Transcript Assessing delirium in the PAD Bundle

Current Guidelines in
Critical Care
Session 1: 2014
Critical Care Boot Camp
Billy Cameron, MSN, ACNP-BC
Assistant in Surgery, Dept of Surgery
Acute Care Nurse Practitioner
Surgical Intensive Care Unit
Current Guidelines in Critical Care
September 8, 2014
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Ventilator Associated Events
Resuscitative Fluid
ICU Delirium Bundle
Glucose Management in the ICU
Antibiotic Rotation in the ICU
Objectives
• Identify background of previous evidence
based critical care practice guidelines
• Identify and apply most recent evidence based
guidelines for critical care practice
• Be able to identify areas in which critical care
practice may be impacted by most recent
guidelines
Ventilator Associated Events in Adults
• Background:
– Formerly known as VAP (Ventilator Associated
Pneumonia); last updated in 2002
– VAEs reported to National Healthcare Safety
Network (NHSN); the CDC’s Healthcare
Associated Infection (HAI) surveillance system;
newly updated in 2011
– Prior reporting systems were too subjective;
CDC’s Division of Healthcare Quality Promotion
teamed with CDC Prevention Epicenters to
develop more objective reporting
Ventilator Associated Events in Adults
• Background continued:
– Previous reportable data:
• 1) Xray component
• 2) Signs and Symptoms component
• 3) Laboratory component
- Previous reports too subjective and variable across
institutions based on resources and lack of
standardization
Ventilator Associated Events in Adults
New Algorithim Created:
- Created in cooperation with critical care
professionals and organizations involved in
the care of mechanically ventilated patients
- More objective
- Requires engagement across disciplines
Ventilator Associated Events in Adults
New Algorithm for Surveillance:
- Patients >/= 18 years of age
- Patients who have been
intubated/mechanically ventilated for at least
3 calendar days
- Include patients in acute and long-term
acute care hospitals and inpatient
rehabilitation facilities
(ECMO, HFV, Prone patients are excluded)
Ventilator Associated Events in Adults
New Algorithim vs Old Algorithm: What’s
Different?:
- Xray: No radiographic reporting is required due to
inconsistency in ordering practices and variability in
resources/techinique. Do not adequately identify
patients with VAP
- Will detect ventilator associated conditions and
complications
- Focuses on readily available, objective clinical data
- Requires a minimum period of time on the
ventilator
Ventilator Associated Events in Adults
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Minimum daily
FiO2 increase >/=
.20 over baseline
>2 days
Minimum PEEP
increase >/= 3
cmH20 over
baseline > 2 days
Ventilator Associated Events in Adults
Infection- Related Ventilator Associated
Complication (IVAC): Definition:
On or after calendar day 3 of mechanical ventilation
within 2 calendar days of onset of worsening
oxygenation, ONE of the following criteria is met:
1) Purulent respiratory secretions (>25 neutrophils
and <10 squamous epithelial cells per lpf) or be
above quantitative thresholds
2) Positive culture of sputum, BAL, lung tissue,
histopathology, + pleural fluid
Ventilator Associated Events in Adults
The events on previous slide are reportable events:
Break Down:
- VAC: Temp, signs of infection, lab data of infection,
new antimicrobial agent >4 days
- IVAC: The above with the addition of positive
cultures from lungs, lung tissue, purulent secretions
 More objective data
 VAP no longer used as the event; it is the result of
the event
Reference: 2011. Improving surveillance for ventilator-associated events in adults. Centers for Disease Control and Prevention
Ventilator Associated Events in Adults
Prevention:
•Oral chlorhexadine rinse reduces opportunistic VAP by 40% when
performed consistently by nursing and care staff q6-8 hours(1)
•Elevate the head of the bed at an angle of 30-45 degrees for a patient at
high risk for aspiration in the absence of medical contraindications.
•Use a dedicated suction line for endotracheal tube suctioning of
respiratory secretions or use ETT with subglottic secretion drainage
•Cuff pressure should be maintained at 20-25 cm H2O.
•Circuit changes should occur when visibly soiled rather than routinely.
•Heat and moisture exchangers should not be changed more frequently than every 48 hours or
when they become visibly soiled or mechanically malfunction.
•Assess patient for daily sedation reduction/discontinuation and implement per institution's
guidelines. Reduce or discontinue sedation until patient is awake and can follow simple
commands OR patient becomes agitated.
•Assess eligibility for daily weaning trials unless contraindicated (2)
Ventilator Associated Events in Adults
References:
Shi, et al. 2013. Oral hygiene care for critically ill patients to
prevent ventilator-associated pneumonia. Cochrane
Database Systematic Review.
Sinuff, et al. 2013. Implementation of clinical practice
guidelines for ventilator-Associated pneumonia prospective
study. Critical Care Medicine. Vol 41-1; 15-23
2011, 2014. Prevention of ventilator-associated pneumonia.
Health care protocol. National Guideline Clearinghouse.
Agency for Healthcare Research and Quality.
Resuscitative Fluid in ICU
Background:
• Recent evidence has shown that hyperchloremic
crystalloid solutions, such as Normal Saline, can
induce and/or exacerbate hyperchloremia, acute
kidney injury (causes renal vasoconstriction and
decreased GFR), and metabolic acidosis in the
critically ill patient.
Resuscitative Fluid
• Recommendations:
• In the critically ill adult, it has been shown that by using
nonchloride-rich fluids, that there are significant
reductions in rise in SCr, AKI (using the RIFLE criteria), and
the use of RRT
• Choosing from the following fluids assist in lowering the
risk of these conditions:
• Lactated Crystalloid Solution (Cl- 109 mmol/L)
• Plasma Lyte (Cl- 98 mmol/L)
• 20% Albumin Solution (Cl- 19 mmol/L). Be considerate
of costs and availability in your institution
Resuscitative Fluid
References:
Yunos, et al. 2012. Association between a
chloride-liberal vs chloride-restrictive
intravenous fluid administration strategy and
kidney injury in critically ill adults. JAMA,
October 17, 2012 – Vol 308, No. 15
ICU Pain, Agitation, Delirium (PAD)
Bundle
• Background:
• In 2013, the American College of Critical Care Medicine
published a revised version of the pain, agitation, and
delirium guidelines (from 2002) to include an ICU pain,
agitation, and delirium care bundle designed to facilitate
implementation of said guidelines.
• Update the ABCDE Bundle (did not address pain
management)
• Link these guidelines with other evidence-based ICU
practices including, SBTs, early mobility, and sleep hygiene
in order to improve ICU patient outcomes and reduce costs
of care/LOS
PAD Bundle: Pain
• Assessing Pain in the PAD Bundle:
• Use a numeric pain scale for patients who can
self-report pain; use a behavioral pain scale for
those who cannot
• Pain is considered >/=4 on a NPS and >/= 6 on a
BPS
• Pain should be assessed at least 4 times per
nursing shift and more often if changes in NPS or
BPS occur
PAD Bundle: Agitation
• Assessing agitation/sedation in the PAD Bundle:
• Assess agitation/sedation with an evidence-based
scale such as the Richmond Agitation and
Sedation Scale (RASS) or Sedation-Agitation Scale
(SAS). This will help avoid over sedation and the
harmful outcomes that can occur (longer vent
days, increased risk of ICU delirium and
neuropsychological sequelae, increased risk of
mortality)
PAD Bundle: Delirium
• Assessing delirium in the PAD Bundle:
• Assess for delirium using an evidence-based scale
such as Confusion Assessment Method (CAM-ICU)
at least once per shift to avoid increasing the risk
of prolonged vent days, increased LOS,
postdischarge institutionalization, long-term
cognitive dysfunction, and increased risk of
mortality
ICU PAD Bundle: Treatment
• Treating pain:
• Treat pain FIRST, then consider sedation (only if needed).
May patients can manage mechanical ventilation with
effective analgesia only.
• Options: opioids (morphine, fentanyl, hydromorphone) for
nonneuropathic pain; nonopioids (acetaminophen);
nonsteroidals (ketorolac, ibuprofen); adjunctives
(ketamine, catapres), epidurals (primarily with rib
fractures), consider gabapentin or carbamazepine for
neuropathic pain
• Assess pain within 30 minutes of administering the
selected pain regimen and adjust as deemed necessary
based on evidence-based pain scale
ICU PAD Bundle: Treatment
• Treating agitation:
• Use the following guidelines when deciding what
type of treatment plan is needed:
1. Specific indications for sedation and the sedative
goals for each patient
2. Compatibility between the clinical pharmacology of a
sedative, its side effect profile, and the relative
contraindications for its use in the critically ill patient
3. Overall costs (not limited to pharmacy costs)
associated with a particular sedative
ICU PAD Bundle: Treatment
• Treating agitation:
• Benzodiazepines vs Nonbenzodiazepines
• Some studies (meta-analyses and Fraser, et al) suggest
that use of nonbenzos over benzos reduce length of
stay and reduction of ventilator days; but, no specific
data suggests decreased prevalence of delirium or
decreased short-term mortality
• Nonbenzo options: Dexmedetomidine and diprovan
• Benzo options: most common choices; lorazepam,
midazolam
• Use clinical judgment when selecting
ICU PAD Bundle: Treatment
• Treating agitation:
• A note about benzos:
• Guidelines do not prohibit use of benzos
• Still a good choice because of their anxiolytic, amnesic,
and anticonvulsant properties
• Still recommended for use of treating ethanol and/or
benzo withdrawal
• Recommended for patients needed sedation who have
intractable seizures
• Synergistic effects can be achieved with benzos when
other sedation options have proven ineffective
ICU PAD Bundle: Treatment
• Treating agitation:
• Sedate only those patient needing sedation based on an
evidence-based approach using the lightest amount of
sedation tolerated by the patient (being able to perform 3
of the 5 following commands: open eyes, maintain eye
contact, squeeze hand, stick out tongue, wiggle toes)
ICU PAD Bundle: Treatment
• Treating delirium:
• First steps in treating delirium:
1. Identify and eliminate potential contributing factors:
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Sepsis

Septic shock
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Glycemic dysregulation
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Electrolyte disorders

Hypoxia/Hypercarbia
2. Treat untreated pain
3. Treat drug withdrawal
4. Discontinuation of psychiatric medications
5. Decrease exposure to deliriogenic medications (ie; benzos)
6. Eliminate adverse drug reactions
7. Improve environmental factors (ie; sleep deprivation, disorientation,
prolonged immobilization, use of restraints)
ICU PAD Bundle: Treatment
• Treating delirium:
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Nonpharmacologic:
• Frequent reorientation
• Allowing for eyeglasses and hearing aids
• Maintaining sleep-wake cycles
• Minimizing nursing activities at night to increase quality sleep
• Mobilizing patients (even ventilated patients)
Pharmacologic:
• Adequate analgesia (opioid/nonopioid; infusions; pca; prn)
• Discontinue benzos (except in patients with benzo/alcohol
withdrawal)
• Resumption of patient’s psychiatric medications
• Treat withdrawal syndromes
• Antipsychotics if needed (olanzapine, quetiapine, haloperidol): Be
careful to monitor Q-T intervals
ICU PAD Bundle: Prevention
• Pain
• Take specific care to prevent procedural pain, especially in the ICU
• Treat sleep deprivation to decrease long term effects such as PTSD
• Agitation
• Reduce the need for sedation; highest reported reason
is for mechanical ventilation; use SBTs; SATs; DSIs to
reduce ventilator days
• Delirium
• Improve sleep quality
• Normalize (increased mobility, remove lines and catheters)
ICU PAD Bundle: Big Picture
1. Optimize pain management first
2. Make light sedation the norm
3. Move away from routinely using benzodiazepines ,
especially in ICU patients who are at high risk for
delirium
4. Implement more effective delirium prevention and
treatment strategies using both pharmacologic and
nonpharmacologic methods
5. Use antipsychotics judiciously and be aware of clinical
effects
ICU PAD Bundle
ICU PAD Bundle
References:
Barr, J., Pandharipande, P. 2013. The pain, agitation, and
delirium care bundle: synergistic benefits of implementing
the 2013 pain, agitation, and delirium guidelines in an
integrated and interdisciplinary fashion. Critical Care
Medicine 2013; 41: S99-115
Barr, et al. 2013. Clinical practrice guidelines for the
management of pain, agitation, and delirium in the intensive
care unit. Critical Care Medicine. 2013; 41: 263-306
Glucose Management in the ICU
• Background:
• Untreated hyperglycemia and/or hypoglycemia
contributes to increased mortality in critically ill
patients; with specific research available for
unstable angina, AMI, CHF, arrhythmia, ischemic
and hemorrhagic stroke, GIB, ARF, pneumonia, PE,
and sepsis
• Morbidity/Mortality can be increased with those
patients with pre-existing diabetes
• There was an established need to define a more
specific glycemic range for target glucose goal.
Glucose Management in the ICU
• Background: General ADA recommendations:
• Patients with diabetes should have their disease clearly
marked in their chart when entering the hospital
• Sole use of sliding scale insulin is discouraged in the
inpatient setting
• All patients with diabetes should have an order to check
their blood glucose with results reported to their primary
healthcare team
• Consider ordering a HgA1C for patients who are suspected
to be poorly controlled diabetics or who have significant
risk factors for diabetes when being hospitalized
Glucose Management in the ICU
Guidelines: (Clinical Practice Guideline Study)
1)A BG >150 mg/dL should trigger initiation of insulin
therapy; titrated to keep BG <150 mg/dL: ADA recommends
140-180 mg/dL for “tight” glycemic control
NICE-SUGAR RCT showed higher incidence of hypoglycemia in “intensive” BG
target range of 81-108 mg/dL
2) Maintain BG absolutely <180 mg/dL
3) Avoid hypoglycemia; defined <70 mg/dL; better achieved
with intravenous insulin infusion with a glucose source
4) Avoid or minimize dextrose infusions when patient have
another source of nutrition such as enteral tube feeds or
parenteral nutrition
Glucose Management in the ICU
Guidelines: (Clinical Practice Guideline Study)
5) Avoid BG <100 mg/dL in patients with brain injury (can
produce or exacerbate neurological deficits, encephalopathy,
seizures, permanent cognitive dysfunction, death)
Glucose Management in the ICU
Guidelines: (Clinical Practice GuidelineStudy)
6)Treatment of hypoglycemia: stop insulin infusion and
adminsiter 10-20 grams of hypertonic (50%) dextrose and
recheck BG within 15 minutes with a goal BG >70 mg/dL
achievement taking effort to avoid iatrogenic hyperglycemia
7)Point of Care testing:
•
•
Care should be taken to realize that glucometers have various
error rates based on condition of patient.
In the critically ill, especially patients on vasopressors, in shock,
or critically anemic, arterial or venous samples should be used
for BG testing
Glucose Management in the ICU
Guidelines: (Clinical Practice Guideline Study)
8)Transitioning from insulin infusion to SSI: Patients in the
ICU should be started on SSI of a protocol-driven basal/bolus
regimen before the insulin infusion is discontinued to avoid
loss of glycemic control
9)Calculate the basal/bolus regimen based on the patient’s
use of IV insulin in the last 24 hours, taking into consideration
carbohydrate intake
Glucose Management in the ICU
Guidelines: Considerations out of the ICU
1)Antihyperglycemics: Okay to use once patient is stabilized
and readied for discharge. May need to avoid metformin as
increased risk for renal insufficiency and hemodynamic
instability in the hospitalized patient
2)Use inpatient specialized diabetes providers when available
for hospitalized patients who have diabetes
3)Self management may be agreed upon by patient and
provider is they mutually agree that the patient understand
the use of his/her insulin pump, insulin injections, and
treatments for “sick day” management of glucose
Glucose Management in the ICU
Guidelines: Considerations out of the ICU
Note: There are more specific recommendation/suggestions
in this study, but address metrics and calculation formulae of
insulin infusion protocols that were outside the scope of this
lecture
References:
Standards of medical care in diabetes – 2014. American Diabetes
Association. Diabetes Care 2014 Jan; 37 S 14-80
Jacobi, et al. 2012. Guidelines for the use of an insulin infusion for the
management of hyperglycemia in critically ill patients. Critical Care
Medicine. Vol 40, No 12 3251-3276.
Antibiotic Rotation in the ICU
Background:
• Patients in the ICU are at an increased risk for
hospital-acquired infections (HAI)
• Gram-negative pathogen resistance to broadspectrum antibiotics poses increase to morbidity and
mortality
• Gram-negative pathogen infections increase
institutional resource utilization and consumption
• Use of antibiotic cycling is proposed to reduce
resistance of gram-negative pathogens
Antibiotic Rotation in the ICU
Background: Definitions
• Antibiotic resistant pathogen: Any pathogen that
is resistant to at least one class of antibiotics (ie;
fluoroquinolones)
• Multidrug resistant pathogen: Any pathogen that
is resistant to 3 or more classes of antibiotics (ie;
aminoglycosides, fluroquinolones, carbapenems)
Antibiotic Rotation in the ICU
Cycling vs Mixing Antibiotics
• Cycling antibiotics allows for a resistance strain of
pathogen to decrease in frequency or perhaps even
disappear in the off-period
• Mixing antibiotics (using randomly selected
antibiotics on different patients)
The majority of research favors cycling in large
populations of patients
Antibiotic Rotation in the ICU
Example antibiotic cycling for HAIs based on annual
quarters:
Pneumonia (Day 1-3)
Pneumonia >/= Day 4 a
Non-pneumonia
b
1st Qtr:
Ceftriaxone
Levofloxacin
Piperacillin/tazobactam
CARB
2nd Qtr:
Ampicillin/sulbactam
Doripenem
Imipenem-cilastatin
Cefepime/metronidazole
FQ
3rd Qtr:
Levofloxacin
Cefepime
Doripenem
BLIC
4th Qtr:
Ertapenem
Piperacilline/tazobactam Levofloxacin/metronidazole
Excluded Class
¾ CEPH
a
Empiric coverage includes vancomycin and aminoglycoside until culture data is available
b
Vancomycin included except in secondary peritonitis; fluconazole included for high risk patients and tertiary peritonitis
BLIC: beta-lactamase inhibitor combinations
CARB: carbapenems
FQ: fluoroquinolones
¾ CEPH: 3rd and 4th generation cephalosporins
Antibiotic Rotation in the ICU
Guidelines:
•
Incorporate multiple disciplines to reduce infection risks (nursing, pharmacy,
physician, infectious disease, pathology, advanced practice nurses/PAs, nutrition,
IT). Terminal room cleans after discharge of patient with resistant pathogen(s)
• Narrow antibiotics to pathogen-specific drug as soon as known (de-escalate)
• Pneumonia: early and late onset
• Non-pneumonia: blood stream, surgical site, urinary tract,
body fluid
• Avoid prophylactic antibiotics except in certain patient populations (abdominal
trauma, orthopedic fractures, craniofacial trauma)
• Rotate antibiotic classes on a quarterly basis to reduce resistance and maintain
heterogeneity
• Aggressively empirically treat suspected pathogens and de-escalate as cultures
are speciated (ie; suspected necrotizing soft tissue infections [use of clindamycin])
Antibiotic Rotation in the ICU
References:
Dortch, M., et al. 2011. Infection reduction strategies including antibiotic stewardship
protocols in surgical and trauma intensive care units are associated with reduced
resistant gram-negative healthcare-associated infections. Surgical Infections.
2011; 12; 15-25
Kouyos, R., Abel zur Wiesch, P., Bonhoeffer, S. 2011. Informed switching strongly
decreases the prevalence of antibiotic resistance in hospital wards. PLoS
Computational Biology. 7(3); e1001094.
May, A., et al. 2006. Influence of broad-spectrum antibiotic prophylaxsis on
intracranial pressure monitor infecitons and subsequent infectious complications
in head-injured patients. Surgical Infections. 2006; 7: 409-417
May, A., 2014. Antibiotic stewardship program; multidisciplinary surgical critical care
guidelines. Vanderbilt Medical Center. www.traumaburn.com. .