on Abs 2/7 ago by GP. Found by neighbour tonight unconscious. BIBA. In ED febrile, confused.

  2. Type 2 DM/glycaemic control

  3. MI 1997, stent. No angina since

  4. COPD FEV1 75%

  5. Smokes 10/day

  6. DVT prophylaxis

  7. Sedation

Meds

Allergies

O/E

A: own, quiet breathing but GCS M3, E2, V2 = 7

B: RR 36, O2 sat 90% on reservoir mask on 15L, bronchial breathing + coarse creps L

base.

C: Mottled, cold peripheries, HR 130, BP 90/30 MAP 50. UO 10ml/hour

E: temp 38.5

G: BSL 12.3, abdo soft non tender

Labs: …

Xray: …

I: Gravely unwell 76 man with LLL pneumonia and septic shock

P:

  1. D/W Dr …..

  2. ETT, etomidate 10mg, sux 100mg, Grade 1 view, easy intubation, 5mg midazolam for transport

  3. ventilate SIMV, 500 by 16, on 60% with 5 and 5

  4. 4 litres normal saline

  5. blood, urine and sputum cultures

  6. urinary antigens

  7. augmentin and clarythromycin

  8. D4S 80ml/hour

  9. NG feed – Glucerna

  10. Sprint

  11. M+M sedation via infuserite

  12. TEDS, enoxaparin 40mg od


Ward round notes

ICU WR Dr …

Day 1 in ICU

Problems

  1. LLL pneumonia with septic shock

  2. type 2 DM

  3. etc as above

o/e

A ETT

B SIMV, 16x 350ml, 5/5, FIO2 0.5, O2 sat 100% Decr ae and bronchial breathing L base

C etc
 
Check:

F = early enteral Feeding 

A = Analgesia

S =  Sedation

T = Thromboembolic prophylaxis 

H = Head of bed elevation

U = stress Ulcer prophylaxis

G = Glycemic control lycemic control


Plan:

  1. increase PEEP to 10, FIO2 decr to 0.4

  2. reduce enoxaparin to 20mg od

  3. etc



Enjoy

Chris Cresswell

July 2010

 

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