ICU Protocols
Memphis VA Medical Center
G. Umberto Meduri, M.D.
W. Andrew Bell, Pharm.D., BCPS
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The ICU Team
• ICU Attending
• Pulmonary and Critical Care Fellow
– Internal Medicine Resident
– Medicine Interns
– Medicine Students
• ICU Pharmacist
– Pharmacist Resident
• Critical Care Nurse
• Respiratory Therapist
• Nutritionist, Physical Therapist, Palliative Care
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ICU Protocols
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Antibiotic treatment of pneumonia
Antibiotic treatment for other infections
Fluid resuscitation and ScvO2-guided therapy
Vasopressors
Mechanical ventilation
Sedation and analgesia
Glucose control
Gastrointestinal and thromboembolic prophylaxis
Weaning from mechanical ventilation
Recombinant human activated protein C (rhAPC)
Prolonged glucocorticoid treatment in patients with shock
Prolonged glucocorticoid treatment in pts with severe ARDS
Guidelines
• ATS / IDSA Pneumonia Guidelines
– 2007 Community-acquired pneumonia
– 2005 Health care associated pneumonia
• Surviving Sepsis Campaign 2008
• SCCM 2002 Analgesia, Sedation, & Neuromuscular
Blockade Guidelines
• ASHP 1999 Stress Ulcer Prophylaxis Guidelines
• Chest 2008 DVT Prophylaxis Guidelines
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SEPSIS PROTOCOL
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Severe Sepsis - Screening
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[continued]
14 ScvO2 = central venous oxygen saturation
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COVERAGE
PREFERRED AGENTS
OPTIONAL AGENTS
Primary Gram -
Anti-Pseudomonal β-LACTAM
Piperacillin/Tazobactam 4.5g Q 6h
IF β-LACTAM ALLERGY
Aztreonam 2g, Q 6h
Double Gram -
Tobramycin 7 mg/kg/day*
Ciprofloxacin
400mg Q 8h
Optional MRSA
Vancomycin 20mg/kg Q12h**
Linezolid
600mg Q 12h
Health Care Associated Pneumonia
Hospitalized
Nursing
last 90 days
home
Within last 30 days
Hemo
Home
dialysis
wound
care
IV Rx
CAP with Risks factors for
Pseudomonas aeruginosa
Bronchiectasis
Chronic
glucocorticoid
use
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YES
*Interval adjusted from Q 24h based on renal function to a trough < 1
**Interval adjusted from Q 12h based on renal function to trough of 15 to 20
YES
Structural
lung
disease
Repeated
antibiotics
NO β-LACTAM ALLERGY
β-LACTAM ALLERGY
Piperacillin/tazobactam 4.5g Q 6h AND
Aztreonam 2g, Q 6 hours AND
Azithromycin 500 mg/d AND
Azithromycin 500 mg/d AND
Tobramycin 7 mg/kg/day*
Tobramycin 7 mg/kg/day*
*Interval adjusted from Q 24h based on renal function to trough < 1
No
NO β-LACTAM ALLERGY
β-LACTAM ALLERGY
Ceftriaxone 2 gm /d
Aztreonam 2 gm q6h
AND
AND
Azithromycin 500mg/d
Moxifloxacin 400 mg/d
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ALI-ARDS PROTOCOL
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Gastrointestinal Prophylaxis
• All patients enrolled in the study should receive stress ulcer
prophylaxis (SUP) with either a H2 antagonist or PPI
Gastrointestinal Prophylaxis
On PPI
at home
Patient tolerates oral intake or enteral feeding
Yes - oral intake
Yes - enteral feeding
No
Yes
Continue home
treatment
Convert home regimen
to Omeprazole
suspension
Pantoprazole 40mg IV at
same schedule (QAM,
BID)
No
Ranitidine Tablets
150mg BID*
Ranitidine syrup 150mg
BID*
Ranitidine 50mg IV Q 8h*
PPI = proton pump inhibitors; *Adjust Ranitidine interval to Q 24h if CrCl is < 50ml/min
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AJHP 1999; 56: 347-379
Thromboembolic Prophylaxis
ICU DVT Prophylaxis
Unless contraindicated, ICU pts should receive Intermittent Pneumatic Compression (IPC).
Ambulatory patient admitted for < 72 hours.
Immediately place IPC
OR
Not ambulatory patient, recent DVT, admitted
for >72 hours without IPC placed.
Obtain a duplex ultrasound LE to rule
out DVT then place IPC.
AND
No evidence of recent or ongoing bleeding  add pharmacologic prophylaxis
No Heparin allergy or recent orthopedic surg.
Heparin 5,000 units SQ Q8H
OR
No Heparin allergy and recent orthopedic surg.
LMWH – prophylactic dose
OR
Heparin Allergy
Fondaparinux 2.5mg SQ Q24H
AVOID: < 50kg BW or CrCl < 30ml/min
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LMWH = Low molecular weight heparin
Albumin 5% 500ml over 30 min
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