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The Practicalities of Starting ICU Call and the Fundamentals of Care for ICU Level Patients

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The Practicalities of Starting ICU Call and the Fundamentals of Care for ICU Level Patients The practicalities of starting ICU call and the fundamentals of care for ICU level patients Dr Peter Mc Cauley SpR in Anaesthesiology Version 1.0, March 2020 The practicalities of starting ICU call and the fundamentals of care for ICU level patients Disclaimer The author has made every effort to ensure the accuracy of this booklet. However, given the time sensitive nature of the COVID-19 pandemic, this booklet version 1.0 has been released ahead of schedule, to make it available as soon as possible. All efforts to proofread and edit the contents have been made and users of this booklet should do so in conjunction with all official guidelines, policies and resources as appropriate. Page 2 of 81 The practicalities of starting ICU call and the fundamentals of care for ICU level patients Table of Contents Introduction ................................................................................................................................... 4 The ICU Referral ........................................................................................................................... 5 The practicalities of intubating in ICU ....................................................................................... 9 Setting up for the night ahead! ................................................................................................. 12 Ventilation ................................................................................................................................... 14 Mechanics of ventilation and gas exchange ........................................................................ 14 Peak, mean and plateau pressure ......................................................................................... 21 Modes of Ventilation .................................................................................................................. 24 Non-invasive Ventilation (NIV) ............................................................................................... 27 High Flow Nasal Oxygen (HFNO) .......................................................................................... 30 ARDS............................................................................................................................................ 31 Recruitment Manoeuvres ...................................................................................................... 33 Ventilation in the Prone position.......................................................................................... 34 Inhaled Nitric Oxide (iNO) ................................................................................................... 37 The ABG ...................................................................................................................................... 38 Vasopressors, inotropes and inodilators ................................................................................. 41 Dialysis ......................................................................................................................................... 45 Sepsis ........................................................................................................................................... 51 Shock ............................................................................................................................................ 54 Sedation and analgesia in the ICU ........................................................................................... 56 Nutrition in the ICU ................................................................................................................... 59 Care Bundles ............................................................................................................................... 61 Common ICU conditions on call .............................................................................................. 62 Delirium ................................................................................................................................... 62 Lactate ...................................................................................................................................... 63 Tachycardia/PVCs ................................................................................................................. 64 Temperature spikes ................................................................................................................ 65 Blood transfusions .................................................................................................................. 66 Ventilator dysynchrony ......................................................................................................... 67 End of life Care ........................................................................................................................ 69 The Cardiac patient .................................................................................................................... 70 The Neurosurgery patient ......................................................................................................... 75 Conclusion: .................................................................................................................................. 81 Page 3 of 81 The practicalities of starting ICU call and the fundamentals of care for ICU level patients Introduction Initially this booklet was designed for those about to be put onto the ICU rota (usually anaesthetic trainees). Now this booklet is also written considering the potential heath crises we face with the arrival of COVID-19 to Ireland. For most, even with anaesthetic training, starting ICU call is an incredibly stressful time. Essentially, you’ve been in theatre every day with assigned Consultants on-site, who are commonly present for most inductions, especially any sick or unstable patients. Now, you are being thrust into the realm of ICU. You are expected to manage the sickest patients in the hospital, often having to intubate haemodynamically unstable patients with a Consultant who is off-site, or busy elsewhere. These are the very patients you wouldn’t be inducing alone in theatre. However, now you have to, sometimes in unfamiliar environments like the wards, the Cath lab, or ED! This is particularly true of COVID-19 patients. Furthermore, we may end up in a situation where non anaesthetic trained NCHDs (whilst not expected to intubate) may have to look after critically ill patients (who would otherwise be in ICU), titrating vasopressor support and oxygen therapy. Anaesthetic trainees may find themselves directing this care. Of course, it may be stressful, but remember the vast majority of trainees will not only get through it, they will thrive on it! The following booklet is designed to familiarise you with key concepts of ICU care, the practicalities of being on call, and to provide clinical pearls and tips for dealing with everyday ICU on-call issues. In reality, it’s not all about assessing sick patients on wards or ED; a lot of ICU call involves housekeeping issues – charting fluids, electrolytes, blood etc. Already, the response of medical and nursing staff to the outbreak of COVID-19 has been inspirational, between those in isolation willing to come back to work as soon as feasible, and those who have been incredibly flexible with work patterns to ensure continuation of high-quality care. I must also, personally, commend the Anaesthetic Department in CUH, who to date, have shown excellent leadership, and a genuine care and empathy for both patients and staff alike. I would like to thank them all for their support in this endeavour. I have no doubt we will face this challenge together as a medical community, provide the best care we can for ourselves, and our patients, and ultimately come away stronger for it. Page 4 of 81 The practicalities of starting ICU call and the fundamentals of care for ICU level patients The ICU Referral What patients need to come to ICU In a nutshell, patients who require organ support over and above that which can be given on the wards. (Please understand that what we consider normal ward level care now, may change in the context of COVID -19.) Another important category here are patients who are at significant risk of deterioration, where a period of intensive treatment now may prevent a prolonged ICU admission later. These patients may not need immediate ICU transfer but likely will in the near future. This presents a potential window of opportunity to admit them to ICU now, in an effort to prevent a deterioration in the very near future (typically in the next hours or days) that will result in a more prolonged ICU stay. This is particularly true of COVID-19 patients. You do not want to intubate unless you have to, but remember that intubation itself is considered source control, and it may be wise to intubate early, if you feel the patient is ultimately heading that way. Firstly, let’s look at categories of patient care. You will likely hear the phrases like ‘level 2’ or ‘level 3’ care. But what does that mean? Levels of Care: · Level 0 – patient can be cared for on a general ward · Level 1 – the patient is either at risk of deterioration or has just stepped down from higher care. These patients should be treated on an acute ward (e.g. an observation ward) · Level 2 – the patient needs more frequent obs, or support for a single failing organ or is postoperative. This category also includes patients who have stepped down from a higher-level
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