Department of Anaesthesia, Intensive Care, Bundaberg Base Hospital

Department of Anaesthesia & Intensive Care Bundaberg Base Hospital

INTENSIVE CARE HANDBOOK

Name: Date:

I have read and understood the duties Signature of Employee: and requirements of the position as described in this position description and agree to be employed under such conditions and the relevant award. I Signature of Supervisor: have read the orientation information and agree to the conditions listed therein.

Review: Annually in January. Next update January 2012

1 Contents:

1. Introduction

2. Staffing

3. Departmental Overview

4. Rostering and Absences

5. Anaesthetics

a. Senior Staff

b. Trainees

c. Education

d. Quality Assurance

6. ICU

a. ICU daily Business

b. Policies for admission and discharge of patients

c. Documentation and drug prescription

d. Duties outside ICU (MET calls, ED referrals)

7. Communication in ICU

8. Pathology tests in ICU

9. Miscellaneous Clinical Topics

10. Resuscitation Guidelines

11. Patient Note/Handover Format in ICU

12. Orientation Objectives

1. Introduction

This manual serves as an introduction to working in anaesthesia, intensive care, acute pain and peri-operative medicine at Bundaberg Base Hospital. All anaesthetic staff are required to familiarise themselves with the manual. New staff should approach existing staff members for any issues requiring further clarification. Welcome to the team, and we hope your time in the department is stimulating and rewarding.

Bundaberg Base Hospital serves a growing population of about 90 000. The anaesthetic department provides a 24hr anaesthetic service for General Surgery, Orthopaedics, Obstetrics & Gynaecology, Urology, Endoscopy and Dental. The department gives over 4500 anaesthetics a year. The mixed Intensive Care / Coronary Care Unit has about 600 admissions a year.

2. Staffing

Current senior staff members with departmental responsibilities:

Dr Morné Terblanche Director of Anaesthesia/ICU Dr David Schapiro Staff Specialist (Pain management) Dr Anna-Louis Reyneke Staff Anaesthetist Dr Isaivanie Lingham Staff Anaesthetist Dr Joseph Tobias Staff Anaesthetist Dr Yaqoob Zia Staff Specialist Dr Vanessa Greig Staff Specialist (Labour anaesthesia) Dr Piotr Konopka Current Supervisor of Training Dr Sunil Singh Staff Anaesthetist/ Acting Director of ICU

Other senior medical Staff with significant ICU involvement

Dr Herman Whitmarr Visiting Consultant Cardiology Dr Andre Conradie Visiting Consultant Cardiology

There are currently 5 training grade staff working in the unit

Dr Widanagamage Epa Dr Sunanda Thilakarathne Dr Brian Chileshe Dr Jatinder Grewal Dr Kavitha Jayachakran

3 All Departmental information, guidelines, learning material can be found at:

G:\Medical Services\Medical Staff\Anaesthesia Files

All rosters can be viewed at:

G:\Medical Services\SPECSEC\ROSTERS\Anaesthetics

3. Departmental Overview

The department of anaesthesia & intensive care has six main areas of activity:

1. Intensive Care / Coronary Care Unit 2. ICU referrals and MET calls 3. Transfers/Retrieval

1. Intensive Care / Coronary Care Unit:

Total: 8 Bed Spaces (6 staffed), (1 Paediatric, 1Isolation).

Future planning for ICU Bundaberg includes accreditation for basic training. To work towards this achievement certain changes are necessary.

Currently our unit has 7 day on-call roster for consultants. Fatigue management will include the on-call consultant for Anaesthetics The daily program looks as follows.

08:00 Handover round. This is a working round, concerned with management decisions. The patient’s progress is reviewed, and short and long term goals are identified together with a prospective timeline. Appropriate investigations are also planned for. Participants include the Duty Anaesthetist, Night PHO, day PHO, ICU consultant and nursing staff. This round should be concise and to the point. New patients may require more time.

10:00 Daily Tele-health ward rounds with RBWH consultant intensivist. This will allow clinicians on both sides to gather and evaluate outstanding special investigations, and to allow for a more comprehensive examination and assessment of the patient.

4 This round is registered for CME points and the department encourages participation. It is an important teaching opportunity. The PHOs do the presentation with input from ICU consultant for the week. As consultants are more involved in the daily care of patients, active participation should be encouraged.

17:00 Business round, to review all old patients and monitor progress of patients and act on results of special investigations received. Also reassess goals and review newly admitted patients.

Outstanding special investigations should be followed up during the afternoon. During the afternoon round outstanding results should be identified and problems assessed. The Consultant and PHO should formulate a clear plan for each patient for the evening which should be handed over to the night PHO. Re-evaluation of the patient, with a review of the goals identified earlier in the day, and re-assessment of the patient.

19:30 Handover to the night PHO. A clear plan should be available with problem areas highlighted. If there are any uncertainties it should be cleared with the consultant on call.

Referrals, admissions and Consultations

New admissions and referrals are always to be discussed with the on-call consultant. Ideally the initial consultation should be at a consultant level. We appreciate that this may not be always available but a consultant should be involved at the earliest opportunity.

Patients admitted via the emergency department should always be seen by at least a PHO from the appropriate discipline. There must always be an admitting discipline and unit who takes responsibility of the discharged patient. For example: A patient presenting with pneumonia should be seen by the on-call medical team. Sometimes due to the patient’s condition assessment in DEM my not be possible. Under these circumstanced the on-call team must come and see the patient within a reasonable time frame. When the patient is fit for discharge he/she will be discharged to that team so it is of the utmost importance that they are aware of the patient from admission. The admitting unit must review the patient at least once daily and document their review and advice. ICU welcome daily ward rounds from other disciplines and will actively seek advice. Ultimately orders and change in management will be the responsibility of the ICU team. This should limit confusion, omissions and other errors.

Management of complicated patients

Decision making in ICU will normally be in consultation with Brisbane. Decision making will take the Clinical Service Capability Framework into consideration.

All decision making will ultimately be in the best interest of the patient and rest with the Consultant on-call. The final decision to transfer or not, is the

5 responsibility of the consultant on-call. If RBWH is not able to accept the patient another unit should be approached. If no bed can be identified the Clinical Coordinator should be asked to help. If a patient can’t be transferred for whatever reasons this should be clearly documented.

Death in ICU

Mortality is unavoidable in ICU. To ensure an appropriate level of care all deaths will be reviewed by the Director and presented at the Critical Care Service forum on a monthly basis. Where appropriate an HEAPS analysis will be completed with the help of the Clinical Governance Unit.

If there is uncertainty about whether a death is reportable to the coroner or not, an A1 form should be completed. The Coroner will respond in a timely manner. If the Coroner does not deem the case reportable the unit will be informed and a death certificate can be issued.

If the death is reportable no death certificate can be issued. The police will be notified by the coroner and they will visit the unit. It is very important to note that the police can only remove the patient’s file when cleared by records. Records will scan the file and make it available to the police.

Remember that your statement must be factual. Don’t include your opinion. You may be asked for that later! Inform someone that is more important then you. An email will do. Managers hate surprises. If appropriate PRIME the incident immediately.

The unit is classified as a Level 1 facility. This means the unit is capable of providing immediate resuscitation and short term cardio-respiratory support for critically ill patients. It also has a major role in the monitoring and prevention of complications in “at risk” medical and surgical patients. Deteriorating patients and patients with multi-system involvement should be discussed with the Royal Brisbane (RBWH) Senior Intensivist as soon as possible (Tel: 3636 5946 direct number 24/7). Transport for retrievals to Brisbane is organised through Queensland Clinical Coordination (QCC) in Brisbane (speed dial 6133).

Currently our Unit participate in a Video business round with a RBWH Intensivist every morning where all patients are presented. Funding has allowed RBWH to allocate an Intensivist and secretarial support for this service. This service has lead to better communication with RBWH as well us better appreciation for the particular organisational, infrastructure and staffing difficulties experienced by our institution. Consequently transfer of patients is easier to facilitate.

The unit is well equipped: with standard invasive and non-invasive monitoring equipment, 1 cardiac output monitors namely ‘Vigileo’, 3 ‘BIPAP Vision’ non-invasive ventilators and, 3 Nellcor Puritan Bennett 840 ventilators and one Sonosite portable Ultrasound Machine There is a

6 standard range of Alaris infusion pumps. You should approach Greg Brown, the nurse unit educator for familiarisation with this equipment.

Additionally, the unit contributes data to the Australian & New Zealand Intensive Care Society (ANZICS) national database called AORTIC (Australasian Outcomes Research Tool for Intensive Care). This allows the department to meet several key performance indicators for the Australian Council of Healthcare Standards for unit accreditation. Your active participation in this data collection is expected.

Cardiology & Coronary Care: Cardiology patients represent about one third of all admissions to the ICU/CCU and they are actively managed in the ICU by the cardiology team. Cardiology advice should be sought with any issues relating to these patients. Dr Conradie expects to be closely involved in the management of all his cardiology patients.

2. ICU referrals and MET/TRAUMA calls:

All new staff members will attend the Met training offered by the hospital.

Urgent/emergency referral to the ICU will come from 4 main areas, (planned admissions will originate in the pre-admission clinic).

1. The Department of Emergency Medicine (DEM) 2. The Wards 3. Theatres & Recovery 4. MET calls

The referring team must be encouraged to communicate at consultant level so that an appropriate management plan can be agreed prior to admission. The Consultant Anaesthetist responsible for the unit must approve all admissions to ICU and the ICU team must assess all patients prior to admission to the Unit.

The only possible exception to non-consultant level communication is for straightforward cases of monitoring following myocardial ischaemia, which are being actively managed by the cardiology team. The on-call ICU Consultant must still be informed and these patients will be seen by the ICU team on a daily basis. These patients will not be presented on the RBWH ward round. The nursing staff may ask the ICU PHO to assess and assist with care. Change of management/ medication should be referred to the Cardiology team.

Bundaberg Hospital Trauma Call Activation.

7 The Trauma call will be activated according to the following criteria:

1. Mechanism a. MVA ejected from vehicle. b. Pedestrian, motorcyclist or pedal cyclist hit by car or truck. c. Fall from 3m or greater d. MVA with one or more fatality e. Fall from a horse f. Inter-hospital trauma transfer g. Penetrating injury (eg gunshot; stabbing) 2. Injuries a. Injury to 2 or more body regions (head/neck/chest/abdomen/pelvis/back/femur) b. Fracture of 2 or more long bones (adjacent radius/ulnar or tibia/fib do not count as 2) c. Spinal cord injury d. Crush injury or amputation of a limb e. Penetrating injury to head, neck, chest, abdomen, pelvis, groin or back f. Burns to airway, smoke inhalation, or >15% adult and >10% child g. Major isolated injuries to neck, abdomen, spinal, head, pelvis h. Near drowning i. Attempted hanging 3. Physiological parameters and vital signs a. Airway obstruction b. Shallow or retractive breathing c. Cyanosis d. Skin pallor or slow capillary refill e. Systolic BP <100mmHg f. Pulse >110 or < 50 bpm g. Depressed LOC or fitting h. Pupils dilated or non-reactive i. Glasgow Coma Scale <=12 j. Deterioration in ED

>= 2 Criteria – Call Switchboard on 2200

Trauma Team Consist of the following:

1. Surgical Registrar on-call 2. Surgical Consultant on-call 3. Anaesthetic/ICU registrar on-call (Consultant on request) 4. DEM SMO 5. Radiographer 6. Trauma nurse educator 7. Nurse manager 8. Pathology

8 9. Dresser x2 10. Security 11. Wardsman

3. Transfers/Retrievals:

The anaesthetic/ICU team will frequently be involved in the stabilisation and preparation for transfer of critically ill patients. Coordination of the retrieval effort, preferably at consultant level, is the key to a prompt onward transfer. Liaison with the receiving intensive care unit and the retrieval service (QCC) is the responsibility of the anaesthetic/ICU team. The referring speciality team must ensure their patient is admitted to the receiving hospital under a designated speciality, eg orthopaedics/general surgery/paediatrics/neurosurgery etc QCC via switchboard or on 6133 have access to ICU bed state information (BEDVIEW) as does the Senior RBH Intensivist on 36365946 24/7. In general, availability of an ICU bed and/or the provision of a tertiary level service are the determining factors in the final destination of a patient.

If there is any confusion regarding the suitability of transfer Telehealth should be considered. It is possible with the mobile telehealth equipment to consult with the clinical coordinator.

4. Rostering and Absences

PHOs/Registrars:

76hrs per fortnight + overtime

ICU day shift: 0800 – 2000 ICU night shift: 1930 – 0830

Rostering practices are subject to the Departmental Policy on Fatigue Management. Junior staff will be responsible for doing there own roster with supervision from the Director. Senior Medical Staff:

Staff Specialists: 80 hrs per fortnight + overtime + on call

8 sessions per week (40hrs) 6 are for direct clinical care (30hrs)

9 1 to develop and oversee a departmental portfolio (5hrs) 1 for personal professional development and administration (5hrs)

Staff specialists not contributing to a departmental portfolio may be required to work an extra direct clinical care session.

VMO’s: Variable as per individual contracts Locums: Daily rate 40hrs week + on call

VMO’s & locums are not eligible for professional development sessions.

Senior medical staff are allocated to clinical sessions as indicated on the weekly roster, such as ICU, Duty anaesthetist (DA), Pre-admission clinic and routine theatre lists.

In the interests of continuity, ICU is a week of sessions followed by the Friday and Sunday night on call.

Duty anaesthetist may be an all day session +/- the night on call.

After a night on call, a reasonable attempt will be made to roster people to PDA sessions or a day off to avoid the effects of fatigue. If this is not possible then the next best option will be a pre-admission clinic session.

Occasionally, when staffing is tight the DA may have to take over responsibility for the ICU, while other available consultants may cover the morning pre-admission clinic pain rounds and any other emergencies. The DA is responsible for the smooth running of daily clinical services and may delegate tasks as necessary.

Work Absences:

All rosters and on-call plotters can be viewed at:

G:\Medical Services\SPECSEC\ROSTERS\Anaesthetics

Planned absences: 3 months notice is required for annual leave, exam leave, and professional development leave. Submit appropriate paperwork for approval.

The on call plot is projected on a three monthly cycle and the weekly rosters are based on this on call plotter.

An attempt will be made to accommodate people’s legitimate leave requests provided:

1. Reasonable notice is given to the department 3 months in advance. 2. It does not compromise service delivery 3. It does not expose patients to potentially fatigued staff

No attempt will be made to accommodate people’s planned absences when:

1. There is insufficient notice 2. It is likely to effect service delivery 3. It is likely to expose patients to fatigued staff

Unavoidable short notice absences:

Sick leave, compassionate leave or late notice of availability on courses or professional interviews will be considered as legitimate short notice requests.

The DA and remaining members of the department will attempt to cover the additional workload as best as possible.

Sick leave must be called in as soon as possible before your work start time, inform the DA and/or the night ICU person and notify the employees service centre so you can be paid appropriately.

Inability to organise one’s personal life effectively and, failure to inform the department and your colleagues of your plans is totally unprofessional & unacceptable.

Fatigue management

Fatigue management is clarified in the departmental policy on fatigue management. This document can be viewed on the G-drive.

Example of Anaesthetics & ICU Trainees Roster

12 a. Senior Staff

Duty Anaesthetic Consultant (Free set 2474)

Possible Shift Patterns

0730-1800 + on call

Or 1230-2230 + on call

Or 0730-1230 + other duties

Free set 2474: This phone is the single point contact number for all clinical requests to the department 24/7 and must be handed over to the night trainee when you leave the department.

Daily Routine

1. 0800 attend ICU ward round, collect free set 2474 from night trainee 2. Liaise with Theatre Coordinating Nurse (free set 2498) to ensure smooth running of elective lists and suitable prioritization of urgent and emergent cases 3. Manage sick and fatigue absences to ensure booked lists proceed on time 4. Provide anaesthetic cover for emergency cases 5. Conduct morning pain round 6. Ensure single handed anaesthetists in theatre receive a break (do yourself, or delegate to theatre trainee as appropriate) 7. Ensure urgent and emergent cases receive an anaesthetic assessment (do yourself, or delegate to theatre or ICU trainee as appropriate) 8. Ensure ICU referrals are assessed and screened prior approving their admission to ICU (do yourself, or delegate to ICU SMO on 2472, or ICU trainee on 2472) 9. Ensure that any legitimate visitors to the department or attached medical, paramedical staff and students are welcomed and receive an appropriate orientation. 10. Afternoon duties will be the same as the morning but may also include anaesthetizing for the emergency list cases as well as providing supervision for the ICU. 11. 1730 if doing a 24 hr DA shift, and if quiet, final review of ICU patients and then hand over free set 2474 to trainee 12. 1930 if doing the late shift 1230-2230, final review of ICU patients at the trainees shift handover, then handover free set 2474 to night trainee.

The late shift is only possible when the department is fully staffed, and the late shift DA must attend the 12.30 ICU midday ward round.

ICU Consultant

See page 5

Billing/Private Patients:

Please ensure that the hospital revenue forms are completed for outpatient appointments, private anaesthetic services and endoscopy patients in a timely manner. Only patients where consultant care was involved can be billed.

b. Trainees

1. All queries regarding training should be referred to the Supervisor of Training. 2. Leave and fatigue management will be in line with departmental protocols. 3. Anaesthesia duties will be allocated on the fortnightly roster. The roster will vary with demand. Every attempt will be made to allocate registrars to a variety of lists, PAC and Chronic pain clinic. 4. Registrars are not expected to remain on site when on call but should be readily available. 5. Registrars will practice according to supervision guidelines as prescribed by the college. 6. Consultants should be informed about all cases that require emergency management. 7. Registrars are expected to participate in the academic program. 8. Departmental meetings on Thursday mornings are compulsory. 9. Attendance of the Thursday afternoon tutorials is compulsory. The program is available in the anaesthetic department room and from the Supervisor. .

Quality Assurance

Regular reviews of key performance indicators (KPI’s) in anaesthesia and intensive care as mandated by the Australian Council for Healthcare Standards (ACHS) forms the corner stone of our commitment to a quality assurance agenda. Furthermore, monthly

14 mortality & morbidity meetings allow discussion of individual cases. The monthly theatre clinical governance and education mornings also provide a forum for multi disciplinary discussion of topics of multi- disciplinary interest.

Individual or departmental audits will be encouraged and supported

6. ICU a. ICU Admission and Discharge Policies

a) Admission of patients to ICU/HDU/CCU must be approved by the consultant anaesthetist on duty for the ICU.

b) Nonetheless, urgent resuscitation of life-threatening illnesses should not be delayed by the process of referral. Resuscitation should commence and the duty consultant notified immediately so that a rapid and appropriate decision can be made about admission.

c) Admission of elective post-operative cases depends upon the availability of beds on that day and is coordinated by the day consultant. Inform the consultant of any new referrals.

d) Referrals to the Clinical Coordination Service should be done after contacting the consultant on duty.

e) While it is appropriate to seek advice from the referral ICU registrars by you, if a formal referral or management advice is necessary it should be done at the consultant level.

f) The process of admission of a patient should proceed as follows i.Consultant of the referring team contacts the consultant on-call for ICU. ii.The ICU consultant will then assess the appropriateness of the admission to the unit. Bed availability, background history and clinical presentation will be taken into consideration. Every reasonable effort will be made to accommodate referred patients. iii.If time permits the ICU registrar will asses the patient in DEM or ward. It is the duty of the ICU registrar to get a proper handover from the receiving doctor. iv.Assess the patient’s for resuscitation status and establish at the earliest whether an Advanced Health Directive is current. Document this in the patient’s chart. v.If input from other departments is required this should requested at the soonest opportunity. The department from which input is required will see the patient within a reasonable time.

15 vi.Transfer over to ICU bed vii.Establish monitoring and ensure normal primary survey (patent airway, breathing, adequate oxygenation on saturation measurement, satisfactory blood pressure) and IV access. viii.Establish monitoring and ensure normal primary survey (patent airway, breathing, adequate oxygenation on saturation measurement, satisfactory blood pressure) and IV access. ix.Make a more thorough examination of patient. x.Complete all request forms so that nurses can proceed with appropriate investigations (Pathology requests, X-rays, ECG, septic screen etc). Remember to follow up these investigations. xi.Document essential drugs, fluids, ventilation orders. These include inotropes, sedation, fluid boluses or maintenance, urgent potassium replacement, insulin sliding scale, antiarrhythmics and antibiotics. xii.Decide upon the necessity for more invasive monitoring. The majority of patients in ICU will require an arterial line and many will need a central line. Ensure that other simple devices are in place (IDC, NG tube) xiii.Enter a comprehensive admission note in the patient’s chart covering nature and duration of current condition, background history with list of medications and allergies, findings on examination, available results of tests and current plan of management. Use the standard ICU admission form. xiv.When starting in ICU, you should have consultant input and advice with most of these steps for admitting a patient. xv. Contact the family as soon as possible.

Admission Criteria

In the case of an mixed Intensive Care Unit/Coronary Care Unit a diagnostic model can be used to delineate admission criteria

1. Cardiac a. Acute myocardial infarction with complications b. Cardiogenic shock c. Complex arrhythmias d. Acute CCF with respiratory failure and/or requiring haemodynamic support. e. Hypertensive emergencies f. Unstable angina with dysrhythmia, instability or persistent chest pain g. Cardiac arrest

16 h. Cardiac tamponade i. Dissecting aneurysm j. Complete heart block

2. Pulmonary a. Acute respiratory failure requiring mechanical support b. Pulmonary emboli with hemodynamic instability c. Patients in intermediate care demonstrating respiratory deterioration d. Need for respiratory care not available elsewhere e. Massive haemoptysis

3. Neurological disorders a. Acute stroke with altered mental status b. Coma – metabolic, toxic or anoxic c. Intracranial haemorrhage with potential for herniation d. Acute SAH e. Meningitis with altered mental state or respiratory compromise f. CNS or neuromuscular disorders with deteriorating neurological or pulmonary function g. Status epilepticus h. Potential organ donation i. Vasospasm j. Severe head injury

4. Drug ingestion and drug overdose a. Haemodynamically unstable b. Altered mental state compromising airway c. Drug induced seizures

5. Gastrointestinal disorders a. Life threatening GI bleed b. Severe pancreatitis c. Oesophageal perforation ± mediastinitis

6. Endocrine a. DKA complicated by haemodynamic instability, altered mental state, respiratory insufficiency or severe acidosis. b. Thyroid storm or myxoedema coma with haemodynamic instability c. Hyperosmolar state and/or haemodynamic instability d. Other endocrine crises with haemodynamic instability

17 e. Severe hypercalcaemia with altered mental status requiring haemodynamic monitoring f. Hypo- or hypernatraemia with seizures, altered mental status g. Hypo- or hypermagnesaemia with haemodynamic compromise or dysrhythmias h. Hypo- or hyperkalaemia with dysrhythmias or muscular weakness i. HypoPHOsphataemia with muscular weakness

7. Surgical Postoperative patients requiring haemodynamic monitoring, ventilatory support or extensive nursing care.

8. Miscellaneous a. Septic shock with haemodynamic instability b. Invasive monitoring c. Environmental injuries i. Lightning strike ii. Near drowning iii. Hypo- or hyperthermia iv. Exposure to industrial toxins

Discharge Policy:

i. In general, decisions about patient discharge will be made on the morning ward round to give the wards sufficient time to arrange transfer within working hours.

ii. All discharges must be sanctioned by the ICU consultant on-call.

iii. Unless absolutely necessary, we endeavour not to discharge patients from ICU at night or in the early hours of morning. If unavoidable, the consultant on duty must always be involved in the decision. a. Once a decision has been made to discharge a patient, the process of discharge is as follow: b. Contact must be made with receiving team by the PHO person to person. It is not sufficient to leave a message on a pager. The receiving team must complete the paperwork for accepting the patient and the consultant should be informed at the earliest.

I. Review of drugs and fluids chart:

I. Finish off the current fluid chart and rewrite them on the new one if necessary to ward fluid sheet II. review drug medication chart and if not clear – rewrite the whole chart III. Ensure ICU medications are changed to ward equivalents (IV insulin to subcut sliding scale, IV opiates to subcut opiates, IV to oral antiarrhythmics, potassium infusion to potassium supplements in maintenance fluids)

2. Write and print a complete discharge summary in patient chart. The template is available in the ICU computer but make sure it includes:

I. Reason for admission (presenting complaint) II. Interventions in ICU (eg. intubation, CVC, IAL, dialysis, inotropes) III. Complications of illness in ICU (eg. ARF, shock, arrhythmia, pneumothorax, nosocomial infection, prolonged respiratory weaning process) IV. Details of any surgical procedures performed V. Current status of patient VI. Current relevant results requiring follow-up (eg. abnormal electrolytes, high WCC, persistent atelectasis on CXR) VII. Current medications VIII. Priority issues which need to be addressed in first 24hours after ICU discharge (eg. follow up of bloods, checking antibiotic serum levels, regular chest or mobilisation physiotherapy, Acute Pain Service review etc) IX. Legible signature and pager number so you can be contacted for any clarification X. Note any regular medications that patient were taking prior to ICU admission and whether these have been recommenced or not XI. On the rare occasion that a patient is discharged home, please complete formal Hospital Discharge form and notify GP.

B. Documentation and Drug Prescription

At all times, entries made in charts should be clear, legible, honest and without the use of slang or derogatory terms. They should be accompanied by a legible signature. There are several important aspects of your job that require concise documentation. Only the ICU team is to make changes in medication charts.

a) Daily entries on ward rounds.  ICU forms: There are 2 types of forms – admission note and daily goals note, both

19  Patient notes entry: They should include the date and time of review, the consultant and PHO involved and a systematic structure comprising patient assessment, results and management plans. The actual layout of the entry will depend upon the consultant conducting the round. The entry can be made by the day consultant himself but it is your duty to ensure that there is an entry in the patient notes every shift. b) Pathology results. They are printed out and inserted in the folder at the patient’s bedside. Nonetheless, it is good practice to list abnormal results in the daily chart entry. c) Any change in physical condition of a patient. This requires a complete reassessment of the patient, further investigation and perhaps a change in management plan d) Any patient interventions. All ICU procedures must be recorded with date, time, persons involved, preparation (eg. aseptic technique, gown, gloves, washed with chlorhexidine), medications given and quantity (eg. lignocaine 1% 5ml, Propofol 100mg), procedure followed, result and any complications encountered. e) Any surgical procedures require a summary of the operation and anaesthetic, any problems encountered, a post-operative assessment in ICU, post-operative investigations and any surgical post-op orders. f) Details of communication with relatives or following family conferences. The consultant on duty will usually conduct these. Nonetheless, any issues arising with family members or friends which could impact on patient care should be documented in the chart. g) Admission and discharge summaries and indicated above h) Obtaining consent in ICU. In many cases, proxy consent is required and care must be taken when completing the generic Q Health consent forms. Procedures that do not require consent are the urgent insertion of an arterial line, vascular catheter or central line, endotracheal intubation, ICC insertion or PA catheters. Nonetheless, if you have sufficient time, it is good practice to explain to patients and/or concerned relatives about the procedures. Occasionally, we are asked to electively insert a central line or vascath. In these cases, we obtain written consent from patients prior to insertion. Procedures that always require consent include percutaneous tracheostomy and any form of surgery. i) Confirming death of a patient in ICU. This involves - Assessment of life extinct by clinical examination of cardiac output, neurological signs and respiratory function. Confirmation of life extinct should be documented in the chart with exact time and date and

20 person examining, This permits the body to be moved to a more appropriate location pending certificate completion - Early notification of consultant on duty of death - Certification of death. If the death is NOT a coroner’s case, the life extinct form, and the death certificate and death notification forms should all be completed. If you have not completed these forms before, please ask the consultant on duty to assist you. These forms should be completed at the latest on the working day following death of the patient. Once completed, the body can then be removed from the mortuary to the appropriate funeral agency

- Deaths those are reportable to the coroner (Coroner’s Act 2003)

I. Patient of unknown identity II. A violent or unnatural death a. A death which was not reasonably expected to be the outcome of a health procedure III. A death in care IV. A death in custody V. A Cause of Death Certificate has not and is not likely to be issued

For more detailed clarification of each criterion, refer to the Coroner’s Act. In the event of a death notified to the coroner, only a life extinct form can be completed. The coronial process is initiated by contacting the local Queensland Police Station. This process needs to fully documented and involves consultant input at all stages.

Drug Prescription

If you have not worked in ICU before, you will be using and prescribing medications with which you may not be familiar. It is important to know something about the drugs you prescribe and if you are in any doubt, there are several available points of reference: 2. Ask consultant 3. Refer to MIMS online on CKN site 4. Refer to your palm pilot if you have one (we don’t!) 5. Ask pharmacist

The general principles of drug prescription in ICU are: a) Always write legibly and sign name with accompanying block capitals

21 b) Adhere to recommended guidelines for preparation, dosages and concentrations c) Rewrite fluid and infusion orders daily d) For prn orders on back of drug chart, always include maximum permitted dose in 1 hour and time between administered doses. e) Rewrite drug and fluid orders forms prior to patient discharge to ward f) Always review chart daily to see if any unnecessary drugs can be discontinued g) Specific medications and their prescriptions:

i. DVT prophylaxis should be considered for all patients without contraindications. TEDs and SCDs should be used if heparin is contraindicated. ii. Stress ulcer prophylaxis will generally be used in patients who are mechanically ventilated, are coagulopathic, have multiorgan failure, have renal or liver failure, have pre-existing GORD/PUD, have previously been taking antiulcer medications or are receiving steroids. Please check with consultant on duty iii. Parenteral multivitamin preparations are prescribed to any patient considered to have poor nutritional state. IV thiamine 100mg daily is used for all patients with a history of chronic alcohol intake iv. Insulin sliding scales should be written by PHO for all patients with BSL>10mmol/L. We use intravenous actrapid titrated each hour to the blood sugar. We aim to keep BSLs between 5 and 10mmol/L v. Medications which can be titrated by the nurse should have a clear and easily measured endpoint. Specify clearly the goal mean arterial pressure for patients on inotropes. Specify range of APTT for those on heparin infusions. vi. Be aware of the changes in dose prescription for patients with renal or liver failure and patients on dialysis. Check with consultant about this. vii. Familiarise yourself with the policies on monitoring of serum drug levels. We check levels of all relevant medications at the time of admission (if not already checked in ED or ward). These include digoxin, theophylline, anticonvulsants, paracetamol and salicylates. Any other drug level screen needs consultant approval. In addition we regularly check TROUGH LEVELS ONLY of aminoglycoside antibiotics. In practice, this means checking level ~24hours after dose for once daily agents(gentamicin) and ~12hours after dose for twice daily agents(vancomycin). First dose gentamicin should be administered at a dose 4-5mg/kg regardless of renal function.

h) IF IN DOUBT ABOUT ANY MEDICATION, ASK THE PHARMACIST

22 C. Duties outside the Intensive Care Unit

See page 8

7. Communication in ICU

Some staff starting in ICU can feel apprehensive about the new and unfamiliar environment and the potential for easily getting out of one’s depth. Many of these issues can be alleviated by communicating well with work colleagues and peers. Managing critically ill patients can at times be stressful and tempers can fray if things don’t proceed as smoothly as you might like. Confrontation is best avoided.

There are some helpful principles to get you through your experiences with the minimum of stress 4. Be open with colleagues, be willing to listen and respect their opinions 5. Be willing to appreciate that there is often more than one way of skinning a cat 6. Respect the nurses. Many have been working in ICU for longer than your consultants and have a good insight into local practices and perhaps a sixth sense regarding patient progress 7. Be willing to ask and to admit to a lack of knowledge in a given area 8. Appreciate that there will be times when you feel strongly that your opinion is the correct one. You may be right! Enlist senior advice if you need support or a second opinion. 9. Refer any complaints or concerns to a consultant so that it may be pursued by the appropriate channels. 10. Communicate all concerns to your consultant. We prefer to know about issues as they occur (when they can be easily fixed) rather than many hours later when management may be more difficult. We will not shout at you down the phone! It might take a few seconds for our brains to catch up with our bodies but we will get there. 11. Remember that a sedated patient can still hear! Respect the patient at the bedside. 12. Remember the worried relatives. They need contact and consoling. While most of the discussions with families will be carried out by consultants, it is absolutely appropriate for you to give relatives a brief summary of progress.

8. Pathology tests in ICU

There are some general guidelines which are useful to follow

23 1. All intubated patients should have an ABG, urea, creatinine, electrolytes, FBC and ECG each morning. Blood forms are completed by the night MO so that the nurses can reserve bloods at 5-6am. Blood results are then ready for the morning ward round. Results should be entered into the pathology flowsheet in the patient’s bedside chart. Frequency of ordering may reduce according to the acuity of patient’s illness. 2. Intubated patients should have magnesium, PO4, coagulation screen and LFTs checked each 2-3days. They may be reserved more or less frequently according to clinical requirements and this will usually be directed by the attending consultant. 3. A septic screen should be taken if the patient’s temperature exceeds 38 degrees. This may vary if the patient is on broad spectrum antibiotics. Please check before sending screen as this may represent wasted resources with minimal benefit. This includes catheter urine, venous blood culture (not from indwelling CVL or IAL), and sputum (if available). Other specific fluids/specimens will be ordered according to clinical situation. Culture results should be listed in the microbiology flowsheet. 4. Pre-op patients should have current coagulation screen, FBC and group/hold (or crossmatched blood depending on surgery planned) 5. Electrolytes may be checked several times daily if a patient has significant fluid shifts or renal dysfunction. Requests should be made for individual electrolytes and NOT for repeated U+Es or ABGs. 6. The following should not be ordered without consultant approval: i. ABGs more frequently than 12hourly. Oxygen saturation gives adequate information about PaO2 and minute ventilation is inversely proportional to PaCO2. Nevertheless, the investigation of any acute change in respiratory status should obviously include an ABG. ii. CK/Troponin iii. D-dimer iv. Thyroid Function tests. These are notoriously difficult to interpret in critical illness. v. Serum drug levels vi. B12/Folate/Iron studies

9. Miscellaneous Clinical Topics

This is not designed as a comprehensive review of these topics. It is a guide to the initial treatments and investigations and the thoughts that should be going through your head when faced with them. In all cases, consultant assistance should be sought as soon as possible. The most important part of clinical assessment is the first part: ABCD This simple universal algorithm is designed to identify life-threatening reversible problems so that they can be treated early to save lives. You must understand how to recognise ABCD compromise.

Airway: Is the airway patent and protected?

24 A patient with a patent airway will be speaking normally, have quiet breathing sounds and chest will be moving with respiratory effort. A patient with an obstructed or partially obstructed airway will have noisy breathing (grunting, snoring or stridor) and chest will not move adequately. Beware the complete airway obstruction with silent breath sounds due to lack of airflow. A patient has a protected airway when their cough and gag reflexes are intact. This occurs when their GCS is ≥9. An obstructed or partially obstructed airway not relieved by simple manoeuvres (below) is an emergency.

Breathing: A patient with adequate breathing has a normal respiratory rate (10-14per minute), adequate chest movement with breaths and endpoint adequacy of respiration (SaO2≥90%). A patient with compromised breathing may have inadequate respiratory effort (sedation, opiates, respiratory muscle weakness) or excess respiratory effort (acute respiratory pathology: pneumonia, pulmonary oedema, pulmonary embolus, exacerbation of asthma/COPD). SaO2 <90% in a patient on O2 15lpm through a non-rebreather mask is an emergency.

Circulation: A patient with adequate circulation has normal CVS observations (SBP ≥90mmHg, HR <100bpm) and clinical confirmation of sufficient organ perfusion (awake and appropriate=brain perfused, passing urine=kidneys perfused, skin warm and short capillary refill time=skin perfused). See hypotension below. Systolic blood pressure <90mmHg not responding to a fluid bolus in a patient with evidence of end-organ hypoperfusion is an emergency.

Disability (neurology): GCS ≤8 correlates with an unprotected airway. This is an emergency.

Scenarios you will encounter during your stay in ICU a) Worsening oxygenation b) Airway emergencies in ICU c) Hypotension d) Arrhythmias e) Fluid guidelines f) Transfusion guidelines g) New fevers h) CTL-spine clearance i) Low urinary output j) Needle stick injuries k) Updated ARC Guidelines for Adult/Paediatric BLS/ALS a) Deterioration in oxygenation

- Increase FiO2: Nasal prongs Hudson Mask Non-rebreather Mask Manual Ventilation with bag and mask +/- artificial airway  Intubation and mechanical ventilation - If on ventilator, increase FiO2 to 1.0 (100%) or PEEP by 2.5cm H20. If ventilator alarms are sounding and ventilation is inadequate, disconnect from ventilator circuit and manually ventilate with Mapleson’s C-circuit resuscitation bag. - Aim for SaO2 >90% in the first instance - Reserve ABG, ECG, CXR - Think of pneumonia, aspiration, acute pulmonary oedema, pulmonary embolism, ARDS and in an intubated patient, consider pneumothorax, ETT occlusion, sputum plug, inadvertent ETT removal, circuit disconnection. - What clinical signs would support the above diagnoses? Look for these clinical signs when assessing patient.

b) Airway emergencies in ICU

While uncommon, acute airway emergencies can occur in ICU. Your response will greatly depend upon level of experience and previous exposure to intubation and airways. The dreaded scenario is Failure to Ventilate. - Causes: ETT dislodgement, ETT occlusion, ETT kinking, ETT cuff rupture, patient asynchrony with coughing against mandatory ventilator breaths - Enlist help early (ED registrar, anaesthetic consultant) - Deliver 100% O2 - Attempt manual ventilation through ETT. This is often sufficient to maintain adequate oxygenation until help arrives - If unable to ventilate through ETT with ambubag then ETT occlusion is likely. This is an emergency. Call for urgent help. Remove ETT and attempt manual ventilation with bag and mask, jaw thrust manoeuvre and an assistant applying cricoid pressure. If unable to ventilate, insert Guedel or nasopharyngeal airway and try again. Try holding mask on face with both hands and allow assistant to compress bag. Persistent failure to ventilate will require an attempt at reintubation with smaller ETT or resorting to an emergency airway eg. Cricothyroidotomy. See diagrams below.

Technique for manual bag ventilation

Effect of jawlift on airway patency

Correct placement of Guedel and Nasopharyngeal Airways

c) Hypotension

A common complication of critical illness. - First ask yourself if this is something you need to treat. A patient who is awake, alert and has urinary output >40ml/hr with a SBP 90mmHg may be physiologically normal. - Always check the patient’s baseline BP pre-admission. A SBP 120mmHg in a hypertensive patient on 3 BP medications may represent hypotension. - For the purposes of this topic, let us consider a patient with SBP <90mmHg, rising HR and urinary output < 0.5ml/kg/hr. - Institute fluid bolus immediately (albumin 250ml or 0.9% saline 500ml) and repeat as required - Consider vasodilatory causes (sepsis, anaphylaxis, autonomic dysfunction in elderly, epidural analgesia, rewarming after episode of hypothermia, post- cardiac arrest reperfusion injury) with typical warm peripheries, rapid capillary refill, hyperdynamic cardiac output, bounding pulses.

27 - Consider hypovolaemic causes (haemorrhage, huge GI losses) with cold, shutdown peripheries, slow capillary refill, poor pulse volume - Consider cardiac causes (Myocardial infarction, cardiac tamponade, tension pneumothorax) with similar clinical features to hypovolaemia (but distended neck veins likely) +/- pulmonary oedema. - Arrange CVP measurement before and after fluid bolus, ECG, CXR, FBC - Can consider short acting catecholamine such as metaraminol, 10mg made up to 20ml Saline 0.9% and given in 0.5mg boluses.

d) Arrhythmias

- Treatment of ventricular arrhythmias follows the usual ACLS protocols. - Multiple ventricular ectopics are usually well tolerated by patients and staff alike. Apart from ensuring a K+ >4mmol/L and Mg++ >1mmol/L, we seldom specifically treat these arrhythmias. - Supraventricular tachycardias are common in acute illness, especially fast atrial fibrillation. In general: i) Remember that tachycardia is an inherent component of the SIRS response. Therefore, a patient with chronic AF and SIRS may simply have a compensatory fast AF which in most cases should not be actively treated. However, with increasingly fast AF, cardiac output falls so treatment should be considered for all AF >140bpm ii) AF with no CVS compromise: correct K+ and Mg++ and consider amiodarone loading. Search for possible cause (hypovolaemia, hypervolaemia, medications, drug toxicity, myocardial ischaemia, LA enlargement, CCF, alcohol excess, valvular heart disease, sepsis) iii) AF with CVS compromise: Synchronised bipolar cardioversion with energy levels 25J/50J/100J. The optimum bipolar energy levels for SVTs are as yet unknown so these are given as a guide for ICU patients. - Bradyarrhythmias are only treated if accompanied by CVS compromise. The algorithm of treatment is: i) Atropine 600mcg IV bolus repeated as required ii) Early Transcutaneous pacing with LIFEPAK adhesive pads: usually anterolateral or anteroposterior application. Set rate (60-70bpm) and current (increase in increments of 5mA until mechanical capture occurs). Some sedation is usually required to tolerate. iii) Consider positive chronotropic agents (adrenaline or isoprenaline) iv) Progress to transvenous pacing

e) Fluid guidelines

- Resuscitation fluids: Must be able to exert an OSMOTIC pressure in the extracellular space by containing substances which do not cross the cell membrane freely (sodium, albumin, polymerised sugars) i) 0.9% saline and Hartmann’s, usually 500-1000ml boluses.

28 ii) Colloids (4% albumin, haemaccel, gelofusin). Usually 250-500ml boluses

- Maintenance fluids: Are isotonic but NOT ISOOSMOTIC in vivo. (Why not?) Therefore, much less of these fluids will remain in the extravascular space. They include 4% glucose in 0.18% saline, 3% glucose in 0.33% saline and 5% dextrose. We do not use these fluids for fluid boluses. Maintenance fluid therapy for children is a contentious area. Currently, we use 4% in 1/5 saline or 2% in ½ saline but there is a statewide move towards Hartmann’s use for maintenance. Remember the rule for kids: 4ml/kg for first 10kg, 2ml/kg for next 10kg then 1ml/kg thereafter. f) Transfusion Guidelines

- Transfuse PRC if Hb <70g/L and patient otherwise stable - Exceptions to this are: i) Active bleeding where Hb is an unreliable indicator of total blood volume and blood losses ii) Active IHD (aim for Hb 90-100g/L) iii) Shock, where further clear fluid resuscitation will lead to haemodilution iv) Jehovah’s witnesses, who refuse blood products on the basis of religious beliefs. - Be aware of district protocols on the administration of fresh frozen plasma, platelets, concentrated factors and cryoprecipitate. QHEPS website has links to transfusion guidelines. - Be alert to acute immunological reactions to blood products. i) Haemolytic transfusion reactions: anxiety, diffuse pain, rigors, vomiting, hypotension, bleeding from DIC progressing to CVS collapse. Resuscitate supportive care and send PRC unit and venous blood to pathology. ii) Non-haemolytic immune reactions: represent a spectrum of presentations from urticaria to fevers and hypotension to mild hypotension and wheeze to cardiac/respiratory arrest. Most mild forms are treated adequately with fluid bolus and IV antihistamine (Phenergan 12.5mg stat).

g) New fever in patient in ICU

- Temps >38 require investigation. Confirm the presence of Systemic Inflammatory Response Syndrome with other criteria (RR, WCC, HR). What are the abnormal ranges for these variables that indicate SIRS? - Check for hypotension to suggest possible septic shock - Possible sources of infection i) ENT: dental abscess, sinusitis, otitis, oral infection ii) CNS infection: rare, but consider if known head injury or skull fracture iii) Line sepsis: check how long CVL and IAL have been in situ iv) Chest sepsis: ventilator-associated or hospital-acquired pneumonia with specific causative organisms

29 v) UTI with catheter in place vi) Intra-abdo sepsis: particularly in post-op patients vii) Soft tissue infection: possibly complicating pressure areas viii) Always consider infective endocarditis, osteomyelitis, and epidural abscess if patient has had recent epidural anaesthesia and GUT infections (especially females of menstruating age)

- Ensure ETT aspirate, catheter urine specimen, blood cultures taken aseptically from peripheral vein NOT from intravascular line, any suspected infected body fluid. - Consider non-infected causes of fever, many of which occur in ICU patients. Can you list some? - Familiarise yourself with antibiotic protocols, ideally from Antibiotic Guidelines on CKN on Q Health website.

h) CTL-spine clearance

We only accept a written report from the radiology consultant on duty to permit full clearance of a cervical spine. Until then, the patient must remain in either of the following: i) Hard cervical collar if awake and prone to movement ii) Sandbags on either side of head if patient sedated and not moving.

These avoid the pressure areas and potential elevation of intracranial pressure associated with hard collars. Clearance of the thoracolumbar spine is an ongoing problem in patients with blunt multitrauma, mainly due to the lack of validated guidelines. TL fractures are more common than c-spine and are more likely to be associated with neurological deficit. In our unit, all trauma patients with back pain, back tenderness, neurological deficit or c-spine injury need full T/L imaging. Patients without these criteria but with GCS ≤14, any distracting injury or drug/alcohol intoxication need TL imaging. Imaging is preferably CT scans. If you have any uncertainties, lay the patient flat, maintain full spinal precautions, logroll for turns and contact the on-duty consultant. This cannot wait until morning to be clarified.

i) Low urinary output

This is the bane of the PHO’s life in ICU. Please avoid the temptation to blindly give frusemide so that you can get back to bed quicker. Approach the problem with some common sense. - Is the catheter blocked or in an incorrect position? Usually suggested by abrupt anuria or a catheter that has drained no urine whatsoever since insertion. Check bladder on ultrasound to confirm - Is the patient hypovolaemic, euvolaemic or hypervolaemic? This is a difficult thing to clinically assess and probably the single most important field of technological research in ICU. Go back to basics. Check the blood pressure, the mucous membranes, skin turgor, the rise in CVP with fluid

30 bolus (much variation seen but a sustained rise of 3mmHg or more with 250ml of fluid probably suggests adequate fluid volume) and the specific gravity of urine (>1.015 suggests a volume contracted state). - Unless the patient is obviously fluid overloaded, always try bolus of fluid first. This allows you to observe changes in BP, CVP and respiratory function. Be prepared to be generous with fluid. Hypovolaemia and critical illness are poor bedfellows. - If you consider the patient has adequate volume status, it is reasonable to try a small dose of frusemide (10-20mg) to assess response. A huge diuresis probably confirms your suspicions. A negative response means that the patient probably needs more fluid. - In post-operative patients, the excess of ADH caused by the stress +/- pain can lead to oliguria despite adequate volume status. In these patients therefore, urinary output is a relatively poor indicator of volume status. Following fluid resuscitation, we have a lower threshold for frusemide in these patients. - In patients with normal renal biochemical function, oliguria means absolute or relative hypovolaemia unless otherwise proven. - Remember: frusemide and dopamine do not make renal failure get better. They make the patient pass more urine, nothing else.

j) Needlestick injuries

We emphasise that you should take all possible precautions to prevent this occurring. Always wear gloves, dispose of sharps in supplied containers, never resheath needles and never pass sharps to another person. Of particular relevance to ICU is the management of procedure trolley. At the end of any sterile procedure, ensure that all your sharps have been discarded prior to leaving the bedside. In the event of a needle injury, the following steps should be followed. They are in more detail on the QHEPS website. - Gentle massage of area to encourage bleeding then wash with soap and water. - Obtain Occupational Exposure Package - Use pre-printed blood forms to give blood sample taken in Emergency Department - Use pre-printed forms to take blood sample from patient involved. Obtain consent from patient prior to venepuncture. If patient is intubated and cannot give consent, consider proxy consent or speak with Medical Supintendent. - Be aware of appropriate follow-up, especially Hep B immunisation.

31 16. Resuscitation Guidelines

Basic Life Support

Adults: - DRCAB - C: Comence immediate compressions. Ratios 30:2 for one or 2 rescuers, rate 100 per minute, depth 4-5cm allowing recoil of chest after compression. Continuous compressions if patient intubated. Rapidly apply monitoring to assess rhythm. - A: chin lift/jaw thrust as required. Consider possibility of c-spine injury. - B: consider 2 immediate effective breaths (+/- bag and mask). Confirm chest movement. -

Children: - DRABC - A: chin lift/jaw thrust as required (infants maintain neutral head position). Consider possibility of c-spine injury. - B: consider 2 immediate effective breaths (+/- bag and mask). Confirm chest movement. - C: check carotid, femoral or brachial pulse +/- commence compressions. Ratio 30:2 with 1 rescuer and 15:2 for 2 rescuers, rate 100 per minute, depth to 1/3 of chest girth allowing recoil of chest after compression. Continuous compressions if patient intubated.

Consider commencing CPR if signs of organ hypoperfusion and a) adult with SBP <50mmHg b) child (1-8y/o) with HR <40 per minute c) infant (<1y/o) with HR <60 per minute

Adult Advanced Life Support

VF/Pulseless VT (witnessed):

Principles a) 3 initial shocks compared with 1 initial shock in unwitnessed arrest b) early CPR if any delay in applying monitoring c) immediate recommencement of CPR after shocking, not delaying for rhythm assessment d) ensuring 2 minutes of effective CPR before any trial of cardioversion e) 360J monopolar/200J bipolar energies for all cardioversions f) search for reversible causes

Practice - effective CPR pending readiness of defibrillator - consider precordial thump if defibrillator not immediately available

32 - 3 stacked electrical cardioversions (monophasic 360J x3/biphasic 200J x3) - Immediate (re-)commencement of CPR if initial shocks unsuccessful. Good CPR should continue for 2 minutes without pause, then reassess rhythm - single shock (monophasic 360J/biphasic 200J) for persistent arrhythmia - immediate recommencement of CPR if shock unsuccessful - during this CPR administer adrenaline 1mg IV through proximal vein with 20ml saline flush (ARC guidelines suggest that adrenaline is given at this stage although it would be reasonable to administer it during the CPR after first series of failed shocks, especially if they were preceded by a period of effective CPR) - complete 2 minutes CPR, reassess rhythm and consider further single shock - immediate recommencement of CPR if shock unsuccessful - during CPR administer amiodarone 300mg rapid IV push through proximal vein with 20ml saline flush - complete 2 minutes CPR, reassess rhythm and consider further single shock - continue shock  CPR +/- medication  reassessment of rhythm  shock - consider reversible causes (4Hs and 4Ts), other medications (MgSO4 10mmol, HCO3 50mmol, KCl 5mmol, lignocaine 1mg/kg IV push) and endotracheal intubation.

VF/pulseless VT (unwitnessed):

Principles a) 1 initial shock compared with 3 initial shocks in witnessed arrest b) Consider 2 minutes effective CPR before cardioversion if OOHCA with call-to-arrival time of > 4minutes or in patients presenting with fine VF. c) all other principles as above

Practice - consider CPR prior to cardioversion as above - single shock 200J/360J followed by immediate effective CPR - guidelines should continue as above following first unsuccessful shock

Asystole/Pulseless Electrical Activity

Principles a) Confirm rhythm in at least 2 leads b) Ensure effective CPR c) Consider early endotracheal intubation d) Administer appropriate medications e) Consider reversible causes f) Be alert for development of shockable rhythm Practice - perform basic life support - check rhythm in 2 leads to confirm asystole

33 - achieve early venous cannulation, preferably in proximal vein and commence rapid fluid bolus - consider early endotracheal intubation - continuous CPR once intubated with ~10 breaths per minute through ET tube - administer adrenaline 1mg each 3 minutes followed by 20ml saline flush - consider other medications (atropine 1mg, HCO3 50mmol, KCl 5mmol) - consider transcutaneous pacing using adhesive chest pads - always consider reversible causes of cardiac arrest ( 4Hs, 4Ts)

Remember that narrow complex PEA (with near normal QRS shape) suggests hypovolaemia, obstructive aetiology (PE, tamponade, pneumothorax) whereas abnormal broad QRS shape suggest electrolyte disorders, toxins (eg digoxin) or myocardial infarction.

Paediatric Advanced life Support

VF/Pulseless VT:

Principles a) General approach as for adult life support b) 3 initial shock if witnessed arrest, 1 initial shock for unwitnessed c) Avoid interruptions in CPR as much as possible d) Consider early interosseus needle if access difficult (usually consider if 2 failed IV attempts) e) All drugs and shock energies are per kg dosings f) Respiratory failure more common in children so early restoration of normal respiratory function a priority g) Be aware of tendency to develop bradycardia in infants and young children and have atropine available h) Check glucose in all paediatric arrests

Practice - establish absence of cardiac output as per BLS and commence effective CPR - establish rhythm as shockable - consider single praecordial thump if witnessed arrest and defibrillator not yet available - Initial cardioversion 2J/kg for unwitnessed and 2J/kg4J/kg4J/kg in witnessed arrest. Rapid stacks of 3 shocks should be performed by manual defibrillation (not AEDs) to expedite shock delivery and reduce interruption to CPR - immediate recommencement of CPR if shock unsuccessful and continue for 2 minutes - Administer adrenaline 10mcg/kg by intravenous (IV) or intraosseus(IO) route followed by 5ml saline flush. Can consider adrenaline 100mcg/kg by endotracheal route if parenteral access not achievable - Administer fluid bolus 20ml/kg hartmanns IV/IO during CPR. IO route will require 3-way tap and 50ml syringe to flush fluid in.

34 - complete 2 minutes CPR, reassess rhythm and consider further single shock 4J/kg - immediate recommencement of CPR if shock unsuccessful - during CPR administer amiodarone 5mg/kg rapid IV/IO push through proximal vein with 5ml saline flush - continue shock  CPR +/- medication  reassessment of rhythm  shock - consider reversible causes (4Hs and 4Ts), other medications (MgSO4 0.1mmol/kg, HCO3 1mmol/kg, KCl 0.05mmol/kg, lignocaine 1mg/kg all IV or IO push) and endotracheal intubation - continue adrenaline 10mcg/kg IV/IO each 3 minutes in addition to above medications

Asystole/PEA

Principles a) Cardiac output is inadequate in an infant (<1y/o) if HR <60bpm and in children (>1y/o) if HR <40bpm. Such bradycardia unresponsive to mechanical ventilation and restoration of normal oxygenation should be treated as for asystole. b) Don’t forget to check glucose c) Consider early IO access if 2 failed IV attempts

Practice - BLS with particular emphasis on good CPR - early IV/IO access - administer adrenaline 10mcg/kg IV/IO (100mcg/kg ET), followed by 5ml saline flush - administer fluid bolus 20ml/kg hartmanns IV/IO - consider early endotracheal intubation and ventilation - consider reversible causes (4Hs and 4Ts) - continue adrenaline each 3 minutes with consideration to other medications (asystole: atropine 20mcg/kg IV/IO, HCO3 1mmol/kg IV/IO, PEA: HCO3 1mmol/kg and further fluid boluses) - consider transcutaneous pacing for persistent refractory asystole

Other helpful paediatric rules

Weight: (agex2)+4

ETT size: Age/4+4

ETT distance at teeth: Age/2+12

Laryngoscope blade: Personal opinion but usually straight blade for <5kg and curved blade for all above

Blood Pressure: Heart Rate:

35 Normal 80+2(age) Neonate 125/1y.o 120/2y.o 110/6y.o 100/10y.o 90

Drug Doses: See attached form For children <1y/o, it can be difficult to accurately administer 0.35-0.7mls of adrenaline 1:10,000. Consider diluting 1ml of 1:10,000 up to 10ml to make adrenaline 1:100,000 (10mcg/ml).

11. Patient Note/Handover Format in ICU

This should cover the following topics in this order

a) Brief summary of patient as an introduction: This is a 43y/o lady admitted to intensive care 3 days ago with Gullian-Barre Syndrome who has ventilatory failure requiring invasive positive pressure ventilation but is otherwise making good progress Or This is 67y/o gentleman with known COPD admitted 12days ago with an acute infective exacerbation of his chest disease who is slow to wean from the ventilator. He has had associated renal failure which is improving Or This is a 58y/o lady admitted yesterday following an elective anterior resection and apart from some initial mild hypotension which responded to fluid boluses, she has had a good post-operative course.

b) Relevant patient background history (including regular medications) c) Current progress, described system by system (Resp, CVS, CNS, GIT, Renal, infective, bloods, medications) d) Summary of progress and plans for next 24hours

EXAMPLE:

9/9/2002 08:00

Mr John Doe age 74y

Day 8 post AAA complicated by: 1. Resp. failure 2. ARF (CVVHD) 3. NSTEMI 4. Massive transfusion

Background: 1. CABG x3 (1997) 2. HTN (Lisinopril)

Current problems:

36 1. Failure to wean 2. Polyuric renal failure 3. Coronary ischaemia 4. Increased bilirubin 5. Sacral ulcer 6. Wound dehiscence

Review of Systems Neuro - Ramsay 4 on Midazolam 4mg/h + morphine 2mg/hr Resp - ABG pH 7.46/PaO2 78/PCO2 48/BE +2/SpO2 94% on FiO2 0.4 PC 20/5 rate 12/’; crackles audible throughout, dull in bases, CXR bilateral infiltrates (ARDS) CVS - BP 120/70, HR 92 (Metoprolol 5mg q6h), CVP 8, normal HS, no murmurs, ECG T-wave inversion across anterior leads GI - abdomen soft, non tender, wound open but clean, post-pyloric feed started (30 ml/h), no stool, Bilirubin increased to 12.6, transaminases normal Renal - balance -500ml/24h, overall +ve 8l. Creatinine 240 (down from 280). Hourly output 80-120ml Endocrine - no problem Extremities - mild ankle oedema, SCDs, Enoxaparin 30mg BD, large (8x8cm) grade 2 pressure sore over sacrum Labs - Na 138/K3.2/Cl 111/Bicarb 29 Hb 90(1u PRC overnight), plat 230, INR 1.5 Microb - Temp 38.2; WCC 19.2; Pseudomonasin BAL x2/7; Cipro (day 2) 200mg BD + Gent (Day2) 350mg OD Devices - RSCL (Day 4), RRAL (Day 8)

Impression 1. ALI not resolving – infectious component, no need for steroids now 2. HR fast for ischaemia – cardiology review for possible PCI 3. Bilirubin high due to hemolysis/cholestasis/sepsis 4. Renal function improving – K+ needs vigorous supplementation 5. Wound healing well 6. Pressure ulcer enlarging

Plan 1. Neuro - stop Midazolam, assess neurologically 2. Resp – trach tomorrow 3. CVS – increase Metoprolol to 10 mg TDS, cardiology to see ?PCI 4. GI – increase feeds to goal 75 ml/h, PO4 enema 5. Renal – replace K+ loses with KPO4 6. Endocrine – NAD 7. Extremities – wound care, surgical consult 8. Haem/labs – transfuse if Hb<90; continue ASA (IHD) 9. ID – continue Ab 5/7 10. Devices – remove CVL, use periph. Line

37 17. Orientation Objectives

Take the opportunity to read through the following objectives. If you are not familiar and comfortable with any objective, seek clarification from a consultant, the clinical nurse educator or the nurse unit manager. Use these objectives to facilitate your learning while in ICU.

DATE OBJECTIVE COMPLETED Unit layout including bed numbers and utilisation. Location of relevant equipment such as : ♦ Resuscitation Trolleys ♦ Arterial Blood Gas Machine ♦ Crates with equipment for Arterial, Swan Ganz, CVP, Transvenous Pacemaker, IDC and NG insertion Introduction on how it all works in relation to medical and nursing cover: ♦ ICU Model of Care ♦ PHO Guidelines ♦ PHO Shift Responsibilities ♦ Admission and Discharge Protocols ♦ Charting Responsibilities ♦ Royal Brisbane Hospital ICU Clinical Coordinator (Direct Dial - 36365946) ♦ Clinical Microbiology ♦ Cardiology Registrar ♦ Neurology/Neurosurgery Transfers – interdepartmental/interhospital including: ♦ Letter of Referral/Xrays ♦ Ward Transfer Form ♦ Patient Transit Scheme Forms ♦ Patient Discharge Form Support services including: ♦ Pharmacy (6316) ♦ Allied health (6118) ♦ Pathology (6333) ♦ Clinical Measurements (6004) ♦ CHEC services Organising special tests: ♦ MRI ♦ CT ♦ Thallium ♦ ECHO ♦ Bone Marrow

38 DATE OBJECTIVE COMPLETED Documentation including familiarisation with: ♦ ICU Flow Chart ♦ AORTIC data sheet ♦ HDU Observation Chart ♦ ICU pathology chart ♦ Refusal book ♦ Admissions book ♦ Procedure log ♦ Clinical Issues Form for morning rounds ♦ ICU/CCU Drug Protocols Paging and phone system Auslab/ Auscare assword Synapse for X-ray Reports Using the blood gas machine Clinician Knowledge Network – reviewed in library orientation session Education and library services MET how it works, beepers, algorithms CPR / ALS competency testing PHO responsibilities relating to Cardioversion On call rosters