Current Guidelines & Topics in Critical Care
Sarah Davis, DNP, AGACNP-BC, FNP-BC
Assistant in Surgery, Deptarment of Surgery
Surgical Intensive Care Unit
• ICU Delirium Updates
• IV Fluids
• Oral Anti-Coagulations & Reversals
• Peri-Operative Risk Stratification
Objectives• Identify current evidence based guidelines
that are utilized in acute and critical care practice.
• Describe changes to evidence based guidelines for acute and critical care practice.
• Integrate knowledge of the updated evidence based guidelines into practice.
Image courtesy of:
http://newsatjama.jama.com/2013/10/02/delirium-implicated-in-long-term-cognitive-problems-after-icu-stay/
SCCM 2013 Delirium Guidelines
ABCDEF
• Assess for/manage pain
• Both SAT/SBT
• Choice of sedation/analgesia
• Delirium Monitoring/management
• Early mobility
• Family Involvement
PAD
• Pain
• Agitation
• Delirium
ICU Delirium
• Behavioral Pain Scale (BPS)
• Critical‐Care Pain Observation Tool (CPOT)
• MINDS
• MENDS/MENDS II
• http://www.icudelirium.org
ICU Delirium• Research Updates
• Patel et al – Prospective cohort study• Proportion of days with no delirium vs rapidly reversailbe
sedation related delirium vs persistent delirium
• Persistent delirium – higher 1 year mortality rate (p<0.001)
• Salluh et al – Systematic Review and Meta-Analysis• 42 studies in final analysis
• Higher mortality during admission
• risk ratio 2.19, 94% confidence interval 1.78 to 2.70; P<0.001)
References
• Barr, J., Gilles, L.F., Puntillo, K., Wely, W.E., Gelinas, C., Dasta, F., Davidsons, J.E., Delvin, J.W., Kress., J.P. (2013).Clinical Practice Guidelines for the Management of Pain, Agitation, 263-306. Doi: 10.1097/ccm.0b013e3182783b72.
• Patel, S.B., Poston, J.T., Pohlman, A., Hall, J.B., & Kress, J.P. (2014). Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit. American Journal of Respiratory Critical Care Medicine, 189(6). 658-665. Doi:10.1164/rccm.201310-1815OC.
• Salluh, J.I., Wang, H., Schneider, E.B., Nagaraja, N., Yenokyan, G., Damluji, A., Serafim, R.B., & Stevens, R.D. (2015). Outcomes of delirium in critically ill patients: systematic review and meta-analysis. British Medical Journal, 350 h2538. Doi: 10.1136/bmj.h2538
IVF
Image courtesy of: http://media.philly.com/images/istock-
iv.jpg
IVF• More is not necessarily better (ARISE, ProCESS, FACTT, Surviving Sepsis)
• Main Considerations
• Effect on intravascular volume
• Chemical composition to ECF
• Metabolism (partial vs. complete) and does it accumulate in the tissues or is it fully excreted
• Adverse metabolic/systemic effects
• Cost (Mybourgh & Mythen, 2013)
• Remaining Questions
– Which fluid?
– How much?
GlycocalyxImage courtesy of: https://vennofem.wordpress.com/2013/12/10/the-glycocalyx/
Glycocalyx
Image courtesy of: http://www.glycocalyx.nl/background.php
Composition of FluidspH Osmolality Na+
(mEq)K+(mEq)
Cl-(mEq)
Reference Range
7.35-7.45 290 136-148 4-5 90-100
0.9% Saline 5.4 308 154 0 154
Lactated Ringer 6.5 280 130 4.0 111
Balanced SaltSolution
7.4 294 140 5 98
References• Alphonsus, C.S. & Rodseth, R.N. (2014). The endothelial glycocolyx: a review of the vascular barrier.
Anaesthesia, (69). Doi: 10.1111anae.12661
• Chowdhury, A.H., Cox, E., Franis, S.T., Lobo, D.N. (2012). A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte ® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Annals of Surgery, 256(1). 18024. Doi: 10.1097/SLA.0b013e318256be72
• Langer, T., Ferrari, M., Zazzeron, L., Gattinoni, L., & Caironi, P. (2014). Effects of intravenous solutions on acid-base equilibrium: from crystalloids to colloids and blood components. Anaesthersiology Intensive Therapy, 45(5). 350-360. Doi; 10.5603?AIT.2014.0059
• McDermid, R.C., Raghunathan, K., Romanovsky, A., Shaw, A.D., & Bagshaw, S.M. (2014). Controversies in fluid therapy: type, dose, and toxicity. World Journal of Critical Care Medicine. 3(10. 24-33. Doi: 10.5492/wjccm.v3.i1.24
• Myburgh, J.A. & Mythen, M.G. (2013). Resuscitation fluids. New England Journal of Medicine, 369. 1243-1251. Doi: 10.1056/NEJMra1208627.
• Myburgh, J.A. (2015). Fluid resuscitation in acute medicine. Journal of Internal Medicine, 277(1). 58-68. Doi: 10.1111/joim.12326.
• Polderman, K.H. (2015). Do not drown the patient: appropriate fluid management in critical illness. The American Journal of Emergency Medicine, 33(3). 448-450. Doi: 10.1016/j.ajem.2015.01.051
• Rizoli, S. (2011). PlasmaLyte. Journal of Trauma, 70(5). S17-8. Doi: 10.1097/TA.0b013e31821a4d89.
Oral Anti-Coagulations & Reversals
• Direct Thrombin Inhibitors
– Dabigatran (Pradaxa)
• Factor Xa Inhibitors
-rivaroxaban (Xarelto)
-apixaban (Eliquis)
-edoxaban (Lixiana)
Coagulation Cascade
Image courtesy of: http://www.frca.co.uk
Anti- coagulant Possible Interventions
Direct Thrombin Inhibitor
DabigatranBivalirudinArgatroban
-Activated PCC (Feiba)-Hemodialysis-Antifibrinolytic agent (amiocaproic acid)-Platelet-PRBC -Surgical/Endoscopic intervention
Factor Xa Inhibititors
RivaroxabanApixabanedoxaban
-4-Factor unactivated PCC (Kcentra)-Antifibrinolytic agent (amiocaproic acid)-Platelet-PRBC -Surgical/Endoscopic intervention
Vitamin K antagonist
WarfarinHeparin
-Protamine-Factor VII-Vitamin K-FFP-4-Factor unactivated PCC (Kcentra), must be given with Vitamin K
References• Goldhammer, J.E., Bakowitz, M.J., Milas, B.L., & Patel, P. (2015). Intracardiac thrombosis after
emergent prothrombin complex concentrate administration for warfarin reveraal. Anesthesiology. 123(2). Doi: 20150800.0-00032.
• Goldstein, J.N., Refaai, M.A., Milling, T.J, Jr., Lewis, B., GOldber-Alberts, R., Sarode, R. (2015). Four-factor prothrombin complex concentrate versus plasma for parid vitamin K anatagonist reversal in patients needings urgent surgical or invasive intervetniosn: a pase 3b, open-label, non-inferiority, randomized trial. Lancet, 385. 2077-2087. Doi: 10.1016/S0140-6736(14)16685-8.
• Herzog, E., Kaspereit, F., Krege, W., Doerr, B., Mueller-Cohrs, J., Pragst, I., Morishima, Y., & Dickneite, G. (2015). Effective reversal of edoxaban-associated bleeding with four-factor prothromibc complex concentrate in a rabbit model of acute hemorrhage. Anesthesiology, 122(2). 236-237. doi: 10.1097/ALN.0000000000000541
• Holbrook, A., Schulman, S., Witt, D.M., Vandivik, P.O., Fish, J., Kovacs, M.J., Svensson PJ, Veenstra DL, Crowther M, Guyatt G.H. (2012). Evidence based management of anticoagulant therapy. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence Based Clinical Practice Guidelines. Chest, 141(2 suppl):e152s–84s. doi: 20150800.0-00032
• Honickel, M., Maron, B., van Ryn, J., Braunschweige, T., Ten Cate, H., Rossaint, R., Grottke, o. (2015). Therapy with activated prothrombin complex oncentrate is effective in reduincg bagifatran-associated blodd loss in a porcine polytrauma model. Thrombosis and Haemostatis, 115(1). Doi: 10.1160/TH15-03-0266
Peri-Operative Risk Stratification
• American Society of Anesthetists (ASA)
• Charlson Comorbidity Score
• Revised Cardiac Risk Index
• Acute Physiology and Chronic Health Conditions II (APACHE)
• Simplified Acute Physiology Score
• Physiological and Operative Severity Score for the Enumeration of Mortality and Morbididy
Prediction System Description Advantages Disadvantages
American Society of Anesthetists
(ASA)
Numeric scale (1-5) based on
severity of co-morbidities
-Simple
-Easily Adaptable
-Well known
-Subjective
-Not individualized for procedure
-Poor sensitivity
-Poor specificity
Charlson Comorbidity Score Additive score based on weighting
of pre-operative diseases
-Simple
-Good for estimating population
risk
-Subjective
-Not specific to procedure
Revised Cardiac Risk Index Based on presence of 1 of 6 major
co-morbidities and the severity of
the operation
-Simple
-Validated
-Good predictor of cardiac risk
-Single-organ risk
-Broad categories
-Subjective
Acute Physiology and Chronic
Health Conditions II (APACHE)
12-17 variables, measured over 24
hours
-Individualized
-Better predictor that ASA
-Well known
-Multiple variables over 24 hours
of critical care
-Difficult to score before emergent
surgery
Simplified Acute Physiology
Score
17 variables measured over 24
hours
-Well validated for predictive
mortality
-Multiple variables over 24 hours
-Difficult to score before emergent
surgery
-Not designed for peri-op use
Physiological and Operative
Severity Score for the
Enumeration of Mortality and
Morbididy
12 phsyiological and 6 operative
variables, entered into 2
mathemetarical equations to
predict M&M
-Best validated and known scoring
system for peri-operative
prediction
-Various surgery-specific
variations
-May overestimate or
underestimate M&M in specific
populations s/t logarithymic
regression
ASA ClassificationClassification Description
I Normal Healthy Patient
II Mild Systemic Disease
III Severe Systemic Disease but not incapacitated
IV Incapacitating systemic disease that is a threat to life
V Morbiund, not expcect to survive 24 hours with or without operative intervention
References
• Jones, H.J.S & de Cossart, L. (1999). Risk scoring in surgical patients. British Journal of Surgery, 86. 149-157.
Questions