A one day ‘basics’ of intensive care course
2012
Saturday January 28th
A Practical Introduction to Intensive Care
A Practical Introduction to Intensive Care
ICU Housekeeping
Where do you start?
Does it matter?
Topic
Author
Outcome
Recommendation
Steroids in septic
shock
Spring, 2008
No effect on 28d or
1 year mortality
Faster time to
resoultion of shock
Steroids for those
on CV support
(inotropes/pressors
) may reduce
duration of support
Semi-recumbent
positioning
Drakulovic, 1999
Reduced ventiator
associated
pneumonia
All mechanically
ventilated patients
should be 45 head
up
Tight Glycaemic
control
NICE-sugar
investigators, 2009
Increased
hypoglycaemia and
mortality with tight
control
Keep BM 4-10 but
tight control
(BM4.5-6) not
recommended
Sedation holidays
Kress, 2000
Reduced duration
of mech ventilation
Reduced LOS on
ICU
Daily sedation holds
recommended
Topic
Author
Outcome
Recommendations
Low tidal Volume
ventilation
(6mls/Kg v
12mls/Kg)
ARDSnet, 2000
Low VT associated
with lower inhospital mortality
(NNT 11)
Aim for VT no
greater than
6mls/Kg keeping
Pplat<30 cmH2O
Transfusion Triggers Herbert, 1999
Restrictive v liberal
(<7 vs <10)
Restrictive stratergy
is probably better in
non-cardiac
patients
DVT prophylaxis
(Enoxaparin
20/40mg)
Reduced DVT
incidence
Prophylactic LMWH
should be
administered unless
contraindicated
Samama, 1999
A Practical Solution …
the Handover Sheet
Problem Lists:
A Solution
Airway
P1: VAP? A1: Start Ceftazidime
Breathing (Ventilatory Mode)
PaO2:FiO2 Ratio
Respiratory & Ventilation
Positive End Expiratory Pressure
RR:TV Ratio
Peak Airway Pressure
Secretions
Chest X-Ray
P:F Ratios
Acute Lung InjuryPaO2 10
Acute Respiratory
on 21%
Distress Syndrome
ALI
≠
ARDS
<300 (mmHg) PaO2 10<200 (mmHg)
on FiO2 100%
<40 (kPa)
<27 (kPa)
P:F = PaO2 / FiO2
Everything’s fine, doc
Weaning
Pressure Sup port Ventilation
“Weanable”
Not “Weanable”
RR/TV
RR/TV <80
RR/TV >100
Spontaneous
Breathing Trial
Rate and Rhythm
MAP
Inotrope / Vasopressor No. 1
Cardiovascular
Inotrope / Vasopressor No. 2
Steroids
Hb
Markers of Perfusion
Clinical – Warm Well Perfused
Central Venous Oxygen Saturation
Lactate
Base Deficit
Cardiovascular Numbers
MAP 65 mmHg is OK
0.5 mcg/kg/min (Adr / NAd) is A LOT
ScvO2 <70% is TOO LOW
Lactate >2 mmol/l is TOO HIGH
Base deficit < -2 is TOO MUCH
Steroids in Sepsis
Controversial
Previously shown to reduce mortality amongst
those unable to mount a steroid stress
response (Synacthen)
CORTICUS study (2008):
 No effect on mortality but faster time to
resolution of shock (i.e. reduced
inotrope/vasopressor duration).
 Same for responders and non-responders thus
synacthen test no longer indicated
Target Fluid Balance
Achieved Fluid Balance
Renal
Urine Output in 24hrs
(= hourly urine output)
Oedema
Biochemistry
Na
K
Urea
Creatinine
Magnesium
Phosphate
Fluid Balance
Colloids for Filling
Controversial
Crystalloids for Maintenance
Crispy or Bloated?
+500ml / day is normal
Add if febrile / diarrhoea
Subtract if oedema / bad lungs
Renal Numbers
Normal Mg2+ >0.8
Give 10mmol over 1 hour
Normal PO43- > 0.8
<0.5 mmol / kg over 6 hours
Target Nutrition In
Achieved Nutrition In
GI / Liver
Nutrition Out
Ulcer prophylaxis
BM - Glycaemia
Bilirubin
Nutrition
Controversial
Starvation is bad (eventually)
30ml/kg/day
TNIN ≠ ANIN?
Metoclopramide
Gastric Protection
Controversial
Ranitidine / Sucralfate
Ventilator Associated Pneumonia
Glycaemic Control
NICE-SUGAR (2009)
Tight (4.5-6 mmol/L) vs conventional
(4.5-10mmol/L) glycaemic control
--------------------------------------------------Increased mortality and
hypoglycaemic episodes for tight
control. Conventional range
recommended
Bilirubin
Haemoglobin
Platelets
Haematology
Clotting
DVT Prophylaxis
Blood in Critical Care
Controversial
TRICC
Exceptions
DVT Prophylaxis
Don’t forget
Sedation Scores
Hypnotic Dose
Opiate Dose
Neuro & Sedation
Sedation Holidays
CNS Intact?
PNS Intact?
Temperature
White Cell Count
C-Reactive Protein
Micro & Sepsis
Organism
Site of infection
Antibiotic 1
Antibiotic 2
Day
Day
║(Lines )
Central
Arterial
Vascath