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