WEST YORKSHIRE CRITICAL CARE NETWORK
VENTILATION
CARE BUNDLE
DISTRIBUTED BY
WEST YORKSHIRE CRITICAL CARE NETWORK
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CONTENTS
Page
Introduction
3-4
Sedation Holds
5-6
Head Elevation
7-8
Venous Thromboembolism
9
Stress Ulceration
10
Glycoma Control
11
Blood Transfusion
12
Appendix 1: Audit Tool for Ventilator Care Bundle
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Introduction
Care bundles are a grouping of care elements for particular symptons,
procedures of treatments.
There are 3 levels:-
Level 1
-
Strong science, good methodology, poor process
Level 2
-
Strong science, debatable methodology, poor process
Level 3
-
Questionable sciences, debatable methodology, poor
process
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Ventilation Care Bundles
Comprises of 6 elements of care to be considered daily for the ventilated
patients.
This concept has been adopted by the NHS Modernisation Agency from the
Intensive Care Quality Improvement Conference in Chicago, USA. The
Society of Critical Care Medicine in USA has published evidence based
clinical guidelines on the use of sedatives and analgesia in critically ill adults
(Jacobs et al 2002).
The components are:
1.
2.
3.
4.
5.
6.
Nursing the patient with head up to an angle of 30o or greater
Sedation hold
Deep vein thrombosis prophylaxis
Peptic ulcer prophylaxis
Normalise blood sugar (4.4 to 6.1)
Normalise Hb (7g)
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Sedation Holds in the Critically Ill Adult Patient
1.
Introduction
The purpose of this care bundle is to
 Reduce the duration of mechanical ventilation
 Reduce the length of patient stay in ICU
The administration of sedatives by continuous infusion may prolong the
duration of mechanical ventilation and length of stay in ICU (Kress et al,
2000 & Kollof et al, 1998). Over administration of sedation can be
detrimental to care of patients (Brattebo et al, 2002). In a prospective
randomised study of 128 mechanically ventilated patients, duration of
ventilation was reduced by more than 2 days and length of stay was
reduced by 3.5 days (Kress et al, 2000).
2.
Indications - Inclusion
Inclusion – Patients who are being mechanically ventilated and
receiving continuous infusion of sedative drugs. These include
benzodiazepines, opiates & propofol.
3.
Contra-indications - Exclusion
 Patients who are receiving infusions of muscle relaxants.
 Patients who’s ventilation requirements require reverse 1:E ratio,
prone positioning, oxygen (02) higher than 60% or PEEP 12.5
increased ratios.
 Patients with raised intracranial pressure.
4.
Procedure for sedation hold
Sedation hold should be assessed by the medical & nursing staff on the
morning ward round. It should not take place during times of high
activity with the patient or reduced staffing levels.
References:
 Jacobi J, Frase GL, Coursn DB et al: Clinical practice care bundle for the use of
sedatives and analgesics in the critically ill adult; Critical Care Medicine 2002; 30:
119-141.
 Kollef MH, Levy NT, Ahren TS et al: The use of continuous IV sedation is associated
with prolongation of mechanical ventilation; Chest 1998; 114: 541-548.
 Kress JP, Pohlmon AS, O’Connor MF, Hall JB: Daily Interruption of sedative
infusions in critically ill patients undergoing mechanical ventilation; N. English
Journal of Medicine 2000; 342: 1471-7.
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ESTABLISH IF SEDATION HOLD APPROPRIATE
YES


Ensure patient lower activity
levels
Ensure environmental noise
minimal


Turn off sedative agents
DO NOT turn off analgesia
NO
Continue Infusion of muscle
relaxants
02 up 60%
Reverse 1 : e ratio
PEEP high 12.5
Pt raised intracranial pressure
Re-assess _ _ hours/daily


Observe patient
Assess sedation score &
document
If patient becomes
anxious due to
sedation hold
When sedation score _ _
re-start sedation infusion to
maintain score _ _
Document dose of sedation
Document score
Sedation score should be set by Medical & Nursing staff in the morning.
Maintain patient safety, comfort & anxiety levels at all times –
continually reassuring patient.
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POSITION OF MINIMUM 30o HEAD ELEVATION IN CRITICALLY ILL
ADULT PATIENTS
1.
Introduction
The purpose of the care bundle is to help to prevent ventilation
associated pneumonia.
Ventilator associated pneumonia accounts for up to half of all infections
in critically ill patients (Vincent et al, 1995). It prolongs the duration of
mechanical ventilation, ICU length of stay (Fragen et al, 1996) and the
risk of mortality (Heyland et al, 1999).
A randomised trial by Drakulevic et al (1999) showed patients nursed in
semi-recumbent position had lower rates of clinically suspected and
microbiologically confirmed pneumonia than patients in a supine
position. We should take a lead to improve practice utilising those
principles as Cook et al (2002) suggest in their study.
2.
Indications - inclusions
All levels of mechanically ventilated patients should be nursed at a
minimum of 30o elevation.
3.
Contra-indications - exclusions
Spinal instability
Patients requiring prone position
Specified instructions for consultants in charge of patient
Acute head injured patients if specified by consultant
Haemodynamically unstable (to be re-assessed by team on each shift)
Physiotherapy treatment for maximum period of 30 minutes
4.
Procedure
Patient nursed at a minimum of 30o head elevation in all resting
positions.
The bedside nurse, nurse in charge and anaesthetic team will ensure
position is maintained.
This care bundle does not mean patients cannot be nursed at a higher
angle than 30 o.
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References:





Cook, DJ MD; Meade, MOMD; Handle RRT; McMujllin JP,MD: Toward understanding evidence
uptake: Semi recumbent for pneumonia prevention. Critical Care Medicine, Vol 30 (7) July 2002;
1472-1477
Drakulovic MB, Torres A, Bauer TT et al (1999): Surpine body position as a risk factor for nosocomal
pneumonia in mechanically ventilated patients: A randomised trial. Lancet 354: 1851 – 1858
Fagon JY, Chastre J, Vuagnat A et al (1996): Nosocomal pneumonia and mortality among patients in
ICU. JAMA 275: 866-869
Heyland DK, Cook DJ, Griffitgh LE, et al (1999): The attributable morbidity and mortality of ventilatorassociated pneumonia in the critically ill patient. The Canadian Critical care Trials Group. American
Journal of Critical Care Medicine 159: 1249-1256.
Vincent JL, Bihari, Suter PM et al (1995): The prevalence of Nosocomal Pneumonia in ICU in Europe
(EPIC ). JAMA 274: 639 - 644
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VENOUS THROMBOEMBOLISM IN CRITICALLY ILL ADULT PATIENTS
1.
Introduction
The purpose of this care bundle is to reduce the incidence of venous
thromboembolism in patients admitted to ICU.
All Level 3 and Level 2 and most Level 1 patients may be of risk of
venous thromboembolism.
Recognised factors which put patients at risk of developing venous
thromboembolism include major trauma, major surgery, acute medical
illness, age, obesity, varicose veins, previous venous
thromboembolism, cancer, heart failure, recent MI or stroke, oestrogen,
pregnancy puerperium, immobility, inflamatory bowel syndrome &
dedhydration.
There are many randomised controlled studies of different patient
populations using different methods of venous thromboembolism
prophylaxis which show positive benefits. There is evidence to support
the use of venous thromboemblism prophylaxis in critical care patients
(Attia et al 2001, Samama et al 1999).
2.
Indications - Inclusion
All Level 2 and Level 3 patients who are critically ill despite their
location.
3.
Contra-Indications - Exclusions
Patients with abnormal cooagulation
At consultants discretion
Head injury or intra-cranial bleed
4.
Procedure
Use local care bundle i.e.
 TED stockings
 Anti-coagulants
 Mechanical foot/leg pumps (in patients not treated with
anticoagulants)
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MINIMISE STRESS ULCERATION IN THE CRITICALLY ILL ADULT
PATIENT
1.
Introduction
The purpose of this care bundle is to minimise the risk of stress
ulceration of the gastric mucosa in patients who are critically ill.
Critically ill patients are at risk of stress ulcers which may lead to upper
GI haemorrhage. There is a lack of concensus on the optimal therapy
to treat and prevent stress ulcers (Lam et al, 1999). Concerns have
grown that suppression of gastric acid may pre-dispose to ventilatorassisted pneumonia (Prod’ham 1994). In mechanically ventilated
patients the use of Ranitidine compared with sucralfate reduced the risk
of upper GI bleeding and did not increase the ventilator associated
pneumonia (Cook 1998).
Apart from drug therapy, entral nutrition, following protocols, is used as
a method of protection (Pringleton & Hadima, 1983) in many units.
2.
Indications - Inclusions
All ventilated patients, unless contra-indicated. All patients with
coagulopathy (platelet < 50, abnormal INR or APTT).
3.
Contra-Indications - Exclusions
 Patients on maintenance Priton Pump Inhibitors at home
 Patients who have had GI bleed during ICU stay
 Caution in renal failure patients
4.
Procedure
“Local” - Drugs used for stress ulcer prophylaxis may be stopped when
enteral feeding is established (unless otherwise directed).
References:




Cook DJ, Penel RG, Cook RJ et al: Incidence of clinically important bleeding in mechanical ventilated
patients. Journal of Intensive Care Medicine, 1991; 6: 167-174.
Lom NP, LE P-DT, Crawford SY et al: National survey of stress ulcer prophylaxis. Critical Care Medicine
1999; 27: 98-105
Pingleton SK & Haozima SK: Enteral ailmentation & gastrointestinal bleeding in mechanically ventilated
patients. Critical Care Medicine 1983; 11: 13-16
Prod’ham G, Levenberger P, Koerfer J et al: Nosocomal pneumonia in mechanically ventilated patients
receiving antacid, ranitidine or sucralfete as prophyliaxis for stress ulcer. ANN Intern Medicine, 1994; 120:
653-662
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GLUCOSE CONTROL IN CRITICALLY ILL PATIENTS
1.
Introduction
The purpose of the care bundle is to reduce morbidity and mortality of
patients who are critically ill by using insulin to maintain blood glucose
levels between 4.4 and 6.1 mmol/L.
Studies by Van den Berghe (2001) have suggested that using
intravenous insulin to maintain a normal blood sugar has a therapeutic
effect. Van den Berghe later study (2003) indicates that blood glucose
level rather than insulin dose was related to reduced mortality, critical
illness polyneuropathy and bactaraemia.
2.
Indications - Inclusion
Patients who require Level 2 and Level 3 care in critical areas.
3.
Contra-indications – Exclusions
Patients being discharged from Level 2 and Level 3 care need to be reassessed by the medical team in charge of patients care.
4.
Procedure
Local protocols
References:


Van den Berghe G, Walters P, Weekers F, Verwaest C, Bruynhinckx F, Schetz M et al:
Intensive Insulin Therapy in Critically Ill Patients. N Eng Journal of Medicine 2001: 345:
359 to 1367.
Van der Berghe G, Walters P, Bouillon R, Weckers F, Verwaest C, Schetz M et al:
Outcome benefit of Intensive Insulin Therapy in the Critically Ill: Insulin dose versus
glycaemic control. Critically Care Medicine 2003; 31: 359 to 366.
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BLOOD TRANSFUSION OF CRITICALLY ILL ADULT PATIENT
1.
Introduction
The purpose of this care bundle is to maintain adequate level of
haemoglobin in the critically ill adult patients in ICU.
2.
Indication
Using a blood transfusion threshold of 7g per decilitre has been shown
to be at least as effective and possible superior to a blood transfusion
threshold of 10g per decilitre. Hebert et al (1999)
3.
In haemodynamically stable patients a Haemoglobin of between 8g –
10g per decilitres is a safe level, even for those with significant cardiorespiratory disease.
Reference:
Herbert PC, Wells G, Blajchman MA et al (1999) A multi-center randomised controled trial
of transfusion requirements in critical care. New England Journal of Medicine. 340: 409417.
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