Post on 03-Apr-2018
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The Intensive Care Unit
at the
Mid Yorkshire Hospitals NHS Trust
20th July 2010
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Contents Contents
Contents
1 Administration 9
1.1 Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
1.1.1 Clinical Lead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.1.2 Consultant Medical Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.1.3 Nursing Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.1.4 SHOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2 Weekly Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
1.2.1 ICU Problem List Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
1.3 Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
1.4 Patient admission
policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.4.1 Patient Triage: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.4.2 Elective admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4.3 Refusal of patient admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
1.4.4 Management of patients in ICU . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
1.5 Patient discharge policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
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1.5.1 Discharge procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.5.2 Deaths in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.6 Clinical duties in the Intensive
Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.6.1 General comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.6.2 Patient Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.6.3 Doctors Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.6.4 Daily management issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.7 Clinical Duties Outside the Intensive Care Unit . . . . . . . . . . . . . . . . . . .
. . . 17
1.7.1 Cardiac Arrest Calls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.7.2 Trauma Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.7.3 Intra-hospital patient transport . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
1.7.4 Out of hospital transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
1.8 Infection
Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.8.2 Hand Hygiene and Standard Precautions . . . . . . . . . . . . . . . . . . . . .
19
1.8.3 Isolation and transmission-based precautions . . . . . . . . . . . . . . . . . .
20
1.8.4 General Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.9 Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 21
1.10Consent in the Intensive Care
Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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1.10.1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.10.2Consent by relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.10.3Consent at the Mid Yorks ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
1.11Hospital Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 22
1.11.1Fire and building emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
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2 Clinical Procedures 23
2.0.2 ICU Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.0.3 Restricted procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.1 Peripheral IV Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
2.2 Arterial Cannulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
2.3 Central Venous Cannulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
2.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.3.2 Types of catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.3.3 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.3.4 Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.3.5 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.3.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.3.7 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.3.8 Line Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.4 Pulmonary artery
catheterisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.4.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4.2 Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4.3 Monitoring PA trace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
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2.4.4 Measurement of pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30
2.4.5 Measurement of haemodynamics . . . . . . . . . . . . . . . . . . . . . . . . . .
30
2.5 Pleural Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30
2.5.1 Pleurocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.5.2 IntercostalCatheter / Underwater Sealed Drain . . . . . . . . . . . . . . . . .
. 31
2.6 Endotracheal
Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.6.1 Intubation Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
2.7 Fibre-optic
Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.8
Cricothyroidotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.9 Tracheostomy-Percutaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.9.1 Patient selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.9.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.9.3 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.9.4 Timing of the procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.9.5 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402.9.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.9.7 Post Insertion Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44
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2.9.8 Decannulation of the Trachea . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44
2.10Nasojejunal tube
insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.11Intra-abdominal pressure
manometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3 Drugs and Infusions 47
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
3.1.1 Prescription practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
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3.2 Cardiovascular
Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.2.1 Inotropes and Vasoactive drugs . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
3.2.2 Assess and correct hypovolaemia . . . . . . . . . . . . . . . . . . . . . . . . .
48
3.2.3 Instituting inotropic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
3.2.4 Vasopressors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.2.5 Steroid use in patients requiring vasopressors . . . . . . . . . . . . . . . . . .
51
3.3 Anti-hypertensive
Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.4 Antiarrhythmic Drugs in Critical
Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3.4.1 General Principles of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .
53
3.4.2 Drug Therapy of Bradyarrhythmias . . . . . . . . . . . . . . . . . . . . . . . . .
54
3.4.3 Supraventricular Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . .
55
3.4.4 Ventricular Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.5 Respiratory Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
3.5.1 Nebulised bronchodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
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3.5.2 Parenteral Therapy in treatment of reversible obstructive airways
disease . 59
3.6 Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
59
3.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.6.2 Principles of Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
60
3.6.3 Monitoring Sedation : Sedation Scoring . . . . . . . . . . . . . . . . . . . . . .
60
3.6.4 Sedation Holds/ Sedation Assessment . . . . . . . . . . . . . . . . . . . . . . .
61
3.6.5 Accumulation of Sedatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62
3.6.6 Sedative Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62
3.6.7 Sleep on the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.6.8 Non-Pharmacological Methods of aiding sleep . . . . . . . . . . . . . . . . . .
63
3.6.9 Pharmacological Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.6.10Management of Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
3.6.11References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.7 Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
73
3.7.1 General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.7.2 Indications for the use of warfarin . . . . . . . . . . . . . . . . . . . . . . . . .
73
3.7.3 Indications for the use of heparin . . . . . . . . . . . . . . . . . . . . . . . . . .
74
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3.7.4 Prophylactic use of heparin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3.7.5 Systemic anticoagulation using unfractionated heparin . . . . . . . . . . . .
75
3.7.6 Heparin Induced Thrombocytopaenia . . . . . . . . . . . . . . . . . . . . . . .75
3.8 Endocrine Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76
3.8.1 Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.8.2 DDAVP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.8.3 Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
3.9 Renal Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
79
3.9.1 General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.9.2 Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.10Gastro-intestinal drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 80
3.10.1Prophylaxis of gastric stress ulceration . . . . . . . . . . . . . . . . . . . . .80
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3.10.2Active GI Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
83
3.10.3Use of gastro-intestinal pro-kinetic agents . . . . . . . . . . . . . . . . . . . .
84
3.11ICU Antibiotic
Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.11.1Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.11.2Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.11.3Principles of prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84
4 Fluids and Electrolytes 85
4.1 Principles of Fluid Management in Intensive Care . . . . . . . . . . . . . . . . .
. . . 85
4.1.1 Fluid charting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.1.2 Assessment of fluid balance and hydration . . . . . . . . . . . . . . . . . . . .
86
4.1.3 Body Fluid and Electrolyte Physiology . . . . . . . . . . . . . . . . . . . . . . .
87
4.2 Electrolyte Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 87
4.2.1 Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
4.2.2 Hyponatraemia: Na+ < 130 mmol.L-1 . . . . . . . . . . . . . . . . . . . . . . .
88
4.2.3 Hypernatraemia: Na+ > 145 mmol.L-
1 . . . . . . . . . . . . . . . . . . . . . . . 89
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4.2.4 Hypokalaemia: K+ < 3.5 mmol.L-1 . . . . . . . . . . . . . . . . . . . . . . . . .
90
4.2.5 Hyperkalaemia: K+ > 5.0 mmolL-1 . . . . . . . . . . . . . . . . . . . . . . . . .
91
4.2.6 Hypophosphataemia: Serum Phosphate < 0.7 mmol.L-
1 . . . . . . . . . . . . 92
4.3 Acid-Base Disturbances in the
ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3.2 General principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.3.3 Metabolic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.3.4 Metabolic Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.3.5 Respiratory Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
97
4.3.6 Respiratory Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.4 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98
4.4.1 Enteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.4.2 Parenteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101
4.5 Blood and Blood
Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1024.5.2 Blood transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102
4.5.3 Platelet transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102
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4.5.4 Fresh Frozen Plasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
103
4.5.5 Cryoprecipitate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.5.6 DIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.5.7 Blood transfusion reaction guidelines . . . . . . . . . . . . . . . . . . . . . . .
105
5 Clinical Management 106
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
106
5.2 Cardio-Pulmonary Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 106
5.2.1 Key Points in the management plan for an adult collapse . . . . . . . . . .
. 106
5.2.2 Induced hypothermia following cardiac arrest . . . . . . . . . . . . . . . . . .
107
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5.3 Respiratory Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
5.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
5.3.2 Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
5.3.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
5.3.4 When Should I Consider Ventilating (_ intubating) Patients? . . . . . . . .
. . 109
5.3.5 Humidification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
5.3.6 Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
110
5.3.7 Ventilator settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
112
5.3.8 Positive Pressure Ventilation and Hypotension . . . . . . . . . . . . . . . . . .
115
5.3.9 Supportive Therapies for Severe Hypoxia . . . . . . . . . . . . . . . . . . . . .
115
5.3.10Weaning from Mechanical ventilation . . . . . . . . . . . . . . . . . . . . . . .
119
5.3.11Ventilation in the prone position . . . . . . . . . . . . . . . . . . . . . . . . . .122
5.3.12Non-invasive ventilation (NIPPV) . . . . . . . . . . . . . . . . . . . . . . . . . .
123
5.3.13Corticosteroids in ARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
124
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5.4 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
124
5.5 Aspects of Renal Failure in Intensive Care . . . . . . . . . . . . . . . . . . . . . .
. . . 125
5.5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
125
5.5.2 Aetiology of renal failure in the ICU . . . . . . . . . . . . . . . . . . . . . . . . .
125
5.5.3 Assessment of renal function in a given patient . . . . . . . . . . . . . . . . .
126
5.5.4 Renal protective strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
126
5.5.5 Renal Replacement Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
127
5.6 Neurosurgical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 130
5.6.1 Neurotrauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
130
5.6.2 Status Epilepticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
132
5.6.3 Subarachnoid haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
133
5.7 Microbiology Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
134
5.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
134
5.7.2 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
5.7.3 Screening for sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
135
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5.7.4 Investigation of Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
136
5.7.5 Vascular Catheter Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
137
5.7.6 Fungal infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
138
5.8 Drug / Toxin
Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
5.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
139
5.8.2 Admission to ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
139
5.8.3 Specific Overdoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
140
5.9 Withdrawal of Treatment in the Intensive
Care . . . . . . . . . . . . . . . . . . . . . . 140
5.9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
140
5.9.2 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
5.9.3 Deciding not to treat (or treat any further) . . . . . . . . . . . . . . . . . . . .
141
5.10Brain death and organ
donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
5.10.1Declaration of brain death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
141
5.10.2Clinical certification of brain death . . . . . . . . . . . . . . . . . . . . . . . . .
142
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6
Contents Contents
6 Appendices 144
6.1 Haemodynamic
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
6.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
144
6.1.2 Diagnosing hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
144
6.1.3 Is there any evidence of shock ? . . . . . . . . . . . . . . . . . . . . . . . . . .
144
6.1.4 Does this patient require more fluid resuscitation? . . . . . . . . . . . . . . .
145
6.2 The Pulmonary Artery
Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
6.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
146
6.3 The PiCCO-catheter /
monitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
6.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
147
6.3.2 Estimation of cardiac output . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
148
6.4 Principles of ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 149
6.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
149
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6.4.2 Ventilatory strategies to provide total ventilatory support . . . . . . . . . .
. 150
6.4.3 Objectives of mechanical ventilation . . . . . . . . . . . . . . . . . . . . . . . .
151
6.4.4 Other Ventilatory strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
151
6.4.5 Ventilation Mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
152
6.5 The Sedation - Agitation Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 153
6.6 Classification of anti-arrhythmic
drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.6.1 Classification of Antiarrhythmic Drugs by Their
Action . . . . . . . . . . . . . 154
6.7 Guidelines for the use of patient controlled anaesthesia (PCA) . . . . . . . .
. . . . 155
6.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
155
6.7.2 Acute Pain Service Standard Orders . . . . . . . . . . . . . . . . . . . . . . . .
155
6.7.3 Programmable Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
156
6.7.4 Standard Prescriptions for PCA . . . . . . . . . . . . . . . . . . . . . . . . . . .
157
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7
Contents Contents
Foreword
Caring for patients in the intensive care setting is a challenging but
potentially rewarding
experience. As we enter the intensive care environment each one of us
brings a unique mix of skills and knowledge. Inevitably though we must find
a common ground on which to base our management, without which optimal
patient care and safety cannot be achieved. The purpose of this document is
not to provide definitive answers for each problem, nor is it meant to be
prescriptive in nature, but rather it describes a number of standardised
approaches and helpful guidelines to facilitate good patient care.
I must acknowledge that this guide has been heavily based on the one
produced by the Intensive Care Staff of The Waikato Hospital in New
Zealand. In particular, my thanks to Dr John Torrance and Dr David Gamble
for their permission to use their manual as a template.
All those who access, use or disseminate these guidelines do so at your own
risk. While you are working in this unit, no matter what your level of
experience, you will encounter situations where you feel uncomfortable,
confused or even scared. While this manual is intended to assist you in
caring for your patients, you should not be embarrassed to seek help from
those around you, including the Consultant Intensivist/Anaesthetist and
senior nursing staff. You will find references to articles which are useful
further reading.
Rajiv Srinivasa
25th June 2008
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8
1 ADMINISTRATION
Mid Yorkshire Hospitals Intensive Care Units
The Mid Yorkshire Hospitals NHS Trust is a 900 bed district general hospital
and trauma centre of the West Yorkshire region and serves a population area
of 800 000. It is composed of 3 Hospitals: Pinderfields, Pontefract and
Dewsbury.
The Intensive Care Units are located in Pinderfields General Hospital and
Dewsbury District Hospital with a total of 14 Level 3 and 8 Level 2 beds and
admits over 1200 patients a year.
There are also 2 Level 3 beds on the Burns unit. Approximately 30% of the
admissions are surgical. The remainder are a mixture of trauma, medical
and surgical patients. 76% of admissions are ventilated. Our average
APACHE II score is 16 and we have a crude mortality rate of about 24%. The
intensive care consultant staff also assist in the management of patients in
the High Dependency Unit which has 8 beds and admits over 1800 cases per
year. The intensive care also provides medical and nursing transport teams
for inter-hospital transfers.
The ICUs are affiliated to the West Yorkshire Critical Care Network.
The Intensive Care unit senior medical staff consists of 13 consultants. The
junior cover is provided by senior SHOs. We have a nursing staff of about
65 full time equivalents for ICU and 25 for HDU.
1 Administration
1.1 Staffing
1.1.1 Clinical Lead
Dr Rajdeep Singh Sandhu
1.1.2 Consultant Medical Staff
Dr Hugh OBeirne
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Dr Anthony Main
Dr Jaqueline Brook
Dr Paul Clarke
Dr Sameer Bhandari (Burns)
Dr Tendai Mbengaranwa (Burns)
Dr Jamie Yarwood (Burns)
Dr Christine Hildyard
Dr Rajiv Srinivasa
Dr Anne Thickett
Dr James Dodman
Dr Helen Buglass
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9
1.2 Weekly Program 1 ADMINISTRATION
1.1.3 Nursing Staff
General Manager (Pain, Anaesthesia, Critical Care, Theatres) - Julie Clark
Head of Nursing PACCT Steve Fenn
Nursing and Service Manager Critical Care Carol Wood
Senior Sister/Charge Nurses
Suzanne Brompton (Practice Development)
Jean Garner
Jan Newton (Practice Development)
Mick Reynolds
Lindsay Shields
Jane Womersley
1.1.4 SHOs
The junior medical team consists of SHOs (or ST1/2s) who have completed
their ICU blocks and are deemed competent in intensive management. They
form the resident medical structure. They operate a day/night shift pattern,
with the change over occurring at 0800 and 2000 hours (vide infra).
Non-intensive Care Trainees
Rotation through the intensive care is made by the following specialty based
training programs: the Acute Care Common Stem for Emergency Medicine
and Intensive Care. There is also provision for a Foundation Year 1
placement (a 4 month rotation).
1.2 Weekly Program
08h00 morning handover (30 minutes) in the Handover Room.
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08h30 Consultant led bedside ward round, followed by HDU
16h00 Afternoon ward round and HDU review. (30min-1hr)
20h00 Evening hand over between trainees and HDU review
All times other than that allocated above should involve patient review, not
only in response to request by nursing staff, but also in the interests of
optimising patient care and progress.
1.2.1 ICU Problem List Formulation
The ICU runs a problem list sheet to help you keep up to date with each
patient. It is the responsibility of the night registrar to review the list for
each patient, and to enter new data or patients where appropriate. Towards
the end of the night shift a report should be generated
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10
1 ADMINISTRATION 1.3 Orientation
for each patient, and this is handed to the team following on. The generated
document is then filed in a folder as evidence of the handover. The process
is repeated for the night handover.
1.3 Orientation
Prior to commencing an ICU on call rota, trainees will have to demonstrate
competence in managing patients on Intensive Care. The training block
consists of 2 months on ICU as a supernumary.
1.4 Patient admission policy
No patient may be accepted into the Intensive Care Unit without the
knowledge and consent of the ICU Consultant or the Consultant Anaesthetist
on call (out of hours).
Resuscitation or admission must not be delayed where the presenting
condition is imminently life threatening unless specific advance directives
exist. In general patients should be admitted to the Intensive Care where it
is perceived they would benefit in some way as a result.
Usually this means patients with actual or potential organ system failure,
which appears reversible with the provision of intensive support measures.
1.4.1 Patient Triage:
A critical care Outreach team operates at the PGH and DDH sites between
the hours of 0800 and 1800. Their primary function is to assist the ward
nurses in managing and troubleshooting critically ill patients on the ward.
They will activate the MEWS pathway if required. The patients at this point
are still under the care of the primary medical team.
ICU admission criteria should select patients who are likely to benefit from
ICU care. Patients not admitted should fall into two categories, too well to
benefit and too sick to benefit. Defining substantial benefit is difficult, and
no pre-admission model exists to predict outcome in a given patient. Rather
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than listing arbitrary objective parameters, patients should be assigned to a
prioritization model to determine appropriateness of admission.
Priority 1: Critically ill patients in need of intensive treatment and
monitoring that is not available outside of the ICU. Generally these patients
would have no limits placed on their care.
Priority 2: Patients that require intensive monitoring, and may need
immediate intervention. No therapeutic limits are generally stipulated for
these patients.
Priority 3: Unstable patients who are critically ill but have a reduced
likelihood of recovery because of underlying disease or the nature of their
acute illness. If these patients are to be treated in ICU/HDU, limits on
therapeutic efforts may be set (such as not for intubation).
Examples include patients with metastatic malignancy complicated by
infection.
Priority 4: These patients are generally not appropriate for ICU admission
as their disease is terminal or irreversible with imminent death (e.g. CVA).
Included in this group would be
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11
1.5 Patient discharge policy 1 ADMINISTRATION
those patients not expected to benefit from ICU based on the low risk of the
intervention that could not be administered in a non-ICU setting (e.g.:
haemodynamically stable DKA, or an awake patient following an
overdose). This category of patients also present a conundrum and often are
the subjects of passionate debates between the referring physician and
Intensivist as to what may reasonably be achieved on the ICU.
1.4.2 Elective admissions
Where possible, elective surgical admissions should be booked at least 48hrs
in advance. A book exists into which the names of prospective patients must
be entered, following discussion with the surgical team and anaesthetist
responsible for that patient. Confirmation of bed availability is the
responsibility of the anaesthetist and surgeon, and must be confirmed by
prior to commencing the anaesthetic on the morning of surgery. Beds will be
ring-fenced only in exceptional circumstances. No elective surgical patient
will be admitted into the last bed scenario.
1.4.3 Refusal of patient admission
When an outside team contacts the ICU with regard a patient, it is
imperative that you clarify whether this is a referral or a courtesy call. If it is
a referral, then the patient should be assessed (at the bedside if possible),
and the problem discussed with the Consultant Anaesthetist/ Intensivist at
the earliest opportunity.
Where a patient is reviewed but not admitted to the Intensive Care Unit, the
pertinent findings and reason for refusal must be clearly communicated to
the referring team and documented in the notes. Where appropriate a
directive regarding future review must be noted, and the managing teamencouraged to define resuscitation status.
This directive holds for patients placed in the HDU following ICU referral.
1.4.4 Management of patients in ICU
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Patients in Intensive Care Unit are managed primarily by the ICU staff.
Visiting Teams should be discouraged from charting drugs, fluids or other
treatment directly.
However, the opinion of all Specialists involved in the case is valued.
The Consultant Intensivist must be kept fully informed of their opinion.
1.5 Patient discharge policy
1.5.1 Discharge procedure
All discharges must be approved by the Consultant Anaesthetist/Intensivist.
The parent team must accept care of the patient, this acceptance must be
recognised at the medical level, either through the SHO/Registrar, or in
some cases to the Consultant directly.
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12
1 ADMINISTRATION 1.5 Patient discharge policy
All other teams involved should be advised, including the pain team,
dietician, special pharmacy requirements (e.g.. TPN). A careful plan for the
immediate discharge period must be discussed with the accepting team, and
be clearly documented in the notes including:
Limitation of treatment where appropriate
Non-return orders
Clear medical management plan, including charting of the following for the
next 24hrs:
Fluids
Feeding
Analgesia
Documentation to be completed prior to discharge:
Entry in the ICU database - this also allows printing of the discharge note.
The database is designed in MS Access, and resides on the Desktop of the 2computer terminals in the ICU nurses station.
Nurses will not send patients to the ward without first checking with the on
call SHO.
1.5.2 Deaths in the ICU
Withdrawal of therapy is a Consultant-only decision.
The Consultant Intensivist must be notified as soon as the patient has been
examined and certified dead, unless other specific arrangements exist (eg.where death is the expected outcome and the issue of a death certificate
issue has been discussed).
The ICU SHO must ensure:
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A death certificate has been completed or arranged (please speak to the
General Office regarding this)
The parent team is notified
Referring colleagues (including GPs) are notified
Post-mortem consent has been acquired from the family (if indicated)
If appropriate, an End of Life Care Pathway must be completed and the
process documented in the patients notes.
If relevant and appropriate, initiate discussions with the Transplant
Coordinator (via switchboard at St James University Hospitals - 70020)
The Coroner must be notified as below:
Every death that appears to have been without known cause, as a result of
suicide, or unnatural or violent death.
Every death in respect of which no doctor has given (or is prepared to
give) a death certificate.
Every death that occurs while the person concerned was undergoing a
medical, surgical or dental procedure, or some similar operation or
procedure.
13
1.6 Clinical duties in the Intensive Care 1 ADMINISTRATION
Death that appears to have been a result of any such operation or
procedure.
Death that occurred while the person was affected by an anaesthetic or
that appears to have been a result of the administration to the person of an
anaesthetic.
Death of any patient detained in an institution pursuant to an order.
Death of any patient committed in a hospital under the Mental Health Act.
The death of any inmate within the meaning of the Penal Institutions Act of
1954
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The death of any person in police custody, or in the custody of a security
officer.
Where a death is referred to the coroner, no death certificate may be issued
by the ICU doctor.
1.6 Clinical duties in the Intensive Care
1.6.1 General comments
Staff will always shoulder a major part of the burden of continuity.
Continuity is central to quality patient care and this expectation is not
diminished with a decrease in working hours. The responsibility for
maintaining continuity and for effective communication both with other unit
staff and with outside teams rests largely with the SHOs. Effective
communication is a basic medico-legal requirement.
There are guidelines covering the medical procedures and the administration
of most of the drugs used in the ICU. These guidelines are under constant
review. The resident staff are required to be familiar with these guidelines
and to consult them when required. In addition, any inconsistencies or
discrepancies within them should be brought to the attention of the
consultant staff.
When asked by a team to review a patient, SHOs are required to obtain a
full history from the patient and the patient notes, to perform acomprehensive examination of the patient and to formulate a differential
diagnosis. They should then have an outline of a suggested investigation and
treatment plan, to be presented to the Consultant Anaesthetist/Intensivist.
The final plan should be clearly documented in the patient record. It is
important that there is a complete transfer of information at the handover
between shifts. This will be facilitated by
Comprehensive admission notes.
Completion of a standardised daily update note.
Daily review of all clinical laboratory tests, microbiology and radiological
tests.
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An update of the problem list by the night on call SHO. This will contain
details of the presentation, the provisional diagnosis, investigations, consults
and opinions and unresolved issues that require follow up.
The on call doctor should briefly familiarise themselves with the patients
before the formal ward rounds.
When leaving the unit for whatever reason, all doctors must inform their
colleagues, or if out of hours, the Charge Nurse. The ICU must never be left
unattended unless in extraordinary
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14
1 ADMINISTRATION 1.6 Clinical duties in the Intensive Care
circumstances and with the permission of the Consultant, and the knowledge
of the Nurse incharge.
1.6.2 Patient Admission
1.6.2.1 Primary patient survey
A: Ensure patient protecting airway / GCS / cognition (is the patient
receiving supplementary oxygen?)
B: Breathing pattern acceptable, Pulse Oximetry acceptable
C: Patient cardiovascularly stable, venous access acceptable
Obtain hand over information from the referring doctor
1.6.2.2 Secondary survey
Examine patient thoroughly
Notify Consultant Intensivist if this has not already been done.
Document essential orders:
Ventilation
Sedation, analgesia, drugs and infusions
Fluid therapy
Discuss management with nursing staff and team: Everyone must be
aware of the plan!
Basic monitoring and procedures:
ECG
Invasive / non-invasive monitoring
Urinary catheter / NG tube
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Basic Investigations (usually a full blood count, coagulation profile, ICU
specific electrolyte profile)
Advanced Investigations; CT, ultrasound
Case note documentation (see below)
Inform and counsel relatives in general terms
1.6.3 Doctors Documentation
Doctors are responsible for documenting an admission note for all patients
and a daily entry into the clinical notes as well as:
Discharge summary (includes database entry)
Death certificate
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15
1.6 Clinical duties in the Intensive Care 1 ADMINISTRATION
Admission Note: a pro forma sheet should be used, documentation must
include:
Date / time
Name/bleep of admitting doctor
Reason for admission: primary and secondary
Standard medical history including current medications
Thorough examination findings
Results of important investigations
Assessment / severity / differential diagnosis
Management plan
Document notification of parent team and duty senior.
Parent teams should be encouraged to write a short note (at least!) when
they visit the Unit.
1.6.3.1 Daily entry in clinical notes
Use the Daily Notes pro forma page.
Ensure each page is dated and labelled with the patients name and
hospital number.
Date / time / name of Senior ICU Doctor conducting the round.
A: Mental state, GCS, airway.
B: Ventilation, saturation (or PaO2), chest findings.
C: Pulse / BP / peripheral perfusion / Precordial exam.
Abdominal examination and description of feeding mode.
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Peripheries
Assessment or Impression
Plan Additional notation must be made in the notes when:
Invasive procedures are undertaken: please use the stickers when
inserting central/arterial lines.
Important management decisions are made.
Significant interaction is made with patient family.
1.6.4 Daily management issues
The daily handover ward round at 0800 is attended by the night on-call
doctor, the incoming day staff, the Consultant or senior Anaesthetist,Consultant Microbiologist and the Charge Nurse (if not too busy).
The night doctor responsible will present a concise report of every patient. It
is the responsibility of the night registrar to review the list for each patient,
and to enter new data or patients
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16
1 ADMINISTRATION 1.7 Clinical Duties Outside the Intensive Care Unit
where appropriate. Towards the end of the night shift a report should be
generated for each patient, and this is handed to the team following on. The
generated document is then filed in a folder as evidence of the handover.
The process is repeated for the night handover. Important decisions
regarding patient discharge and specialist investigations may be made at
this meeting and it is important that junior staff have a good understanding
of the patient status, including:
Patient details and demographics
Day of admission
Diagnosis and major problems
Relevant pre-morbid problems
Progress and significant events
Important results
Plan for the next 24 hours
1.7 Clinical Duties Outside the Intensive Care Unit
1.7.1 Cardiac Arrest Calls
1.7.1.1 Indications Cardiac arrest calls may be called for the following:
In-hospital cardiac arrest
Collapse of unknown origin in the hospital environs
Out of hospital arrest arriving in the A&E
The anaesthetic input for cardiac arrests is nominally the Acutes on call
team. However, if the Acutes team is otherwise occupied, the ICU doctor
may attend provided the patients on ICU are stable, and only after informing
the Charge Nurse.
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1.7.1.2 CPR (Cardio Pulmonary Resuscitation) We encourage the use of the
UK Resuscitation Council Guidelines for CPR
http://www.resus.org.uk/pages/als.pdf. The anaesthetist is responsible for
securing the airway and establishing effective ventilation, whilst the Medical
team should concern themselves with cardiac and general aspects. It wouldbe expected however that directing advanced life support be the
responsibility of the most senior doctor present.
Where CPR has been successful but further active treatment may not be in
the interests of the patient, the decision to withdraw care must only made
following consultation with senior doctors involved - this will usually be the
Anaesthetic and Specialty Consultants. All involvement in an arrest call must
be documented in the patient case notes.
1.7.2 Trauma Call
Again, the first responder for trauma calls is usually a member of the Acutes
on call team. However, should that team be busy, or in the event of a poly
trauma, the ICU doctor may be
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17
1.8 Infection Control 1 ADMINISTRATION
called upon to assist.
Ensure that the ICU Charge Nurse and Consultant Intensivist are aware of
where you are going, and communicate with the ICU team once the patient
has been assessed and the likely admission destination known.
1.7.3 Intra-hospital patient transport
No patient may be transported from the unit without the direction of the
Senior Anaesthetist/Intensivist on ICU or on call.
Medical escort is the rule if the patient is Level 2 or 3. In a minority of
circumstances a nurse escort may be sufficient, providing it is acceptable to
the Senior Anaesthetist and the Charge Nurse. It may not be appropriate for
all ICU doctors to undertake prolonged transport, or transport to unfamiliar
areas. Always ask the senior Anaesthetist if you are unsure. Prior to
embarking on an escort all equipment, oxygen supply and emergency drugs
must be checked.
All problems encountered on the escort must be recorded in the notes, and
an incident form completed if appropriate.
If a test is deemed urgent the medical escort should endeavour to get an
informal report written in the notes, failing which they should request formal
review and notification to the unit as soon as possible.
1.7.4 Out of hospital transfers
Should a patient require Level 3 care in the absence of bed availability, the
transfer process must be initiated by the parent team with assistance from
the ICU team. The first point of contact must be the West Yorkshire CriticalCare Network Bed Bureau.
The doctor who accompanies the patient must be competent to transfer the
ventilated patient, and to manage a compromised airway during transfer.
The doctor must also have attended a Transfer Training course. Transfer of a
Level 2 patient is fraught with danger. It may be safer to intubate/ventilate
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prior to transfer, especially if there is respiratory compromise. Discuss with
the Consultant Anaesthetist/Intensivists at both ends (i.e. Mid Yorks and the
receiving ICU/HDU).
1.8 Infection Control
1.8.1 Introduction
Patients requiring intensive care are highly susceptible to infection due to
immunosuppressive effects of drugs and disease, the use of invasive
monitoring techniques and the severity of the underlying illness requiring
admission. The use of broad-spectrum antibiotics may predispose to
infection with resistant organisms.
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1 ADMINISTRATION 1.8 Infection Control
Nosocomial infection delays patient discharge from the intensive care unit
(ICU) and contributes significantly to morbidity. The prevalence of hospital-
acquired (nosocomial) infection in the ICU can be considerably higher than
other clinical areas of the hospital.
Significant risk factors for infection include:
mechanical ventilation
prolonged length of stay
trauma or burns
intravascular catheterisation
urinary catheterisation
prior antibiotic use
The four most common nosocomial infections seen in ICU are:
Pneumonia
urinary tract
intra-vascular catheter-related bacteraemia
surgical wound infection
All ICU staff are responsible for ensuring good infection control policies are
adhered to, in particular good hand hygiene practice. In keeping with Trust
Infection Control policies, you are required to ensure you are bare below
the elbows, and to hand wash with alcohol gel before and after everypatient contact.
Skin preparation for invasive procedures (CVP catheters, VasCath, ICD
tracheostomy) must be with the prefilled 2% chlorhexidine/alcohol swabs.
Please ensure you adopt suitable barrier protection (gowns, masks, gloves).
1.8.2 Hand Hygiene and Standard Precautions
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Hand washing and hand disinfection remain the most important measures in
the prevention of cross infection. Hands should be washed before and after
contact with every patient and after manipulation of the patient
environment, especially after contact with a patients with C.difficile infection
or if the hands are soiled. Either use a 15-second handwash with soap andwater, or alternatively the waterless hand gel may be used if hands are not
visibly soiled. A longer handwash with antibacterial soap is required prior to
any major invasive procedures such as insertion of central venous catheter.
In addition to hand hygiene standard precautions are used for all patients:
Wear gloves for all contact with blood and body fluids including dressings
and wounds. Gloves must be changed and discarded between patients.
Hands must be decontaminated after the removal of gloves.
Wear a disposable plastic apron or fluid-resistant gown to protect the skinand clothing for procedures likely to generate splash or cause soiling.
Wear a mask and eye protection to protect mucous membranes of the
eyes, nose and mouth during procedures likely to generate splash or cause
soiling.
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1.8 Infection Control 1 ADMINISTRATION
Ensure patient-care equipment is cleaned and disinfected appropriately
between patient use.
Staff who generate a sharp product (e.g.: needle or blade) are responsible
for its safe disposal into an approved puncture resistant sharps container.
1.8.3 Isolation and transmission-based precautions
In addition to standard precautions, isolation and appropriate transmission-
based precautions are to be used with the following: Multi-resistant
organisms (MRO) Patients infected or colonised with the following MROsrequire isolation and contact precautions (gloves and gown/apron for direct
patient care):
Methicillin Resistant Staph. Aureus (MRSA)
Vancomycin Resistant Enterococcus (VRE)
Extended Spectrum Beta Lactamase (ESBL) producing enterobacters
Multi-resistant gram negative organisms
Meningococcal disease - proven or suspected
Patients require isolation and droplet precautions (surgical mask within 1
meter of the patient) until 24hrs of completed antibiotic treatment.
Miscellaneous
Burns patients require isolation and contact precautions
Febrile neutropaenic patients require isolation and contact precautions
High risk immunosuppressed patients require isolation and contact
precautions
Respiratory syncytial virus require contact precautions
1.8.4 General Measures
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The ICU should be kept tidy and uncluttered. Equipment not in use should be
stored in a clean area.
Movement of people through the unit should be kept to a minimum. This
applies equally to colleagues and relatives. All visitors are to be encouraged
to wash their hands before and after visiting the patient. Staff withcommunicable diseases should take sick leave. If suffering from D&V, ensure
at least 48 hours have elapsed since the last symptom before returning to
work.
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1 ADMINISTRATION 1.9 Information Technology
1.9 Information Technology
There are numerous terminals in the intensive care unit. All computers are
networked to the Intranet, which also functions as a gateway to the
Internet. The computers are logged in as a generic ICU-user, with
permissions to view Pathology results. The intranet allows access to all
inpatients in the hospital. The ward administrator section allows you to view
the pathology results of patients on the ICU and HDU. All imaging is now
film-less, and may only be viewed on the computer terminals. You should
have completed a tutorial, and received a smartcard following this in orderto view the images.
You will be given a separate login by the IT department. This allows you
access to your own account. You will have an e-mail address with access to
the Outlook mail program via a link on the Intranet front page.
The local area network provides access to the Internet. This is controlled and
closely monitored by the IT department. Access to the Internet requires
personal login, and all websites visited may be monitored. Please ensure you
close the browser window when you have finished. This prevents fraudulentand unauthorised access to websites in your name.
1.10 Consent in the Intensive Care Setting
1.10.1 Introduction
A competent patient may give or withhold consent for any medical
treatment. Unfortunately, patients in ICU often cannot have their
competency established with certainty. When a patient cannot give consent
in an emergency, in the absence of convincing evidence to the contrary (e.g.presence of a person with enduring power of attorney who can categorically
state that the person does not wish to receive the treatment in question, or
applicable advance directive) consent to treatment is implied.
1.10.2 Consent by relatives
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Relatives or friends cannot give or withhold consent for the performance of a
medical treatment. However, it is strongly recommended the treating doctor
takes the families views into account in deciding whether to perform a
particular treatment.
1.10.3 Consent at the Mid Yorks ICU
The consent form and the attendant process can record the attempt to take
the families views into account. In any case, completion of the appropriate
form is necessary to comply with hospital policy in certain procedures. A
written record of informed consent is unnecessary for the vast majority of
bedside procedures in ICU.
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1.11 Hospital Emergencies 1 ADMINISTRATION
When it is necessary to obtain consent for a particular procedure to be
performed on an ICU patient, it is appropriate for ICU medical staff to play a
role in this process. That role may not necessarily mean obtaining consent
directly, but may mean ensuring that the staff performing a procedure make
the requisite information available to the ICU doctor to enable them to get
consent, or in many cases obtain consent themselves.
1.11 Hospital Emergencies
Mass casualty
Communications or utility failure
Cardiac Arrest
Earthquake
Fire (or smoke smell)
Hazardous substance spill
Personal safety threat
Threat from telephone, letter or suspicious object
Bomb or arson
Radiation spill
Dialling 4444 and thereby contacting the switchboard will in most
circumstances allow you to initiate an emergency response that is
appropriate to the threat.
1.11.1 Fire and building emergencies
Attend formal fire training sessions
Become familiar with location of fire exits
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Assess medical condition of persons in an emergency area, and the likely
effects of evacuation on them.
Follow instructions of trained accredited staff.
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2 CLINICAL PROCEDURES
2 Clinical Procedures
Introduction It is inevitable that during your stay in the Intensive Care Unit
you will be exposed to a number of procedures with which you are not
familiar. All staff are encouraged to become proficient with routine
procedures:
2.0.2 ICU Procedures
Endotracheal intubation
Peripheral venous catheterisation
Central venous catheterisation
Arterial cannulation / PiCCO insertion
Pulmonary artery catheterisation
Urinary catheterisation
Lumbar puncture
Intercostal drain insertion or pleurocentesis
Naso-gastric / jejunal tube insertion
Patient consent should be obtained if appropriate as outlined elsewhere in
these guidelines.
No member of staff is permitted to attempt a procedure without adequate
training. Staff with previous experience must affirm this with the Senior
Anaesthetist or Consultant Intensivist prior to attempting unsupervised
procedures. All junior staff should be supervised for their first 2 arterial
cannulations and at least 5 central venous access procedures prior to
performing these procedures unsupervised.
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No matter how experienced you are, repeated unsuccessful vascular
punctures are unacceptable and a more experienced member of staff should
be asked to help.
All procedures must be annotated in the case notes, including the
indication / complications for the procedures.
2.0.3 Restricted procedures
Specialised procedures should only be performed by the Senior Anaesthetist
or Consultant Intensivist. They may not be attempted prior to discussion
with the Consultant.
Percutaneous tracheostomy
Fibreoptic bronchoscopy
2.1 Peripheral IV Catheter
2.1.0.1 Indications
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2.2 Arterial Cannulae 2 CLINICAL PROCEDURES
Initial IVI access for resuscitation
Stable or convalescent patients where more invasive access is not
warranted.
2.1.0.2 Management All lines placed in situations where aseptic technique
was not followed must be removed (eg. Placement by emergency staff at the
roadside). Peripheral lines must be removed after 72 hours (or before, if not
required), and replaced if there is a continuing need for peripheral IV access.
Acceptable aseptic technique must be followed including:
Thorough hand-washing
Skin preparation with alcohol swab
Occlusive but transparent dressing
All lines should be removed if not being actively used, or if > 2 days old.
An exception may be made where venous access is challenging (eg. IV drug
abusers).
2.1.0.3 Complications
Infection
Thrombosis
Extravasation
2.2 Arterial Cannulae
2.2.0.4 Indications
Invasive measurement of systemic blood pressure in ICU or during patient
transport / retrieval.
Multiple blood gas sampling and laboratory analysis
2.2.0.5 Site and catheter choice
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1st choice: Radial artery
2nd choice: Femoral.
Site of choice for PiCCO catheter monitoring (Pulsiocath 5F 16 cm catheter)
is generally the femoral artery.
The axillary artery may be considered after consultation with the Consultant
(usually 4F catheter).
The Brachial artery is an end-artery, and catheterisation has been
considered a risk for distal arterial complication (although this has also been
disputed). It may be used if there are no alternatives.
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2 CLINICAL PROCEDURES 2.3 Central Venous Cannulae
2.2.0.6 Technique
All catheters should be inserted with full sterile technique (gown, sterile
gloves, topical antiseptic)
The arterial line must be firmly anchored (suturing is not recommended)
The insertion site and all connectors must be visible through the applied
dressing.
2.2.0.7 Complications
Infection
Thrombosis
Digital Ischaemia
Vessel trauma and fistula formation.
NB: Interpretation of arterial waveforms requires familiarity with normal
arterial waveforms as well as trace damping, amplification and arterial
harmonics. If you are unsure as to the reliability of a trace / reading you
must seek assistance before removing the arterial cannula.
2.3 Central Venous Cannulae
2.3.1 Introduction
The use of CVCs is associated with adverse effects both hazardous to
patients and expensive to treat. More than 15% of patients with CVCs have
some complication from them:
Mechanical 5-19%
Infectious 5-26%use
Thrombotic 2-26%
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The first 5 CVC insertions performed by the trainee should be performed
under direct supervision and then (if the competency is signed off) the
trainee may insert the lines without supervision, on the understanding that
when a difficult catheterisation is anticipated, they will ask for senior
assistance.Failure to insert the catheter after 3 attempts, should prompt the clinician to
seek help rather than continue to attempt the procedure, as the incidence of
mechanical complications after three or more insertion attempts is six times
the rate after one attempt.
2.3.2 Types of catheter
2.3.2.1 Anti-microbial-Impregnated Catheters These catheters have been
shown to lower the rate of catheter-related bloodstream infections.
Consider the use of an Anti-microbial-Impregnated CVC for adult patients
who require shortterm (1-3 weeks) CVC and who are at high risk for
catheter-related blood stream infection (CR-BSI)
It may be appropriate to use this type of CVP in selected patients, ie those
with neutropaenic sepsis.
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2.3 Central Venous Cannulae 2 CLINICAL PROCEDURES
2.3.2.2 Single-lumen and Multi-lumen catheters The number of lumina does
not directly affect the rate of catheter-related complications, so the choice of
either single- or multilumen catheter should be dictated by clinical need.
2.3.3 Indications
2.3.3.1 Monitoring haemodynamic variables
Fluid administration (particularly if large volumes of fluids or blood
products are required)
Infusions of
TPN
Inotropes
Hypertonic solutions
Irritant solutions
Chemotherapy
Potassium solutions
For haemofiltration or haemodiafiltration
2.3.4 Site
Subclavian
Internal Jugular
Femoral
Internal jugular catheterisation can be difficult in morbidly obese patients,
although with ultrasound may be made easier.
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Subclavian venous catheterisation should be avoided in patients with severe
hypoxaemia, as the risks and complications of pneumothorax and
haemothorax are greater than with internal jugular approach.
Femoral catheterisation should be avoided in patients with grossly
contaminated inguinal regions, as the risk of development of catheter-related infections is increased.
If central venous access is needed rapidly in the shocked patient, the
femoral approach may be the fastest technique and used for the initial
resuscitation.
2.3.5 Technique
Asepsis
Full scrub
Sterile gown
Sterile gloves
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2 CLINICAL PROCEDURES 2.3 Central Venous Cannulae
Large sterile drape
Skin decontamination
Alcoholic chlorhexidine gluconate for skin
Allow to dry before cannulation
Use Seldinger technique to access vein
NICE guidance on use of ultrasound for placing CVCs
1.1 Two-dimensional (2-D) imaging ultrasound guidance is recommended as
the preferred method for insertion of central venous catheters (CVCs) into
the internal jugular vein (IJV) in adults and children in elective situations.
1.2 The use of two-dimensional (2-D) imaging ultrasound guidance should
be considered in most clinical circumstances where CVC insertion is
necessary either electively or in an emergency situation.
1.3 It is recommended that all those involved in placing CVCs using two
dimensional (2-D) imaging ultrasound guidance should undertakeappropriate training to achieve competence.
1.4 Audio-guided Doppler ultrasound guidance is not recommended for CVC
insertion.
Flush all parts of catheter with heplock prior to insertion
Trendelenburg tilt for internal jugular or subclavian routes
Use blade to ensure insertion site on skin will allow passage of dilator and
catheter
Insert catheter to estimated appropriate depth, according to insertion site
and patient anatomy
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Aspirate from each port. Easy aspiration of blood should be possible from
each line, and then flush each line with heplock, and the the catheter ports
must then be closed with caps.
Secure the catheter to the skin by suturing the holder on the catheter to
the skin (not the clip for adjusting the catheter position)
Apply a sterile semi-permeable polyurethane dressing to the catheter
insertion site eg Tegaderm. If the insertion site is bleeding or oozing, a
sterile gauze dressing may be used.
Chest X-Ray when the catheter is secure, to look for pneumothorax and
assess catheter tip position
2.3.6 Complications
At Insertion
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2.3 Central Venous Cannulae 2 CLINICAL PROCEDURES
Arterial puncture
Pneumothorax
Neural injury
Guidewire induced arrhythmia
Air embolus
During catheter presence
Infection
Thrombosis
Embolism
Pulmonary infarct or PA rupture (with PAF catheter)
Arterio-venous fistula
2.3.6.1 Mechanical complications Arterial puncture, haematoma andpneumothorax are the commonest Frequency of mechanical complications,
according to approach :
Internal Jugular Subclavian Femoral
Arterial Punture 6.3-9.4% 3.1-4.9% 9-15%
Haematoma
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Data from a systematic review of complications of CVS has shown the rate of
bloodstream infections may be as high as 8.6% with jugular access, and
4.0% with subclavian access.
2.3.6.3 Thrombotic complications The risk of catheter-related thrombosis
varies according to site of catheter.
Approximate figures are:
21% of patients with femoral catheters
2% of patients with subclavian venous catheters
8% of patients with internal jugular
The clinical importance of catheter-related thrombosis remains undefined,
although all thromboses have the potential to embolize.
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2 CLINICAL PROCEDURES 2.4 Pulmonary artery catheterisation
2.3.7 Documentation
Documentation of the procedure undertaken should appear in the patient
case notes using a procedure sticker. ALL complications or difficulties
encountered, should be documented beneath the sticker.
2.3.8 Line Management
Routine line replacement is not necessary
The practice of changing the central line over a guidewire should beavoided unless it is the only option
Lines should be removed
as soon as a clinical indication no longer exists
if patient shows signs of unexplained systemic infection
if insertion site appears infected or blood cultures suggest infection with a
skin organism (eg staph epidermidis). The catheter-tip should be sent to
microbiology for culture and sensitivities
If suspecting catheter-related bloodstream infection, a wound swab should
be taken from the catheter insertion site, and blood should cultured from the
suspect line and from a sample taken from a peripheral stab.
References
1. NICE Technology Appraisal Guidance No.49, ultrasound locating devices
for placing central venous catheters - September 2002. Moved to static list
of guidance November 2005 following period of consultation.2. Guidelines for the prevention of intravascular catheter-related infections.
Centers for Disease Control and Prevention. MMWR 2002;51(NoRR-10):1-33
3. Preventing Complications of Central Venous Catheterization. McGee DC,
Gould MK The New England Journal of Medicine. 2003 Vol 348:1123-1133
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4. National Evidence-based guidelines for preventing healthcare associated
infections in NHS hospitals in England. London. Richard Wells Research
Centre, Thames Valley University, 2006 epic2.
5. Complications of central venous catheters: Internal jugular versus
subclavian access A systematic review. Ruesch S, Walder B, Tramer M.Critical Care Medicine 30(2):454-460, February 2002
2.4 Pulmonary artery catheterisation
The PA Catheter is not a resuscitation tool and should only be inserted in a
controlled environment after discussion with the senior Anaesthetist.
Dwindling use of the PA catheter has resulted in a loss of familiarity with its
use. Junior medical staff and nursing staff not familiar with this instrument
should not manipulate / advance / inflate the PA catheter balloon.
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2.5 Pleural Procedures 2 CLINICAL PROCEDURES
2.4.1 Indications
Haemodynamic measurement: (cardiac output, stroke volume, systemic
vascular resistance)
Measurement of right heart pressures (pulmonary hypertension,
pulmonary embolus)
Estimation of preload to the left ventricle - controversial.
2.4.2 Insertion
PA Catheter insertion is technically difficult and requires a working
knowledge of right heart pressures and waveforms. They should only be
inserted by accredited staff. See appendix on pulmonary artery
catheterisation
2.4.3 Monitoring PA trace
An adequate tracing should be visible on the monitor at all times. A damped
tracing may represent a wedged catheter, clot at the catheter tip or
inappropriate equipment set-up (wrong monitor calibration, faulty pressure
transducer).
Flush the distal lumen generously (using closed mechanism)
Withdraw catheter until a trace is present. NB: Never withdraw the
catheter with an inflated ballon.
2.4.4 Measurement of pressures
Pressure should be referenced to the mid-axillary line The true wedge pressure is measured at end-expiration
PEEP may influence wedge pressures, however this is not a factor at PEEP 10% from average discarded.
2.5 Pleural Procedures
As with all invasive procedures this should not be attempted by
inexperienced staff.
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2 CLINICAL PROCEDURES 2.5 Pleural Procedures
Indications for accessing pleural space
Pneumothorax ( temporising procedure if under tension)
Haemothorax
Symptomatic or infected pleural effusion
Needle Thoracostomy for Tension Pneumothorax
16G cannula placed in mid clavicular line, 2nd intercostal space
Proceed to formal intercostal drain insertion.
2.5.1 Pleurocentesis
2.5.1.1 Indications
Diagnostic procedure: Exudate vs Transudate, or to exclude infected
collection or malignancy.
Therapeutic procedure: Drainage of an infected collection requires an
underwater sealed drain. It is not appropriate to perform one-off drainage.The practice of draining non-infected pleural collections by pleurocentesis is
controversial and should not be performed without direction by the senior
Anaesthetist.
2.5.1.2 Technique Local anaesthesia and sterile technique.
Unless the fluid collection is grossly detectable on clinical examination and
on plain radiology, pleurocentesis should be ultrasound directed.
Investigation of pleurocentesis fluid Aspirated fluid should , at the very least,be submitted for pH or analysed in ICU blood gas analyser (pH < 7.20 =
empyema, 7.20-7.25 = equivocal)
2.5.2 IntercostalCatheter / Underwater Sealed Drain
2.5.2.1 Insertion
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Local Anaesthesia is mandatory in awake patients, and should be used in
sedated patients
Strict aseptic technique
28F catheter inserted into 3-4th intercostal space, mid-axillary line, usingblunt dissection as described and recommended in the ATLS guidelines.
The Catheter must be guided through the ribs without use of sharp
instruments (preferably finger). Trochar aided insertion techniques are not
acceptable.
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2.6 Endotracheal Intubation 2 CLINICAL PROCEDURES
2.5.2.2 Maintenance Drains placed in un-sterile environs should be removed
as soon as possible.
Drains should remain in-situ until radiological resolution has occurred and
there is no further bubbling or drainage of significance ( < 150 ml.24-hr)
In patients at risk (due previous large air leak, or multiple rib fractures) who
remain on positive pressure ventilation, the drain may be clamped for 4hrs
prior to removal as a safety measure, although this is by no means
universally practiced. Drains placed electively in theatre are the
responsibility of the surgeon
2.5.2.3 Complications
Incorrect placement
Pulmonary laceration
Pneumothorax
Bleeding as a result traumatic drain insertion (intercostal or, lateral
thoracic artery, lung etc)
Microbial innocculation
2.6 Endotracheal Intubation
2.6.0.4 Introduction Endotracheal intubation in ICU patients is a high risk
but vital emergency procedure in patients who often have limited reserve,
are difficult to position and may have a difficult airway. All staff should
familiarise themselves with the intubation trolley and equipment. Whenever
possible make sure that you have capable and trained staff to assist you. Ifyou are alone or inexperienced always call for assistance. If the senior
anaesthetist cannot be reached for some reason, or is detained, then
assistance should be sought from an anaesthetic colleague.
Rapid sequence induction is the rule in ICU patients unless previously
discussed with senior medical staff.
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2.6.0.5 Indications
Institution of mechanical ventilation
To maintain an airway
Upper airway obstruction or threat
Control of arterial carbon dioxide content (eg. in the setting of traumatic
brain injury)
Patient transportation
To protect an airway
Patients at risk of aspiration
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2 CLINICAL PROCEDURES 2.6 Endotracheal Intubation
Altered conscious state
Tracheal toilet
2.6.0.6 Techniques Orotracheal intubation is the rule.
Blind nasal awake intubation, or fibreoptic awake intubation, may be
indicated in selected patients with cervical spine injury, limited mouth
opening or oro-facial surgery / trauma. These techniques should only be
undertaken by staff with current experience of these techniques, and only
after discussion with and the presence of the Consultant Intensivist.
2.6.0.7 Standard endotracheal tube choice All patients in the Intensive Care
Unit should be intubated with a low pressure high volume PVC tube (eg
Portex blue line oral/nasal tube)
2.6.0.8 Non-standard tubes Patients returning from theatre (or transported
from another centre) may have a different ET tube (eg. armoured ETT) in
situ. Where there is no good reason for this to remain it should be changed
to the standard ETT if it is anticipated that the patient will require intubation
> 48 hrs, and would not be exposed to significant risk during the ETTchange.
2.6.1 Intubation Guideline
2.6.1.1 Personnel
Skilled assistance is mandatory, where possible a team of 4 is required.
Intubator who controls and co-ordinates the procedure.
Drug administration
A person to apply in-line traction where the stability of the cervical spine is
unclear.
Cricoid Pressure: Cricoid pressure is recommended in all emergency
situations and should be applied at the commencement of induction. Cricoid
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pressure may distort the larynx so that intubation is made more difficult. It
should be modified at the discretion of the intubator, and requires an
understanding of the procedure.
2.6.1.2 Preparation
Secure adequate IVI access
Check all equipment prior to intubation:
Adequate lighting
Selection of oropharyngeal airways
Working suction with Yankauer attachment
AMBU bag assembly and appropriate mask
100% oxygen with flow capability > 15 l/min
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2.6 Endotracheal Intubation 2 CLINICAL PROCEDURES
2 working laryngoscopes with appropriate choice of blade
Magill forceps
Malleable introducer and gum-elastic bougie
2 ETT: estimated patient size and one smaller size. (Female = 7-8 mm,
Male = 8-9 mm)
A selection of laryngeal masks
Emergency cricothyrotomy kit: (#15 scalpel and 6.0mm cuffed ETT)
Ensure adequate monitoring
Pulse oximetry
Reliable blood pressure monitoring (eg. invasive if necessary)
ECG telemetery
Difficult intubationKit A difficult intubation kit can be found on the side of
the intubation trolley. This contains:
An intubating LMA
McCoy laryngoscopes
Light wands
Emergency cricothyrotomy kit
Jet ventilation system
2.6.1.3 Drugs
Induction agent
eg. Thiopentone, Fentanyl, Ketamine, Midazolam
Muscle relaxant
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Suxamethonium 1-2 mg/kg
Consider Rocuronium 1-2 mg/kg if Suxemethonium contra-indicated ie:
Burns patients > 48 hrs post injury
Spinal injury patients where spasticity is present
Chronic neuromuscular disease (Myasthenia Gravis, GBS)
Hyperkalaemic states
Miscellaneous
Atropine 0.6-1.2 mg
Adrenaline 10 ml of 1:10 000 solution.
Metaraminol 0.5 mg/ml (usually in 10 ml)
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2 CLINICAL PROCEDURES 2.6 Endotracheal Intubation
2.6.1.4 Procedure: Rapid sequence induction and orotracheal intubation
Pre-oxygenate for 3-4 minutes with 100% oxygen. Patients receiving non-
invasive ventilation should continue on this form of ventilation until the point
of induction, and a PEEP valve applied to the AMBU-bag mask assembly.
Administer induction agent and suxamethonium
Apply cricoid pressure
Intubation under direct visualisation
Inflate ETT cuff until there is no air leak during ventilation
Confirm ETT placement with capnograph and chest auscultation with
manual ventilation.
Release cricoid pressure
Secure ETT at correct length (Female = 19-21cm at incisors, Males = 21-
23 cm at incisors)
Do not cut ETT at less than 26 cm (if at all).
Connect patient to ventilator
Ensure adequate sedation and analgesia to cover period of muscle relaxant
and continue as indicated by clinical scenario.
Insert naso-/-orogastric tube or naso-jejunal tube if not already present.
A follow-up CXR should be performed as soon as convenient.
2.6.1.5 Maintenance of endotracheal tubes
Tapes ETT are generally secured with white tape.
Tapes are changed daily or PRN by nursing staff.
In certain circumstances personalised ETT security may be required.
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Cuff integrity Sufficient air should be placed into the cuff to prevent an air
leak, as assessed by auscultating over the trachea.
ETT manometry is not routinely required, and may be misleading as the
correlation with mucosal pressure is unreliable.
Persistent cuff leakage Any ETT that constantly requires additional air
instilled into the cuff should be reviewed for:
Herniation above the cords
Cuff damage (rare)
Malfunctioning pilot tube valve (which can be excluded by placing distal
pilot tube into container of water and observing for bubbling)
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2.6 Endotracheal Intubation 2 CLINICAL PROCEDURES
Airway suctioning Airway suction may be performed every 2-3 hrs prn
Routine suctioning should be avoided where:
it requires disconnection of PEEP (open suction system)
may exacerbate the patients condition (asthma, reactive Intra-cranial
pressure, florid pulmonary oedema).
2.6.1.6 Endotracheal tube change
Equipment and assistance The procedure / setup is the same as for
intubation de novo
Ensure patient is adequately oxygenated (Saturation 98-100%). An FiO2 of
1.0 may be excessive and promote atelectasis.
Ensure adequate anaesthesia and muscle relaxation
Procedure Perform direct laryngoscopy:
If a good view of the larynx and vocal cords is obtained then proceed to
manual exchange of ETT with application of cricoid pressure, or proceed as
below using gum-elastic bougie.
If direct laryngoscopy reveals abnormal or swollen anatomy, or only partial
view of anatomy, then proceed as follows:
Place gum elastic or ventilating bougie through the ETT and insert to a
length corresponding to a few cm distal to the end of the ETT.
With an assistant stabilising the bougie, and applying cricoid pressure,
remove faulty ETT under direct laryngoscopy, while maintaining bougie inthe same position.
Confirm the bougie is still in place through cords once ETT removed, and
then replace new ETT over the top of the bougie apparatus.
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If the ETT does not progress smoothly through the cords, rotate 90 deg
anti-clockwise and attempt again (ie. realign beveled edge of ETT along
upper border of bougie)
Check position of ETT and secure as for de novo intubation procedure.
2.6.1.7 Extubation guideline Ensure