Current Guidelines in
Critical Care
Session 2: 2014
Critical Care Boot Camp
Billy Cameron, MSN, ACNP-BC
Assistant in Surgery, Dept of Surgery
Acute Care Nurse Practitioner
Surgical Intensive Care Unit
Current Guidelines in Critical Care
September 9, 2014
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Rapid Response Teams
Use of Corticosteroids in Septic Shock
Central Venous Catheter Infection Prevention
Critical Care of the Organ Donor
Advanced Cardiac Life Support Algorithms
Objectives
• Identify background of previous evidence
based critical care practice guidelines
• Identify and apply most recent evidence based
guidelines for critical care practice
• Be able to identify areas in which critical care
practice may be impacted by most recent
guidelines
Rapid Response Teams
Background:
• Literature supports Rapid Response Teams in
reducing mortality of patients, reducing lengths of
stay, reducing unplanned transfers to ICUs, and
increasing patient satisfaction
• Rapid Response Teams can intervene prior to an
acute cardiac event, or other deterioration of
clinical status (ie; early intervention for sepsis)
Rapid Response Teams
Goals of Rapid Response Teams:
• Increase early intervention and stabilization to
prevent clinical deterioration prior to cardiac
arrest or other life-threatening event
• Decrease the number of cardiopulmonary arrests
that occur outside of the ICU and ED
• Decrease hospital mortality
• Increase patient, family, and staff satisfaction
Rapid Response Teams
Guideline: Develop an Early Warning System:
1) “Something isn’t right”
2) Heart rate: <40/>160 (some systems use 120); new onset chest pain
3) Blood pressure: Consider range of SBP <80/>180
or DBP >100
4) Respiratory status: Consider rate <8/>28 bpm
– consider SpO2 <85-90% for more than 5 minutes
– increasing O2 demand to maintain baseline SpO2 evidenced
by increased work of breathing or change in breathing
pattern
5) Neurological status: Acute change in baseline neuro status
– Alteration in LOC; AMS
– Unexplained lethargy and/or agitation; new delirium
– Seizure
– Symptoms of stroke: change in speech, facial/extremity weakness,
numbness/tingling
Rapid Response Teams
Guideline: Develop an Early Warning System:
Some institutions use Early Warning Score: 3 or more institutes activation of RRT
Rapid Response Teams
Guideline: Other Considerations
• RRT should consist of qualified individual providers with
excellent assessment, communication, and clinical skills
• Have a means by which to active an ACS protocol with
qualified cardiopulmonary providers should the event be
an ACS event; have an algorithm that drives activity
• Encourage family members to be educated and feel
comfortable activating the RRT
• Bedside report upon arrival of the RRT should include
SBAR (situation, background, assessment,
recommendation) in a concise, brief exchange in order to
give the providers on the RRT enough information to begin
piecing the events together
Rapid Response Teams
Guideline: Other Considerations
• Provide ongoing simulation training to the RRT
members
• Provide ongoing evaluation of RRT events and
problems that arise
• Post early warning signs for activation of the RRT
with clear visibility for patients, their family
members, and healthcare staff (ie; posters)
Rapid Response Teams
Rapid Response Teams
• Algorithm example at:
https://www.icsi.org/_asset/8snj28/rrt.pdf
Rapid Response Teams
References:
Health care protocol: rapid response teams. Institute for Clinical Systems
Improvement. Retrieved from internet on 8/11/2014 at
https://www.icsi.org/_asset/8snj28/rrt.pdf
Romero-Brufau, S., et al. (2014). Widely used track and trigger scores: Are
they ready for automation in practice? Resuscitation 85 (2014) 549-552.
Pliego, J., Sheather, S., Villamaria, F. Wehbe-Janek, H., (2014). System-based
interprofessional simulation-based training program increases awareness
and use of rapid response teams. The Joint Commission on Quality and
Patient Safety. Vol 40; No 6.
Use of Corticosteroids in Septic Shock
Background:
• The use of corticosteroids as an adjunctive therapy has been used for
decades, controversial and often misunderstood.
• High-dose corticosteroids have been shown to provide no real benefit
in septic shock
• Hypothetically, severely prolonged systemic inflammation can lead to
adrenal insufficiency resulting in “critical illness-related corticosteroid
insufficiency”; which, can be treated with physiologic doses of
corticosteroid (hydrocortisone 200mg – 300 mg per day)
• Studies have shown reduction in mortality in patients with relative
adrenal insufficiency when treated with physiologic doses of
corticosteroid
• The 2012 Surviving Sepsis Guidelines attempted to clarify often
misunderstood guidelines from 2008.
Use of Corticosteroids in Septic Shock
Barriers to Guideline Implementation:
• No specific dosing recommendations beyond
stating a limit of 300mg/day
• Intensivists “individualizing” treatment
• Different interpretations of the guidelines
• Discrepancy between a clinician’s interpretation of
guidelines and the reality of their clinical practice
• Lack of support from institution to implement
prevention and treatment “bundles” based on
evidence
Use of Corticosteroids in Septic Shock
2008 Surviving Sepsis Guidelines for Corticosteroids:
1) Hydrocortisone IV should be given only to adult
patients in septic shock after it has been
confirmed that their blood pressure is poorly
responsive to fluid resuscitation and vasopressor
therapy.
2) ACTH stimulation test should not be used to
identify the subset of adults with septic shock,
who should receive hydrocortisone
3) Steroids need to be weaned by the clinician
when vasopressors are no long required
Use of Corticosteroids in Septic Shock
2012 Surviving Sepsis Guidelines for Corticosteroids:
1) Do not administer IV hydrocortisone to treat adult septic shock
patients if adequate fluid resuscitation and vasopressor therapy are
able to restore hemodynamic stability. If this is not achievable, the
suggestion is IV hydrocortisone alone at a dose of 200mg per day
RATIONALE: Several studies have shown benefit on mortality with the
use of hydrocortisone in patients who exhibit shock, as well as low
results. Because of study design and patient population differences,
disparity continues in the research. So, it is best to use fluid
resuscitation and vasopressors when the patient is responsive to such
treatments.
Use of Corticosteroids in Septic Shock
2012 Surviving Sepsis Guidelines for Corticosteroids:
2) Do not use the ACTH stimulation test to identify the subset of adults
with septic shock who should receive hydrocortisone
RATIONALE: Observations have been made in multicenter trials
regarding responders and nonresponders to hydrocortisone in septic
shock and ACTH stimulation tests are not significant predictors of
adrenal insufficiency. Random cortisol tests may still be useful for
absolute adrenal insufficiency , but not relative adrenal insufficiency
(no absolute stress response). A random cortisol level of less than 15
μg/dl in critical illness is where most literature sets the limit to treat
relative adrenal insufficiency; some studies suggest as high as 20 – 25
μg/dl Of note, etomidate when used for intubation, can suppress the
hypothalamic-pituitary-adrenal axis; therefore, reducing levels of
Use of Corticosteroids in Septic Shock
2012 Surviving Sepsis Guidelines for Corticosteroids:
3) Taper treated patients from steroid therapy when vasopressors are no
longer being used
RATIONALE: There has been no comparative study between fixedduration and clinically guided regimen or between tapering and
abrupt cessation of steroids. There have been randomized controlled
trials that have shown good results in a weaning regimen, abrupt
cessation (however, one study showed hemodynamic and
immunologic rebound effects after abrupt cessation), and no
difference in outcome with regimens of low dose steroids for 3 or 7
days.
 This leads to a barrier in practice giving rise of clinicians to implement
their own practice biases. More large center trials are needed.
Use of Corticosteroids in Septic Shock
2012 Surviving Sepsis Guidelines for Corticosteroids:
4) Do not administer steroids for the treatment of sepsis in the absence of shock
RATIONALE: There is no sufficient evidence to show that steroid treatment has
benefit in treating patients who have sepsis; but, who do not have shock. In
this case, steroids may be considered for adrenal dysfunction, but no evidence
supports steroid treatment for a preventive potency in reducing the incidence
of severe sepsis and shock in critically ill patients.
5) When low-dose hydrocortisone is given, use continuous infusion rather than
bolus injections
RATIONALE: Several randomized trials show an increase in hyperglycemia and
hypernatremia with the use of bolus high-dose steroids.
Use of Corticosteroids in Septic Shock
References:
Contrael, K., et al. (2013). Prescribing patterns of hydrocortisone in septic shock:
a single-center experience of how surviving sepsis guidelines are interpreted
and translated into bedside practice. Critical Care Medicine. 41:10.
Dellinger, R., et al. (2013). Surviving sepsis campaign: international guidelines
for management of severe sepsis and septic shock: 2012. Critical Care
Medicine. 41:2.
Pastores, S., Rajendram, P., (2013). Prescribing patterns for corticosteroids in
septic shock: translating guidelines into bedside practice. Critical Care
Medicine. 41:10.
Central Venous Catheter
Infection Prevention
Background
• Central venous catheters (CVC) are routinely used in the
ICU and bloodstream infections are a major complication
in those patients with indwelling CVC.
• CVC tubing may contribute to bacteremia and other
infections.
• Healthcare associated infections can contribute to
increased mortality and morbidity when hospital staff do
not adhere to proper aseptic technique when inserting
CVCs and caring for them
• Over 80,000 CVC-related blood stream infections occur
annually in ICUs and increase LOS.
Central Venous Catheter
Infection Prevention
Current 2011 CDC Guidelines: Summary
1) Educate clinicians regarding the indications of CVC use,
proper procedures to insertion and maintenance, and
appropriate infection control measures
2) Periodically assess knowledge of and adherence to
guidelines for all involved with insertion and care of CVCs.
3) Designate only trained personnel who demonstrate
competence for insertion and maintenance of CVCs
4) Ensure appropriate nursing staff levels in ICUs. Studies
suggest that a higher proportion of “pool nurses” or elevated
patient-to-nurse ratio is associated in increased occurrence of
CVC-related infections
Central Venous Catheter
Infection Prevention
Current 2011 CDC Guidelines:
• Use maximal sterile barriers during CVC insertion
• Use >0.5% chlorhexidine skin preparation with alcohol for
skin antisepsis
• Avoid routine placement of CVC as a strategy to prevent
infection
• Avoid femoral vein placement of CVC (higher risk for
infection due to location)
• Change dressings using aseptic technique
• Perform daily audits to assess whether central line is still
needed
• Promote hand hygiene
Central Venous Catheter
Infection Prevention
Current 2011 CDC Guidelines:
• Promote evidence based bundles for prevention of CVC
infections
• Avoid subclavian site in patients receiving hemodialysis to
avoid subclavian vein stenosis
• Use ultrasound guidance to place CVCs to reduce number
of cannulation attempts and mechanical complications
• Promptly remove any CVC that is no longer deemed
necessary
• When adherence to aseptic technique cannot be ensured,
replace catheter as soon as possible (outside hospital
admisisons)
Central Venous Catheter
Infection Prevention
Current 2011 CDC Guidelines:
• Do not remove CVCs or PICCs on the basis of fever alone. Use clinical
judgement
• Do not use guidewire exchange routinely for non-tunneled CVCs to
prevent infection, or for CVC that is suspicious of infection
• Replace administration tubing no more frequently than 96 hours for
those sets not infusing blood, blood products, or fat emulsions (ie;
TPN, propofol, lipids), but at least every 7 days
• Replace administration tubing for blood, blood products, and fat
emulsions every 24 hours
• Replace tubing for propofol every 6-12 hours or with each new bottle
of medication
Central Venous Catheter
Infection Prevention
Suggested Updates to Guidelines:
• Use antimicrobial CVCs (no significant difference between nonimpregnated or impregnated) to reduce line infections, especially in ICUs,
where the primary evidence shows to be most effective. Use caution
outside the ICU where nursing staff may be less aware of CVC-related
infection precautions.
• Provide ongoing education to hospital staff regarding infection prevention
in order to assess knowledge and adherence to guidelines
• When introducing bundles for prevention of infection, introduce one new
intervention at a time to decrease confusion and/or overwhelming the
hospital staff to increase adherence
Central Venous Catheter
Infection Prevention
References
Flodgren, G., et al. (2013). Interventions to improve professional adherence
to guidelines for prevention of device-related infections. Cochrane
Database of Systematic Reviews, Issue 3. CD 006559
O’Grady, N., et al. (2011). Guidelines for the prevention of intravascular
catheter-related infections. Centers for Disease Control.
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Lai, NM., et al. (2013). Catheter impregnation, coating or bonding for
reducing central venous catheter-related infections in adults. Cochrane
Database of Systematic Reviews, Issue 6. CD 007878
Ullman, AJ., et al. (2013). Optimal timing for intravascular administration set
replacement. Cochrane Database of Systematic Reviews, Issue 9. CD
003588
Critical Care of the Organ Donor
Background:
• Organ donation is often surrounded by ethical
and policy issues that require strict adherence
• Donation after circulatory determination of
death (DCDD: Formerly known as donation after
cardiac death) has the potential to increase the
number of organs available for transplantation.
• Consent and management of potential donors
must occur before death; therefore, unique
ethical considerations exist
Critical Care of the Organ Donor
Background:
• DCDD organs are accounting for more available
organs across the Organ Procurement
Organizations (OPO), allowing for more policies
to be enacted in hospitals to consider ethical
principles and advanced directives regarding
organ donation
• Care of the DCDD donor/patient requires
dedicated and informed hospital staff along with
OPO staff
Critical Care of the Organ Donor
Underlying Ethical Principles:
1)Acts that promote the opportunity to donate
viable organs respect the patient’s potential
interest in becoming an organ donor.
RATIONALE: In controlled DCDD, actions must be
taken on living persons which are more for the intent
of organ preservation for donation. It becomes
imperative to promote the donor’s legitimate interests
in what becomes of their bodies after death
Critical Care of the Organ Donor
Underlying Ethical Principles:
2) The legitimacy of surrogate decision making for
critically ill patients whose wishes are unknown
extends to decisions regarding organ donation:
RATIONALE: Critically ill patients are often
incapacitated of decision making. Surrogates are
viable decision makers; however, care must be taken
that the wishes of the surrogate do not overshadow
the wishes of the donor prior to critical illness
Critical Care of the Organ Donor
Underlying Ethical Principles:
3) If real or perceived conflicts arise between the
goals of providing optimal end-of-life care and the
goals of procuring organs, delivery of quality endof-life care should take priority
RATIONALE: Patients or their surrogates must be well
informed of how certain end-of-life treatment
strategies may impact opportunities for donation
before they are initiated.
Critical Care of the Organ Donor
Treatment Guidelines for Organ Optimization
with DCDD:
1) Hemodynamics: Immediate attention
should be given to correcting hypotension;
resulting in maximized organ perfusion.
- Use volume
- Use vasoactive drugs cautiously;
vasopressin has become the drug of choice in
lieu of high dose vasopressors
Critical Care of the Organ Donor
Treatment Guidelines for Organ Optimization
with DCDD:
2) Pulmonary: Lungs are transplanted most
rarely (15-25% of donors); therefore, care
should be taken to optimize if viable:
- Adequate gas exchange is imperative
- Mechanical ventilation should focus short periods of PEEP
of 15 cm H2O for 2 hours followed by lower PEEP of 5 cm
H2O to prevent atelectasis and open alveoli.
- Avoid excess fluid administration
Critical Care of the Organ Donor
Treatment Guidelines for Organ Optimization
with DCDD:
3) Hormonal Therapy:
- Catecholamine surges following DCDD are common. These
need to be avoided by doing the following:
• Exogenous replacement of ADH following posterior pituitary
insufficiency; this has been shown to improve graft function of kidneys,
liver, and cardiac recipients
• Volume replacement is essential to treat Diabetes Incipidus
• Correct Hypernatremia
• Deficiencies of pituitary hormones need to be corrected: TSH, T4, HGH.
UNOS has done research hormone replacement and has been shown to
increase donation of organs by 22.5%
• Correct hyperglycemia using insulin infusion, if needed
Critical Care of the Organ Donor
Guidelines for Organ Optimization with DCDD:
• Organ procurement can only occur once death
has been certified by a physician
• To decrease warm ischemic time, withdrawal of
life support should occur in the OR where
procurement can begin immediately thereafter.
• Consideration for Extracorporeal Membrane
Oxygenation (ECMO) to increase oxygenation
and organ preservation is controversial and an
extreme measure that must be understood by
those involved in premortem care
Critical Care of the Organ Donor
References:
Baumann, A., et al. (2013). Elective non-therapeutic intensive care and the
four principles of medical ethics. Journal of Medical Ethics. 39: 139-142
Dare, A., Bartlett, A., Fraser, J. (2012). Critical care of the potential organ
donor. Curr Neurol Neurosci Rep. 12: 456-465
Gries, C., et al. (2013). An official American Thoracic Society/International
Society for Heart and Lung Transplantation/Society of Critical Care
Medicine/Association of Organ and Procurement Organizations/United
Network of Organ Sharing Statement: Ethical and policy considerations
in organ donation after circulatory determination of death. American
Journal of Respiratory Critical Care. 188: 1, 103-109
Advanced Cardiac Life Support
Simplified Algorithms for Easy Memorization and Use in Acute Events
TOO FAST: VT, VF
1) Determine whether stable or unstable
Stable:
Narrow complex (SVT)
1) Vagal
2) Drugs:
• Adenosine 6mg  12mg/12mg
Then, consider betablocker, CCB
Wide complex (VT)
Amiodarone 150mg bolus; Sotalol
Unstable: (hypotension/shock/ACS/AMS/CP)  Cardioversion
Advanced Cardiac Life Support
Simplified Algorithms for Easy Memorization and Use in Acute Events
TOO SLOW: sinus brady/heart blocks
1)Determine whether symptomatic (unstable) or asymptomatic
Symptomatic:
1)Atropine 0.5mg q3-5 mins (max 3mg)…only use for atropine now
2)Call for TCP
3)Epinephrine/domamine infusion
Asymptomatic:
1) Monitor; identify causes
Advanced Cardiac Life Support
Simplified Algorithms for Easy Memorization and Use in Acute Events
Pulseless VT/VF:
SHOCK (Defib VF) @ 200 J
 CPR 2 mins. (prep meds)
 Rhythm check
SHOCK if still no pulse; VF/VT
 CPR 2 mins. (give meds; epi; call for amio)
 Rhythm check
Consider H’s/T’s (hypoxia, hypothermia, hypovolemia, hypo/hyperK,
Hydrogen ion acidosis) (Toxins, Thromboses (cardiac/pulmonary),
Tamponade [Mg], Tension pthx)
 Continue cycles of CPR
Advanced Cardiac Life Support
Simplified Algorithms for Easy Memorization and Use in Acute Events
Pulseless Electrical Activity/Asystole:
1)CPR
2)Epinephrine 1mg q3-5 mins
3)H/T’s
Return of Spontaneous Circulation:
V:
VS, values (labs)
O:
O2; ETT with capnography
M:
Mentation (candidate for hypothermia?)
I:
IVs, ICE
T:
Twelve lead; transport (either cath lab for STEMI; ICU for NSTEMI)