Ward Rounds
ICU Ward Round
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FASTHUGS BID
A short mnemonic that highlights some easily forgotten but essential daily ICU housekeeping for ALL ICU patients
Feeding
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Should be initiated within 24 - 48 hours of admission
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Aim for 20 - 25 kcal/kg/day
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Methods:
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Enteral feeding regime
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Oral
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NGT
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PEJ/PEG tube
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Parenteral administration
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Requires central venous access
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Enteral administration is always preferable
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Assess whether patients are tolerating NG feeds?
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Check residual gastric volumes
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Consider pro-kinetics if high residual volumes
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Has the patient developed diarrhoea?
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Is there evidence of ileus?
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Sources of pain:
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Illness
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Routine procedures
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eg. turning, suctioning, dressing changes
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Invasive procedures
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Lines/drains
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Therapies
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Regular background vs breakthrough therapy
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Opioid vs non-opioid
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Methods:
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Oral/enteral
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Sublingual
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Intramuscular/subcutaneous
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Patch
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IV
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Infusion
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PCA
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Intermittent
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Regional
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Epidural
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Wound catheters, Pain busters
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Paravertebral catheters
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REMEMBER, COMMON SEDATION AGENTS (EG. PROPOFOL AND MIDAZOLAM) ARE NOT ANALGAESIC AGENTS!
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Titrate to each individual patient
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Aims:
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RASS 0 -> -2
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Riker 3 - 4
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Consider daily sedation breaks
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Aids weaning and neurological assessment
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RIKER Sedation-Agitation Scale
Thromboprophylaxis
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Unless there are significant contra-indiations, ALL ICU patients require chemical thromboprophylaxis
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Use mechanical prophylaxis if chemical prophylaxis contraindicated
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Enoxaparin 40mg subcut daily
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60 mg daily if > 120kg
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20 mg daily if eGFR < 30 ml/min
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Alternative therapies include:
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Heparin 5000 units BD in certain circumstances
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Consider withholding if:
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Platelets < 50
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Use of other anticoagulant agents
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Peri-procedure
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Coagulopathy
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Head Up (35 - 45 degrees)
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Reduces risk of ventilator-associated pneumonia
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Improves lung mechanics and oxygenation
Ulcer Prophylaxis
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All intubated patients require PPI for ulcer prophylaxis
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Agents:
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Pantoprazole or Esomeprazole 40mg daily
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IV or PO; similar dosing
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H2 Receptor blocker (eg. ranitidine) may be used if PPI contraindicated
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Cease PPI when patient extubated and eating normally
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Continue if PPI is regular medication
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Aim BSL 6 - 12
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Management options:
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Insulin sliding scale
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Long-acting Insulin
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Insulin infusion
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It is not uncommon for critically ill non-diabetic patients to require glycaemic management
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Diabetic patients admitted to ICU should have their regular oral hypoglycaemic agents suspended
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Sugars should initially be managed with insulin
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Spontaneous Breathing Trial
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Perform daily if appropriate
- Reduces weaning time from ventilator
Bowel Care
- Diarrhoea, constipation, ileus are all common in critically ill patients
- Assess and treat to maintain normal gut function
Indwelling Catheters
- Assess all lines/catheters for evidence of infection
- Remove all devices that are no longer required
- Urinary catheters
- Venous access devices
- Arterial cannulas
- Neuraxial catheters
- Wound drains
- Intercostal catheters
- Assess and treat to maintain normal gut function
De-Escalation of Antibiotics
- Daily review of microbiology
- De-escalate to narrow-spectrum, targeted therapies as soon as possible
- De-escalate to oral / cease antibiotics as soon as practicable
- Similar principle applies to other pharmacological agents
- Cease treatments as soon as practicable
- Minimises risks of adverse effects and medication errors
- Commonly commenced therapies in ICU that should be reviewed on discharge from ICU AND/OR Hospital:
- Anti-psychotic agents
- Analgaesics
- Diuretics
- Beta blockers
- Insulin
- Electrolyte supplements
- Cease treatments as soon as practicable