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HOUSESTAFF

MICU HANDBOOK

2013-2014

2020 – 2021

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To all residents/medical students/fellows:

Welcome to the MICU. The MICU is a very unique environment which stresses teamwork between residents, interns, sub-interns, fellows, and nursing staff, and can be one of the most rewarding rotations in your medical training.

This handbook is provided as a resource to help you

through these next 4 weeks, as well as the remainder of your training. Obviously, it is not all-inclusive, but will hopefully serve as a good introduction to the MICU and a nice reference. You should try to at least glance over this handbook in the first couple of days of the rotation, and then make a more thorough perusal during the remainder of the month. If you have any thoughts on improvements, additions, or subtractions from the handbook, please let the chief residents know. In addition to this handbook, be sure to visit the MICU rotation webpage (https://www.loyolamedicine.org/gme/internal-medicine-residency/pulmonology-curriculum/loyola-micu) where you can find many more learning resources. Go to www.ICULiberation.org to learn more about the care bundles being utilized in the ICU. Good luck and have fun!

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Table of Contents

RN Welcome 4 Things to Know about the ICU 5-6

Tips from Attendings 7

Daily ICU Check list 8-11

ABCDEF Bundle 12

ICU Rounds: Oral Presentations 13

ICU Progress Note: SOAP format 14

Order Sets in the MICU 15

ICU Formulas 16-17

The Ventilator 18-19

High Peak Pressure Alarms 20

Intubating a Patient 21-22

Weaning off the Ventilator 23-24

ARDS Protocol for Low Tidal Volumes 25

Oxygen Dissociation Curve 26

Oxygen Delivery Devices 27

Ventilatory Failure 28

Hemodynamics & Shock 29

Pressors 30

Sepsis Guidelines 31

SOFA and qSOFA 32-33

Sepsis Bundle Flowchart 34

Sepsis Protocol for Cirrhotic Patients 35

Acid-Base Formulas 36

COVID-19 37-39

Liver Failure 40-41

Anaphylaxis 42

Procedures: IO Insertion 43

Procedures: Central Venous Catheter Insertion 44-45

Procedures: Arterial Line Insertion 46-47

Sign-out in the MICU 48

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ICU Nurse Welcome Page

Welcome MICU Residents!! Patient Care

• Let the Charge Nurse know of any admissions or potential admissions as soon as you are aware

• If you are planning to order a CT, MRI or any test that requires the nurse to travel with the patient, please let us know ASAP. If the patient is unstable, the resident will be asked to accompany us.

• If you put in stat orders on a patient, let the nurses know right away… we are not always by a computer to check.

• Please Do Not Touch the Infusion Pumps. If you would like something titrated or discontinued, let a nurse know!

• Please Do Not silence alarms (monitors, IV pumps, or Ventilators).

• After examining a patient, make sure certain restraints are on, side rails are up, and the bed is in low position.

Nurse’s Station • Please Plug-In WOWs after you are done with rounds!!

• Please introduce yourself to all of our secretaries so they can identify you if you get a phone call.

• If you page a colleague, please pick up the phone when it rings. If you need to leave the nurses station, tell the secretary who you paged and where to find you when they call back. Please don’t call the desk and ask us to look around for somebody. If they have a pager just page them.

MICU Necessities • If a patient needs a CXR, EKG, morning labs, or weaning parameters, please enter them the night

before. Restraints need to be updated daily.

• Most of our patients should have some very simple orders that make a big difference in their care and outcome. Please make sure SCDs, SQH, PPIs, stool softeners, and PT/OT are ordered for the appropriate patients. Of course, there will be some contraindications to these orders.

• When putting in a central line or performing a procedure, please fill out the CLIP form.

Night-time • Please observe “Silent Night” after 9 PM and speak quietly while on the unit.

• Before going to bed for the night, please check with the nurses to see if there is anything that they may need ordered before turning in.

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Things To Know about the ICU

Responsibilities • In addition to participating in the admission of patients to their primary service, the night float

intern is responsible for cross covering all patients on their service as well as those patients on the pulmonary transplant service and the COVID MICU services.

• Senior residents are responsible for admissions to the MICU/COVID MICU and pulmonary transplant service as determined by the fellow. Overnight admissions are the responsibility of the night float senior resident who will then staff the patient with the ICU fellow and/or overnight attending.

Overflow Patients - will be triaged as follows:

• Once assigned to a team by patient placement, patients awaiting floor beds will have their care assumed by the appropriate floor team (even though the patient is still physically located in the MICU).

• If both MICU services are over cap, the MICU fellow/attending will identify appropriate patients to be managed by the Transplant Attending/Fellow with the assistance of the CCU housestaff.

Transfer Policy • For the most up to date information on transfer policies, please visit the rotation webpage.

When to Call the MICU fellow? • Any change in hemodynamic parameters of a patient as well as mentation.

• Any ventilator changes other than slight increases in FiO2; If FiO2 requirements increase significantly you should also let the fellow know.

• Any significant clinical issues with transplant patients. (They are very tenuous!)

• With any potential transfers out of the MICU.

• To staff all new admissions to the MICU during the day and overnight (if not staffed with the in-house intensivist).

• The ICU fellow is responsible for MICU evaluations. Evaluations that are to be admitted to the MICU will be communicated to the senior resident who is then responsible for the admission. The senior resident will then staff the patient with the ICU fellow on call or overnight attending.

• On the nights where a fellow (or attending) isn't in house the fellow should be called to staff ALL evals (rejections or admissions).

Pulmonary Transplant Patients • Transplant admissions overnight are done by the senior resident. However, admissions/consults

for “fresh” lung transplant patients post-operatively should be directed to the on-call transplant attending/fellow.

• All admissions need to be staffed with the fellow on call.

• Call the fellow with ANY significant clinical changes or with any questions.

• If you cannot reach the fellow, call the transplant attending directly.

• NF intern: Page or call the daytime transplant fellow with sign-out in the am before you leave!

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Night Float • At least one senior resident from each team should be present for sign out.

• Remember that you’re not the only doctor in the house; call your senior resident when you need help. It’s always better to call than to not call. ALWAYS. If still unsure, please call your fellow with questions.

• Some nights of the month there is an in-house intensivist attending with whom you will staff new patients.

RRT Policy • Residents are technically not required to attend RRTs. That being said, it is prudent for a MICU

resident to attend in order to help triage the patient and give an opinion regarding

appropriateness for floor versus transfer to an ICU. Also, if the patient is coming to your ICU

service, it may be helpful to learn about them sooner than later.

• If you are already busy managing unstable patients on your MICU service, then you should NOT

go to the RRT.

• The final decision of disposition of a patient for whom an RRT is called ultimately lies with the

RRT nurse; however there should always be a respectful multidisciplinary discussion between

MICU residents and the RRT team regarding what is in the patient’s best interest.

• Any questions, concerns, or post-RRT issues should be directed to the Loyola Chief Resident

shortly after the RRT to ensure that the process continues to run smoothly for all involved.

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ICU Tips From Attendings *The only thing that is more boring than listening to you read your H&P is listening to you read someone else’s H&P *Your notes need to be complete, but that doesn’t mean I need to hear about the family history in your presentation *Know the antibiotics as day #/ length of course (ie day 4 of 10) *For ABGs- read them as pH/ pCO2/ pO2 and nothing else (I don’t need to hear the calculated bicarb or base excess) *The only thing that will ever get you in trouble is not calling when you need help *Trust the RNs and RTs *Don’t change the vents without talking to the fellow *Get your notes in early

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Daily ICU Checklist

• Get sign-out from night float intern, inform senior resident and fellow of any significant events.

• Examine sickest patients/ patients with significant changes overnight/ new patients.

• Vitals o Use ICU Accordion Report tab to view the vital trends (drips, vent settings, I/Os, and

lines can be found in this tab as well) o Subtle changes in HR and BP are especially important to know in hemodynamically

unstable patients. o Make sure you note blood pressure changes both as systolic/diastolic BP and as mean

arterial pressures (MAPs). o Note if BP/MAPs are recorded non-invasively (cuff pressures) or with an arterial line. o BP/MAPs need to be reported with changes in pressor doses since both of those affect a

patient’s hemodynamic status. o Telemetry is found on the ICU monitors at the nurse’s station, not on the floor.

• Check Labs o In addition to normal daily labs that you may see on any medicine patient, ICU patients

may have morning blood gases. Pay close attention to blood gases especially if they are mechanically ventilated. Note the vent settings on which the blood gas was drawn.

• Examining the Patient o Lines and tubes

▪ Central lines → Which side, Type (cordis, triple lumen, PICC etc.) ** DON’T FORGET ABOUT PICCs

▪ Arterial lines → Which side, also try and figure out how the wave form looks, if it’s working correctly or dampened due to clots etc.

▪ Foley catheter: Can it come out today? ▪ ET tube (only note if any changes in position occurred overnight)

o Drips ▪ Pressors → Which kind, current dose (usually dosed in mcg/kg/min or units if

vasopressin), whether RN has been increasing or decreasing the dose

▪ Sedation → Examples include propofol, precedex (dexmedetomidine) and

versed (midazolam) drips. Don’t forget that these medications can be ordered

as PRN pushes as well. Please note drip rate changes overnight and/or how

many pushes patient received

▪ Analgesia → Examples include fentanyl, morphine, dilaudid. Same as sedation

above for dosing and note if pushes ordered instead of drips.

▪ Other drips → heparin, bicarb, etc.

o Physical exam o ANSWER THESE QUESTIONS EVERY DAY:

▪ Is the patient uncomfortable or over sedated? ▪ If the patient is uncomfortable, is it because of pain or anxiety/agitation?

• This will determine which drug you titrate (analgesic vs. anxiolytic) ▪ Can I do a sedation holiday today to assess weaning? (See below) ▪ Does the patient need more access, or can lines (central or arterial line) and

tubes (foley) come out?

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Daily ICU Checklist (cont.)

• Check the Vent o Look at the ventilator settings and then look at what the patient is doing.

▪ Note patient’s respiratory rate and compare it to set ventilator rate ▪ Note if patient is “double-stacking” or not otherwise synchronous with the

ventilator (ask someone to show you how to check for this) ▪ IF the patient is in VOLUME CONTROL MODE:

• Note the set respiratory rate, tidal volume, FiO2, PEEP, Flow rate and waveform (square vs. ramp)

• Note the patient’s actual respiratory rate and SpO2

• Check peak and plateau pressure – Ask someone to show you how and until told otherwise, do it under supervision.

• Here’s the CLIFF notes version: Make sure patient is in volume control, square waveform and with a flow rate of 60 L/M. Then hit the inspiratory pause button and record peak, plateau and resistive pressures. Place patient back on previous ventilator settings.

• Caveat: Plateau pressures will work if patient is in ramp waveform, but you won’t get accurate airways resistance.

▪ If the patient is in PRESSURE CONTROL MODE:

• Note the following: set rate, inspiratory pressure, inspiratory time, FiO2, and PEEP

• Note patient’s actual respiratory rate and SpO2

• Check the current tidal volumes patient is exhaling on the set pressure and inspiratory time

o ANSWER THESE QUESTIONS EVERY DAY TO ASSESS WEANING (also see “weaning” section on page 23-24):

▪ Is this patient hemodynamically stable? (not on pressors) ▪ Is this patient awake? Often, patient needs to be on sedation holiday. ▪ Have I fixed the underlying cause of his respiratory failure? ▪ Have I weaned his ventilation to as close to physiological as possible? For most

people, this is VC, RR 12-14 (patient breathing over the ventilator comfortably), PEEP ≤ 5, FiO2 ≤ 40%.

▪ If YES to the above, can I try a spontaneous breathing trial (SBT)? ▪ Hold tube feeds if you are assessing a patient who will likely be extubated.

Resume tube feeds if SBT fails.

• Review Today’s CXR o Ask yourself if the patient needs a CXR for the next day (newly ventilated or has various

lines/catheters put in like a balloon pump, swan etc.). If yes, then order one for tomorrow NOW.

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Daily ICU Checklist (cont.)

• Characterize Pain, Agitation and Delirium Levels o Generally assessed by RNs as below: o Pain

▪ Preferably use BPS (Behavioral Pain Scale) or CPOT (Critical-Care Pain Observation Tool), can also self-report

• BPS: Assesses facial expression, upper limbs, and compliance with ventilation

• CPOT: Assesses facial expression, body movements, muscle tension, compliance with vent or vocalization

o Agitation ▪ RASS: Ranges -5 to +4, aim for score of -2 to 0 if on sedatives

o Delirium ▪ CAM-ICU: Assesses onset/course, inattention, level of consciousness,

disorganized thinking

• Transferring Patients o Refer to “Service Rules” under Loyola Medical Intensive Care Unit via the Loyola

Internal Medicine Residency Program website for most up to date rules.

o When a patient is determined ready for transfer out of the unit, the MICU

residents should place a transfer order and place the patient on the Epic List

entitled "MICU Downgrade List”

▪ If transfer order is placed between 7:00 AM and Noon – the MICU

resident should also page PPC to request transfer out of the Unit.

▪ If transfer order is placed between Noon and 7:00 AM (the following

day), MICU resident does not need to page PPC.

o When PPC assigns patient to a team, PPC will page the MICU team pager and the

accepting Gen Med team pager with the team assignment. The MICU team is

responsible for contacting the team accepting the patient.

▪ PPC assignment for patients on the MICU Downgrade List will occur

between 5AM-7AM. PPC will alert the respective teams between 7:30AM

and 8:00AM of the patient's new assignment.

• If Gen Med is at cap, PPC will alert the MICU service pagers that

there is a hold on transfers ▪ Write a transfer summary, and then call the hospitalist or resident that will be

assuming care of that patient on the floor. Note, all Sub-I verbal sign outs must be verified and monitored by intern or resident and all Sub-I transfer summaries must be verified and co-signed by intern or resident.

• Please f/u with transplant service on all lung transplant patients at least daily. Make sure to follow up on their recs re immunosuppressive therapy, prophylactic abx, etc

• Orders for the next day → Assess if patient needs a morning ABG, MvO2, or CXR (if not already considered), then order one.

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Daily ICU Checklist (cont.)

Finally, 2 mnemonics to assess every day together with the ICU staff to make sure nothing gets missed.

ABCDEF FAST HUGS BASIC

Assess and treat pain Both SAT (spontaneous awakening trial) and SBT (spontaneous breathing trial) Choice of sedation and analgesia Delirium monitoring and treatment Early mobility Family involvement

Feeding (Are patients getting nutrition? Do they need tube feeds?) Analgesia Sedation Thromboembolic prophylaxis Head of bed elevated to 30 degrees Ulcer prophylaxis (if on mechanical ventilation or stress dose steroids) Glycemic control (goal 120-180) Spontaneous Breathing Trial Assessment (Are patients ready for weaning off vent?) Bowel regimen Activity (PT/OT) Skin Care Indwelling foley care—can we take it out? Catheters—how long have they been there and can we take them out?

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ABCDEF Bundles

• A: Assess, Prevent, and Manage Pain. o Pain should be assessed at least four times per shift. Significant pain is indicated by a

BPS>5 or a CPOT>2. Once identified, pain should be treated within 30 minutes via pharmacologic or non-pharmacologic means, and then reassessed. To the best of our ability, we should aim to prevent pain by using pre-procedural analgesia and/or non-pharmacological interventions. Treating pain is preferred to using sedation during procedures.

• B: Both Spontaneous Awakening Trials and Spontaneous Breathing Trials o While ICU sedation can reduce anxiety for patients, deep sedation has been associated

with reduced 6-month survival and survival to hospital discharge, as well as increased ICU length of stay and ventilator duration.

o Use of the “Wake up and Breath” Protocol encourages SAT and SBT daily via sedation vacations (see iculiberation.org for protocol details).

• C: Choice of sedation and analgesia o All ICU patients should routinely be assessed for pain control (using either patient self-

report, or the BPS or CPOT tools described above), agitation and depth of sedation (we use the RASS), and for delirium (our nurses regularly record the CAM-ICU score).

o For patients with initially very high oxygenation needs or marked patient-ventilator desynchrony, consider starting with propofol for sedation over precedex

• D: Delirium: Assess, Prevent, and Manage o Delirium is seen in up to 80% of ventilated patients and is associated with increased

mortality, prolonged hospitalization, and increased cost. The ABCDEF bundle recommends using, Stop, THINK, and medicate to manage delirium

▪ Stop: Review medication list and stop meds associated with delirium. ▪ THINK: Toxic situations, hypoxemia, infection/sepsis, immobilization,

nonpharmacologic interventions, K+ or other electrolyte disturbances. ▪ Medication: Nonbenzodiazepine sedatives recommended by guidelines.

• E: Early Mobility and Exercise o Try to incorporate early mobilization and physical therapy.

• F: Family Involvement o Keep families involved and informed, involve patient and families in decision-making

and self-management, provide emotional support, and maintain clear understanding of the patient’s concept of illness and cultural beliefs.

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ICUliberation.org

ICU

Rounds:

Oral Presentations

The key to a good oral presentation is organization, completeness, and brevity. All significant changes since the last rounds need to be mentioned, but small changes can be addressed with the senior and/or fellow before or after rounds. It is a good idea, at least initially, to run through the presentation prior to rounds to make sure it is organized and complete. Different attendings have different preferences for presentations. Some will ask for problem-based assessment and plans (starting with patient’s most important problem and then going in descending order of acuity). Others prefer system-based assessments (e.g., describe all problems and associated plans in a particular system, then go to next system). Finally, some attendings prefer head to toe presentations. SOAP FORMAT: Subjective: 24 hour events: started on pressor/ weaned off pressors, intubated/extubated, transfused, etc Currently: intubated & sedated; has no complaints, is confused, etc. Objective: Vital signs: Temperature (max and current), RR, HR (state if rate controlled, or on cardizem drip, etc), BP/MAP (state if on/off pressors and know most recent dose and whether increasing or decreasing), O2 sat (on what amount of O2 – if vent see below), I/O Ventilator settings: Mode (AC-vol or pressure control, SIMV, PS), Rate (and if patient is breathing over the vent), Tidal Volume, FiO2, PEEP, Compliance, Resistance FOR ALL AC. Weaning parameters (if available) Exam: focused! Only pertinent positives and negatives Labs: only significant (although, some attendings may prefer you read off entire cbc w diff, bmp)

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Microbiology: new culture results Radiology: significant findings A/P: xx y/o male/female with xx disease admitted to the MICU with xx. Know if your attending prefers problem or system-based problem lists (ask your senior or fellow well before rounds so that you can prepare).

ICU Progress Notes: SOAP Format

**Ask your seniors for templates! 24 hour events: Subjective: O: Vital signs (Tmax/min, RR, HR, BP, SpO2) Vent settings: (Mode/Rate/Tidal Volume/Fio2/PEEP) ABG: Drips: (pressors, analgesics, sedatives, insulin, etc) Physical Exam: (include the presence of any central lines/chest tubes/foleys/ng tubes) Labs: Microbiology: (respiratory cultures/blood cultures/urine cultures/CSF cultures) Medications: Radiology: Assessment/Plan: __y/o male with _____ who was admitted to the MICU on ____ for ____

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Specific Orders/Sets in the MICU • MICU generic admission order set – MICU admissions

• Adult Critical care analgesia and sedation – Order all initial sedation/analgesia. Can order

versed/fentanyl pushes independently.

• IP Sepsis Order Set Adults Only – Use for all septic patients, will give you priority in pharmacy for

getting chosen antibiotics. Also includes easy access to appropriate fluid management for patients

with severe sepsis.

• Endotool- Insulin drip order set – Once the patient’s blood glucose is within target range and has

been stable (as determined by the Endotool program) it will provide a recommended dosage for

basal/bolus insulin.

• Heparin Nomogram (Low, intermediate and high range) – For heparin gtt (look at specific

nomogram order set for the correct indications for each nomogram)

• Transfuse RBCs/Plasma/Platelets – For transplant patients, be sure to order CMV negative blood if

the patient is CMV negative.

• Mechanical Ventilation initial – Order panel for initial ventilation orders (includes chlorhexidine and

RASS)

• Mechanical Ventilation subsequent – change vent settings

• Respiratory culture order panel – should include Blind BAL (aka mini-BAL) for intubated patients

(remember to talk to the respiratory therapist if you place this order)

• Neuromuscular Blockade in the ICU – should be used to order paralytics when a patient needs to be

paralyzed for ARDS management

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Helpful ICU Formulas

Respiratory

A-a Gradient = [(Patm-PH2O)*FiO2 – (PaCO2/R)] – PaO2

Patm = 760mmHg (though Fahey says Chicago is above sea level so Patm here is 747mmHg) PH20= 47mmHg R = 0.8

Normal A-a gradient = (age + 4)/4

Compliance = Tidal volume (cc) / (Plateau pressure – PEEP) (normal compliance = 60-100) Airway Resistance = (Peak pressure – Plateau pressure) / Flow (L/sec) Keep in mind that vent gives your flow in L/min so you have to convert it

(normal resistance ≤ 10). Remember that you can’t calculate this on ramp waveform!

Minute Ventilation: RR x Vt (in L)

Plateau Pressure: goal <30 Driving Pressure: Plateau-PEEP Tidal Volume: Inspiratory time x Flow Ideal body weight, male: 50 + [2.3*(height in cm-110)] Ideal body weight, female: 45.5 + [2.3*(height in cm – 110)]

Cardiovascular Cardiac Output: SV x HR Normal = 75cc x 75 bpm = ~5LPM MAP = D + 1/3 PP Normal = 75-105 = SBP + 2/3DBP SVR = (MAP-CVP/CO) x 80 Normal = 800-1200 Stroke Volume Variation (SVV) <10% = not fluid responsive >13% = likely to respond to fluids Fick Equation CO = VO2/[10(CaO2-CvO2)]

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O2 Content or CaO2 = 1.34 x Hgb x O2 sat Normal = 20ml O2/dL Oxygen Delivery or DO2 = CaO2 x CO Normal = 1000ml/min or 1 LPM O2 Consumption or VO2 = 250 cc/min

Renal/Acid-Base Anion Gap = Na - (Cl+HCO3) *Corrected for low albumin = [Na – (Cl + HCO3)] + 2.5(4 – serum albumin) Sodium Correction for Glucose: For each 100mg/dL increase in glucose, sodium decreases by 1.6mEq/L Serum Osmolarity: 2(Na + K) + BUN/2.8 + glucose/18 normal = 270-290 mOsm/kg Serum Osmolar Gap = (Calculated osmolarity – measured osmolarity) normal < ±10 (remember to correct for EtOH) Corrected Serum Ca: measured Ca mg/dL + 0.8 x (4 – serum albumin g/dL) Fractional Excretion of Sodium (FENa) =

(Urine sodium x Plasma creatinine)/(Plasma Sodium x Urine creatinine) FENa<1% = prerenal FENa>2% = ATN FENa 1-2 = either *Substitute urea for sodium, and you get the FEurea. <35% = prerenal Free Water Deficit for Hypernatremia = 0.6 x Weight (kg) x [(Plasma sodium/Desired plasma sodium)-1]

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The Ventilator

• Please do not change the ventilator without talking to the fellow/senior resident first!!!

• Please place a “Mechanical ventilation subsequent” order in the computer detailing your changes so RTs are aware. Please also talk to either the RT or the RN about your changes and write them down on the paper log by the ventilator.

Non-Invasive Positive Pressure Ventilation • BiPAP

o Relatively airtight fitting mask attached to a positive pressure ventilator o Patient driven respiratory rate and inspiratory time, but you set the inspiratory pressure

and PEEP o Indications:

▪ High pressure pulmonary edema ▪ Certain types of hypo-ventilatory failure (COPD exacerbations etc.) ▪ Immunosuppressed patients with hypoxemic respiratory failure, fever, and

pulmonary infiltrates. o Check ABGs about 1-2 hours after placing patient on BiPAP or adjusting settings. o Contraindications to BiPAP:

▪ Altered mental status resulting in an inability to comply with mask ▪ Inability to protect airway/high aspiration risk (BiPAP can increase risk of

aspiration in these patients) ▪ Hemodynamic instability (pressor requirements) ▪ Severe metabolic acidosis

• CPAP o Continuous positive airway pressure o Basically, PEEP without an inspiratory pressure o Useful in patients with OSA, Obesity Hypoventilation Syndrome

Invasive Positive Pressure Ventilation • Check ABGs about 15-30 mins after any significant changes

• Assist Control (AC) o Volume Control → Fixed tidal volumes, varying peak and plateau pressures depending

on lung/chest wall compliance. Always report peaks/plateaus with volume control as these vary.

o Pressure Control → Fixed airway pressures, varying tidal volumes depending on lung/chest wall compliance. Always report tidal volumes with pressure control as these vary.

▪ Length of pressure driven inspiration is set by an Inspiratory time (i-time) which determines how long the ventilator should generate your pressure driven breath.

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The Ventilator (cont.) Invasive Positive Pressure Ventilation cont.

• Synchronized Intermittent Mandatory Ventilation (SIMV) o Used predominantly by anesthesia and in the SICU. As a rule, don’t use in MICU. In the

MICU, we generally want to “rest” the patient with increased work of breathing so this is not a good mode.

o Essentially volume control with ventilator delivering set tidal volumes at a set respiratory rate.

o If patient decides to take spontaneous breaths, there is no support to these breaths (ventilator just lets them take whatever tidal volume they can do on their own). The idea is that this is supposed to assist with weaning and extubation, although this is largely unproven.

o Can provide pressure support to spontaneous breaths if needed.

• Pressure Support Ventilation (PSV) o Spontaneous mode of ventilation which is pressure driven. Spontaneous means that

patient sets their own RR and i-time (compare this to pressure control where there is a minimum set RR and inspiratory time that will cause ventilator to deliver breaths)

o Set inspiratory pressure and PEEP, resulting in variable tidal volumes. o If patient is apneic for too long, the last assist control mode (VC or PC) will kick in

automatically (back-up ventilation). o Can be used to extubate people but we do T-Piece trials at LUMC. Ask your friendly

neighborhood pulmonary fellow to teach you about “flow by” and how to get weaning parameters directly from the ventilator.

• BiLevel (APRV or Airway Pressure Release Ventilation) o Ask your friendly neighborhood pulmonary fellow if interested.

Vent Settings

• Rate o 12-14 breaths per minute is good starting point o You want the patient breathing about 4 bpm over set rate. If not, assess why (too

sedated, paralyzed or otherwise altered)

• Tidal volume o 5-8cc/kg ideal body weight (IBW) (use an online calculator for IBW) o Ballpark (small patient: 400cc, medium pt: 500cc, large patient: 600cc) o 4-6cc/kg IBW for ARDS

• FiO2 o Start at 100% and titrate down to keep sat >92% o Want FiO2 <60% to avoid O2 toxicity

• Decreasing PEEP o Abrupt reduction in PEEP may produce severe hypoxemia that takes days to reverse

(may take up to 2 weeks for re-recruitment of alveoli). This is typically seen in ARDS patients.

• Standard way of noting/presenting vent settings: o Volume control: VC/RR/Vt/PEEP/FiO2% o Pressure control: PC/RR/Pi/PEEP/FiO2%. Then say i-time.

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The Ventilator: Troubleshooting the High Peak Pressure Alarm

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The Ventilator: Intubating a Patient

• “Code respiratory” = anesthesia intubating your patient in the ICU. Cannot be called on the floor

• “Code blue” = anesthesia intubating your patient on the floor.

• Know the most recent potassium value (cannot use succinylcholine if high K, since it's a

depolarizing agent)

• Some things anesthesia does in the room

o Bag patient with 100% oxygen

o Sedate patient, usually with etomidate or propofol** (rapid onset – 1 min, duration

about 3-5 minutes), occasionally with ketamine.

o Paralyze patient

▪ Succinylcholine: Rapid neuromuscular depolarizing agent, contraindicated in

hyperkalemia. Duration of action of minutes.

▪ Rocuronium: Longer acting non-depolarizing neuromuscular agent. Duration of

paralysis is about 30-60 minutes.

▪ Vecuronium: Longer acting non-depolarizing neuromuscular agent. Duration of

paralysis is about 45-75 minutes.

o Intubate

o Leave

o ** Etomidate doesn’t theoretically cause hypotension, but intubated people usually end

up hypotensive for various reasons. So, if patient is in shock or bordering on

hemodynamic instability, consider ordering vasopressors prior to intubation.

• Initial ventilator settings

o Mode: Volume control for the most part

o RR: 12-14

o Tidal Volumes: 6-8cc/kg IBW,

▪ Ballpark → small patient: 400cc, medium pt: 500cc, large patient: 600cc

o PEEP: 5

o FiO2: 100%

o Place “mechanical ventilation initial order panel” in computer with settings

o Blood gas within 30 minutes of intubation

• Order CXR (for now and for tomorrow morning)

o ETT 2-5 cm above the carina (Between carina and clavicles).

o If ETT needs to be pushed in or out, ask RT to do it and enter the ETT reposition order

o Repeat CXR every time you change ETT positioning

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The Ventilator: Intubating a Patient (cont.)

• Order Sedation/Analgesia – Order set under “Adult critical care analgesia/sedation” There are

many options in this order set; below are some general suggestions. Start off by asking “Is the

patient uncomfortable because of pain or agitation or both?”. Refer to info in the ABCDEF

Bundle section.

o Pain

▪ Preferably assessed through self-report, but use BPS (Behavioral Pain Scale) or

CPOT (Critical Care Pain Observation Tool) in patients who cannot communicate

▪ Needs routine assessment

▪ Treatment: IV opioids for non-neuropathic pain and gabapentin or

carbamazepine + IV opioids for neuropathic pain

• The order set includes orders for fentanyl, hydromorphone and

morphine drips

• Consider if the patient may be better suited by IV pushes instead of a

continuous infusion

o Agitation

▪ Assess using RASS, which is included in order set; usual goal is 0 to -2.

▪ Preferably treated with non-benzodiazepine medications—we have propofol

and dexmedetomodine (precedex) available; the order set also contains

benzodiazepine infusions

▪ For patients with initially very high oxygenation needs or marked patient-ventilator desynchrony, consider starting with propofol for sedation over precedex (dexmedetomadine)

▪ Eligible patients should have daily awakening trial; some exceptions may

include:

• Sedative infusion for status epilepticus or EtOH withdrawal

• Escalating doses 2/2 agitation

• Neuromuscular blockade

• Evidence of increased ICP

• Acute MI in the past 24 hours

• Auto-PEEP ≥ 10 cm H2O

• Intra-aortic balloon pump or LVAD

23

The Ventilator: Weaning

• Assess readiness to wean on a DAILY basis o Is this patient hemodynamically stable? (not on pressors) o Is this patient awake? o Have I fixed the underlying cause of his respiratory failure? o Have I weaned his ventilation to as close to physiological as possible?

▪ For most people, this is VC, RR 12-14 (patient breathing over the ventilator comfortably), PEEP ≤5, FiO2≤40%.

o If YES to the above, can I try a spontaneous breathing trial (SBT)?

• Spontaneous Breathing Trial (SBT): Way to trial a patient to assess his/her readiness to wean. o At Loyola, this is done with a T-piece: a device attaches to the ET tube which is open to

room air. Patients essentially breathe room air on their own through the ET tube. o Duration: 30-60 minutes (Longer SBTs will cause patient to tire out because they are

essentially breathing through a straw) ▪ RSBI → Rapid Shallow Breathing Index

• Diaphragm fatigue is characterized by a patient taking shallow breaths (low tidal volumes or Vt) with a fast respiratory rate (RR) i.e rapid (fast RR), shallow (low Vt) breathing.

• The ratio of the RR/Vt is a measure of this. High = respiratory distress, low = good respiratory function. This is called the RSBI.

• RSBI > 105 predicts unsuccessful extubation. Remember, however, that RSBI < 105 does not always predict successful extubation.

▪ NIF → Negative inspiratory force

• A method to measure the force generated by a patient’s diaphragm during spontaneous breathing.

• Requires a cooperative patient and an RT using a Wright’s spirometer (can be approximated by the ventilator) to measure this pressure.

• Normal NIF is -60 or less (NIF is measured by negative pressures).

• We look for -20 or less when extubating someone. ▪ Cuff leak

• Theory is that prolonged intubation with a cuff causes tracheal edema around the cuff site which can cause problems after extubation.

• Way to test this is to have RT deflate ET cuff and determine if there is an appropriate leak of air during inspiration.

• Essentially, ask RT to tell you if patient has cuff leak or not & treat with steroids if needed.

o Assess for evidence of hypoxemia (decreased O2 saturations/increased RR/ABG) or hypoventilation (ABG, mental status, respiratory fatigue etc.)

o Assess for evidence of hemodynamic instability (including increased pressor requirements)

o Assess for respiratory distress/failure → Accessory muscle use, “the look”

• Extubate if patient passes SBT (make sure patient/family understands that there is appx 20% chance of re-intubation)

o Done by RT. Place the “extubate patient” order in the computer.

24

The Ventilator: Weaning (cont.)

Criteria:

-Respiratory failure cause has improved -Arousable, GCS>12

-HR <140, not on pressors -PaO2>60 mm Hg on FiO2 <40-50% and PEEP <5-8

-Afebrile, no electrolyte disturbances, adequate fluids

Parameter Definition Normal Adult

Weaning Threshold

Utility

Rapid Shallow Breathing Index (RSBI)

Ratio of respiratory frequency to tidal volume (f/VT)

<50/min/L <105/min/L Best predictor for successful weaning and failure

LR+ 1.66-2.1

LR- 0.11

Max Inspiratory Pressure; Negative Inspiratory Force (MIP or NIF)

Strength of inspiratory muscles by attaching an aneroid manometer to endotracheal tube and inspiring against occluded airway

>-90 cm (F); >-120 (M)

>-25 cm H2O Next best predictor of failure

LR+ 1.15-1.57 LR- 0.31-0.65

Minute Ventilation Estimates the demand on the respiratory system

5-7 L/min <10 L/min

Very poor LR+ 0.87-2.37

Respiratory Rate (RR or f)

Breaths per minute 12-8 /min <40 /min Unknown

Vital Capacity Greatest volume of air that can be expelled from the lungs after taking the deepest possible breath

65-75 mL/kg >10 mL/kg Unknown

Tidal Volume (VT) Normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied

5-7 mL/kg >5 mL/kg Unknown

PaO2/FiO2 Ratio between arterial O2 and FiO2

>400 >200 Unknown

Integrative indices – predictors that take into account multiple factors (ie, Inspiratory effort quotient (IEQ); CROP index (Compliance, Rate, Oxygenation, Pressure); CORE index (Compliance, Oxygenation, Respiration, Effort); Weaning Index (WI); Integrative weaning index (IWI), and more)

25

General ARDS Management

(Low volume ventilation is explained below but ask your pulm fellow about some other strategies, if needed)

• Treat the underlying cause

• Supportive care

o Limit further injury and DO NO HARM

▪ Avoid toxic levels FiO2: <60% FiO2

▪ Avoid volutrauma: 4-6cc/kg, plateau <30

▪ Avoid atelectrauma: find “best” PEEP

• PEEP: Minimize driving pressure (Plat – PEEP)

• Conservative fluid therapy to prevent pulmonary edema

• Prone positioning and early paralytics for severe ARDS (P:F < 150)

Protocol for Low Volume Ventilation in ARDS

GOALS: TV = 6 mL/kg, Ppl <30 cm H2O, pH = 7.30 – 7.45

I. FIRST STAGE:

1. Calculate patient's predicted body weight (PBW)

Males: PBW = 50 + [0.905 × (height in cm – 152.4)]

Females: PBW = 45.5 + [0.905 × (height in cm – 152.4)]

2. Set initial tidal volume (TV) to 6 mL/kg PBW.

3. Add positive end-expiratory pressure (PEEP) at = 5-7 cm H2O,

II. SECOND STAGE

1. When TV down to 6 mL/kg, measure plateau pressure (Ppl).

A. Target Ppl <30 cm H2O.

B. If Ppl > 30 cm H2O, decrease TV in 1 mL/kg steps until Ppl drops

below 30 cm H2O or TV down to 4 mL/kg.

III. THIRD STAGE

1. Monitor arterial blood gases for respiratory acidosis.

A. Target pH = 7.30 - 7.45

B. If pH 7.15 - 7.30, increase respiratory rate (RR) until pH > 7.30

or RR = 35 bpm.

C. If pH, <7.15, increase RR to 35 bpm. If pH still, <7.15, increase

TV at 1 mL/kg increments until pH >7.15.

26

Oxygen Dissociation Curve

Approximate correlation between PaO2 and SaO2

PaO2 SaO2 40 ------------------------------- ~70% 50 ------------------------------- ~80% 60 ------------------------------- ~90%

27

Oxygen Delivery Devices 1. Nasal Cannula

a. 1 – 6 LPM b. FIO2 0.24 – 0.44 (approx 4% per liter flow) c. FIO2 decreases as Ve increases

2. Simple Mask a. 5 – 8 LPM b. FIO2 0.35 – 0.55 (approx 4% per liter flow) c. Minimum flow 5 LPM to flush CO2 from mask

3. Venturi Mask a. Variable LPM b. FIO2 0.24 – 0.50 c. Flow and corresponding FIO2 varies by manufacturer

4. Partial Rebreather a. 6 – 10 LPM b. FIO2 0.50 – 0.70 c. Flow must be sufficient to keep reservoir bag from deflating upon inspiration

5. Nonrebreather a. 6 – 10 LPM b. FIO2 0.70 – 1.0 c. Flow must be sufficient to keep reservoir bag from deflating upon inspiration

The above are all low flow oxygen delivery systems, with exception of the Venti Mask, and therefore the exact FiO2 will be based on the patient's anatomic reservoir and minute ventilation.

28

Ventilatory Failure

29

Hemodynamics Right atrial pressure (RAP) 2-6 mmHg Right ventricular pressure (RVP) 15-25mmHg Pulmonary artery systolic pressure (PASP) 15-25mmHg Pulmonary artery diastolic pressure (PADP) 8-15mmHg Mean pulmonary artery pressure (MPAP) 6-12mmHg Left atrial pressure (LAP) 6-12mmHg Pulmonary capillary wedge pressure (PCWP) 6-12mmHg Cardiac output 4-8 L/min Cardiac index 2.5-4 L/min SVR 800-1200 dynes sec/cm5 PVR <250 dynes sec/cm5

Hemodynamics of Shock

30

Pressor Review

Drug Receptor Clinical Effect Indication

Dopamine α1 +++ β1 +++

β2 + Dopamine ++

- Positive inotrope and chronotrope, less than dobutamine. - Vasopressor

Cardiogenic shock, Distributive Shock

Norepinephrine α1 ++++ β1 +++

- Increases SVR Distributive Shock (first line for sepsis)

Epinephrine α1 +++ β1 +++ β2 ++

- Positive inotrope and chronotrope. - α>β at higher doses

Distributive, mixed, or cardiogenic shock

Phenylephrine α1 ++++ - Pure vasopressor - No tachyarrhythmias - Less potent than norepinephrine

Distributive shock

Vasopressin Smooth muscle V1 receptor agonist

- Pure vasopressor - Maintains pressor activity in acidosis - ? Safety in CAD, MI, Bowel ischemia

Distributive shock

Dobutamine α1 β1 +++

β2 + Dopamine

- Positive inotrope and chronotrope - Some afterload reduction

Cardiogenic shock

Milrinone PDE inhibitor - Non-catecholamine - Positive inotrope and chronotrope - Afterload reduction

Cardiogenic shock

*Norepinephrine first line in septic shock, followed by vasopressin, if needing to add a third

consider epinephrine rather than phenylephrine (more evidence for) *Dopamine is what is available readily in crash carts. If needed emergently (when located outside of the ICU), use it. Can always transition to another vasopressor or inotrope later.

31

Sepsis

** Make sure you use the sepsis admission order set when admitting a septic patient to the ICU

SEVERE SEPSIS CRITERIA (all 3 must be present in the chart within 6 hrs of each other):

SIRS + SEPSIS + ORGAN DYSFUNCTION

2 or more of the following:

- T<36.3 or >38

- RR>20 or pCO2<32

- HR>90

- WBC >12K, <4K or >10% bands

Documentation of a suspected source of infection or “Infection source unknown”

- SBP< 90, or MAP < 65, OR a SBP decrease > 40 mmHg from the last previously recorded SBP considered normal for that patient

- Acute respiratory failure = new need for invasive or non-invasive mechanical ventilation

- Creatinine > 2.0, or UOP < 0.5 mL/kg/hour for 2 hours

- Bilirubin > 2 mg/dL (34.2 mmol/L)

- Platelet count < 100,000

- INR > 1.5 or aPTT > 60 sec

- Lactate > 2 mmol/L (18.0 mg/dL)

Do not include organ dysfunction that is due to chronic condition or medication (e.g., Cr >2 for ESRD pt or INR>1.5 for pt on Coumadin)

32

SOFA SCORE AND qSOFA SCORE

In 2016, the European Society of Intensive Care Medicine and Society of Critical Care Medicine Third Internal Consensus Task Force published a new definition of sepsis and septic shock to replace the SIRS based definition.

• Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to

infection

• Septic Shock: Subset of sepsis in which underlying circulatory and cellular/metabolic

abnormalities are profound enough to substantially increase mortality.

In place of the prior SIRS criteria, alternative prediction models were retrospectively applied to a large cohort of patients with suspected infections. Ultimately, the Sequential Organ Failure Assessment (SOFA) score was found to be useful in identifying organ dysfunction more effectively than SIRS and was applied. The Task Force recommended defining sepsis as a change in baseline SOFA score of at least 2, and septic shock as a change in SOFA score plus the use of a vasopressor to maintain MAP of 65 mmHg or a lactate >2 mmol/L despite fluid resucitation. The SOFA score is somewhat involved with many different parameters, which can make it difficult to use in real time. The Task Force therefore proposed the “quick SOFA” or “qSOFA” score, which is a 3 point metric. A score of 2 or more predicts poor outcomes in non-ICU patients. A recent European study evaluating ED patients with clinically suspected infections found that qSOFA was the best at predicting in hospital death. A Study evaluting qSOFA in ICU patients found an increase in SOFA score of 2 or more points within 24 hours of admission was the best predictor of in hospital mortality and prolonged ICU stays, however qSOFA did not perform very well in this population.

Quick SOFA Score

Assessment q SOFA Score

Low blood pressure (SBP <100 mmHg) 1

High respiratory rate (≥22 breaths/min) 1

Altered mentation (GCS < 15) 1

33

SOFA Score

System Metric SOFA Score

Respiratory PaO2/FiO2

<400 1

<300 2

<200 and intubated 3

< 100 and intubated 4

Nervous system Glasgow coma scale

13-14 1

10-12 2

6-9 3

<6 4

Cardiovascular System MAP or Vasopressors required

MAP < 70 mmHg 1

Dopamine ≤5 or dobutamine (any dose)

2

Dopamine ≥5 or epinephrine ≤0.1 or norepinephrine ≤0.1

3

Dopamine >15 or epinephrine >0.1 or norepinphrine > 0.1

4

Liver Bilirubin (mg/dL)

1.2-1.9 1

2.0-5.9 2

6.0-11.9 3

>12 4

Coagulation Platelets

<150 1

<100 2

<50 3

<20 4

Kidneys Cr (mg/dL)

1.2-1.9 1

2.0-3.4 2

3.5-4.9 3

>5 4

34

35

Patient has a positive nurse sepsis screen

Nurse calls RRT, starts sepsis clock, and notifies primary service

Does patient meet criteria for severe sepsis?: 2/4 SIRS AND

suspected or documented infection AND End organ dysfunction (including lactate >2)

THIS IS TIME ZERO

Yes

Sepsis Protocol for

Cirrhotic Patients

SBP<75mmHg OR

SBP decreased

>10mmHg from baseline

Compensated cirrhotic: - Normal blood pressure at baseline - No edema, ascites or pleural effusion

Decompensated cirrhotic: + edema or + ascites or + pleural effusion

Follow sepsis flowsheet

as per non-cirrhotic

patients

SBP>75mmHg AND

SBP <10mmHg from baseline

Give 1L crystalloid - Can order additional bolus based on clinical judgement - Call RRT

Fluids not necessary

If initial lactate is >2mmol/L, repeat lactate every 2 hours for 12 hours

If lactate increases ≥1 mmol/L from original value: Give 1L crystalloid Call RRT

Use initial response to sepsis order set to order:

1. antibiotics x1 dose 2. lactate

3. blood cultures

Remember to DOCUMENT severe sepsis or septic shock in your note

No

Stop the sepsis clock

in the navigator

Remember to go into the

IP sepsis order set for

longer antibiotic

coverage

36

Acid-Base

1. Acidosis (pH<7.36) or Alkalosis (pH>7.44)?

2. Primary metabolic or Respiratory process?

pCO2 ▼

HCO3 *▼*

Metabolic Acidosis

-check albumin!

Actual gap = calc gap + 2.5 (4 - pt’s albumin)

Gap

1. Winters formula to check for appropriate resp compensation:

Exp pCO2 =

1.5[HCO3] + 8 ± 2

Obs > exp pCO2: resp acidosis

Obs < exp pCO2: resp alkalosis

2. =

gap + serum bicarb

If <24: non-gap acidosis

If >24: metabolic alkalosis

3. If no explanation for gap, check osm gap (difference between

calc and meas osm)

Calc osm = 2[Na]+(gluc/18)+(BUN/2.8)

Normal osm gap = 10-15

>25 suggests meth or EG poisoning

Non-gap

1. Winters formula to check for appropriate resp

compensation:

Exp pCO2 =

1.5[HCO3] + 8 ± 2

Obs > exp pCO2: resp acidosis

Obs < exp pCO2: resp alkalosis

2. If no explanation, check urine anion gap

(normal = 20-80)

Urine AG =

Urine Na + Urine K – Urine Cl

Ne-GUT-ive = GI loss

Positive = RTA

PCO2 *▲* ▲ *▼*

HCO3 ▲ *▲* ▼

Respiratory Acidosis Metabolic Alkalosis Respiratory Alkalosis

Acute or Chronic

Acute:

For every 10 pCO2:

-pH decrease by 0.08

-HCO3 increase by 1

Chronic:

For every 10 pCO2:

-pH decrease by 0.03

-HCO3 increase by 4

1. Check for respiratory compensation

pCO2 = 2/3 (HCO3)

2. Measure urine Cl:

Urine Cl<20 (volume responsive):

Vomiting, dehydration, diuretics

Urine Cl>20 (volume unresponsive):

Hypokalemia (<2), mineralocorticoid

excess, Bartters/Gitelman’s

Acute or Chronic

Acute:

For every 10 pCO2:

-pH increase by 0.08

-HCO3 decrease by 2

Chronic:

For every 10 pCO2:

-pH increase by 0.03

-HCO3 decrease by 5

37

COVID-19 **Disclaimer: our understanding of how to manage and treat patients with COVID-19 is constantly evolving, so please consider this information as a guideline and refer to the sharepoint documents and coronavirus central on the spirit homepage for more recently updated information (your MICU attendings/fellows are another excellent resource!) Clinical Presentation

• High Risk Features: age, CAD, HF, CKD, COPD, DM, immunocompromised/HIV

• Week 1 prodrome of mild symptoms → week 2 progressive dyspnea with eventual rapid respiratory decompensation

• Symptoms: cough, dyspnea, fever, GI, URI sx, loss of taste/smell Testing:

• COVID testing is done in-house with <24hr turnaround time (tests are being run in batches) o ID is not automatically consulted when a test is ordered or comes back positive, so make

sure to formally consult them

• Only order CXR when needed, avoid daily CXRs

• Typical CXR findings: bilateral and peripheral hazy opacities

• Inflammatory markers (usually checked every other day): LDH, ferritin, CRP, d-dimer, troponin, CPK, ESR, procalcitonin

Treatment • Consider azithromycin/doxycycline and ceftriaxone

o We are not using plaquenil (400mg for first 2 doses then 200mg BID for 4 days) as much anymore, discuss with ID before initiating

• Tocilizumab (IL-6 inhibitor) should be considered to prevent cytokine storm (this decision is made by ID based on inflammatory markers)

o Prior to administering tocilizumab make sure to draw HIV, hepatitis panel, IL-6 level, and quant gold (you do not need to wait for results before administering tocilizumab)

• Remdesivir is available for selected patients (this is up to the discretion of ID)

End organ damage • Neuro:

o These pts tend require a high level of sedation (to keep them from being agitated and fighting the vent)

▪ If using propofol, make sure to check triglycerides q3days

• CV: o Shock 2/2 sedation vs sepsis vs obstructive (2/2 PE) vs cardiogenic o Watch for myocarditis/arrhythmias

• Pulmonary o OK to use HFNC, CPAP, BiPAP to avoid intubation o Check P:F ratio everyday

▪ < 300 = ARDS

• Lung protective ventilation: keep Vt 4-6cc/kg predicted body weight,

maintain plat pressure <30-32, titrate PEEP to driving pressure goal <15,

target pO2 >60, goal FiO2 <60%

• OK for permissive hypercapnia (as long as pH ≥ 7.1 – this threshold is somewhat attending specific) to allow for low tidal volumes

38

▪ If < 150 consider paralyzing and proning (if pt is not yet intubated, encourage awake proning for as long as pt is able to tolerate)

• Paralytics can be ordered through the order set titled Neuromuscular Blockade in the ICU

o If refractory hypoxemia noted despite paralytics and proning with PF<100, consider inhaled vasodilator: iNO (antiviral properties) or epoprostenol (anti-plt and anti-thrombotic properties)

• GI o Mild transaminitis: monitoring o OK for pts to get TFs while paralyzed/proned

• Renal o AKI, Hyponatremia

▪ Low threshold to consult renal, these pts often require dialysis

• Hematology o Hypercoaguable state: use the algorithm below to determine dose of SQH/lovenox

based on d-dimer, CrCl, and BMI

o If there is a high suspicion for VTE start therapeutic AC o Given that most patients are receiving higher than normal levels of ppx AC, make sure to

remember the risk of bleeding in these pts

• Endocrine: o Hyperglycemia: consider titrating up on glargine, lispro, and SSI (if possible avoid

endotool to decrease frequency of RNs needing to go into the rooms)

To decrease exposure, minimize the number of people that go into a COVID positive/PUI room • Defer daily exams to attending/fellow when on rounds

• If there is a clinical change discuss with your fellow who should evaluate the patient

39

• Minimize need for RN to go into the patient’s room if possible: cluster labs and meds, avoid drips that require frequent titrations (e.g. consider SQ insulin over endotool if clinically appropriate)

• Call the SWAT team for procedures

If you need to go into a patient room, please wear appropriate PPE: • At MINIMUM: surgical face mask, eye protection, gown, and gloves

• For aerosol generating procedures: N95 mask and face shield, or PAPR

• Masks should be removed or changed if they become humid/wet, the mask is touched, or the mask is pulled below the chin

Ancillary Services are available for COVID+ patients • CT/MRI have protocols in place for scanning COVID+ patients

• Avoid reflex ordering PT/OT/speech to limit unnecessary exposure. But remember that if patients have been intubated/proned/paralyzed for a prolonged period of time PT/OT will be critical to their overall recovery

o IF a patient would benefit from services, place order as usual but specify within order the following:

▪ “Discussed with attending on rounds. Okay to proceed with ancillary services” ▪ “Nursing has initiated or attempted mobility”

• Prior to speech evaluation, have nurse assess at bedside

• Patients will likely be seen at the end of the day

Protected Codes/RRTs • Fellow and senior should be present for all protected codes and rapid responses

• Bring blue jump bag (located in 4853) that contains PPE

• Minimize number of people in room. Ideally (primary RN, RRT RN, RRT RT, primary physician, COVID MICU fellow)

• Most senior physician should be code leader

• Ask RT to place in-circuit spacer to allow for breathing treatments

• If patient is likely to be intubated, try to place arterial and central line immediately following

Miscellaneous Tips • If a patient is stable for the floor or if their COVID test comes back negative (and the clinical

suspicion for COVID is low), the patient can be transferred to a COVID gen med team or the most appropriate ICU (MICU, CCU, CVICU, etc) at any time during the day

• Given the visitor restrictions, families should be called and updated every day after rounds o iPads are available for zoom family meetings and for non-intubated patients to use to

talk to their families (OK to bring the iPads into the patient rooms, but makes sure to wipe them down when you’re done)

40

Liver Failure • MELD Score: Takes into account INR, Creatinine, Bilirubin (use dot phrase “.meld” for fast

calculation)

• Paracentesis

o When to perform a diagnostic para: New onset

ascites, when decompensated cirrhotics get

admitted to the hospital (unless for something

really minor), clinical deterioration (sepsis,

encephalopathy, acute renal failure)

o No absolute INR or platelet count that is safe for

a diagnostic tap (except in DIC)

o For a large volume tap, INR should be <1.5

(careful of large volume in renal failure)

o 25 gauge needle for diagnostic tap, remember to

use the Z-technique.

• Ascites diagnostic tests

o Routine: cell count, albumin (ascites/serum),

protein, (ascites/serum)

o Optional: glucose, LDH, amylase, gram stain & culture

o SAAG = serum albumin – ascites albumin

▪ >1.1 = portal htn

• SBP (spontaneous bacterial peritonitis)

o PMN’s>250 (correction: for every 250 rbc, take

one PMN away)

o Treatment: antibiotics (ceftriaxone), IV albumin

days 1 (1.5g/kg) and 3 (1g/kg), stop propranolol

o Tap should be repeated at 48 hours, PMN’s

should have decreased by 50%

o Any GIB in a liver patient in the MICU should receive antibiotics! (5 days PPX w/

ceftriaxone 1g)

o PPX if history of SBP with Cipro daily

• Indications for albumin infusion

o If >4L is removed via paracentesis replace 6-8g albumin per liter taken

o Hepatorenal syndrome

• Hepatorenal syndrome

o Acute renal failure in severe liver disease (cirrhosis or acute liver failure)

o Creatinine >1.5, does not improve with IVF hydration after 2 days

o Treatment: octreotide (50-100 TID), midodrine (5-10 TID), albumin (25% 50ml TID) –

decreases mortality

A) Relative locations where needle enters skin &

peritoneal cavity.

B) Skin is pulled down, and needle is then

advanced in 5 mm increments, pulling the

plunger back a few millimeters with each

advancement to see if any blood or ascitic

fluid is aspirated.

C) Skin is released, returning skin & peritoneal

cavity entry sites to their original positions.

UptoDate.com

41

Liver Failure

• Alcoholic hepatitis: Give prednisone if MDF (maddrey discriminent function) score >32 and no

contraindication. If there is a contr-indication, consider giving penoxyfilline.

o Can send urine ethyl glucuronide (to test for alcohol abuse)

o Lille score: used to evaluate if pt is responding appropriately to 7 days of steroids

• Variceal bleeding treatment:

o Vasopressin (not used much due to side effects), octreotide (inhibits vasodilation),

propranolol

o Banding: 90% effective

o Intractable cases: balloon tamponade, TIPS, shunt surgery, liver transplant

• Cerebral edema develops in 75-80% of stage IV hepatic encephalopathy

o Cushing’s reflex – HTN, bradycardia

o Goal cerebral perfusion pressure is >40-50 (CPP = MAP-ICP)

o Goal ICP is <20

o Elevate head of bed not more than 30 degrees

o Hyperventilate to pCO2 25-35

o Medications: Mannitol, loop diuretics, IV lidocaine, pentobarb coma

o Pentobarbitol coma results in EEG flatline; can eliminate EEG criteria for brain death

42

Anaphylaxis/Angioedema:

*Note that many definitions exist. For this handbook’s purpose, consider the definition below. Definition: Life-threatening syndrome of sudden onset with one or more of the following manifestations (generally #1 + any other is considered anaphylaxis):

1. Skin: sudden urticaria, angioedema (88%) 2. Respiratory: bronchospasm, laryngeal edema/stridor (50%) 3. GI: nausea, vomiting, diarrhea (30%) 4. CV: hypotension, dysrhythmia (30%) 5. Constitutional: diaphoresis, pruritis, anxiety

Anaphylaxis vs Anaphylactoid: Anaphylaxis: IgE-mediated immediate hypersensitivity reaction to antigen Anaphylactoid: non-IgE-mediated, but present and are treated the same. Etiologies:

• 60% have idiopathic anaphylaxis

• Drugs: penicillins most common, ASA/NSAIDs, exercise, opiates, radiocontrast

produces anaphylactoid reactions

• Food: nuts, fish most common, generally in teenagers

• Venoms: insect stings

• Blood products

• Latex

Treatment: 2% mortality w/ anaphylaxis

• ABC’s: intubate for stridor, severe dyspnea; get IV access, give IVF, lie flat

• Epinephrine: drug of choice 0.3 to 0.5 mL of 1:1000 (1 mg/mL) epinephrine

intramuscularly into the anterior or lateral thigh

• Antihistamines: Use Both H1 and H2 blockade

• Inhaled B agonists

• Corticosteroids: useful to prevent biphasic anaphylaxis (10hrs out). For refractory

hypotension: epinephrine gtt 5-15mcg/min, glucagon if on beta-blocker. Patients

need to be discharged with an epi-pen and instructions on how to use. Should

have allergy outpatient appointment to test for triggers.

• For angioedema: start with decadron 10mg q6 hours, Benadryl 50mg q6 hours,

famotidine 50mg q 6 hours

43

PROCEDURES: Intra-Osseous (IO) Line Insertion

• Indications o When you need fast vascular access but are unable to obtain it through

more traditional means (peripheral IVs, central venous catheter) o Traditionally reserved for CODES o Can run anything except chemo and TFs (IV and IO meds are

pharmacokinetically equivalent) o Pressors are limited to 2 hours o Lab draws same as venous samples (except alk phos, lactate, CBC)

• Risks o Infection, bleeding, fracture, compartment syndrome

• Contra-indications o Current fracture, infection of overlying soft tissue, or high fracture risk

(osteopetrosis, osteogenesis imperfecta) o Do not place in a site where prior IO was attempted within 48 hours o FYI: You cannot get an MRI with an IO.

Materials

• Chloraprep

• Gloves

• EZ-IO kit: includes driver, needle set (45 mm, 25 mm, 15mm – all are 15 gauge), IV tubing, 10 mL syringes x3,

sterile saline flush, 2% lidocaine, dressing

Placement Locations

• Humerus: start at neck just below the greater tubercle then go up by 1-2 cm. Can run fluids at 5L/hr.

• Tibial: 2 finger breadths below patella and 1-2cm medial to tibial tuberosity. Can run fluids at 2L/hr.

Instructions

• Locate site for insertion. (Humerus is better.)

• Clean with chloraprep.

• Position patient. For humerus, bend the elbow and adduct the arm so the hand is on their abdomen. Pick the

needle and attach to the driver. For humerus, use 45 mm needle (yellow).

• Place needle over site. Angle needle toward opposite hip. Push needle into skin (without turning on the driver)

until you hit bone. At this point there should be 1 or more black lines visible on the needle

• Now press driver trigger to twist the needle into the bone. For humerus, hub the needle. For other sites, stop

once no longer meeting resistance (to prevent going through)

• Remove driver and needle inside. Place bandage over IO. Connect IV tubing and secure dressing.

• Attach sterile saline flush. Pull back and should get blood or bone marrow.

• If patient is conscious, insert lidocaine first. Push 40mg of 2% lidocaine and let sit for 2 min. Then get another

20mg and let sit for 1 min.

• Flush with 5-10 mL of saline.

• Put wrist band on patient to notify of IO placement (and prevent placing second IO in same arm within 48 hrs).

Remove within 24 hours of Insertion

• Take off the flush and dressing.

• Attach an empty syringe and pull syringe with IO straight out. *You may use a twisting motion, but don’t rock.

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PROCEDURES: Ultrasound Guided Central Venous Catheter Insertion

• Indications:

o Pressor requirement (pressors can only run

peripherally at a low dose for <4 hrs)

o Central venous pressure monitoring

o Access in patients with difficult access or needing

large amounts of fluid/blood resuscitation

• Risks: Bleeding, infection, clot, pneumothorax (IJ only)

• Before beginning: o Assess for optimum location with US (R or L IJ,

femoral vein, subclavian vein, etc). o Discuss with your fellow or attending which type

of line (ie triple lumen, Quinton, Cordis, etc), at what location, and of which length you will be using. This may vary based on indication and site.

• Resources:

https://www.nejm.org/doi/full/10.1056/NEJMvcm0810156

Materials (for the ARROW triple lumen CVC)

• ARROW triple lumen central venous catheter insertion kit (Each kit contains: gauze, tegaderm, drape, anesthetic

needles, lidocaine, angiocath needle, 3-0 silk suture with clamp, guidewire, dilator, scalpel, triple lumen catheter,

chloraprep, and needle holder)

• Ultrasound with vascular (linear array) probe

• Sterile ultrasound probe cover kit

• 3 dark blue sterile IV caps

• Sterile PPE: surgical gown, mask, hair cap, sized gloves (one mask, cap, and gown are provided in kit)

• Extra chloral-prep wipe and gauze

• 2-3 sterile saline syringes

Preparation

• Let the nurse know you are beginning

• Position the patient with bed flat and at a height that is comfortable for you. Move head of bed away from

wall so there is room for you to stand if doing IJ.

• Check site with nonsterile ultrasound. May do internal jugular vein or femoral vein.

Remember, a vein is larger, less muscular, non-pulsatile, and compressible AND femoral vein is medial to the artery.

• Clean site with your extra chloraprep.

• Open central line kit; do not touch anything inside.

• Carefully drop IV caps and US probe cover on to sterile field (the open kit).

• Don hat and mask. Wash hands and don sterile gown and gloves.

• Clean site again with chloraprep provided in kit.

• Get drape and carefully lay it over the site (open drape as indicated by arrows). The blue surface of the drape

is now your sterile field. Ask nurse (or other non-sterile assistant) for help.

• Ask your non-sterile assistant to place non-sterile gel on to non-sterile US probe.

• For probe cover, place hand in opposite end as the arrow (arrow points to where the probe goes in).

Nonsterile person puts probe into arrow side and drape is pulled down over probe wire. Place rubber bands to

hold cover over probe in place. Place sterile gel on the probe tip and rest it on the sterile field.

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• Prep catheter by putting IV caps on the blue and white lumens (NOT the brown lumen as that is how the

guidewire will be removed). Push saline through the IV cap to remove air in the blue and white lumens. For

the brown, push saline as well but seal instead with the sliding seal attached to the lumen.

Procedure

• Perform a brief time-out with the nurse (patient name, DOB or MRN, procedure, confirm consent obtained).

• Begin by again locating the target site with the now-sterile ultrasound.

• Draw up lidocaine into small anesthetic syringe and inject in desired area. First, create a wheal in immediate subcutaneous area, let sit for 30 sec, then inject deeper. Be sure to always draw back before pushing to make sure you are not in a vessel.

• Prepare guidewire by removing cap and making sure it advances. Place guidewire for easy access.

• Now take angiocath needle (needle with blue plunger) and place it into vein using ultrasound guidance with care to avoid artery. Maintain negative suction by drawing back into the syringe to determine when there is blood return. If blood return is brisk and pulsatile, consider that you may be in the artery (or the patient may have high BP, elevated CVP, or severe valvular regurgitation).

• Once in vein, grab your guidewire and advance it through the blue introducer hole in your angiocath needle. Maintain control of your wire at all times, with at least one hand firmly ahold of it. Fully remove guidewire from casing.

• With ahold of the tip of the wire, slide the angiocath needle out of patient along the wire. Once wire is visible at insertion site, grab the wire there so that the needle can slide completely off of the wire.

• Confirm wire position with ultrasound - look longitudinally to see wire’s path in the vein (and not in artery).

• With the razor, nick the skin at site of wire entry to about half the max width of the razor blade. Clean the area with gauze as needed.

• Next, slide the dilator catheter over the wire and into the skin with a pushing and twisting motion against resistance.

• Remove the dilator, at all times keeping ahold of the wire.

• Place the triple-lumen catheter over the wire, but do not advance into the skin yet.

• Keep ahold of the wire at the level of the skin. Begin pulling the wire out, watching for it to emerge through the brown lumen of the catheter.

• Unclamp the brown lumen once the wire begins to come through. Pull the wire out as far as needed until it is coming out of the brown lumen and can be grabbed at that distal end. Once firmly held at that end, the catheter can be inserted into the skin.

• Generally speaking, a 16 cm catheter can be hubbed, and a 20 cm catheter stopped around the 15-17 cm at RIJ (depends on patient’s height and location of insertion site though).

• Completely remove the wire. Place IV cap over the brown lumen.

• For each of the three lumens, attach the sterile saline flush and pull back to ensure blood return into the lumen then push forward to flush until clear.

• The blue clamp at the hub of the catheter should be sutured in two spots to the patient's skin, cutting excess thread with the razor.

• Clean the area with saline and gauze.

• Place biopatch and tegaderm over insertion site. Wrap-up

• Discard sharps and lidocaine. Make sure to account for all sharps including guidewire.

• Take down drape and discard materials.

• Order a CXR for IJ and subclavian lines. Note that a tip too far in can cause tachyarrythmias. Reposition if needed by

pulling the catheter out, but you cannot push it in. (The part of the catheter that is not inside the patient is now not sterile.)

• Place order for “central line ok to use.”

• Document your procedure with a note using the CLIP Navigator.

46

PROCEDURES: Ultrasound Guided Radial Arterial Catheter Insertion

• Indications o Continuous arterial pressure monitoring o Frequent ABG monitoring

• Risks o Infection, bleeding, thrombosis, vascular injury

• Contra-indications o Infection of skin or soft tissue at insertion site

o Severe peripheral vascular disease o Impaired collateral circulation o Severe coagulopathy

• Before beginning: o Assess for optimum location with US (usually

one of the radial arteries but if you think another location should be used ie ulnar artery, axillary artery, or femoral artery then talk to your fellow)

• Resources:

https://www.nejm.org/doi/full/10.1056/NEJMvcm04414

Materials (for ARROW Radial Artery Catheterization Kit)

• ARROW Radial Artery Catheterization kit (Each kit contains: arterial line catheter introducer with guidewire (“arrow”),

gauze, tegaderm, drape, anesthetic needles, lidocaine (1% solution), silk suture with clamp, chloraprep, and needle holder)

• 2 extra arterial line catheter introducer with removable guidewire (“arrows”)

• Ultrasound with vascular (linear array) probe

• Sterile ultrasound probe cover kit

• Sterile PPE: surgical gown, mask, hair cap, sized gloves

• Extra chlora-prep wipe and gauze

• Wiped down table to rest arm

• Extra towels and masking tape

Preparation

• Let nurse know you will be performing procedure and ask them to set up the pressure bag, pressure

transducer, and the monitor to appropriate settings while you prepare.

• Position the patient’s wrist comfortably on your table (use a bed of towels underneath) so that forearm is flat.

Adjust your table and bed comfortably for yourself and for the patient. Consider rolling a towel under wrist

and taping down at forearm and palm to allow for best radial artery target.

• Check your site with nonsterile ultrasound.

o Remember, an artery is more muscular, pulsatile, and less compressible than a vein.

o Consider scanning your artery in transverse view up and down the forearm to ensure lack of tortuosity.

o Ensure your target site lumen is large enough for your catheter and not compressed by significant calcifications.

• Clean site with your extra chloraprep.

• Open arterial line kit; do not touch anything inside.

• Carefully drop US probe cover kit on to sterile field (the open kit).

• Don hat and mask. Wash hands and don sterile gown and gloves.

• Clean site again with chloraprep provided in kit.

• Get drape(s) and carefully lay it over the site. Extend your sterile field as needed.

• Ask your non-sterile assistant to place non-sterile gel on to non-sterile US probe.

47

• For probe cover, place hand in opposite end as the arrow (arrow points to where the probe goes in).

Nonsterile person puts probe into arrow side and drape is pulled down over probe wire. Place rubber bands to

hold cover over probe in place. Place sterile gel on the probe tip and rest it on the sterile field.

Procedure

• Perform a time-out with the nurse (recite patient name, DOB or MRN, procedure, confirm consent obtained).

• Begin by again looking at the target site with the now-sterile ultrasound. Consider mapping route of your artery by

scanning the artery in transverse view toward ante-cubital fossa.

• Draw up lidocaine into small anesthetic syringe and inject in desired area. First, create a wheal in immediate

subcutaneous area, let sit for 30 sec, then inject deeper. Be sure to always draw back before pushing to make

sure you are not in a vessel.

• Now take your “arrow” and place introducer needle (bevel up) into artery (hold it like a pencil at 45-60

degrees and angle toward route of target artery which you previously mapped out). Bounce your needle

(gently) up and down to check its position. As you advance, tilt your probe in the same direction to assess

location of needle tip. Once you enter the artery, watch for pulsatile blood return and then stop advancing.

Lower arrow to about 30 degrees. Ensure blood return continues.

• Once in artery with good blood return, let go of your US probe and use that hand to advance your guidewire

slowly until the advancer is at least at black line. You may advance further if there is no resistance.

• Carefully advance the white catheter over your guidewire. Continue to keep guidewire hand steady.

• Once catheter is in, remove your guidewire and introducer needle kit. Consider covering catheter with thumb

while you do this so blood does not spray everywhere. Keep a hold of catheter; due to high pressures in

arterial system, your catheter can easily be dislodged.

• Connect the catheter to transducer. Zero the transducer and assess pulsatile arterial waveform on monitor.

• Secure your catheter with a stitch around the hollow part near insertion site. *You may learn different methods

for securing from different fellows.

• Cover insertion site with a biopatch and place tegardarm over the catheter.

• Wrap transducer lumen over the thenar web-space (area between thumb and index finger) and tape down

with masking tape at dorsum of hand for further security and to prevent entanglement.

Wrap-up

o Discard sharps and lidocaine. Make sure to account for all sharps. o Take down drape and discard materials. o Document your procedure with a note.

48

Sign Out in the MICU

• Seniors and interns sign out at 6 pm. If an overnight fellow or attending is

in house, they arrive at 7 pm.

• Every intern sign-out must be supervised by the senior resident or fellow.

• Whenever possible, the nightfloat intern and resident should be present for

the fellow-to-attending signout.

• The following information should be provided during a signout, if

applicable:

o Indicate which patients are sickest and need to be watched closely

o A brief description of patient’s history, reason for MICU admission,

and current condition

o Intubated versus non-invasive ventilation versus nasal cannula flow

o Ventilator settings and peak/plateau pressures, resistance, and

compliance if intubated

o Vasopressor doses if in shock

o Date of tracheostomy placement if applicable

o Items for follow up overnight

o If/thens (issues that the day team could foresee happening overnight

and how they would like the night team to approach these issues)

o Code status