ICU Management Protocols Published by Malaysian Society of Intensive Care Printed by Malaysian Society of Intensive Care (MSIC) Unit 1.6, Level 1, Enterprise 3B Technology Park Malaysia Jalan Innovasi 1, Bukit Jalil 57000 Kuala Lumpur, Wilayah Persekutuan Website: www.msic.org.my In collabration with Ministry of Health Malaysia Copyright © Malaysian Society of Intensive Care Pusat Kebangsaan ISBN Malaysia ISBN 978-967-11415-4-0 Cover design by Nabil bin Ali Disclaimer: The content of this book has been produced in good faith to guide medical practitioners. However practitioners are advised to keep abreast the current evidence-based practices that are constantly evolving and to take into account the local issues and limitations. Foreword There are many aspects in the care and management of the critically ill patient. As clinicians we need to keep abreast with the most current evidence-based practices to ensure optimal patient care and safety. This is an update of the management protocol book written in 2012, to facilitate clinicians in the management of the critically ill. Each protocol was developed with careful consideration of current evidence as well as the practical application and cost containment within our institutions. The algorithms in the protocols are simple to use and can be easily implemented. There are great concerns on the rise of multi-drug resistant organisms. We know that critically ill patients are at high risk of acquiring infections. To address this, a protocol on prevention and control of multi-drug organisms is included. This protocol materialised due to the many hours of discussion and exchange of opinions. I hope the protocol will serve as a guide to ICU management that will enhance the quality of patient care. I like to express my gratitude to the writing committee for their effort in publishing this excellent management protocol book. Dr Melor bin Mohd Mansor Head of Anaesthetic and Intensive Care Services Ministry of Health Malaysia i Writing Committee Dr Shanti Rudra Deva (Chairperson and Editor) Intensivist Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur, Kuala Lumpur Dr Tai Li Ling (Co-Chairperson) Intensivist Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur, Kuala Lumpur Dr Azmin Huda Abdul Rahim Intensivist Department of Anaesthesia and Intensive Care Hospital Sultan Ismail, Johor Bahru, Johor Dr Foong Kit Weng Intensivist Department of Anaesthesia and Intensive Care Hospital Raja Permaisuri Bainun, Ipoh, Perak Dr Ismail Tan Mohd Ali Tan Intensivist Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur, Kuala Lumpur Dr Khoo Tien Meng Intensivist Department of Anaesthesia and Intensive Care Hospital Queen Elizabeth 1, Kota Kinabalu, Sabah Dr Lee See Pheng Intensivist Department of Anaesthesia and Intensive Care Hospital Tengku Ampuan Rahimah, Klang, Selangor ii Writing Committee Dato’ Dr Lim Chew Har Intensivist Department of Anaesthesia and Intensive Care Hospital Pulau Pinang, Pulau Pinang Dr Mahazir bin Kassim Intensivist Department of Anaesthesia and Intensive Care Hospital Sultanah Aminah, Johor Bahru, Johor Dr Mohd Ridhwan Mohd Noor Intensivist Department of Anaesthesia and Intensive Care Hospital Sultanah Nur Zahirah, Kuala Terengganu, Terengganu Dr Muhammad Zihni Abdullah Intensivist Department of Anaesthesia and Intensive Care Hospital Tengku Ampuan Afzan, Kuantan, Pahang Dr Nahla Irtiza Ismail Intensivist Department of Anaesthesia and Intensive Care Hospital Melaka, Melaka Dr Noor Airini Ibrahim Senior Lecturer and Intensivist Faculty of Medicine and Health Sciences Universiti Putra Malaysia, Serdang, Selangor Dr Wan Daud bin Wan Kadir Intensivist Department of Anaesthesia and Intensive Care Hospital Umum Sarawak, Kuching, Sarawak iii Table of Contents Contents Page Foreword i Writing Committee ii Admission, Discharge and Triage 1 Vasoactive Agents in Acute Circulatory Failure 6 Severe Hypoxaemic Respiratory Failure 14 Weaning from Mechanical Ventilation 21 Pain, Sedation and Delirium 29 Nutritional Therapy 39 Early Mobilisation 47 Stress Ulcer Prophylaxis 54 Venous Thromboprophylaxis 57 Prevention and Control of Multi-Drug Resistant Organisms 62 Withholding and Withdrawing Life-Sustaining Treatment 67 Invasive Mechanical Ventilation in Non-Critical Care Areas 74 iv Admission, Discharge and Triage Introduction Appropriate utilisation of ICU bed is essential as intensive care resources are limited and expensive. Demand for intensive care will continue to exceed supply, hence clear and rationale decision-making regarding admission and discharge is required. Principles 1. The decision to admit a patient to ICU should be based on the concept of potential benefit. 2. Critically ill patients with a reversible medical condition, having a reasonable prospect of meaningful recovery should be admitted. 3. A combination of criteria should be used to determine ICU admission or discharge. 4. ICU triaging is necessary to ensure optimal and equitable use of limited intensive care resources. Admission policy 1. It is the responsibility of the patient’s attending clinician to request for ICU admission. 2. It is the responsibility of the ICU specialist to decide on admission based on his/her clinical judgement guided by the admission criteria. 3. The decision to admit or deny admission shall not be made at the level of a medical officer. 4. Admission from the Emergency and Trauma Department or from another hospital shall have a primary unit. 5. Admission from other hospitals shall be discussed with the ICU specialist prior to transfer. 6. It is the responsibility of the primary team to continue resuscitation of patients while awaiting ICU admission. 1 7. Patients in ICU remain under the responsibility of the primary unit. Transfer of care to a different unit shall be arranged by the primary unit. 8. Family shall be informed of patient’s admission to ICU as soon as possible, with further updates when required. ICU admission criteria To optimise ICU resources and improve outcomes, ICU admissions should be guided on the basis of a combination of factors: a. Prioritisation according to the patient’s severity of illness b. Specific patient needs such as life-supportive therapies c. Diagnosis d. Prognosis e. Potential benefit from interventions f. Objective parameters at the time of referral g. Available clinical expertise h. Bed availability ICU admission based on priority In evaluating the appropriateness of ICU admission, the priority should be based on the needs of the patient and the likelihood of benefitting from admission. This prioritisation defines those who will benefit most from ICU (Priority 1) to those who will not benefit at all (Priority 3). 1. Priority 1 a. Critically ill, unstable b. Require life support for organ failure, intensive monitoring and therapies that cannot be provided elsewhere. This includes invasive ventilation, renal replacement therapy, invasive haemodynamic monitoring and other interventions c. Do not have limitations of treatment d. High likelihood of benefit 2. Priority 2 Priority 2A a. Acutely ill, relatively stable b. Requires intensive monitoring and/or therapies for organ dysfunction, that can be managed in an intermediate care facility (high dependency unit or post anaesthetic care unit) 2 c. Admit to ICU, if early management fails to prevent deterioration or there is no intermediate care facility in the hospital d. Examples include: i. post-operative patients who require close monitoring ii. respiratory insufficiency on intermittent non-invasive ventilation Priority 2B a. Critically ill, unstable b. Require life support for organ failure c. With significantly lower probability of recovery because of advanced underlying disease d. May have specific limitations of care e.g. no cardiopulmonary resuscitation e. Lower likelihood of potential benefit f. Examples include: i. metastatic cancer in septic shock secondary to hospital acquired pneumonia but with some limitations of therapy e.g. no CPR ii. decompensated heart failure with deteriorating functional status and multiple hospital admissions 3. Priority 3 a. Terminally ill or moribund patients with no possibility of recovery b. Not appropriate for ICU admission c. May benefit from palliative care rather than intensive care d. Examples include: i. severe irreversible brain pathology impairing cognition and consciousness or in a persistent vegetative state ii. metastatic cancer unresponsive to chemotherapy and/or radiotherapy iii. end-stage cardiac, respiratory or liver disease with no options for transplant iv. severe disability with poor quality of life v. advanced disease of a progressive life-limiting condition e.g. - motor neuron disease with rapid decline in physical status, - severe Parkinson’s disease with reduced independence and needs assistance for activities of daily living vi. poor response to current treatment e.g. - bowel leak despite multiple laparotomies, - recurrent soft tissue or musculoskeletal infections despite multiple surgical intervention, - chronic medical conditions that fail to respond to treatment such as SLE or HIV 3 vii. end-stage renal disease with no option or refusal for renal replacement therapy viii. those who have explicitly stated their wish not to receive life-support therapy Triage Triage is the process of placing patients at their most appropriate level of care. It is often needed as the number of potential ICU patients exceeds the availability of ICU beds. Appropriate triaging allows effective bed utilisation and resource