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Generic care of the critically ill patient 

Generic care of the critically ill patient
Chapter:
Generic care of the critically ill patient
Author(s):

Heather Baid

, Fiona Creed

, and Jessica Hargreaves

DOI:
10.1093/med/9780198701071.003.0003
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date: 09 May 2021

Care bundles

Definition

A care bundle is a simple tool, consisting of current, evidence-based recommendations, which helps to standardize practice to improve patient care. Lengthy clinical guidelines can be linked to actual clinical practice through a care bundle (see Figure 3.1). The actions identified in a care bundle should be very specific, and should avoid being so broad that the meaning and focus of the bundle are diluted. Box 3.1 provides an overview of the distinguishing features of a care bundle.

Examples of care bundles

  • Sepsis (see Generic care of the critically ill patient p. [link]).

  • Pain management.

  • Enteral nutrition.

  • Tracheostomy care.

  • Weaning from mechanical ventilation.

  • High-impact interventions (see Generic care of the critically ill patient p. [link]):

    • processes for key clinical procedures identified by the Department of Health1 as making a significant contribution to reducing the risk of infection.

Challenges and criticism

Academic debate

  • Elements may not satisfy all people despite research and other evidence.

  • Limitations of standardized practice (e.g. discouragement of critical thinking or inability of inexperienced staff to recognize when individualized care is needed).

Industry

  • Conflict of interest and other issues may arise if private companies provide funding to promote elements within the bundle.

Operational

  • Some areas may lack the necessary resources to undertake each element of the care bundle.

References

1 Department of Health. High Impact Interventions. Department of Health: London, 2010. Generic care of the critically ill patient http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/whatdoido/high-impact-interventions/.

2 Horner DL and Bellamy MC. Care bundles in intensive care. Continuing Education in Anaesthesia, Critical Care & Pain 2012; 12: 199–202.Find this resource:

Further reading

Camporota L and Brett S. Care bundles: implementing evidence or common sense? Critical Care 2011; 15: 159.Find this resource:

Clarkson D et al. The role of ‘care bundles’ in healthcare. British Journal of Healthcare Management 2013; 19: 63–8.Find this resource:

Infection prevention and control

Hospital-acquired infection

Critically ill patients are at significant risk of developing a hospital-acquired (nosocomial) infection for three main reasons:

  • invasive devices, especially central venous catheters, urinary catheters, and endotracheal tubes (breaching of skin integrity and the facilitation of colonization by bypassing normal defence mechanisms)

  • increased requirement for antibiotics among the critically ill, which creates resistant strains of organisms that can be transmitted rapidly from patient to patient

  • lowered immune function related to sepsis or other disease processes.

Other influencing factors that may be involved in the development of hospital-acquired infections include genetic predisposition, the presence of nasogastric tubes for enteral nutrition increasing the risk of tracheal reflux and aspiration, and supine body positioning. Levels of nurse staffing that are less than 1:1 can also increase cross-infection. Prevention of the development of infections in the critical care setting should take into consideration the following factors:3

  • hand hygiene (the single most important factor)

  • environmental cleaning

  • patient isolation

  • fomite elimination

  • decolonization

  • device insertion and care

  • antimicrobial stewardship (appropriate use of antibiotics)

  • prophylactic antibiotics

  • chlorhexidine bathing.

Hand hygiene

Poor hand hygiene is the most important and persistent source of cross-infection in patients. Hand washing is time-consuming (requiring approximately 2 min in total), and despite the use of gel-based alcohol products to supplement hand washing, staff compliance can be poor, at around 50–60%.4 Box 3.2 lists some of the factors that have a negative impact on hand hygiene compliance among staff.

Infection prevention and control measures

Critical care units should develop policies that cover standard precautions, cleaning schedules, antibiotic-prescribing practice, and evidence-based preventive measures for specific risks such as ventilator-associated pneumonia. Standard infection control precautions should apply to care of all patients (see Table 3.1).

Table 3.1 Standard infection control precautions

Hand hygiene

After contact with body fluids, after removing gloves, and between patient contacts

Gloves

For anticipated contact with body fluids, mucous membranes, non-intact skin, and irritants

Masks, eye protection, face shield

To protect mucous membranes during procedures that are likely to splash or spray body fluids

Gowns or aprons

To protect skin and clothing during procedures that are likely to splash or spray body fluids

Handling of sharp objects

Not recapping needles, use of puncture-resistant sharps containers, and responsible disposal of sharps in sharps bin

Handling of patient care equipment

Discarding of single-use items, appropriate cleaning of reusable items, and avoidance of contamination from used equipment

References

3 Rupp ME. Environmental cleaning and disinfection: only one piece of the critical care infection control puzzle. Critical Care Medicine 2011; 39: 881–2.Find this resource:

4 De Wandel D et al. Behavioral determinants of hand hygiene compliance in intensive care units. American Journal of Critical Care 2010; 19: 230–39.Find this resource:

Further reading

Bion J et al. ‘Matching Michigan’: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Quality & Safety 2013; 22: 110–23.Find this resource:

Sax H et al. Implementation of infection control best practice in intensive care units throughout Europe: a mixed-method evaluation study. Implementation Science 2013; 8: 24.Find this resource:

High-impact interventions

The Department of Health5 has identified the processes involved in key clinical procedures that help to reduce the risk of infection and which are presented in the form of care bundles entitled ‘high-impact interventions.’ Those that are relevant to the critical care setting include:

  • ventilator-associated pneumonia (see Generic care of the critically ill patient p. [link])

  • central venous catheter care (see Table 3.2)

  • peripheral intravenous cannula care

  • prevention of surgical site infection

  • urinary catheter care

  • Clostridium difficile infection

  • cleaning and decontamination

  • enteral feeding

  • blood cultures.

Table 3.2 Central venous catheter care bundle: insertion

Catheter type

  • Single-lumen catheter unless otherwise indicated.

  • Antimicrobial-impregnated catheter if duration is estimated to be 1–3 weeks and risk of catheter-related bloodstream infection is high.

Insertion site

  • Subclavian or internal jugular vein.

  • Avoid femoral vein if possible.

Personal protective equipment

  • Maximal sterile barriers and aseptic technique, including a sterile gown, sterile gloves, and a large sterile drape.

  • Eye and full protection is worn if there is a risk of splashing of blood or other body fluids.

Skin preparation

2% chlorhexidine gluconate in 70% isopropyl alcohol, and allow to dry for at least 30 s. If the patient has a sensitivity, use a single-patient-use povidone–iodine application.

Hand hygiene

Hands should be decontaminated immediately before and after each episode of patient contact, using the correct hand hygiene technique.

Dressing

Sterile transparent semi-permeable dressing that allows observation of the insertion site.

Safe disposal of sharps

Disposed of safely at the point of care and in line with local policy.

Documentation

Details of insertion are documented in the records (including date, location, catheter lot number, and signature and name of operator undertaking insertion).

Hand hygiene

Hands are decontaminated immediately before and after each episode of patient contact using the correct hand hygiene technique.

Site inspection

Site is inspected daily for signs of infection, and observations noted in the patient’s record.

Dressing

  • An intact dry adherent transparent dressing is present.

  • Insertion site should be cleaned with 2% chlorhexidine gluconate in 70% isopropyl alcohol prior to dressing change.

Catheter injection ports

Injection ports are covered by caps or valved connectors.

Catheter access

  • Aseptic non-touch techniques are used for all access to the line.

  • Ports or hubs are cleaned with 2% chlorhexidine gluconate in 70% isopropyl alcohol prior to catheter access.

  • Flush line with 0.9% sodium chloride for lumens in frequent use.

Administration of set replacement

  • Set is replaced immediately after administration of blood or blood products.

  • Set is replaced after 24 h following total parenteral nutrition (if it contains lipids).

  • Set is replaced within 72 h of all other fluid sets or within 12–24 h if medications are present.

Catheter replacement

  • Catheter is removed if it is no longer required, or decision not to remove it is recorded.

  • Details of removal are documented in the records (including date, location, and signature and name of operator undertaking removal).

Reference

5 Department of Health. High Impact Interventions. Department of Health: London, 2010. Generic care of the critically ill patient http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/whatdoido/high-impact-interventions/

Oral hygiene

The lining of the mouth and oropharynx consists of squamous epithelial cells that are highly vulnerable to the effects of poor blood flow, malnutrition, and drug toxicity. Saliva has a strong protective antimicrobial effect. However, in intubated patients the salivary flow is greatly reduced or absent. This reduced flow of saliva along with the presence of an endotracheal tube increases the risk of:

  • oral microbe colonization

  • mucositis

  • ventilator-associated pneumonia (VAP).

Frequent mouth assessment and oral hygiene are required in the critical care setting to prevent mouth abnormalities (see Table 3.3).

Table 3.3 Assessment and management of the mouth

Area

Normal

Abnormal

Intervention

Mucosa

Pink, moist, intact, smooth

Reddening, ulceration, other lesions

Hydration, use of neutral mouthwash solution, pain-relieving anaesthetic gels for ulcers

Tongue

Pink, moist, intact, papillae present

Coated, absence of papillae, smooth shiny appearance, debris, lesions, crusted, cracked, blackened

Hydration, frequent, neutral mouthwashes, use of a debriding agent (e.g. sodium bicarbonate) for blackened areas

Lips

Clean, intact, pink

Dry skin, cracks, reddened, encrusted, ulcerated, bleeding, oedematous

Hydration, protection using petroleum jelly or lubricant jelly

Saliva

Watery, white, or clear

Thick, viscous, absent, bloodstained

Hydration, use of artificial salivas

Gingiva

Pink, moist, firm

Receding, overgrown, oedematous, reddened, bleeding

  • Tooth brushing 12-hourly with small soft brush

  • Chlorhexidine (0.1–0.2%) mouthwash

Teeth

White, firm in sockets, no debris, no decay

Discoloured, decayed, debris, wobbly

  • Tooth brushing 12-hourly with small soft brush

  • Dental assessment

Prevention of VAP

  • The VAP care bundle published by the Department of Health6 recommends:

    • cleaning the mouth with chlorhexidine gluconate gel or liquid 6-hourly

    • leaving at least a 2-h gap between chlorhexidine and tooth brushing because of inactivation of chlorhexidine by toothpaste

    • brushing the teeth 12-hourly with standard toothpaste

    • see Generic care of the critically ill patient p. [link].

  • Use of either chlorhexidine gel or mouthwash reduces the incidence of VAP by 40% in critically ill adults.7

References

6 Department of Health. High Impact Intervention. Care bundle to reduce ventilation-associated pneumonia. Department of Health: London, 2010. Generic care of the critically ill patient http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/whatdoido/high-impact-interventions/Find this resource:

7 Shi Z et al. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Systematic Reviews 2013; Issue 8: CD008367.Find this resource:

Further reading

Alhazzani W et al. Toothbrushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. Critical Care Medicine 2013; 41: 646–55.Find this resource:

Richards D. Oral hygiene regimes for mechanically ventilated patients that use chlorhexidine reduce ventilator-associated pneumonia. Evidence-Based Dentistry 2013; 14: 91–2.Find this resource:

Yildiz M, Durna Z and Akin S. Assessment of oral care needs of patients treated at the intensive care unit. Journal of Clinical Nursing 2013; 22: 2734–47.Find this resource:

Yusef H. Toothbrushing may reduce ventilator-associated pneumonia. Evidence-Based Dentistry 2013; 14: 89–90.Find this resource:

Eye care

Normally the eyes are protected from dehydration by the tear film, which is continually replenished by the lacrimal gland at a rate of approximately 1–2 µL/min. Tears are spread over the surface of the eye by the blink reflex. Frequent eye assessment and eye care are required to keep the eyes moist, protected, and free of abnormality, particularly if the patient is sedated (see Table 3.4). The patient should be referred to specialist ophthalmology services as appropriate.

Table 3.4 Assessment and management of the eyes

Area

Normal

Abnormal

Intervention

Eyelid closure

Upper eyelid completely covers the eye

Eyelids do not fully meet, or corneas are swollen and extruded

Close eyelids with hydropolymer dressing, lubricating ophthalmic ointment, or moisture seal chamber

Hydration status

No fluid restriction, no signs of dehydration, corneal surface is moist

Other features of dehydration or restricted fluid intake, plus dry corneal surface

Use sterile water to cleanse the eye, and apply artificial tears (hydroxyethylcellulose or hypromellose)

Corneal surface

Moist, clear, white

Purulent, coated, crusting exudate, clouding, oedematous, haemorrhage

Swab for culture, clean with sterile water, and apply appropriate topical antibiotic as per culture result

Orbital oedema

Cornea and orbital area are not swollen or extruded

Cornea and orbital area are swollen, reddened, or extruding

Maintain a head-up position to reduce pressure; ensure that tapes securing endotracheal or tracheal tube are not too tight

Critical care risk factors for eye abnormalities

  • Reduced ability to blink.

  • Dehydration affecting tear production.

  • Incomplete eyelid closure.

  • Drug side effects.

  • Lowered immune function.

  • Increased likelihood of cross-infection.

  • Orbital oedema due to:

    • increased intra-thoracic pressure from mechanical ventilation

    • prone positioning.

Dry eyes

  • Can be caused by a combination of critical care risk factors for eye abnormalities (see previous list).

  • Result in a further increased risk of developing other eye abnormalities.

Exposure keratopathy

  • Non-inflammatory corneal disease caused by incomplete lid closure.

  • Damage to the corneal epithelium can lead to abrasion, ulceration, or scarring, which may result in permanent damage.

Infection and inflammation

  • Keratitis—affects the cornea:

    • white/yellow areas on the cornea, redness, discharge, and excessive tear production.

  • Conjunctivitis—affects the conjunctiva:

    • redness, swelling, and discharge affecting eye and inner eyelids.

  • Blepharitis—affects the eyelash follicles and sebaceous glands:

    • redness, swelling, and discharge affecting eyelid and lid margins.

Further reading

Azfar MF, Khan MF and Alzeer AH. Protocolized eye care prevents corneal complications in ventilated patients in a medical intensive care unit. Saudi Journal of Anaesthesia 2013; 7: 33–6.Find this resource:

Marshall AP et al. Eyecare in the critically ill: clinical practice guideline. Australian Critical Care 2008; 21: 97–109.Find this resource:

Rosenberg JB and Eisen LA. Eye care in the intensive care unit: narrative review and meta-analysis. Critical Care Medicine 2008; 36: 3151–5.Find this resource:

Shan H and Min D. Prevention of exposure keratopathy in intensive care unit. International Journal of Ophthalmology 2010; 3: 346–8.Find this resource:

Werli-Alvarenga A et al. Nursing interventions for adult intensive care patients with risk for corneal injury: a systematic review. International Journal of Nursing Knowledge 2013; 24: 25–9.Find this resource:

Fluid management

See Generic care of the critically ill patient p. [link] for an overview of key principles for assessing the fluid status of a critically ill patient. It is important to consider whether there is an effective circulating blood volume (volume of arterial blood required to ensure that there is sufficient tissue perfusion), because a patient can have large amounts of fluid within a ‘third space’ but still experience relative hypovolaemia with a low intravascular volume. Third spacing occurs when excessive fluid accumulates in the extracellular space where the fluid is not physiologically useful or ‘effective’ because it is not in the vasculature or cells. Examples of third spacing include peripheral and pulmonary oedema (fluid in the interstitium), ascites (fluid in the peritoneum), pleural effusion (fluid in the pleural space), and ileus (fluid in obstructed intestine).

Critically ill patients can experience either severe fluid deficit or fluid excess depending on the clinical context and progression of the critical illness. The aim of fluid management is for the patient to achieve normovolaemia. A patient with fluid deficit requires the administration of IV fluids (see Generic care of the critically ill patient p. [link]), and a patient with fluid excess requires fluid removal by means of diuretics (see Generic care of the critically ill patient p. [link]) or renal replacement therapy (see Generic care of the critically ill patient pp. [link] and [link]).

Goals of fluid management

The following clinical findings of normovolaemia can be used as goals to help to guide fluid management therapies:

  • blood pressure: sufficient mean arterial pressure (MAP), no swing in arterial trace (see Generic care of the critically ill patient p. [link])

  • urine output: > 0.5 mL/kg/h

  • mucous membranes: pink and moist

  • central venous pressure (CVP): 2–10 mmHg:

    • CVP monitoring (see Generic care of the critically ill patient p. [link]) is routine practice in critical care, with the assumption that CVP is a direct indicator of intravascular volume and right ventricular preload, and is also an indirect indicator of left ventricular preload

    • however, a systematic review by Marik and colleagues8 demonstrated that there is a very poor correlation between CVP as a pressure reading and actual blood volume, and showed that CVP is not a reliable way to predict responsiveness to a fluid challenge; this could possibly be due to other factors, such as venous tone, intra-thoracic pressure, and ventricular compliance, influencing pressure readings

    • CVP readings should therefore be interpreted with caution, taking into account that the absolute value of the CVP reading may not be accurate, although extreme values or the CVP trend may be clinically useful while managing the fluid status of a patient.

  • stroke volume: 60–100 mL.

  • other clinical findings: FTc, SVV, GEDV, ITBV, EVLW, PAWP (see Generic care of the critically ill patient p. [link] for normal values for these types of haemodynamic monitoring values, depending on the type of monitoring device used), to help to guide fluid management strategies (e.g. PiCCO, LiDCO, Doppler, or pulmonary artery catheter).

IV therapy: fluids and electrolytes

The administration of IV fluids and electrolytes requires clinical decision making about the type of solution to be given (see Generic care of the critically ill patient p. [link]), the rate of delivery, and the total volume to be infused within a set period of time. The National Institute for Health and Care Excellence (NICE)9 recommends key principles based on ‘the 5 Rs’—resuscitation, routine maintenance, replacement, redistribution, and reassessment.

Resuscitation

  • There is an urgent need for IV fluids if hypovolaemia causes decreased tissue perfusion (see Generic care of the critically ill patient p. [link]).

  • Goal-directed therapy should be used with specific end points of resuscitation identified (e.g. urine output, blood pressure, lactate, CVP) to prevent under- or over-resuscitation.

  • An initial fluid-challenge bolus of 500 mL crystalloid with Na+ in the range 130–154 mmol/L should be given, followed by further fluid challenges as required9.

  • For fluid resuscitation of trauma patients, see Generic care of the critically ill patient p. [link].

Routine maintenance

  • Give 25–30 mL/kg/day of water with 1 mmol/kg/day K+, Na+, and Cl, and 50–100 g/day glucose.9

  • Use ideal body weight for obese patients using lower-range volumes.

  • Administer with caution and consider reduced doses for patients who are older or who have renal or cardiac dysfunction.

  • Promote discontinuation of maintenance IV fluids if oral or enteral fluid intake can be established.

Replacement

  • Non-urgent replacement of fluid and electrolyte losses (e.g. losses from gastrointestinal tract, urine, fever, or burns).

  • Consider other intake from enteral nutrition and routine IV maintenance.

Redistribution

  • Consider which type of IV solution is needed to help correct internal fluid shifts (e.g. third spacing) or abnormal distribution of electrolytes.

  • Patients who are particularly at risk for fluid and electrolyte distribution abnormalities include those with:

    • gross oedema

    • severe sepsis

    • increased or decreased Na+ levels

    • decreased albumin levels

    • renal, liver, or cardiac dysfunction.

References

8 Marik PE and Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Critical Care Medicine 2013; 41: 1774–81.Find this resource:

9 National Institute for Health and Care Excellence (NICE). Intravenous Fluid Therapy in Adults in Hospital. CG174. NICE: London, 2013. Generic care of the critically ill patient www.nice.org.uk/guidance/cg174

IV fluids: crystalloids

Crystalloids are solutions that contain substances such as electrolytes and glucose. They are classified according to their osmolarity in comparison with blood tonicity (see Table 3.5).

Table 3.5 Crystalloid IV fluids

Type of fluid

Content (mmol/L)

Osmolarity (mOsm/L)

0.9% NaCl

Isotonic

Na+ 154 Cl 154

308

Hartmann’s solution

Isotonic

  • Na+ 131 Cl 111

  • K+ 5 Ca2+ 2

  • HCO3 29 (lactate)

278

Lactated Ringer’s solution

Isotonic

  • Na+ 130 Cl 109

  • K+ 4 Ca2+ 3

  • HCO3 28 (lactate)

273

  • 0.18% NaCl

  • Glucose 4%

Hypotonic

  • Na+ 31 Cl 31

  • Glucose 40 g/L

284

0.45% NaCl

Hypotonic

Na+ 77 Cl 77

154

Glucose 5%

Hypotonic

Glucose 50 g/L

278

3% NaCl

Hypertonic

Na+ 513 Cl 513

1026

Isotonic saline

  • This consists of 0.9% NaCl, available premixed with or without K+ added.

  • Fluid is distributed throughout the extracellular space (30% as intravascular fluid and 70% as interstitial fluid). If present in large amounts it contributes to oedema.

  • High Cl content can cause hyperchloraemic metabolic acidosis.

  • High Na+ content can cause increased intravascular Na+ and water retention.

Indications

  • Fluid resuscitation—it is the safest IV fluid to give initially for hypovolaemia, until the patient’s full fluid and electrolyte status is known.

  • Maintenance IV fluid therapy.

Contraindications

  • Hypernatraemia.

Balanced isotonic crystalloid solutions

  • Examples include:

    • Hartmann’s solution (compound sodium lactate)

    • Lactated Ringer’s solution.

  • Fluid is distributed throughout the extracellular space. However, due to lower levels of Na+ and Cl, there is less Na+ retention, water retention, and hyperchloraemia compared with isotonic saline.

  • Include K+, Ca2+, and lactate (which is converted into HCO3 by the liver).

Indications

  • Fluid resuscitation.

  • Maintenance IV fluid therapy.

Contraindications

  • Liver dysfunction (because the liver is unable to convert lactate into HCO3).

  • Lactic acidosis.

  • Hyperkalaemia.

Hypotonic crystalloid solutions

  • Examples include:

    • 0.18% NaCl/4% glucose

    • 0.45% NaCl

    • 5% glucose—isotonic in the bag, but considered to be hypotonic because glucose is quickly metabolized, leaving free water.

  • Fluid is distributed across both the intracellular and extracellular (interstitial and vascular) spaces.

Indications

  • Cellular dehydration.

  • Hypernatraemia.

Contraindications

  • Raised ICP (hypotonicity will increase cerebral oedema).

  • Hypotension.

  • Hyponatraemia.

Hypertonic crystalloid solutions

  • Examples include 3% NaCl and 7% NaCl.

  • Promote rapid intravascular volume expansion with a relatively reduced water content compared with other IV fluids.

  • Should be used with caution because of the potential for heart failure due to fluid overload, hypernatraemia, and hyperchloraemia.

Indications

  • Raised ICP.

  • Hypovolaemia due to trauma, although further research is needed.

Contraindications

  • Fluid overload.

  • Hypernatraemia.

Further reading

Bauer M et al. Isotonic and hypertonic crystalloid solutions in the critically ill. Best Practice & Research. Clinical Anaesthesiology 2009; 23: 173–81.Find this resource:

Lobo DN et al. Basic Concepts of Fluid and Electrolyte Therapy. Bibliomed: Melsungen, Germany, 2013.Generic care of the critically ill patienthttp://www.bbraun.com/documents/Knowledge/Basic_Concepts_of_Fluid_and_Electrolyte_Therapy.pdf

Williams E and von Fintel N. Hypertonic saline: a change of practice. Nursing in Critical Care 2012; 17: 99–104.Find this resource:

IV fluids: colloids

Colloids are solutions that contain macromolecules (e.g. starch or protein) which increase the oncotic pressure, resulting in plasma volume expansion. There has been a recent move towards discouraging the use of colloids for fluid resuscitation of critically ill patients because of the following:

  • Colloids do not improve survival and have an increased financial cost compared with crystalloids.10

  • The CHEST trial showed that there is no significant difference in mortality between patients who receive crystalloid and those given hydroxyethyl starch (HES), and there is an increased need for renal replacement therapy with HES use.11

  • Septic patients who receive HES (compared with crystalloid or albumin) have an increased need for renal replacement therapy and transfusion of red blood cells, and an increased risk of serious adverse events.12

  • A significant number of publications about HES by Joachim Boldt have been withdrawn due to his fraudulent colloid research.13

The current literature therefore suggests that the routine use of colloids for the fluid resuscitation of critically ill patients should be avoided. However, there may be a role for albumin administration in patients with severe sepsis, or as a replacement fluid after ascites has been drained (see Generic care of the critically ill patient p. [link]). Further research is needed to clarify the role of albumin as a colloid in the critical care setting.

References

10 Perel P, Roberts I and Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2013; Issue 2: CD000567. Generic care of the critically ill patient http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000567.pub6/pdfFind this resource:

11 Myburgh JA et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. New England Journal of Medicine 2012; 367: 1901–11.Find this resource:

12 Haase N et al. Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysis. British Medical Journal 2013; 346: f839.Find this resource:

13 Wise J. Boldt: the great pretender. British Medical Journal 2013; 346: f1738.Find this resource:

Nutrition: critical care implications

Nutrition should be given via the oral, enteral, or parenteral route as appropriate, depending on the clinical context and the type of feeding tolerated by the patient (for an overview of assessment of the nutritional status of the critically ill patient, see Generic care of the critically ill patient p. [link]). Factors that influence how nutrition is delivered include:

  • level of consciousness

  • the presence of an endotracheal tube or tracheostomy

  • the patient’s ability to swallow

  • the level of function of the gastrointestinal tract.

In the acute phase of critical illness, nutrition should provide sufficient calories and protein to maintain body weight and reduce nitrogen loss. The level of catabolism associated with the stressed state of critical illness does not allow the replenishment of body stores until the recovery phase, which puts critically ill patients at risk for malnutrition. It is estimated that 45% of intensive care unit patients are malnourished.14 Table 3.6 compares malnutrition due to starvation with malnutrition of critical illness.

Table 3.6 Comparison of malnutrition caused by starvation and critical illness

Starvation

Critical Illness

Cause

Insufficient storage of essential nutrients

Abnormal processing of nutrients

Treatment

Increase in nutrient intake

Resolution of cause of critical illness, not just increased intake of nutrients

Consequences of malnutrition

  • Decreased immune function, ventilatory drive, and respiratory muscle strength.

  • Increased ventilatory dependence, infections, and morbidity and mortality.

Reference

14 Racco M. Nutrition in the ICU. RN 2009; 72: 26–31.Find this resource:

Further reading

British Association for Parenteral and Enteral Nutrition. Generic care of the critically ill patient www.bapen.org.uk

Critical Care Nutrition. Generic care of the critically ill patient www.criticalcarenutrition.com

European Society for Clinical Nutrition and Metabolism. Generic care of the critically ill patient www.espen.org

Faber P and Siervo M, eds. Nutrition in critical care. Cambridge University Press: Cambridge, 2014.Find this resource:

McClave SA et al. Feeding the critically ill patient. Critical Care Medicine; 2014 42: 2600–10.Find this resource:

Nutrition: daily requirements

Tables 3.7, 3.8, 3.9, and 3.10 list the recommended daily requirements for nutrients, electrolytes, trace elements, and vitamins (these tables are intended to serve as a guide, and each patient should be assessed individually).

Table 3.7 Daily nutrient requirements

Nutrient

Amount per day

Influencing factors

Protein (nitrogen)

  • 0.7–1.0 g/kg/day

  • (0.15–0.3 g/kg/day)

Hypermetabolism can increase protein requirements to 1.5–2.0 g/kg/day

Carbohydrate

  • Amount needed will depend on the patient’s energy requirements, two-thirds of which are usually provided by carbohydrate, and one-third by fat

  • A useful quick estimate of requirements is:

  • Male: 25–30 kcal/kg/day

  • Female: 20–25 kcal/kg/day

Patients with respiratory insufficiency or weaning after long-term ventilation may not handle the amount of carbon dioxide produced when intake exceeds requirement. Ratios of fat to carbohydrate should be changed to 50:50

Fat

  • Only necessary in very small amounts to prevent fatty acid deficiency. Usually the amount delivered contributes to providing energy. It represents between one-third and one-half of the total number of calories required

  • A useful quick estimate of requirements is 0.8–1.0 g/kg/day

Tolerance of intravenous fat can be limited (see Generic care of the critically ill patient p. [link] on parenteral nutrition complications), and the amount delivered may need to be adjusted if this is the case

Table 3.8 Daily electrolyte requirements

Typical daily requirement

Additional factors

Sodium 70–100 mmol/day

More may be needed with loop diuretic therapy or during increased gastrointestinal losses (e.g. due to diarrhoea or fistulae)

Less may be needed in oedema and hypernatraemia

Potassium 70–100 mmol/day

More may be needed during early repletion, post-obstructive diuresis, loop diuretic therapy, and increased gastrointestinal losses

Less may be required in renal failure

Magnesium 7.5–10 mmol/day

As above

Calcium 5–10 mmol/day

Phosphate 20–30 mmol/day

More may be needed in early nutritional repletion, when there may be dramatic falls in serum phosphate levels (see Generic care of the critically ill patient p. [link] on refeeding syndrome)

Less may be required with renal dysfunction

Table 3.9 Daily trace element requirements

Recommended daily requirement

Effects of deficiency

Enteral nutrition (µmol/L)

Parenteral nutrition (µmol/L)

Zinc

110–145

145

Impaired cellular immunity, poor wound healing, diarrhoea

Chromium

0.5–1.0

0.2–0.4

Insulin-resistant glucose intolerance, elevated serum lipids

Copper

16–20

20

Hypochromic microcytic anaemia, neutropenia

Iodine

1–1.2

1.0

Selenium

0.8–0.9

0.25–0.5

Cardiomyopathy

Molybdenum

0.5–4.0

0.2–1.2

Manganese

30–60

5–10

CNS dysfunction

Fluoride

95–150

50

Table 3.10 Daily vitamin requirements

Vitamin

Recommended daily requirement

Enteral nutrition

Parenteral nutrition

A (retinol) 5000 (mcg)

600–1200

800–2500

B1 (thiamine) (mg)

0.8–1.1

3–20

B2 (riboflavin) (mg)

1.1–1.3

3–8

Niacin (mg)

2–18

40

B6 (pyridoxine) (mg)

1.2–2.0

4.0–6.0

B12 (cyanocobalamin) (mcg)

1.5–3.0

5–15

C (ascorbic acid) (mg)

40–60

100

D (cholecalciferol) (mcg)

5

5

E (δ‎- and α‎-tocopherol) (mg)

10

10

Folic acid (mcg)

200–400

200–400

K (phytomenadione) (mcg/kg)

1

0.03–1.5

Pantothenic acid (mg)

3–7

10–20

Biotin (mcg)

10–200

60

Enteral nutrition

If the patient is unable to take food orally, enteral nutrition is the preferred route (its advantages and disadvantages are listed in Boxes 3.3 and 3.4). The local protocol for enteral nutrition should be followed. This typically involves initiating enteral nutrition at 30 mL/h within 24–48 h following admission, checking gastric residuals every 4 h (see Generic care of the critically ill patient p. [link]), and increasing the feeds as tolerated until the target enteral feeding rate has been reached. Safe delivery of enteral feeding requires ongoing monitoring of tube placement and integrity, checking for tolerance of the feed, and ensuring that the required volumes are delivered.

Types of enteral feeding tubes

Wide-bore feeding tubes

  • Sizes 12–16 Fr.

  • Made from polyvinylchloride (PVC).

  • Short-term use (< 10 days) because gastric acid degrades PVC.

  • Also used for gastric drainage, aspiration, and decompression.

Fine-bore feeding tubes

  • Sizes 8–10 Fr.

  • Made from a range of materials.

    • PVC tubes should not be used for more than 14 days.

    • Polyurethane can be used for longer periods (e.g. up to 6 weeks: always check the manufacturer’s guidelines), and is the material of choice for enteral feeding.

  • Available with or without a guidewire and weighted tip.

Feeding tube position

Placement of all enteral tubes should be documented, including the time, date, length of insertion, and position site (see Table 3.11). It is also important to check that the feeding tube is in the correct position after the initial insertion, before commending feeds, prior to giving medications if feeds are not in progress, and if there are physical signs of possible displacement (e.g. vomiting, regurgitation, excessive coughing, or prolonged hiccupping). This checking process should follow the guidelines issued by the National Patient Safety Agency.15

  • X-ray is the most reliable method of assessing the feeding tube position.

  • pH paper:

    • Only use pH indicator paper that is made specifically for checking gastric aspirate and which is CE marked.

    • The pH of gastric content aspirates should be in the range 1–5.5.

    • pH paper is of limited use in critical care because continuous enteral feeding and proton pump inhibitors increase the gastric pH. A high pH value may then be misinterpreted as the feeding tube being placed in the small intestine or lungs when it is in fact in the stomach.

Table 3.11 Feeding tube position sites

NG

Nasogastric

Routine route for establishing enteral feeding

OG

Orogastric

Used for patients with basal skull or facial fractures

ND

Nasoduodenal

Post-pyloric enteral feeding

NJ

Nasojejunal

PEG

Percutaneous gastrostomy

Long-term enteral feeding

PEJ

Percutaneous jejunostomy

Long-term enteral feeding

Types of enteral feeds

  • Standard:

    • 1 kcal/mL with or without fibre (routine feeding).

  • High energy:

    • 1.2–2 kcal/mL (fluid restriction or increased caloric requirements).

  • Low energy:

    • 0.5–1 kcal/mL (long-term feeding with reduced caloric requirements).

  • Elemental or peptide:

    • proteins provided as free amino acids or peptides to aid digestion (e.g. in pancreatic insufficiency or inflammatory bowel disease).

  • Therapeutic:

    • tailored to specific conditions (e.g. renal, cardiac, respiratory, or immune modulating).

  • Probiotic supplements:

    • may help to restore the flora of the gastrointestinal tract and decrease VAP, although further research is needed to confirm this.16,17

Post-pyloric feeding

Post-pyloric feeding occurs when the tip of the feeding tube sits past the stomach through a nasoduodenal (ND), nasojejunal (NJ), or percutaneous jejunostomy (PEJ) tube. Insertion of an ND or NJ tube can be done at the bedside using prokinetics (e.g. metoclopramide, erythromycin) to aid the advancement of the tip of the feeding tube into the small intestine. Alternatively, endoscopy or fluoroscopy may be required for ND or NJ tube placement, and a PEJ tube is surgically placed for long-term feeding.

The time, cost, and expertise required for post-pyloric feeding limit its routine use, and debate continues as to its benefits compared with gastric tube feeding. However, the possible benefits of post-pyloric feeding include decreased gastric residual volume (GRV), a reduced risk of aspiration pneumonia, and increased delivery of required calories.18,19

Indications for post-pyloric feeding

  • High GRV that is not responsive to prokinetics (see Generic care of the critically ill patient p. [link]).

  • Acute pancreatitis.

  • Gastric outlet stenosis.

  • Hyperemesis.

  • Frequent pulmonary aspiration.

Complications of enteral feeding

  • Mechanical (tube related):

    • Knotting of the tube can occur with increased curling in the stomach. Endoscopic or even surgical removal may be necessary.

    • Clogging or blockage can occur due to fragments of inadequately crushed tablets, adherence of feed residue, or incompatibilities between feed and medication given (e.g. phenytoin). Tablets should be crushed and dissolved well, or soluble forms of drugs used if available. The feeding tube should be flushed with 20 mL of water after drug delivery or aspiration checks.

    • Incorrect placement (usually in the bronchial tree).

    • Nasopharyngeal erosion and discomfort—the patient’s nostrils should be checked for signs of pressure externally, and the tube should not be left in for longer than the recommended time.

    • Sinusitis and otitis—the tube should be changed at the recommended intervals.

    • Oesophageal reflux and oesophagitis—tube placement should be checked regularly and the patient nursed at 45°.

    • Tracheo-oesophageal fistula—the tube should be changed at the recommended intervals, and never use force when placing the tube. Consideration should be given to placing a PEG if the tube is likely to remain in for longer than 12 weeks.

  • Nausea and vomiting (see Generic care of the critically ill patient p. [link]).

  • Pulmonary aspiration.

  • Diarrhoea (see Generic care of the critically ill patient p. [link]).

  • Abdominal distension and/or delayed gastric emptying caused by:

    • critical illness and altered immune system

    • feed formula (associated with high density and high lipid content)

    • medications (e.g. opiates)

    • ileus

    • gastric atony

    • medical conditions (e.g. pancreatitis, diabetes, malnutrition, or post-vagotomy).

  • Cramping.

  • Constipation (see Generic care of the critically ill patient p. [link]).

  • Hyperglycaemia.

  • Electrolyte and trace element abnormalities.

  • Hypercapnia:

    • higher than required levels of carbohydrate in feeds can produce large amounts of CO2 that require increased minute volumes and respiratory rate in order to be excreted

    • this may precipitate ventilatory failure in a patient with compromised respiratory function or during weaning of a patient. Accurate calculation of the patient’s nutritional requirements is essential.

References

15 National Patient Safety Agency (NPSA). Reducing the Harm Caused by Misplaced Nasogastric Feeding Tubes in Adults, Children and Infants. NPSA: London, 2011. Generic care of the critically ill patient www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=129697?Find this resource:

16 Morrow LE, Gogineni V, and Malesker MA. Probiotics in the intensive care unit. Nutrition in Clinical Practice 2012; 27: 235–41.Find this resource:

17 Petrof EO et al. Probiotics in the critically ill: a systematic review of the randomized trial evidence. Critical Care Medicine 2012; 40: 3290–302.Find this resource:

18 Jiyong J et al. Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients: observations from traditional and Bayesian random-effects meta-analysis. Clinical Nutrition 2013; 32: 8–15.Find this resource:

19 Zhang Z et al. Comparison of postpyloric tube feeding and gastric tube feeding in intensive care unit patients: a meta-analysis. Nutrition in Clinical Practice 2013; 28: 371–80.Find this resource:

Further reading

Kreymann KG et al. ESPEN guidelines on enteral nutrition: intensive care. Clinical Nutrition 2006; 25: 210–23. Generic care of the critically ill patient http://espen.info/documents/ENICU.pdfFind this resource:

Medlin S. Recent developments in enteral feeding for adults: an update. British Journal of Nursing 2012; 21: 1061–7.Find this resource:

Simons SR and Abdallah LM. Bedside assessment of enteral tube placement: aligning practice with evidence. American Journal of Nursing 2012; 112: 40–46.Find this resource:

Parenteral nutrition

Parenteral nutrition is indicated within 24–48 h if the following conditions are present:20

  • oral nutrition is not expected to be given within the next 3 days

  • enteral nutrition is contraindicated or not tolerated.

Boxes 3.5 and 3.6 list the advantages and disadvantages of parenteral nutrition. The parenteral feeding solution should be provided as an all-in-one, pre-mixed bag and administered through central venous access, although some solutions (e.g. < 850 mOsm/L) can be delivered via peripheral venous routes. Multiple-lumen central venous catheters can be used for parenteral nutrition delivery, so long as one lumen is dedicated solely to this. Care of the catheter must be meticulous due to the increased risk of infection. Ongoing monitoring for metabolic abnormalities (see Table 3.12) is also required while caring for a patient who is receiving parenteral nutrition.

Table 3.12 Metabolic abnormalities associated with parenteral nutrition

Hyperglycaemia

Causes include persistent gluconeogenesis, blunted insulin response, decreased sensitivity to insulin, impaired peripheral utilization of glucose or phosphate, and chromium deficiency. Late development in a stable patient may signal a new infection or complication

Hypoglycaemia

Sudden discontinuation of total parenteral nutrition (TPN) may induce hypoglycaemia, particularly if the patient is concurrently receiving insulin. Insulin should be discontinued or reduced prior to stopping TPN. If this is not possible, 10–20% glucose may be commenced. Blood glucose should be frequently monitored

Hyperlipidaemia

Lipid clearance can be impaired in liver disease. Rapid infusion of lipid may also result in transient hyperlipidaemia

Hepatic dysfunction

Abnormal liver function tests (LFTs) and fatty infiltration of the liver can develop in carbohydrate-based parenteral nutrition. It is treated by reducing the amount of calories or increasing the proportion of fat

Acid–base disturbances

Hyperchloraemia can develop from amino acid metabolism, but the resulting acidosis is usually mild, and most amino acid preparations contain acetate as a buffer. Metabolic alkalosis can be seen with diuretic use, continuous nasogastric drainage, or corticosteroid therapy if concomitant replacement of sodium, potassium, and/or chloride ions is inadequate

Electrolyte imbalance

Generally, sodium, potassium, chloride, and bicarbonate are monitored and corrected before problems occur. However, significant body deficiencies may not be reflected by plasma levels due to the effect of pH and serum albumin levels or hormonal influences, such as aldosterone or antidiuretic hormone (ADH), which are often altered in the critically ill. Occasionally, magnesium, calcium, and phosphate may become imbalanced

Metabolic abnormalities

Other complications of parenteral feeding are rare, but include:

  • precipitation of respiratory failure and failure of weaning due to excessive carbohydrate administration

  • hyperosmolar states with an excessive osmotic diuresis

  • abnormal platelet function and hypercoagulability states

  • anaemia after prolonged use of IV lipids.

Clinical guidelines for the delivery of parenteral nutrition to critically ill patients have been provided by the European Society for Clinical Nutrition and Metabolism.20 The key aspects that are relevant to critical care nursing practice are summarized here.

Caloric requirements

  • Minimize negative energy balance by providing sufficient calories as close to measured energy expenditure as possible.

  • If indirect calorimetry is not available, use a target of 25 kcal/kg/day.

  • Patients who are receiving enteral nutrition at less than the targeted dose for more than 2 days should have supplementary parenteral nutrition considered.

Carbohydrates

  • Use a minimum of 2 g/kg/day glucose.

  • Avoid hyper- and hypoglycaemia.

Lipids

  • Use 0.7–1.5 g/kg over 12–24 h.

  • Fish oils may have a role in parenteral nutrition of critically ill patients.

Amino acids

  • Use 1.3–1.5 g/kg/day of a balanced amino acid mixture.

  • Amino acid solution should include 0.2–0.4 g/kg/day of L-glutamine.

Micronutrients

  • All parenteral nutrition should include daily multivitamins and trace elements.

Reference

20 Singer P et al. ESPEN guidelines on parenteral nutrition: intensive care. Clinical Nutrition 2009; 28: 387–400. Generic care of the critically ill patient http://espen.info/documents/0909/Intensive%20Care.pdfFind this resource:

Further reading

Canadian Clinical Practice Guidelines Committee. Critical Care Nutrition. Canadian Clinical Practice Guidelines Updated in 2013. Generic care of the critically ill patient www.criticalcarenutrition.com/index.php?option=com_content&view=category&layout=blog&id=21&Itemid=10

National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Parenteral Nutrition: a mixed bag. NCEPOD: London, 2010. Generic care of the critically ill patient www.ncepod.org.uk/2010pn.htmFind this resource:

Anxiety and fear

Anxiety

Anxiety is defined as a state of disequilibrium or tension caused by apprehension of a potential non-specific threat. It is a natural response to the experience of critical illness and potential closeness of death associated with admission to critical care.

Assessment of the level of anxiety depends almost wholly on subjective judgement, as complex tools, such as the Hospital Anxiety and Depression Scale (HADS), are beyond the scope of critically ill patients to complete.

A recently developed facial expression scale for assessing anxiety has yet to be validated fully, but may help to identify anxiety in the critically ill.

Interventions to reduce anxiety

Nursing interventions that may be helpful are listed in Table 3.13.

Table 3.13 Coping mechanisms for anxiety

Patient mechanisms

Nursing interventions to enhance coping mechanism

Denial

Encouragement to verbalize fears. Recognition of the need for denial

Rationalization

Giving appropriately worded and timed information

Substituting positive thoughts for negative ones

Positive feedback for coping techniques

Retention of control of environment, timing of care, etc. (this is often via the nurse, who must facilitate this)

Facilitation of patient retention of control

Additional nursing interventions

Use of empathetic and therapeutic touch

Access to spiritual counselling as needed

Supporting unrestricted family visiting

Amelioration of environmental stressors (e.g. noise from alarms, etc.)

Offering relaxation and/or meditation techniques

Providing appropriate background music (e.g. slow, flowing rhythms)

Speaking calmly and slowly using warm tones

If necessary, administration of anxiolytics (e.g. lorazepam)

Ensuring that pain relief is adequate

Nursing presence, attentiveness, and reassurance

Providing biofeedback (e.g. patient view of heart rate on monitor)

Fear

Fear is defined as a state of distress and apprehension that causes sympathetic arousal.

The physiological response invoked by fear reflects the level of sympathetic stimulation, and is mediated by adrenaline (epinephrine) and noradrenaline (norepinephrine) release. Symptoms include:

  • increased heart rate and blood pressure

  • dilated pupils

  • dry mouth

  • peripheral and splanchnic vasoconstriction

  • sweating.

The patient’s behavioural response can be affected by their background, culture, and social conditioning.

Pain management

Pain is a complex phenomenon involving social, cultural, emotional, psychological, and physiological components. It is aggravated by anxiety and fear, and compounded in the critically ill by difficulties with communicating.

Due to communication barriers (e.g. confusion, intubation, or sedation), critically ill patients often have difficulty indicating that they are experiencing pain or discomfort. This leads to pain frequently being unrecognized and undertreated in the critical care setting.21 Critical care nurses should take an active role in the ongoing assessment of pain (see Generic care of the critically ill patient p. [link]) to enable the initiation of suitable pain management strategies. Relief of pain is important in order to:

  • improve patient comfort, and reduce emotional stress and anxiety (see Generic care of the critically ill patient p. [link])

  • reduce the physiological stress response, which can lead to increased metabolic rate and oxygen requirements, as well as increased water and sodium retention

  • promote mobility to reduce the risk of DVTs

  • promote deep breathing and coughing to reduce the risk of pneumonia

  • prevent sleep deprivation caused by discomfort (see Generic care of the critically ill patient p. [link]).

Non-pharmacological methods

  • Repositioning.

  • Massage.

  • Relaxation techniques.

  • Localized warmth for relief of aches and muscular spasms.

  • Localized cooling, particularly for burn pain.

  • Reassurance and communication to relieve underlying fear and anxiety.

  • Transcutaneous electrical nerve stimulation (TENS)—this is more successful in reducing analgesic requirements than in providing total alleviation of pain.

Pharmacological methods

Opioids are the mainstay of analgesia in critical care. They are usually delivered intravenously, and commonly by infusion to ensure consistent analgesia. Other ways to deliver analgesia include patient-controlled analgesia (PCA) (in the conscious patient), and the epidural, oral/nasogastric, intramuscular, and rectal routes. The dose depends on age, weight, haemodynamic status, and renal and hepatic function, as well as clinical effect (see Table 3.14).

Table 3.14 Doses for IV opioids

Bolus dose

Infusion

Morphine

0.1–0.2 mg/kg

0.05–0.07 mg/kg/h

Diamorphine

0.05–0.1 mg/kg

0.03–0.06 mg/kg/h

Fentanyl

5–7.5 mcg/kg

5–20 mcg/kg/h

Alfentanil

15–30 mcg/kg

20–120 mcg/kg/h

Remifentanil

1 mcg/kg

0.05–2 mcg/kg/h

Pethidine

0.5 mg/kg

0.1–0.3 mg/kg/h

Paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) can be used for less severe pain, or in addition to opioids as a background to reduce analgesic requirements. NSAIDs should be used with caution because they have a number of serious side effects, including gastrointestinal bleeding (due to increased likelihood of gastric ulceration), general bleeding (due to platelet inhibition), renal impairment, and sodium retention. Antidepressant or anticonvulsant medications (e.g. amitriptyline, gabapentin) may be considered for neuropathic pain.

Patient-controlled analgesia

PCA has the advantage of allowing the patient to be in control of the pain management, which reduces dose requirements by avoiding excessive levels of pain, and decreases the likelihood of overdose, as a drowsy patient will not self-administer ongoing doses of pain relief. Comparison of the number of demands for analgesia made by a patient with the number of delivered doses allows effectiveness to be evaluated.

Epidural

An epidural may be indicated in the critical care setting for the pain management of non-sedated patients (e.g. post-operative, trauma, or high-dependency patients with other sources of acute pain). Contraindications for an epidural include:

  • infection near the epidural insertion site

  • systemic infection

  • low blood pressure

  • coagulopathy

  • raised intracranial pressure.

Analgesia can be delivered through an epidural as intermittent boluses or as a continuous epidural infusion using an opioid, a local anaesthetic (e.g. bupivacaine), or both. Local protocols for the care of an epidural infusion should be followed, ensuring that the epidural site is monitored and the epidural pump/tubing is clearly marked as dedicated for epidural use only. The patient should also have ongoing assessment of their vital signs, pain score, sedation score, and level of motor–sensory block. Potential complications of an epidural include:

  • low blood pressure, low respiratory rate, and reduced level of consciousness (LOC)

  • nausea and vomiting

  • pruritus

  • urinary retention

  • back pain

  • leakage of cerebrospinal fluid

  • motor–sensory dysfunction (limb weakness and/or altered sensation)

  • insertion site infection or haematoma

  • local anaesthetic toxicity (mouth tingling, reduced LOC, lowered blood pressure, lowered heart rate, tinnitus, seizures, or arrhythmias).

Local protocols should be followed for removal of an epidural, with particular care taken to check that the patient has not recently had an anticoagulant, and to observe the epidural site for signs of infection or bleeding. Oral analgesia should be prescribed to ensure that the patient remains comfortable after the epidural is no longer needed.

Reference

21 Alderson SM and McKechnie SR. Unrecognised, undertreated pain in ICU: causes, effects, and how to do better. Open Journal of Nursing 2013; 3: 108–13.Find this resource:

Further reading

Barr J et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine 2013; 41: 263–306.Find this resource:

Opioids: medication review

Opioids may be administered as an analgesic primarily for pain relief, or for their sedative properties while sedating a critically ill patient. The dosage should be titrated according to the targeted patient response, with ongoing review and adjustment to ensure that the patient is not under- or over-treated. For sedated patients, there should be a daily interruption of continuous IV analgesia, with the infusion restarted as clinically appropriate. Opioids have a synergistic effect when given simultaneously with sedative medications, which allows reduced dosages of both to be given to achieve the same effect (see Table 3.14 for doses of IV opioids, and Table 3.15 for a summary of the timing and side effects of opioids).

Table 3.15 Timing and side effects of IV opioids

Timing

Side effects

Notes

Morphine

  • Onset: 5–10 min

  • Duration: 3–4 h

↓BP, ↓RR, ↓CNS, H2 release, ↓gut motility, nausea, ↑muscle tone

Poor GI absorption, accumulation in renal dysfunction, avoid with severe asthma

Diamorphine

  • Onset: 5 min

  • Duration: 2–3 h

↓BP, ↓RR, ↓CNS, H2 release, ↓gut motility, nausea, ↑muscle tone

Poor GI absorption, accumulation in renal dysfunction, avoid with severe asthma

Fentanyl

  • Onset: 1–2 min

  • Duration: 2–4 h

↓BP, ↓RR, ↓CNS, ↓gut motility, nausea, ↑muscle tone

Muscular rigidity seen with high doses

Alfentanil

  • Onset: 1–2 min

  • Duration: 30–60 min

↓BP, ↓RR, ↓CNS, ↓gut motility, nausea, ↑muscle tone

Muscular rigidity seen with high doses

Remifentanil

  • Onset: 1–2 min

  • Duration: 5–10 min

↓BP, ↓RR, ↓CNS, ↓gut motility, nausea, ↑muscle tone

Ultra-short-acting, may cause rebound pain if stopped suddenly

Pethidine

  • Onset: 5–10 min

  • Duration: 2–4 h

↓BP, ↓RR, ↓CNS, H2 release, ↓gut motility, nausea, ↑muscle tone

Respiratory depression despite maintained RR, seizures with accumulation

BP, blood pressure; RR, respiratory rate; CNS, central nervous system; GI, gastrointestinal.

Patients with renal or liver dysfunction may require careful assessment to identify whether a reduced opioid dosage is needed due to metabolite accumulation, which increases both therapeutic and adverse effects. Alternatives to morphine (e.g. fentanyl, alfentanil, or remifentanil) should also be considered if there is renal impairment, or if a short-acting analgesic is required. Remifentanil differs from other opioids in that it is metabolized by blood and tissue esterases rather than by the liver. With such an extremely rapid onset, metabolism, and excretion, there is no residual analgesia after a remifentanil infusion is turned off, and therefore another analgesic needs to be provided after discontinuing remifentanil if discomfort is likely to persist.

Further reading

Erstad BL et al. Pain management principles in the critically ill. Chest 2009; 135: 1075–86.Find this resource:

Sedation management

Possible reasons for using sedative medications in critically ill patients include:

  • alleviation of anxiety

  • relief of discomfort

  • promotion of sleep

  • facilitation of procedures or treatment

  • obtundation of detrimental physiological responses (e.g. increased FiO2 requirements, raised intracranial pressure).

If the clinical context requires the patient to be kept continuously sedated, it is important for the nurse to ensure that an appropriate amount of sedative medication is administered to achieve the optimal sedation level required at that particular time. Ideally, the patient should be kept as lightly sedated as possible to prevent the complications of over-sedation (in particular, prolonged mechanical ventilator days and incidence of delirium, which both significantly contribute to increased ICU length of stay and patient discomfort). Table 3.16 lists the consequences of under-sedating and over-sedating patients.

Table 3.16 Sedation practice

Under-sedation

Over-sedation

  • Problems with ventilation

  • Ventilation/perfusion (V/Q) mismatch

  • Accidental extubation

  • Catheter displacement

  • Cardiac stress

  • Anxiety

  • Post-traumatic stress disorder

  • Prolonged mechanical ventilation

  • Weaning difficulties

  • Tolerance of sedatives

  • Withdrawal syndrome

  • Delirium

  • Cardiovascular depression

  • Sleep disturbances

Factors that influence the response to sedatives

  • Kidney dysfunction.

  • Liver dysfunction.

  • Advanced age.

  • Malnutrition, fat and muscle mass, and high total body water.

  • Increased volume distribution.

  • Slow metabolism.

  • Underlying illness.

  • Substance misuse:

    • patients with a history of alcohol and/or drug misuse may require higher doses of analgesia and sedation

    • withdrawal symptoms (e.g. raised blood pressure, tachycardia, tachypnoea) may occur with interruptions to sedation.

  • Chronic medication use.

  • Polypharmacy.

Patient-oriented goal-directed sedation

  • Use a sedation scoring tool, to identify a specific target sedation level.

  • The target sedation level for most patients is a calm patient who is easily aroused and who maintains a diurnal rhythm that is normal for them.

    • Specific circumstances may require deeper sedation (e.g. facilitation of ‘difficult to tolerate’ modes of ventilation such as inverse ratio ventilation, hypoxaemia on maximal oxygen therapy, raised intracranial pressure).

    • Patients who require pharmacological paralysis (see Generic care of the critically ill patient p. [link]) must be deeply sedated prior to giving them a neuromuscular blocker.

    • Some patients will tolerate an endotracheal tube with no or minimal sedation, and patients with a tracheostomy may not need any sedatives.

  • Sedative drug doses should be adjusted and infusion rates titrated according to ongoing hourly monitoring to maintain the target level of sedation.

  • Bispectral index (BIS) monitoring may help with sedation assessment (see Generic care of the critically ill patient p. [link]).

  • Consider the need for pain relief before administering sedatives.

    • Analgesics can provide some degree of sedative effect.

    • A hypnotic or anxiolytic should then only be given if the patient needs it in order to reach the identified sedation-level goal.

  • Non-pharmacological interventions that may help to alleviate discomfort, relieve anxiety, and keep the patient safe while reducing or stopping sedative infusions include:

    • frequent reassurance and reorientation by the nurse

    • physical contact and communication by the family

    • holding the patient’s hands to prevent them from pulling out the endotracheal tube, intravenous lines, nasogastric tube, Foley catheter, or other drains or lines.

Daily interruption of sedation (DIS)

  • Sedation target and dosage should be assessed daily in order to determine whether continuous infusions can have their rate reduced or be stopped.

  • Landmark clinical trials by Kress and colleagues22 and Girard and colleagues23 showed that DIS resulted in:

    • a reduction in the duration of mechanical ventilation

    • an increase in spontaneous breathing while being mechanically ventilated

    • a reduction in the length of ICU stay and hospital stay .

    • a decrease in the amount of sedative medication needed to achieve the target sedation level

    • a reduced requirement to assess altered mental status using radiological studies.

  • Research by Mehta and colleagues24 did not show that DIS improved length of ICU stay, the number of ventilator days, or the incidence of delirium, and suggested that more daily sedative medication is needed because of sedation boluses required after DIS.

    • Current practice promotes minimal sedative administration and use of shorter-acting drugs, which may explain these results compared with earlier research when patients were kept deeply sedated.

    • Even if DIS is not undertaken, only the minimum amount of sedation drug necessary should be used to maintain the target sedation level.

    • DIS is included in the ventilation care bundle (see Generic care of the critically ill patient p. [link]).

    • DIS is referred to as ‘spontaneous awakening trial’ in the ‘Wake Up and Breathe’ protocol25 (see Figure 3.2).


Figure 3.2 ‘Wake Up and Breathe’ protocol. SAT, spontaneous awakening trial; SBT, spontaneous breathing trial.

Figure 3.2 ‘Wake Up and Breathe’ protocol. SAT, spontaneous awakening trial; SBT, spontaneous breathing trial.

(Reproduced with permission of Vanderbilt University © 2008.)

References

22 Kress JP et al. Daily interruption of sedative infusions reduced duration of mechanical ventilation and intensive care unit stay in critically ill patients. New England Journal of Medicine 2000; 342: 1471–7.Find this resource:

23 Girard TD et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371: 126–34.Find this resource:

24 Mehta S et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. Journal of the American Medical Association 2012; 308: 1985–92.Find this resource:

25 Vanderbilt University. 2008. “Wake Up and Breathe” Protocol. Generic care of the critically ill patient www.icudelirium.org/docs/WakeUpAndBreathe.pdf

Further reading

Barr J et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine 2013; 41: 263–306.Find this resource:

Sedatives: medication review

Table 3.17 lists the definitions of sedation-related medication properties, and Table 3.18 summarizes the classification of medications used during the sedation of critically ill patients.

Table 3.17 Medication properties

Analgesic

↓ Pain and discomfort

Sedative

↓ Level of consciousness

Anxiolytic

↓ Anxiety

Hypnotic

Maintains loss of consciousness

Amnesic

Causes loss of memory

Muscle relaxant

↓ Skeletal muscle tone

Anticonvulsant

↓ Seizures

Table 3.18 Drugs used for sedated patients

Opioids

Morphine, fentanyl, alfentanil, remifentanil See Generic care of the critically ill patient p. [link]

Benzodiazepines

Midazolam, lorazepam, diazepam

α‎2-Agonists

Clonidine, dexmedetomidine

Anaesthetics

Propofol, ketamine, etomidate

Barbiturates

Thiopental, phenobarbital

Neuromuscular blocking agents

Suxamethonium, rocuronium, cisatracurium See Generic care of the critically ill patient p. [link]

Antipsychotics

Haloperidol, olanzapine

Benzodiazepines

Benzodiazepines are commonly used in critical care for their multifactorial effects, which include sedative, anxiolytic, hypnotic, amnesiac, and muscle relaxant properties. They are mainly administered intravenously and in combination with analgesia. For patients with renal dysfunction, use benzodiazepines with caution—reduce the dosage, perform daily interruption to prevent over-sedation, or consider using an alternative drug.

Propofol

Developed as an anaesthetic agent, propofol is now used in lower doses for short-term sedative infusions (48–72 h). It has vasodilator and negative inotropic properties, and should be used with caution if hypovolaemia has not been fully corrected or cardiac function is poor.

There is an increased risk of propofol infusion syndrome with prolonged use at high doses along with the administration of catecholamines or steroids (see Box 3.7). Caution is needed when administering an IV infusion for more than 48 h, and there is a higher incidence of propofol infusion syndrome with children, teenagers, and head injury patients.

α‎2-Agonists

These act as synergistic analgesics with opiates, but cause minimal respiratory depression and the patient is easily rousable. Side effects include hypotension and bradycardia, and the patient will experience a dry mouth. Although adverse effects need to be considered and long-term outcomes are not yet known, clinical trials indicate that dexmedetomidine reduces the number of mechanical ventilator days and allows patients to communicate their pain better compared with midazolam and propofol.26,27

Ketamine

This is an anaesthetic agent that is also a powerful analgesic. It is associated with good airway maintenance, spontaneous respiration, bronchodilation, and cardiovascular stimulation. Side effects include hypertension and tachycardia as well as hallucinations and psychotic episodes, which usually require concurrent benzodiazepines to invoke amnesia.

Antipsychotics

Antipsychotics may have a role in the management of delirium (see Generic care of the critically ill patient p. [link]). Caution is necessary, as arrhythmias and extrapyramidal disorders are associated with their use.

References

26 Jakob SM et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. Journal of the American Medical Association 2012; 307: 1151–60.Find this resource:

27 Reardon DP et al. Role of dexmedetomidine in adults in the intensive care unit: an update. American Journal of Health-System Pharmacy 2013; 70: 767–77.Find this resource:

Pharmacological paralysis

Neuromuscular blocking agents (NMBAs) are muscle relaxants that block synaptic transmission at the neuromuscular junction of skeletal muscle, causing therapeutic paralysis. Table 3.19 provides rationales for and clinical examples of paralysis of critical care patients. Ongoing paralysis should be avoided if at all possible, due to the need for concurrent deep sedation and the risk of potential complications. However, administering an NMBA as a continuous infusion during the early phase of ARDS improves patient outcomes without increasing ICU-acquired muscle weakness.28,29

Table 3.19 Indications for pharmacological paralysis

Indication

Rationale

Clinical examples

Endotracheal intubation

Relaxes vocal cords

  • Mechanical ventilation

  • Airway protection

Problems with mechanical ventilation

  • Improves chest wall compliance

  • ↓ Airway resistance causing high airway pressures

  • ARDS

  • Severe asthma

  • Bronchoconstriction

  • Prone position

High ICP

↓ Cerebral oxygen requirements

  • Traumatic brain injury

  • Post-operative neuro-surgery

  • Cerebral oedema

Muscle abnormality

  • ↓ Seizures

  • ↓ Shivering

  • ↓ Hypertonicity

  • Status epilepticus

  • Hypothermia

  • Tetanus

Investigations and interventions

Paralysis may be required for specific tests and procedures relevant to the critical care setting

  • Bronchoscopy

  • Tracheostomy

  • CT or MRI scan

  • Patient transport

Potential complications

  • Suppression of cough and gag reflexes:

    • increased oral and pulmonary secretions

    • atelectasis

    • increased risk of pneumonia.

  • Critical illness polyneuropathy and critical illness myopathy:

    • increased risk with prolonged paralysis

    • increased risk if NMBA is administered concurrently with steroids

    • respiratory muscle weakness—increased weaning duration

    • long-term muscle weakness.

Nursing management

  • For nursing care during endotracheal intubation, see Generic care of the critically ill patient p. [link].

  • Ensure that an Ambu bag is kept at the patient’s bedside in case accidental extubation occurs.

  • Mechanically ventilate the patient using a controlled mode of ventilation.

  • Establish deep sedation prior to paralysing the patient, and use BIS monitoring for continuous assessment of sedation level.

  • For ongoing paralysis, consider stopping NMBA infusion daily to ensure that the patient remains sufficiently sedated and to assess whether there is still a need for the NMBA infusion.

  • Keep the patient’s eyelids closed and provide frequent eye care for corneal protection due to loss of the blink reflex (see Generic care of the critically ill patient p. [link]).

  • Peripheral nerve stimulator:

    • This ensures that the minimum amount of NMBA is given without over- or under-paralysing the patient.

    • Monitor the degree of blockade using the train-of-four method (see Table 3.20).

    • Titrate the NMBA to maintain 1–2 twitches.

  • Perform regular head-to-toe assessment, but bear in mind that:

    • the patient will not be able to communicate or indicate if they are in pain

    • pupil reaction is the only relevant neurological assessment (GCS score and peripheral motor–sensory function tests will not be accurate)

    • NMBAs will mask muscle activity, so abnormalities such as seizures, shivering, and abdominal rigidity may go undetected.

  • Stop administering the NMBA as a continuous infusion as soon as it is clinically appropriate, and restart only if necessary.

  • Educate the patient’s family about the need to paralyse the patient.

Table 3.20 Train-of-four assessment

Number of twitches after peripheral stimulation

Degree of blockade

Outcome

4

0–75%

Under-paralysed

3

80%

Under-paralysed

2

85%

Goal achieved

1

90%

Goal achieved

0

100%

Over-paralysed

References

28 Alhazzani W et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Critical Care 2013; 17: R43.Find this resource:

29 Neto AS et al. Neuromuscular blocking agents in patients with acute respiratory distress syndrome: a summary of the current evidence from three randomized controlled trials. Annals of Intensive Care 2012; 2: 33.Find this resource:

Neuromuscular blocking agents (NMBAs): medication review

Depolarizing NMBAs

  • Depolarize the plasma membrane of skeletal muscle.

  • Persistent depolarization caused by the drug makes muscle fibres resistant to further stimulation by acetylcholine.

  • Suxamethonium chloride (succinylcholine chloride) is the only depolarizing NMBA available (see Table 3.21).

  • Commonly used for rapid sequence induction prior to endotracheal intubation.

Table 3.21 Suxamethonium chloride (succinylcholine chloride)

Clinical information

Side effects

Contraindications

  • Onset: 30–60 s

  • Duration: 4–6 min

  • Intubation dosage: 1–1.5 mg/kg IV

  • Elimination: plasma cholinesterase

  • Hyperkalaemia

  • Bradycardia

  • Ventricular arrhythmias

  • Hypotension

  • ↑ Intra-ocular pressure

  • ↑ Intragastric pressure

  • ↑ Intracranial pressure

  • Malignant hyperthermia

  • Myalgia

  • Hyperkalaemia

  • Major trauma

  • Severe burns

  • Spinal cord injury

  • Low plasma cholinesterase activity (e.g. severe liver disease)

  • Muscular dystrophy

Non-depolarizing NMBAs

  • Compete with acetylcholine by binding to receptors at the neuromuscular junction to prevent acetylcholine from stimulating receptors.

  • Reversed by anticholinesterases (e.g. neostigmine).

  • For a comparison of various non-depolarizing NMBAs, see Table 3.22.

Table 3.22 Non-depolarizing NMBAs

Drug

Timing

Dosage

Atracurium

Onset: 2–3 min

Initial 300–600 mcg/kg IV injection

Duration: 25–35 min

270–1770 mcg/kg/h IV infusion

Cisatracurium

Onset: 2–3 min

Initial 150 mcg/kg IV injection

Duration: 25–45 min

30–600 mcg/kg/h IV infusion

Rocuronium

Onset: 30–60 s

Initial 600 mcg/kg IV injection

Duration: 30–40 min

300–600 mcg/kg/h IV infusion

Vecuronium

Onset: 1–2 min

Initial 80–100 mcg/kg IV injection

Duration: 20–30 min

0.8–1.4 mcg/kg/min infusion

Pancuronium

Onset: 2–3 min

Initial 100 mcg/kg IV injection

Duration: 90–100 min

60 mcg/kg IV every 60–90 min

Aminosteroids: rocuronium, vecuronium, and pancuronium

  • Eliminated by the liver.

  • Not associated with histamine release.

Benzylisoquinolinium class of drugs: atracurium and cisatracurium

  • Histamine release occurs with atracurium but not with cisatracurium.

  • Metabolized by Hoffman degradation and ester hydrolysis in the plasma (elimination is independent of the liver and kidneys).

Factors that enhance the effect of NMBAs

  • Acid–base imbalance (acidosis and alkalosis).

  • Hypothermia.

  • Electrolyte imbalance (↓K+, ↓Na+, ↓Ca2+, ↑Mg2+).

  • Neuromuscular disease.

  • Medications:

    • depolarizing—neostigmine, metoclopramide, esmolol, etomidate.

    • non-depolarizing—Ca2+-channel blockers, aminoglycosides, erythromycin, clindamycin, metronidazole, immunosuppressants, lithium, H2-receptor antagonists.

Further reading

Gupta A and Singh-Radcliff N (eds). Pharmacology in Anesthesia Practice. Oxford University Press: Oxford, 2013.Find this resource:

Smith S, Scarth E and Sasada M. Drugs in Anaesthesia and Intensive Care, 4th edn. Oxford University Press: Oxford, 2011.Find this resource:

Sleep

Critically ill patients have disrupted circadian rhythms due to the severity of the underlying illness or injury causing changes to adrenocorticotropic hormone and melatonin levels, the physical environment of the critical care setting, and alterations of the light–dark cycle. An altered sleep pattern can then result in the patient sleeping during the day instead of at night, sleep fragmentation (frequently waking), and reduced slow-wave sleep (SWS) and rapid eye movement (REM) stages of sleep. Critical care patients commonly suffer from sleep deprivation, and this is significant because sleep is needed for the growth and rejuvenation of the immune system.30

Table 3.23 outlines a structured approach to assessment of sleep.

Table 3.23 Sleep assessment

Quantity*

How many hours the patient has slept in a 24-h period

Distribution over 24 h

Timing of the sleep in relation to day and night

Continuity

How long sleep continued without being interrupted

* Assessment of quality of sleep is difficult because it requires polysomnography, which is not readily available to critical care nurses.

Pharmacological sedation vs. physiological sleep

  • Benzodiazepines increase level 2 sleep and total sleep time but decrease SWS and REM sleep.

  • Non-benzodiazepine hypnotics increase SWS and REM sleep.

  • Sedative medications may increase quantity of sleep, but sleep fragmentation where the patient is frequently woken up decreases quality of sleep.

Effects of sleep deprivation

  • Increased risk of delirium.

  • Increased risk of post-traumatic stress disorder.

  • Increased sympathetic stimulation.

  • Reduced immune function.

  • Respiratory fatigue and increase in weaning time.

  • Increased number of mechanical ventilation days.

  • Increased number of ICU days.

  • Increased mortality.

Causes of sleep deprivation

  • Noise—patients report that staff conversations and alarms are the most disturbing sources of noise.31

  • Lights.

  • Pain and discomfort.

  • Medications.

  • Stress.

Factors that promote sleep

  • Patient comfort.

  • Noise and light reduction.

  • Clustering of patient care.

  • Uninterrupted time to sleep (a full sleep cycle requires ≥ 90 min).

  • Optimal mechanical ventilation settings.

  • Only essential early-morning care.

  • Avoiding or minimizing the use of drugs that influence sleep.

  • Melatonin.32,33

References

30 Wenham T and Pittard A. Intensive care unit environment. Continuing Education in Anaesthesia, Critical Care & Pain 2009; 9: 178–83.Find this resource:

31 Xie H, Kang J and Mills GH. Clinical review: the impact of noise on patients’ sleep and the effectiveness of noise reduction strategies in intensive care units. Critical Care 2009; 13: 208.Find this resource:

32 Bourne RS, Mills GH and Minelli C. Melatonin therapy to improve nocturnal sleep in critically ill patients: encouraging results from a small randomised controlled trial. Critical Care 2008; 12: R52.Find this resource:

33 Riutta A, Ylitalo P and Kaukinen S. Diurnal variation of melatonin and cortisol is maintained in non-septic intensive care patients. Intensive Care Medicine 2009; 35: 1720–27.Find this resource:

Further reading

Castro R, Angus DC and Rosengart MR. The effect of light on critical illness. Critical Care 2011; 15: 218.Find this resource:

Chan MC et al. Circadian rhythms: from basic mechanisms to the intensive care unit. Critical Care Medicine 2012; 40: 246–53.Find this resource:

Eliassen KM and Hopstock LA. Sleep promotion in the intensive care unit—a survey of nurses’ interventions. Intensive and Critical Care Nursing 2011; 27: 138–42.Find this resource:

Tembo AC and Parker V. Factors that impact on sleep in intensive care patients. Intensive and Critical Care Nursing 2009; 25: 314–22.Find this resource:

Immobility

Critically ill patients can remain immobile due to a combination of factors, including physiological instability, weakness, sedation, NMBAs, traction, and multiple invasive devices. Ideally, the patient should be frequently repositioned, with early mobilization as soon as their condition permits.

Complications

  • Chest infection: due to decreased sputum clearance, impaired functional residual capacity (FRC), and reduced cough.

  • Muscle atrophy: due to disuse—occurs rapidly with lack of use, and requires long periods to rebuild.

  • Joint stiffness and contractures: stronger flexor muscles increase flexion, commonly the plantar, shoulder, hand, and hip flexors.

  • Demineralization and loss of long bone density: loss of weight-bearing pressure decreases osteoblastic activity within 1–2 days.

  • Pressure ulcers: high risk due to immobility plus altered tissue perfusion, reduced sensory function, malnutrition, and chronic disease factors.

  • Venous thromboembolism (VTE) and peripheral oedema: venous stasis and increased coagulability due to loss of muscle pumps.

  • Urinary tract infection: urinary stasis in the supine position due to dependent bladder portion filling and increased infection risk associated with urinary catheter.

  • Nephrolithiasis: increased urinary calcium excretion due to disuse bone density loss.

  • Decreased gut motility and constipation: partly due to muscle atrophy, and compounded by sedation and loss of enteral stimuli if the patient is not enterally fed.

  • Peripheral nerve injury: the ulnar nerve is at particular risk from pronation and elbow flexion when the patient is supine.

Interventions to reduce the risk of complications are summarized in Box 3.8.

Communicating with patients

Normal communication processes are disrupted in the critically ill patient by sedation, opiates, endotracheal and tracheal tubes, and fluctuating consciousness. This is complicated by pain, fear, and anxiety. Communication requires patience, motivation, the ability to see the patient as an individual, perseverance, a willingness to try new methods, and experience. Many patients are able to hear, understand, and respond emotionally to what is said to them, even when they are not thought to be aware by critical care staff.

Patients can feel isolated, alienated, and fearful. This should be recognized in any communication by showing empathy, giving information, and acknowledging these concerns. Box 3.9 provides a list of suggestions on how to communicate effectively with critically ill patients, Box 3.10 lists examples of communication assistance devices, and Box 3.11 lists specific nursing skills that can enhance communication.

Critical care survivors have given accounts of their experiences, which are a valuable source of information about what is important. Orientation to time, day, and situation is an important baseline, in addition to a clear introduction of self and others.

Family care

Family members of critically ill patients commonly report the need for:34,35

  • support

  • comfort

  • information

  • proximity

  • assurance.

Families require a positive, supportive relationship with the critical care staff, and documentation about family care should be kept to ensure that the entire multi-professional team is aware of what has been communicated (see Box 3.12). Strategies for helping to support and communicate with large families include the following:

  • Establish who is next of kin, and ensure that this is clearly documented in the patient record.

  • Ask the family to appoint one spokesperson who will be responsible for receiving information and communicating it to the rest of the family.

  • Limit concurrent visiting numbers, and organize relays of attendance at the bedside.

  • Ensure that visitors are aware of rest periods.

  • Specify a daily update time.

  • Encourage mutual support within the family.

References

34 Al-Mutair AS et al. Family needs and involvement in the intensive care unit: a literature review. Journal of Clinical Nursing 2013; 22: 1805–17.Find this resource:

35 Obringer K et al. Needs of adult family members of intensive care unit patients. Journal of Clinical Nursing 2012; 21: 1651–8.Find this resource:

Further reading

Buckley P and Andrews T. Intensive care nurses’ knowledge of critical care family needs. Intensive and Critical Care Nursing 2011; 27: 263–72.Find this resource:

Davidson JE. Family-centered care: meeting the needs of patients’ families and helping families adapt to critical illness. Critical Care Nurse 2009; 29: 28–34.Find this resource:

HealthTalkOnline. Generic care of the critically ill patient www.healthtalkonline.org/Intensive_care

ICUSteps. Generic care of the critically ill patient www.icusteps.org

Intensive Care Society. Patients and Relatives Committee. Generic care of the critically ill patient www.ics.ac.uk/about-us/council-and-committee-pages/patients-and-relatives-committee

Khalaila R. Patients’ family satisfaction with needs met at the medical intensive care unit. Journal of Advanced Nursing 2013; 69: 1172–82.Find this resource:

Visiting

The British Association of Critical Care Nurses (BACCN) Position Statement Standards36 on visiting in adult critical care units in the UK state that:

‘Patients should expect:

  • to have their privacy, dignity and cultural beliefs recognized

  • confidentiality

  • the choice of whether or not to have visitors

  • the choice to decide who they want to visit, including children and other loved ones

  • the choice of care assisted by their relatives

  • a critical care team who recognize the importance and value of visiting.

Relatives should have:

  • a comfortable and accessible waiting room with bathroom facilities nearby

  • access to overnight accommodation in the vicinity of the ICU

  • easy access to food and drink

  • a telephone nearby

  • access to relevant information regarding critical illness, the critical care environment and aftercare and support; this should be reinforced with written materials

  • a separate area for private discussions with healthcare professionals

  • involvement in patient care as the patient would wish

  • written information regarding the unit procedures e.g. hand washing, time of ward rounds

  • information concerning patient progress on at least a daily basis

  • information when there are any significant changes to the patient’s condition

  • not have to wait for long periods of time in the waiting room without regular updates

  • access to interpretation facilities if needed.’ (Reproduced with permission of BACCN © 2012.)

Reference

36 Gibson V et al. Position Statement on Visiting in Adult Critical Care Units in the United Kingdom. British Association of Critical Care Nurses (BACCN)L: Newcastle Upon Tyne, 2012.Find this resource:

Non-technical skills

Communication with the multidisciplinary team

Critical care nurses frequently interact with a variety of people within the multidisciplinary team, which requires them to have strong communication skills. Use of a handover structure, such as the nursing care plan or SBAR (Situation, Background, Assessment, Recommendation) tool,37 will ensure that essential information is handed over in a systematic manner (see Table 3.24). Closed loop communication encourages checking back and verifying that information was received and understood by the person to whom it was being communicated.

Table 3.24 SBAR tool37

S

Situation

What is going on with the patient?

B

Background

What clinical information is pertinent to the situation?

A

Assessment

What are the key aspects of your assessment?

R

Recommendation

What actions are needed? What do you want to happen for this patient?

Teamwork

Collaborative, team-based working is essential within the critical care unit, and helps to improve:

  • patient care

  • productivity

  • staff satisfaction

  • the working environment

  • outcomes, including mortality.

Teamwork requires mutual respect among professionals, and recognition that all team members’ contributions are necessary to give the patient the best outcome. Teams should have a recognized team leader, although there are often several different team groupings, such as:

  • unit clinical team—team leader is a medical consultant.

  • unit nursing team—team leader is a sister or charge nurse.

  • bedside team—team leader is nurse at bedside.

  • unit management team—team leader is general manager or clinical director.

Effective teamworking requires a key decision-making point, such as the traditional ward round, during which the patient’s case can be discussed and a plan of care decided on. However, the key to effective and safe teams is the opportunity for all team members to raise concerns and question decisions.

Markers of effective teamwork

  • Common goals and values are shared by all team members, focus on patient-centred care, and foster staff empowerment, support, and development.

  • Roles within the team are clearly defined, with all members of the team fully understanding and respecting the role of each of the other members.

  • Team members monitor each other’s performance and step in to help out and support each other—trust is implicit in this.

  • Giving and receiving feedback is the norm for all team members and is seen as part of their role.

  • Communication is made real (i.e. senders check that messages are received as they intended).

  • Team members collectively learn from experiences, enable constructive feedback from critical incidents, and show a willingness to address and resolve causes of conflict.

  • A range of qualities, skills, and knowledge is evident within the team, along with commitment from all team members.

Methods of improving team effectiveness

  • Enhance multidisciplinary decision making by drawing from a broad spectrum of knowledge about the patient’s condition. This could also include listening to the patient and their family.

  • Reward the team as a whole.

  • Encourage innovative solutions to problems.

  • Promote a shared multidisciplinary team approach to clinical practice, education, research, and management activities.

  • Establish clear roles and responsibilities for all members of the critical care team.

  • Endorse a positive working culture with strong leadership, flexible service planning, successful communication systems, and effective resource use.

  • Ensure that all members of the team are aware of clear procedures for:

    • daily routine practice

    • admissions and discharges

    • acting upon early warning signs of the deteriorating patient

    • outreach systems

    • unplanned events (e.g. resuscitation, evacuation, major incident).

Time management

It is important for critical nurses to demonstrate effective time management skills in order to provide safe, high-quality nursing care despite the pressures and demands placed on nurses in a busy critical care unit (see Table 3.25). Improving the productivity and efficiency of critical care nursing practice through effective time management also helps to reduce waste and thus the overall financial and environmental cost of critical care. These are significant considerations in view of current initiatives for the NHS to become a more sustainable healthcare service.38,39

Table 3.25 The implications of time management

Poor use of time

Good use of time

Unsafe practice

Safe practice

Poor quality of care

High-quality nursing care

Loss of productivity

Productivity and efficiency

Increase in cost

Increase in cost-effectiveness

Increase in stress levels of staff

Improved working culture

Strategies for improving time management skills

  • Prioritize urgent care.

  • Actively engage in early recognition of risk factors for patient deterioration in order to initiate preventive measures and trouble-shoot potential clinical problems.

  • Collaborate with colleagues.

  • At the beginning of a clinical shift, plan out nursing care so as to efficiently complete nursing care for the patient and their family and also ensure that breaks can be taken and arrange break coverage of other colleagues.

  • Consider rationales for clinical decisions to help to justify and prioritize nursing care while making nursing practice more efficient (e.g. protocols, guidelines, care bundles, research, intuition, local culture, and past experience).

Situation awareness

Critical care nurses must not only be aware of and understand the clinical context of their patients, but also have an appreciation of what is happening within the surrounding environment in the critical care unit (see Box 3.13). In addition, they need to be able to consider the implications of acting or not acting upon specific events that occur within the current situation. The process of situation awareness has three elements:40

  • perception—awareness of the environment and context of the current situation

  • comprehension—understanding, interpreting, and evaluating the current situation

  • projection—anticipation of future possibilities and ability to plan trouble-shooting measures.

Notes and references

37 NHS Institute for Innovation and Improvement. SBAR: situation-background-assessment-recommendation, 2008. Generic care of the critically ill patient http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_-_recommendation.html.

38 National Audit Office. Securing the Future Financial Sustainability of the NHS. Generic care of the critically ill patient http://www.nao.org.uk/report/securing-the-future-financial-sustainability-of-the-nhs/

39 NHS Sustainable Development Unit. Sustainability in the NHS: Health Check 2012. Generic care of the critically ill patient www.sdu.nhs.uk/documents/publications/Sustainability_in_the_NHS_Health_Check_2012_On-Screen_Version.pdf

40 Schulz CM et al. Situation awareness in anaesthesia: concept and research. Anesthesiology 2013; 118: 729–42.Find this resource:

Further reading

Coleman NE and Pon S. Quality: performance improvement, teamwork, information technology and protocols. Critical Care Clinics 2013; 29: 129–51.Find this resource:

Manthous C, Nembhard IM and Hollingshead AB. Building effective critical care teams. Critical Care 2011; 15: 307.Find this resource:

Reader TW et al. Developing a team performance framework for the intensive care unit. Critical Care Medicine 2009; 37: 1787–93.Find this resource:

Rose L. Interprofessional collaboration in the ICU: how to define? Nursing in Critical Care 2011; 16: 5–10.Find this resource:

Stubbings L, Chaboyer W and McMurray A. Nurses’ use of situation awareness in decision-making: an integrative review. Journal of Advanced Nursing 2012; 68: 1443–53.Find this resource: