3PLAY THE IMPORTANT ROLES !! Reduce errorsEncourages teamworkHelp improves the quality of care received by intensive care patient
4Outline of presentation GoalReview communicationsCheck ventilator settings & modeCare of ETTGeneral Care- FAST HUG- FAST HUGSBIDOral, Eyes & Skin CareSleepRadiationPhysiotherapyMonitoringInfection controlEducate patient & family
5Goals of Monitoring & Managing the ventilated patient Ensure proper airwayEnsure adequate oxygenation & ventilationMaintain hemodynamic stabilityInterpretation of Ventilator alarms &troubleshootingPrevent infectionPrevent complications related to bedridden state
71) Communication among care providers ~ Promotes optimal outcome ~ Find out the goal of the therapy for patient ~ Indication for mechanical ventilation ~ Indication for icu admission ~ Do-not–resuscitate status 2) Communication with the patient ~ Provide writing tools or a communication board so pt can express her needs
8Check Ventilator Settings & Modes Read patient order & obtain in formation about the ventilator. Familiarize with ventilator alarms and the actions to take when an alarm sounds. Keep resuscitation bag at bedside Know how to hyperventilate & hyperoxygenate patient.Provides/restore adequate ventilation when patient or equipment problems require patient removed from ventilator.
9Check following settings: Respiratory rate Fraction of inspired oxygen ( fio2)Tidal volumePeak inspiratory pressure (PIP)Ventilator mode of patient:Ventilator itselfRespiratory flow sheetPIP – the pressure needed to provide each breath. Target below 30cm H20.High indicate a kinked tube, need for suctioning, bronchospasm,e.g. pulmonaryh edema or pneumothorax.
10Care of ETTEnsuring correct position Securing the tube Measuring cuff pressure Suspecting leak Suspecting tube blockade Suctioning
11Size of ETTmm formm forLarger ETT in Asthma, COPDTube position, confirmed by:Clinical examination 5 point auscultationCXREtco2
12Cuff pressure keep < 25mmHg - Inflate cuff to seal - lowest pressure that seal or low leak Every nursing duty check cuff pressure If partial block is suspected. change ETT **ETT with subglottic suction port- reduced incidence of VAP RCTHigh cuff pressure ( > 25 cm H20) affect ciliaryFunction & cause mucosal ischaemia.
14SUCTIONING General suctioning recommendation: Suction only as needed –not according to a schedule.Hyperoxygenate the patient BEFORE & AFTER suctioning to help prevent O2 desaturationDon’t instill normal saline into the ETT in an attempt to promote secretion removal2004 American Association for respiratory care CPGLimit suctioning pressure to the lowest level needed to remove secretionsSuction for the shortest duration possible
16Occlude catheter while passing in Fresh cathether with every usePreoxygenate with 100% o2Suction cycle < 20sOcclude catheter while passing inOnce obstruction is encountered withdrawslightly & suck while coming outRepeat if requiredOpen suction
22FAST HUGA simple, short mneumonic to highlights some keys aspects in the general care of all critically ill patients.Should be considered at least once a day during roundsCan be used as mental checklist when individual staff members attending the patients.
23GENERAL CAREF = Feeding A = Analgesic S = Sedation T = Thromboembolic prophylaxis H= Head- of- bed elevation U= Stress Ulcer prevention G= Glucose control
25Malnutrition increases complications & worsens outcomes of critically ill patients. In general, kcal/kg/day is acceptable & achievable target intake. Should started early , preferably within 24-48hrs icu admission. Optimal constituents of feeding solutions remain under debate.
26A = AnalgesicPain can effect patient’s psychological & physiological recovery. Critically ill pt feel pain due not only to their illness but also routine procedures e.g. turning, suctioning& dressing changes. One study of 5957 patients , > 63% received no analgesic before painful procedure.
27How to assess pain in critically ill patients? Subjective measures of pain- related behaviours ~ facial expression, movementPhysiologic indicators~ Heart rate, blood pressure> 5 indicate of pain
29Pharmacological therapies to relieve pain included: opioidsnon opioidsContinuous infusion of analgesic drugs or regularlyadministered doses are more effective than bolusdoses given as “needed”I.V. administration of analgesic allows closer andmore rapid titration to patients needs than I.M. orsubcutaneous administration.Care should be taken to ensure analgesic is adequatebut not excessive.
30S = Sedation No rules governing how much to give & how often. Sedative administration must be titrated individual.CCC ( Calm, comfortable and collaboration) rule helpto determine whether patients are appropriatelysedated.Daily discontinuation of sedation may reduce thelength of ICU stay & the need for imaging proceduresKress et al
34T – Thromboembolic Prophylaxis Still underused because is still often forgotten and yet mortality & morbildity rates a/w thromboembolism are considerable & can be reduce by prophylaxis. Among patients who do not received prophylaxis, objectively confirmed rate of DVT range between %. It has thus recommended all patients received at least s/c heparin unless CI.
35The most effective method of prophylaxis still unclear The most effective method of prophylaxis still unclear. The benefit of prophylaxis must be weighed against the risk of complications.
38Several studies demonstrated that having the head of bed inclined at 45 degrees can decrease the riskincidence of gastroesophageal reflux.Patient nurses in semirecumbent reduce rate ofnosocomial pneumonia.A randomised trial. Lancet 1999Raising the head of the bed may not be enough,because patients especially when sedated might slidesdown in the bed.Attempts must be made to keep head of bed & thoraxelevated.
39U= Stress Ulcer prevention Stress ulcer prevention is important notably for patients who areat risk of developing stress- related gastrointestinalhemorrhages.The optimal medication is still not clear.In 1200 critically ill patients undergoing mechanical ventilation,those treated with ranitidine had significantly lower rates ofclinically significant GI bleeding than patients treated withsucralfate although there was no difference in the mortality ratesbetween two groups.Multicenter study by Cook et al
42Many units now aim to keep blood sugar levels below 8.3 mmol/L as recommended guidelines for themanagement of severe sepsis & septic shock.Keeping blood glucose levels < 7.8 mmol/L resulted in29.3% decrease in hospital mortality rates & 10.8%reduction in length of ICU stay.Krinsley
43FAST HUGSBIDS = Spontaneous Breathing Trial B = Bowel Care I = Indwelling Catheter removal D = De-escalation of Antibiotitcs
44S = Spontaneous Breathing Trial Daily assessment of SBT has been show to be a safe, effective & highly predictive method for determining which pt will tolerate ventilator separation. Prolonged mechanical ventilation a/w increased rate VAP & in hospital & total mortality. Should be considered at least daily & performed in highly protocolized fashion by well-trained team of nurses & respiratory therapist.
45WEANING: ReadinessAll ventilated patients must have “ readiness criteria” evaluated daily ( after discontinuing sedation)
50During weaning trial all patient must be observed Closely to identify the existence of “ distress”High RRRespiratory patern ( paradox, nasal flaring)Low VTDrop in O2 saturation < 90%Increased hr ( > 20% from baseline)Anxiety, agitation, diaphoresisSomnolence
52B = Bowel CareDisorders of GI motility, including ileus, constipation & diarrhoea are common in critically ill patient & may contribute to additional disease burden. Institutional guidelines & use of standardized definitions of constipation & diarrhoea may facilitate bowel dysfunction management. Routine assessment & tx to maintain normal bowel function should be conducted in all critically ill patients.
53I = Indwelling Catheter removal Indwelling catheter including urinary, arterial, central venous, pulmonary artery & dialysis catheters are commonly used in critically ill patients. Because they penetrate through body’s natural protective mechanism, they are at risk for local & systemic infection. Early discontinuation & removal, when these catheters are no longer needed, remains an important strategy to combat catheter-associated infections.
54Daily more frequent) assessment should be performed of the ongoing need for these catheters, and their removal, when not medically necessary.
55D = De-escalation of Antibiotitcs/Streamlining Once a pathogen has been identified & antimicorbial susceptibilities have been reported, the regime should be converted to most narrow-spectrum, cost effective& pathogen specific antibiotic. Minimizes exposure to broad-spectrum antimicrobial therapy. Same principles can be applied to other pharmacologic treatments which should be regularly re-evaluated for appropriate indications to minimize risk of adverse effects & medications errors.
57Oral Care preferably 8 hourly Remove oral airway Move ET tube to opposite cornerClear mouth of all secretionsPaint mouth with 2% chlorhexidine** Reduces rates of VAP
58Eye Care Moisol eyes drop Tape both eyes in paralysed pt Appropriate antibiotic drops
59Skin Care Daily Bath makes patient comfortable & fresh improves circulationObserve skin daily for redness, injuries, swelling,rashes or other infections & bony prominences for bedsore.Cut short the finger & toe nailsHair care- Shampoo as requiredBack care- Apply olive oil from shoulders to buttockswith brisk circular movement
60SLEEP IN ICU Cause of sleep deprivation in ICU: Environmental factors Pathophysiological factors
61Enviromental factorsNoiseLighting practicesPt care activitiesDiagnostic proceduresSedativesAnalgesics
63Integrated strategy to promote sleep in the intensive care unit:Noise reduction ( < 50dB)Diurnal lighting practicesUse of sleep- promoting pharmacologic agentMinimizing use of pharmacologic agents inhibiting sleepUninterrupted time for adequate sleepAppropriate physiologic supportActive promotion of patient orientationPatient- ventilator synchronyRelaxation techniques
65A daily CXR is indicated for pt with acute cardiopulmonary problems & for patients on mechanicalventilation.In pt with a central venous catheter, a Swan- Ganzcatheter, Feeding tube, chest tube placement, only postprocedure radiographs indicated.Stable cardiac monitoring pt & those with purelyextrathoracic disease require only admission films uponentry to ICU, unless clinical condition demands.American College Of Radiology
66PHYSIOTHERAPY Specialized job Round the clock Continuum from preventing respiratory failure, tomanaging pt on ventilator to pt who have beenweanedPrevented complications related to MVPercussion, vibration, change of position, posturaldrainage ,suction for chest physiotherapyLimb physiotherapy
70Infection Control Measures Control of the reservoirs of infectionInterruption of the transmission of bacteria fromperson to personIndividual device related measuresStaff educationSurveillanceRegular audit
71Control of the reservoirs of infection Disinfection of pt area/bay between pt ( include bed, monitor, ventilator, other equipment, furniture, floor , walls) Appropriate sterilization of reusable equipment Appropriate disposal of disposable equipment including sharps Appropriate surveillance of personnel as reservoirs.
72Cross contaminationPut on gloves before handling respiratory contaminated objects. Wash hands with soap & water or an alcohol- based antiseptic hand rub before & after contact with mucous membrane, respiratory secretions, or contaminated objects and before and after contact with pt with respiratory device. Wear gown when you anticipate being soiled with respiratory secretions and change it before caring for another patient.
73Between their uses on different patients, sterilize or subject to high-level disinfection reusable hand- powered resuscitation bags ( AMBU)
74In addition to routine hand hygiene the following should also be considered in ventilated pt: Intubation: If elective- standard handwash + sterile gloves Emergency – handrub + sterile gloves Suctioning : Alcohol hand rub before & after procedure Clean glove Bronch: Surgical hand/forearm scrub Full sterile field, gown & gloves. Always consider masks, splash guard & eyewear ( PPE) Full chlorhexidine handwash if accidental exposure to secretions.
76Educate family & patient Seeing a loved one attached to mechanical ventilation frightening. To ease distress in pt & family, teach them why mechanical ventilation is needed & emphasize the positive outcomes it can provide. Explain what you are doing Communicate desired outcomes so the patient & family can actively participate in the plan of care.
78REFERENCEGive your patient a fast hug ( at least) once a day Jean- Louis Vincent, MD, PhD,FFCM[PPT] Care of the ventilated patient: FAST HUG-SBIDCritically ill patients need “FAST HUGS BID” ( an update mnemonic)Top 10 Care Essentials for ventilator PatientsEvidence-based Interventions and Teamwork are crucial whencaring for patients on Mechanical Ventilators, Laura C. Parker,MSN,RN,CCRN
80Thromboembolic prevention COMPONENTCONSIDERATIONSFeedingCan the patient be fed orally, if not enterally? If no, should we start parenteral feeding?AnalgesiaThe patient should not suffer pain, but excessive analgesia should be avoidedSedationThe patient should not experience discomfort but excessive sedation should be avoided; ‘calm, comfortable, collaborative”Thromboembolic preventionShould we give low-molecular weight heparin or use mechanical adjunctsHead of the bed elevatedOptimally , 300 to 450 ,unless contraindications e.g. threatened cerebral perfusion pressureStress ulcer prophylaxisUsually H2 antagonist: sometimes proton pump inhibitorsGlucose controlWithin limits defined in each ICU