2007
Saturday July 28
A Practical Introduction to Intensive Care
A one day ‘basics’ of intensive care course
DELTEX MEDICAL
GAMBRO
INTERSURGICAL
MAQUET
SIEMENS
A Practical Introduction to Intensive Care
ICU Housekeeping
Where do you start?
Does it matter?
Steroids
Annane, 2002
10 NNT 28 day mortality
Semi-Recumbent Position
Drakulovic 1999
Tight Glycaemic Control
Van der Berghe, 2001
Sedation Holidays
Kress 2000
Low Tidal Volume Ventilation
ARDSnet 2000
11 NNT Hospital Mortality
Transfusion Triggers
Hebert 1999
17 NNT Hospital Mortality
DVT Prophylaxis
Samama 1999
11 NNT DVT Incidence
Spontaneous Breathing Trials
Esteban 1999
Stress Ulcer Prophylaxis
Cook 1998
4 NNT Ventilator Associated Pneumonia
30 NNT 1 year mortality
3.5 days ICU Length of Stay
2.0 days ICU Length of Stay
10 NNT Upper GI Bleed
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
Weaning
Pressure Support 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 (±Short Synacthen Test)
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
Avoid High Dose
‘Low Dose’ 50mg Hydrocortisone qds
Short Synacthen Tests
Discontinue if SST > 250 nmol/l
Dexamethasone 2mg ≈ Hydrocortisone 50mg
Target Fluid Balance
Achieved Fluid Balance
Renal
Urine Output in 24hrs
Oedema
Biochemistry
Na
K
Urea
Creatinine
Magnesium
Phosphate
Renal Numbers
Normal Mg2+ >0.8
Give 10mmol over 1 hour
Normal PO43- > 0.8
<0.5 mmol / kg over 6 hours
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
Target Nutrition In
Achieved Nutrition In
GI / Liver
Nutrition Out
Ulcer prophylaxis
BM - Glycaemia
Bilirubin
Nutrition
Controversial
Big Topic
Starvation is bad (eventually)
30ml/kg/day
EN (Prokinetics)
TPN
Gastric Protection
Controversial
Ranitidine
Sucralfate
Ventilator Associated
Pneumonia
Haemoglobin
Platelets
Haematology
Clotting
DVT Prophylaxis
Blood in Critical Care
Controversial
TRICC
Exceptions
Platelets
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