the intensive care unit maual

7/28/2019 The Intensive Care Unit Maual

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The Intensive Care Unit

at the

Mid Yorkshire Hospitals NHS Trust

20th July 2010


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1

Contents Contents

Contents

1 Administration 9

1.1 Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

1.1.1 Clinical Lead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.1.2 Consultant Medical Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.1.3 Nursing Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.1.4 SHOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.2 Weekly Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

1.2.1 ICU Problem List Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

1.3 Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

1.4 Patient admission

policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.4.1 Patient Triage: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.4.2 Elective admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.4.3 Refusal of patient admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

1.4.4 Management of patients in ICU . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

1.5 Patient discharge policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12


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1.5.1 Discharge procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.5.2 Deaths in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.6 Clinical duties in the Intensive

Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.6.1 General comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.6.2 Patient Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.6.3 Doctors Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.6.4 Daily management issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.7 Clinical Duties Outside the Intensive Care Unit . . . . . . . . . . . . . . . . . . .

. . . 17

1.7.1 Cardiac Arrest Calls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.7.2 Trauma Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.7.3 Intra-hospital patient transport . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

1.7.4 Out of hospital transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

1.8 Infection

Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.8.2 Hand Hygiene and Standard Precautions . . . . . . . . . . . . . . . . . . . . .

19

1.8.3 Isolation and transmission-based precautions . . . . . . . . . . . . . . . . . .

20

1.8.4 General Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.9 Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 21

1.10Consent in the Intensive Care

Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


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1.10.1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.10.2Consent by relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.10.3Consent at the Mid Yorks ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

1.11Hospital Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 22

1.11.1Fire and building emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22


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2

Contents Contents

2 Clinical Procedures 23

2.0.2 ICU Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

2.0.3 Restricted procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

2.1 Peripheral IV Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

2.2 Arterial Cannulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24

2.3 Central Venous Cannulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25

2.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

2.3.2 Types of catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

2.3.3 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

2.3.4 Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

2.3.5 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

2.3.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

2.3.7 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

2.3.8 Line Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

2.4 Pulmonary artery

catheterisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

2.4.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

2.4.2 Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

2.4.3 Monitoring PA trace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30


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2.4.4 Measurement of pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30

2.4.5 Measurement of haemodynamics . . . . . . . . . . . . . . . . . . . . . . . . . .

30

2.5 Pleural Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30

2.5.1 Pleurocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

2.5.2 IntercostalCatheter / Underwater Sealed Drain . . . . . . . . . . . . . . . . .

. 31

2.6 Endotracheal

Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

2.6.1 Intubation Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33

2.7 Fibre-optic

Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.8

Cricothyroidotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.9 Tracheostomy-Percutaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.9.1 Patient selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.9.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.9.3 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

2.9.4 Timing of the procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

2.9.5 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402.9.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2.9.7 Post Insertion Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44


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2.9.8 Decannulation of the Trachea . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44

2.10Nasojejunal tube

insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2.11Intra-abdominal pressure

manometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

3 Drugs and Infusions 47

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47

3.1.1 Prescription practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47


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3.2 Cardiovascular

Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

3.2.1 Inotropes and Vasoactive drugs . . . . . . . . . . . . . . . . . . . . . . . . . . .

48

3.2.2 Assess and correct hypovolaemia . . . . . . . . . . . . . . . . . . . . . . . . .

48

3.2.3 Instituting inotropic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

48

3.2.4 Vasopressors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

3.2.5 Steroid use in patients requiring vasopressors . . . . . . . . . . . . . . . . . .

51

3.3 Anti-hypertensive

Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

3.4 Antiarrhythmic Drugs in Critical

Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

3.4.1 General Principles of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .

53

3.4.2 Drug Therapy of Bradyarrhythmias . . . . . . . . . . . . . . . . . . . . . . . . .

54

3.4.3 Supraventricular Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55

3.4.4 Ventricular Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

3.5 Respiratory Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

58

3.5.1 Nebulised bronchodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

58


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3.5.2 Parenteral Therapy in treatment of reversible obstructive airways

disease . 59

3.6 Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

59

3.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

3.6.2 Principles of Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60

3.6.3 Monitoring Sedation : Sedation Scoring . . . . . . . . . . . . . . . . . . . . . .

60

3.6.4 Sedation Holds/ Sedation Assessment . . . . . . . . . . . . . . . . . . . . . . .

61

3.6.5 Accumulation of Sedatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

62

3.6.6 Sedative Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

62

3.6.7 Sleep on the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

3.6.8 Non-Pharmacological Methods of aiding sleep . . . . . . . . . . . . . . . . . .

63

3.6.9 Pharmacological Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

3.6.10Management of Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69

3.6.11References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

3.7 Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

73

3.7.1 General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

3.7.2 Indications for the use of warfarin . . . . . . . . . . . . . . . . . . . . . . . . .

73

3.7.3 Indications for the use of heparin . . . . . . . . . . . . . . . . . . . . . . . . . .

74


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3.7.4 Prophylactic use of heparin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

3.7.5 Systemic anticoagulation using unfractionated heparin . . . . . . . . . . . .

75

3.7.6 Heparin Induced Thrombocytopaenia . . . . . . . . . . . . . . . . . . . . . . .75

3.8 Endocrine Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

76

3.8.1 Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

3.8.2 DDAVP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

3.8.3 Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

3.9 Renal Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

79

3.9.1 General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

3.9.2 Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

3.10Gastro-intestinal drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 80

3.10.1Prophylaxis of gastric stress ulceration . . . . . . . . . . . . . . . . . . . . .80


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3.10.2Active GI Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

83

3.10.3Use of gastro-intestinal pro-kinetic agents . . . . . . . . . . . . . . . . . . . .

84

3.11ICU Antibiotic

Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

3.11.1Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

3.11.2Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

3.11.3Principles of prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

84

4 Fluids and Electrolytes 85

4.1 Principles of Fluid Management in Intensive Care . . . . . . . . . . . . . . . . .

. . . 85

4.1.1 Fluid charting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

4.1.2 Assessment of fluid balance and hydration . . . . . . . . . . . . . . . . . . . .

86

4.1.3 Body Fluid and Electrolyte Physiology . . . . . . . . . . . . . . . . . . . . . . .

87

4.2 Electrolyte Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 87

4.2.1 Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

4.2.2 Hyponatraemia: Na+ < 130 mmol.L-1 . . . . . . . . . . . . . . . . . . . . . . .

88

4.2.3 Hypernatraemia: Na+ > 145 mmol.L-

1 . . . . . . . . . . . . . . . . . . . . . . . 89


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4.2.4 Hypokalaemia: K+ < 3.5 mmol.L-1 . . . . . . . . . . . . . . . . . . . . . . . . .

90

4.2.5 Hyperkalaemia: K+ > 5.0 mmolL-1 . . . . . . . . . . . . . . . . . . . . . . . . .

91

4.2.6 Hypophosphataemia: Serum Phosphate < 0.7 mmol.L-

1 . . . . . . . . . . . . 92

4.3 Acid-Base Disturbances in the

ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

4.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

4.3.2 General principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

4.3.3 Metabolic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

4.3.4 Metabolic Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

4.3.5 Respiratory Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

97

4.3.6 Respiratory Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

4.4 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

98

4.4.1 Enteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

4.4.2 Parenteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

101

4.5 Blood and Blood

Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

4.5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1024.5.2 Blood transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

102

4.5.3 Platelet transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

102


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4.5.4 Fresh Frozen Plasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

103

4.5.5 Cryoprecipitate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

4.5.6 DIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

4.5.7 Blood transfusion reaction guidelines . . . . . . . . . . . . . . . . . . . . . . .

105

5 Clinical Management 106

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

106

5.2 Cardio-Pulmonary Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 106

5.2.1 Key Points in the management plan for an adult collapse . . . . . . . . . .

. 106

5.2.2 Induced hypothermia following cardiac arrest . . . . . . . . . . . . . . . . . .

107


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5.3 Respiratory Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108

5.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108

5.3.2 Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108

5.3.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

5.3.4 When Should I Consider Ventilating (_ intubating) Patients? . . . . . . . .

. . 109

5.3.5 Humidification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

5.3.6 Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110

5.3.7 Ventilator settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

112

5.3.8 Positive Pressure Ventilation and Hypotension . . . . . . . . . . . . . . . . . .

115

5.3.9 Supportive Therapies for Severe Hypoxia . . . . . . . . . . . . . . . . . . . . .

115

5.3.10Weaning from Mechanical ventilation . . . . . . . . . . . . . . . . . . . . . . .

119

5.3.11Ventilation in the prone position . . . . . . . . . . . . . . . . . . . . . . . . . .122

5.3.12Non-invasive ventilation (NIPPV) . . . . . . . . . . . . . . . . . . . . . . . . . .

123

5.3.13Corticosteroids in ARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

124


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5.4 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

124

5.5 Aspects of Renal Failure in Intensive Care . . . . . . . . . . . . . . . . . . . . . .

. . . 125

5.5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

125

5.5.2 Aetiology of renal failure in the ICU . . . . . . . . . . . . . . . . . . . . . . . . .

125

5.5.3 Assessment of renal function in a given patient . . . . . . . . . . . . . . . . .

126

5.5.4 Renal protective strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

126

5.5.5 Renal Replacement Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

127

5.6 Neurosurgical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 130

5.6.1 Neurotrauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

130

5.6.2 Status Epilepticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

132

5.6.3 Subarachnoid haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

133

5.7 Microbiology Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

134

5.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

134

5.7.2 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

5.7.3 Screening for sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

135


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5.7.4 Investigation of Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

136

5.7.5 Vascular Catheter Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137

5.7.6 Fungal infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

138

5.8 Drug / Toxin

Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

5.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

139

5.8.2 Admission to ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

139

5.8.3 Specific Overdoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

140

5.9 Withdrawal of Treatment in the Intensive

Care . . . . . . . . . . . . . . . . . . . . . . 140

5.9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

140

5.9.2 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

5.9.3 Deciding not to treat (or treat any further) . . . . . . . . . . . . . . . . . . . .

141

5.10Brain death and organ

donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

5.10.1Declaration of brain death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

141

5.10.2Clinical certification of brain death . . . . . . . . . . . . . . . . . . . . . . . . .

142


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6

Contents Contents

6 Appendices 144

6.1 Haemodynamic

Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

6.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

144

6.1.2 Diagnosing hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

144

6.1.3 Is there any evidence of shock ? . . . . . . . . . . . . . . . . . . . . . . . . . .

144

6.1.4 Does this patient require more fluid resuscitation? . . . . . . . . . . . . . . .

145

6.2 The Pulmonary Artery

Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

6.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

146

6.3 The PiCCO-catheter /

monitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

6.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

147

6.3.2 Estimation of cardiac output . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

148

6.4 Principles of ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 149

6.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

149


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6.4.2 Ventilatory strategies to provide total ventilatory support . . . . . . . . . .

. 150

6.4.3 Objectives of mechanical ventilation . . . . . . . . . . . . . . . . . . . . . . . .

151

6.4.4 Other Ventilatory strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

151

6.4.5 Ventilation Mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

152

6.5 The Sedation - Agitation Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 153

6.6 Classification of anti-arrhythmic

drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

6.6.1 Classification of Antiarrhythmic Drugs by Their

Action . . . . . . . . . . . . . 154

6.7 Guidelines for the use of patient controlled anaesthesia (PCA) . . . . . . . .

. . . . 155

6.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

155

6.7.2 Acute Pain Service Standard Orders . . . . . . . . . . . . . . . . . . . . . . . .

155

6.7.3 Programmable Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

156

6.7.4 Standard Prescriptions for PCA . . . . . . . . . . . . . . . . . . . . . . . . . . .

157


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7

Contents Contents

Foreword

Caring for patients in the intensive care setting is a challenging but

potentially rewarding

experience. As we enter the intensive care environment each one of us

brings a unique mix of skills and knowledge. Inevitably though we must find

a common ground on which to base our management, without which optimal

patient care and safety cannot be achieved. The purpose of this document is

not to provide definitive answers for each problem, nor is it meant to be

prescriptive in nature, but rather it describes a number of standardised

approaches and helpful guidelines to facilitate good patient care.

I must acknowledge that this guide has been heavily based on the one

produced by the Intensive Care Staff of The Waikato Hospital in New

Zealand. In particular, my thanks to Dr John Torrance and Dr David Gamble

for their permission to use their manual as a template.

All those who access, use or disseminate these guidelines do so at your own

risk. While you are working in this unit, no matter what your level of

experience, you will encounter situations where you feel uncomfortable,

confused or even scared. While this manual is intended to assist you in

caring for your patients, you should not be embarrassed to seek help from

those around you, including the Consultant Intensivist/Anaesthetist and

senior nursing staff. You will find references to articles which are useful

further reading.

Rajiv Srinivasa

25th June 2008


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8

1 ADMINISTRATION

Mid Yorkshire Hospitals Intensive Care Units

The Mid Yorkshire Hospitals NHS Trust is a 900 bed district general hospital

and trauma centre of the West Yorkshire region and serves a population area

of 800 000. It is composed of 3 Hospitals: Pinderfields, Pontefract and

Dewsbury.

The Intensive Care Units are located in Pinderfields General Hospital and

Dewsbury District Hospital with a total of 14 Level 3 and 8 Level 2 beds and

admits over 1200 patients a year.

There are also 2 Level 3 beds on the Burns unit. Approximately 30% of the

admissions are surgical. The remainder are a mixture of trauma, medical

and surgical patients. 76% of admissions are ventilated. Our average

APACHE II score is 16 and we have a crude mortality rate of about 24%. The

intensive care consultant staff also assist in the management of patients in

the High Dependency Unit which has 8 beds and admits over 1800 cases per

year. The intensive care also provides medical and nursing transport teams

for inter-hospital transfers.

The ICUs are affiliated to the West Yorkshire Critical Care Network.

The Intensive Care unit senior medical staff consists of 13 consultants. The

junior cover is provided by senior SHOs. We have a nursing staff of about

65 full time equivalents for ICU and 25 for HDU.

1 Administration

1.1 Staffing

1.1.1 Clinical Lead

Dr Rajdeep Singh Sandhu

1.1.2 Consultant Medical Staff

Dr Hugh OBeirne


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Dr Anthony Main

Dr Jaqueline Brook

Dr Paul Clarke

Dr Sameer Bhandari (Burns)

Dr Tendai Mbengaranwa (Burns)

Dr Jamie Yarwood (Burns)

Dr Christine Hildyard

Dr Rajiv Srinivasa

Dr Anne Thickett

Dr James Dodman

Dr Helen Buglass


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9

1.2 Weekly Program 1 ADMINISTRATION

1.1.3 Nursing Staff

General Manager (Pain, Anaesthesia, Critical Care, Theatres) - Julie Clark

Head of Nursing PACCT Steve Fenn

Nursing and Service Manager Critical Care Carol Wood

Senior Sister/Charge Nurses

Suzanne Brompton (Practice Development)

Jean Garner

Jan Newton (Practice Development)

Mick Reynolds

Lindsay Shields

Jane Womersley

1.1.4 SHOs

The junior medical team consists of SHOs (or ST1/2s) who have completed

their ICU blocks and are deemed competent in intensive management. They

form the resident medical structure. They operate a day/night shift pattern,

with the change over occurring at 0800 and 2000 hours (vide infra).

Non-intensive Care Trainees

Rotation through the intensive care is made by the following specialty based

training programs: the Acute Care Common Stem for Emergency Medicine

and Intensive Care. There is also provision for a Foundation Year 1

placement (a 4 month rotation).

1.2 Weekly Program

08h00 morning handover (30 minutes) in the Handover Room.


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08h30 Consultant led bedside ward round, followed by HDU

16h00 Afternoon ward round and HDU review. (30min-1hr)

20h00 Evening hand over between trainees and HDU review

All times other than that allocated above should involve patient review, not

only in response to request by nursing staff, but also in the interests of

optimising patient care and progress.

1.2.1 ICU Problem List Formulation

The ICU runs a problem list sheet to help you keep up to date with each

patient. It is the responsibility of the night registrar to review the list for

each patient, and to enter new data or patients where appropriate. Towards

the end of the night shift a report should be generated


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10

1 ADMINISTRATION 1.3 Orientation

for each patient, and this is handed to the team following on. The generated

document is then filed in a folder as evidence of the handover. The process

is repeated for the night handover.

1.3 Orientation

Prior to commencing an ICU on call rota, trainees will have to demonstrate

competence in managing patients on Intensive Care. The training block

consists of 2 months on ICU as a supernumary.

1.4 Patient admission policy

No patient may be accepted into the Intensive Care Unit without the

knowledge and consent of the ICU Consultant or the Consultant Anaesthetist

on call (out of hours).

Resuscitation or admission must not be delayed where the presenting

condition is imminently life threatening unless specific advance directives

exist. In general patients should be admitted to the Intensive Care where it

is perceived they would benefit in some way as a result.

Usually this means patients with actual or potential organ system failure,

which appears reversible with the provision of intensive support measures.

1.4.1 Patient Triage:

A critical care Outreach team operates at the PGH and DDH sites between

the hours of 0800 and 1800. Their primary function is to assist the ward

nurses in managing and troubleshooting critically ill patients on the ward.

They will activate the MEWS pathway if required. The patients at this point

are still under the care of the primary medical team.

ICU admission criteria should select patients who are likely to benefit from

ICU care. Patients not admitted should fall into two categories, too well to

benefit and too sick to benefit. Defining substantial benefit is difficult, and

no pre-admission model exists to predict outcome in a given patient. Rather


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than listing arbitrary objective parameters, patients should be assigned to a

prioritization model to determine appropriateness of admission.

Priority 1: Critically ill patients in need of intensive treatment and

monitoring that is not available outside of the ICU. Generally these patients

would have no limits placed on their care.

Priority 2: Patients that require intensive monitoring, and may need

immediate intervention. No therapeutic limits are generally stipulated for

these patients.

Priority 3: Unstable patients who are critically ill but have a reduced

likelihood of recovery because of underlying disease or the nature of their

acute illness. If these patients are to be treated in ICU/HDU, limits on

therapeutic efforts may be set (such as not for intubation).

Examples include patients with metastatic malignancy complicated by

infection.

Priority 4: These patients are generally not appropriate for ICU admission

as their disease is terminal or irreversible with imminent death (e.g. CVA).

Included in this group would be


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11

1.5 Patient discharge policy 1 ADMINISTRATION

those patients not expected to benefit from ICU based on the low risk of the

intervention that could not be administered in a non-ICU setting (e.g.:

haemodynamically stable DKA, or an awake patient following an

overdose). This category of patients also present a conundrum and often are

the subjects of passionate debates between the referring physician and

Intensivist as to what may reasonably be achieved on the ICU.

1.4.2 Elective admissions

Where possible, elective surgical admissions should be booked at least 48hrs

in advance. A book exists into which the names of prospective patients must

be entered, following discussion with the surgical team and anaesthetist

responsible for that patient. Confirmation of bed availability is the

responsibility of the anaesthetist and surgeon, and must be confirmed by

prior to commencing the anaesthetic on the morning of surgery. Beds will be

ring-fenced only in exceptional circumstances. No elective surgical patient

will be admitted into the last bed scenario.

1.4.3 Refusal of patient admission

When an outside team contacts the ICU with regard a patient, it is

imperative that you clarify whether this is a referral or a courtesy call. If it is

a referral, then the patient should be assessed (at the bedside if possible),

and the problem discussed with the Consultant Anaesthetist/ Intensivist at

the earliest opportunity.

Where a patient is reviewed but not admitted to the Intensive Care Unit, the

pertinent findings and reason for refusal must be clearly communicated to

the referring team and documented in the notes. Where appropriate a

directive regarding future review must be noted, and the managing teamencouraged to define resuscitation status.

This directive holds for patients placed in the HDU following ICU referral.

1.4.4 Management of patients in ICU


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Patients in Intensive Care Unit are managed primarily by the ICU staff.

Visiting Teams should be discouraged from charting drugs, fluids or other

treatment directly.

However, the opinion of all Specialists involved in the case is valued.

The Consultant Intensivist must be kept fully informed of their opinion.

1.5 Patient discharge policy

1.5.1 Discharge procedure

All discharges must be approved by the Consultant Anaesthetist/Intensivist.

The parent team must accept care of the patient, this acceptance must be

recognised at the medical level, either through the SHO/Registrar, or in

some cases to the Consultant directly.


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12

1 ADMINISTRATION 1.5 Patient discharge policy

All other teams involved should be advised, including the pain team,

dietician, special pharmacy requirements (e.g.. TPN). A careful plan for the

immediate discharge period must be discussed with the accepting team, and

be clearly documented in the notes including:

Limitation of treatment where appropriate

Non-return orders

Clear medical management plan, including charting of the following for the

next 24hrs:

Fluids

Feeding

Analgesia

Documentation to be completed prior to discharge:

Entry in the ICU database - this also allows printing of the discharge note.

The database is designed in MS Access, and resides on the Desktop of the 2computer terminals in the ICU nurses station.

Nurses will not send patients to the ward without first checking with the on

call SHO.

1.5.2 Deaths in the ICU

Withdrawal of therapy is a Consultant-only decision.

The Consultant Intensivist must be notified as soon as the patient has been

examined and certified dead, unless other specific arrangements exist (eg.where death is the expected outcome and the issue of a death certificate

issue has been discussed).

The ICU SHO must ensure:


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A death certificate has been completed or arranged (please speak to the

General Office regarding this)

The parent team is notified

Referring colleagues (including GPs) are notified

Post-mortem consent has been acquired from the family (if indicated)

If appropriate, an End of Life Care Pathway must be completed and the

process documented in the patients notes.

If relevant and appropriate, initiate discussions with the Transplant

Coordinator (via switchboard at St James University Hospitals - 70020)

The Coroner must be notified as below:

Every death that appears to have been without known cause, as a result of

suicide, or unnatural or violent death.

Every death in respect of which no doctor has given (or is prepared to

give) a death certificate.

Every death that occurs while the person concerned was undergoing a

medical, surgical or dental procedure, or some similar operation or

procedure.

13

1.6 Clinical duties in the Intensive Care 1 ADMINISTRATION

Death that appears to have been a result of any such operation or

procedure.

Death that occurred while the person was affected by an anaesthetic or

that appears to have been a result of the administration to the person of an

anaesthetic.

Death of any patient detained in an institution pursuant to an order.

Death of any patient committed in a hospital under the Mental Health Act.

The death of any inmate within the meaning of the Penal Institutions Act of

1954


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The death of any person in police custody, or in the custody of a security

officer.

Where a death is referred to the coroner, no death certificate may be issued

by the ICU doctor.

1.6 Clinical duties in the Intensive Care

1.6.1 General comments

Staff will always shoulder a major part of the burden of continuity.

Continuity is central to quality patient care and this expectation is not

diminished with a decrease in working hours. The responsibility for

maintaining continuity and for effective communication both with other unit

staff and with outside teams rests largely with the SHOs. Effective

communication is a basic medico-legal requirement.

There are guidelines covering the medical procedures and the administration

of most of the drugs used in the ICU. These guidelines are under constant

review. The resident staff are required to be familiar with these guidelines

and to consult them when required. In addition, any inconsistencies or

discrepancies within them should be brought to the attention of the

consultant staff.

When asked by a team to review a patient, SHOs are required to obtain a

full history from the patient and the patient notes, to perform acomprehensive examination of the patient and to formulate a differential

diagnosis. They should then have an outline of a suggested investigation and

treatment plan, to be presented to the Consultant Anaesthetist/Intensivist.

The final plan should be clearly documented in the patient record. It is

important that there is a complete transfer of information at the handover

between shifts. This will be facilitated by

Comprehensive admission notes.

Completion of a standardised daily update note.

Daily review of all clinical laboratory tests, microbiology and radiological

tests.


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An update of the problem list by the night on call SHO. This will contain

details of the presentation, the provisional diagnosis, investigations, consults

and opinions and unresolved issues that require follow up.

The on call doctor should briefly familiarise themselves with the patients

before the formal ward rounds.

When leaving the unit for whatever reason, all doctors must inform their

colleagues, or if out of hours, the Charge Nurse. The ICU must never be left

unattended unless in extraordinary


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14

1 ADMINISTRATION 1.6 Clinical duties in the Intensive Care

circumstances and with the permission of the Consultant, and the knowledge

of the Nurse incharge.

1.6.2 Patient Admission

1.6.2.1 Primary patient survey

A: Ensure patient protecting airway / GCS / cognition (is the patient

receiving supplementary oxygen?)

B: Breathing pattern acceptable, Pulse Oximetry acceptable

C: Patient cardiovascularly stable, venous access acceptable

Obtain hand over information from the referring doctor

1.6.2.2 Secondary survey

Examine patient thoroughly

Notify Consultant Intensivist if this has not already been done.

Document essential orders:

Ventilation

Sedation, analgesia, drugs and infusions

Fluid therapy

Discuss management with nursing staff and team: Everyone must be

aware of the plan!

Basic monitoring and procedures:

ECG

Invasive / non-invasive monitoring

Urinary catheter / NG tube


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Basic Investigations (usually a full blood count, coagulation profile, ICU

specific electrolyte profile)

Advanced Investigations; CT, ultrasound

Case note documentation (see below)

Inform and counsel relatives in general terms

1.6.3 Doctors Documentation

Doctors are responsible for documenting an admission note for all patients

and a daily entry into the clinical notes as well as:

Discharge summary (includes database entry)

Death certificate


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15

1.6 Clinical duties in the Intensive Care 1 ADMINISTRATION

Admission Note: a pro forma sheet should be used, documentation must

include:

Date / time

Name/bleep of admitting doctor

Reason for admission: primary and secondary

Standard medical history including current medications

Thorough examination findings

Results of important investigations

Assessment / severity / differential diagnosis

Management plan

Document notification of parent team and duty senior.

Parent teams should be encouraged to write a short note (at least!) when

they visit the Unit.

1.6.3.1 Daily entry in clinical notes

Use the Daily Notes pro forma page.

Ensure each page is dated and labelled with the patients name and

hospital number.

Date / time / name of Senior ICU Doctor conducting the round.

A: Mental state, GCS, airway.

B: Ventilation, saturation (or PaO2), chest findings.

C: Pulse / BP / peripheral perfusion / Precordial exam.

Abdominal examination and description of feeding mode.


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Peripheries

Assessment or Impression

Plan Additional notation must be made in the notes when:

Invasive procedures are undertaken: please use the stickers when

inserting central/arterial lines.

Important management decisions are made.

Significant interaction is made with patient family.

1.6.4 Daily management issues

The daily handover ward round at 0800 is attended by the night on-call

doctor, the incoming day staff, the Consultant or senior Anaesthetist,Consultant Microbiologist and the Charge Nurse (if not too busy).

The night doctor responsible will present a concise report of every patient. It

is the responsibility of the night registrar to review the list for each patient,

and to enter new data or patients


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16

1 ADMINISTRATION 1.7 Clinical Duties Outside the Intensive Care Unit

where appropriate. Towards the end of the night shift a report should be

generated for each patient, and this is handed to the team following on. The

generated document is then filed in a folder as evidence of the handover.

The process is repeated for the night handover. Important decisions

regarding patient discharge and specialist investigations may be made at

this meeting and it is important that junior staff have a good understanding

of the patient status, including:

Patient details and demographics

Day of admission

Diagnosis and major problems

Relevant pre-morbid problems

Progress and significant events

Important results

Plan for the next 24 hours

1.7 Clinical Duties Outside the Intensive Care Unit

1.7.1 Cardiac Arrest Calls

1.7.1.1 Indications Cardiac arrest calls may be called for the following:

In-hospital cardiac arrest

Collapse of unknown origin in the hospital environs

Out of hospital arrest arriving in the A&E

The anaesthetic input for cardiac arrests is nominally the Acutes on call

team. However, if the Acutes team is otherwise occupied, the ICU doctor

may attend provided the patients on ICU are stable, and only after informing

the Charge Nurse.


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1.7.1.2 CPR (Cardio Pulmonary Resuscitation) We encourage the use of the

UK Resuscitation Council Guidelines for CPR

http://www.resus.org.uk/pages/als.pdf. The anaesthetist is responsible for

securing the airway and establishing effective ventilation, whilst the Medical

team should concern themselves with cardiac and general aspects. It wouldbe expected however that directing advanced life support be the

responsibility of the most senior doctor present.

Where CPR has been successful but further active treatment may not be in

the interests of the patient, the decision to withdraw care must only made

following consultation with senior doctors involved - this will usually be the

Anaesthetic and Specialty Consultants. All involvement in an arrest call must

be documented in the patient case notes.

1.7.2 Trauma Call

Again, the first responder for trauma calls is usually a member of the Acutes

on call team. However, should that team be busy, or in the event of a poly

trauma, the ICU doctor may be


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17

1.8 Infection Control 1 ADMINISTRATION

called upon to assist.

Ensure that the ICU Charge Nurse and Consultant Intensivist are aware of

where you are going, and communicate with the ICU team once the patient

has been assessed and the likely admission destination known.

1.7.3 Intra-hospital patient transport

No patient may be transported from the unit without the direction of the

Senior Anaesthetist/Intensivist on ICU or on call.

Medical escort is the rule if the patient is Level 2 or 3. In a minority of

circumstances a nurse escort may be sufficient, providing it is acceptable to

the Senior Anaesthetist and the Charge Nurse. It may not be appropriate for

all ICU doctors to undertake prolonged transport, or transport to unfamiliar

areas. Always ask the senior Anaesthetist if you are unsure. Prior to

embarking on an escort all equipment, oxygen supply and emergency drugs

must be checked.

All problems encountered on the escort must be recorded in the notes, and

an incident form completed if appropriate.

If a test is deemed urgent the medical escort should endeavour to get an

informal report written in the notes, failing which they should request formal

review and notification to the unit as soon as possible.

1.7.4 Out of hospital transfers

Should a patient require Level 3 care in the absence of bed availability, the

transfer process must be initiated by the parent team with assistance from

the ICU team. The first point of contact must be the West Yorkshire CriticalCare Network Bed Bureau.

The doctor who accompanies the patient must be competent to transfer the

ventilated patient, and to manage a compromised airway during transfer.

The doctor must also have attended a Transfer Training course. Transfer of a

Level 2 patient is fraught with danger. It may be safer to intubate/ventilate


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prior to transfer, especially if there is respiratory compromise. Discuss with

the Consultant Anaesthetist/Intensivists at both ends (i.e. Mid Yorks and the

receiving ICU/HDU).

1.8 Infection Control

1.8.1 Introduction

Patients requiring intensive care are highly susceptible to infection due to

immunosuppressive effects of drugs and disease, the use of invasive

monitoring techniques and the severity of the underlying illness requiring

admission. The use of broad-spectrum antibiotics may predispose to

infection with resistant organisms.


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18

1 ADMINISTRATION 1.8 Infection Control

Nosocomial infection delays patient discharge from the intensive care unit

(ICU) and contributes significantly to morbidity. The prevalence of hospital-

acquired (nosocomial) infection in the ICU can be considerably higher than

other clinical areas of the hospital.

Significant risk factors for infection include:

mechanical ventilation

prolonged length of stay

trauma or burns

intravascular catheterisation

urinary catheterisation

prior antibiotic use

The four most common nosocomial infections seen in ICU are:

Pneumonia

urinary tract

intra-vascular catheter-related bacteraemia

surgical wound infection

All ICU staff are responsible for ensuring good infection control policies are

adhered to, in particular good hand hygiene practice. In keeping with Trust

Infection Control policies, you are required to ensure you are bare below

the elbows, and to hand wash with alcohol gel before and after everypatient contact.

Skin preparation for invasive procedures (CVP catheters, VasCath, ICD

tracheostomy) must be with the prefilled 2% chlorhexidine/alcohol swabs.

Please ensure you adopt suitable barrier protection (gowns, masks, gloves).

1.8.2 Hand Hygiene and Standard Precautions


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Hand washing and hand disinfection remain the most important measures in

the prevention of cross infection. Hands should be washed before and after

contact with every patient and after manipulation of the patient

environment, especially after contact with a patients with C.difficile infection

or if the hands are soiled. Either use a 15-second handwash with soap andwater, or alternatively the waterless hand gel may be used if hands are not

visibly soiled. A longer handwash with antibacterial soap is required prior to

any major invasive procedures such as insertion of central venous catheter.

In addition to hand hygiene standard precautions are used for all patients:

Wear gloves for all contact with blood and body fluids including dressings

and wounds. Gloves must be changed and discarded between patients.

Hands must be decontaminated after the removal of gloves.

Wear a disposable plastic apron or fluid-resistant gown to protect the skinand clothing for procedures likely to generate splash or cause soiling.

Wear a mask and eye protection to protect mucous membranes of the

eyes, nose and mouth during procedures likely to generate splash or cause

soiling.


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1.8 Infection Control 1 ADMINISTRATION

Ensure patient-care equipment is cleaned and disinfected appropriately

between patient use.

Staff who generate a sharp product (e.g.: needle or blade) are responsible

for its safe disposal into an approved puncture resistant sharps container.

1.8.3 Isolation and transmission-based precautions

In addition to standard precautions, isolation and appropriate transmission-

based precautions are to be used with the following: Multi-resistant

organisms (MRO) Patients infected or colonised with the following MROsrequire isolation and contact precautions (gloves and gown/apron for direct

patient care):

Methicillin Resistant Staph. Aureus (MRSA)

Vancomycin Resistant Enterococcus (VRE)

Extended Spectrum Beta Lactamase (ESBL) producing enterobacters

Multi-resistant gram negative organisms

Meningococcal disease - proven or suspected

Patients require isolation and droplet precautions (surgical mask within 1

meter of the patient) until 24hrs of completed antibiotic treatment.

Miscellaneous

Burns patients require isolation and contact precautions

Febrile neutropaenic patients require isolation and contact precautions

High risk immunosuppressed patients require isolation and contact

precautions

Respiratory syncytial virus require contact precautions

1.8.4 General Measures


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The ICU should be kept tidy and uncluttered. Equipment not in use should be

stored in a clean area.

Movement of people through the unit should be kept to a minimum. This

applies equally to colleagues and relatives. All visitors are to be encouraged

to wash their hands before and after visiting the patient. Staff withcommunicable diseases should take sick leave. If suffering from D&V, ensure

at least 48 hours have elapsed since the last symptom before returning to

work.


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1 ADMINISTRATION 1.9 Information Technology

1.9 Information Technology

There are numerous terminals in the intensive care unit. All computers are

networked to the Intranet, which also functions as a gateway to the

Internet. The computers are logged in as a generic ICU-user, with

permissions to view Pathology results. The intranet allows access to all

inpatients in the hospital. The ward administrator section allows you to view

the pathology results of patients on the ICU and HDU. All imaging is now

film-less, and may only be viewed on the computer terminals. You should

have completed a tutorial, and received a smartcard following this in orderto view the images.

You will be given a separate login by the IT department. This allows you

access to your own account. You will have an e-mail address with access to

the Outlook mail program via a link on the Intranet front page.

The local area network provides access to the Internet. This is controlled and

closely monitored by the IT department. Access to the Internet requires

personal login, and all websites visited may be monitored. Please ensure you

close the browser window when you have finished. This prevents fraudulentand unauthorised access to websites in your name.

1.10 Consent in the Intensive Care Setting

1.10.1 Introduction

A competent patient may give or withhold consent for any medical

treatment. Unfortunately, patients in ICU often cannot have their

competency established with certainty. When a patient cannot give consent

in an emergency, in the absence of convincing evidence to the contrary (e.g.presence of a person with enduring power of attorney who can categorically

state that the person does not wish to receive the treatment in question, or

applicable advance directive) consent to treatment is implied.

1.10.2 Consent by relatives


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Relatives or friends cannot give or withhold consent for the performance of a

medical treatment. However, it is strongly recommended the treating doctor

takes the families views into account in deciding whether to perform a

particular treatment.

1.10.3 Consent at the Mid Yorks ICU

The consent form and the attendant process can record the attempt to take

the families views into account. In any case, completion of the appropriate

form is necessary to comply with hospital policy in certain procedures. A

written record of informed consent is unnecessary for the vast majority of

bedside procedures in ICU.


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1.11 Hospital Emergencies 1 ADMINISTRATION

When it is necessary to obtain consent for a particular procedure to be

performed on an ICU patient, it is appropriate for ICU medical staff to play a

role in this process. That role may not necessarily mean obtaining consent

directly, but may mean ensuring that the staff performing a procedure make

the requisite information available to the ICU doctor to enable them to get

consent, or in many cases obtain consent themselves.

1.11 Hospital Emergencies

Mass casualty

Communications or utility failure

Cardiac Arrest

Earthquake

Fire (or smoke smell)

Hazardous substance spill

Personal safety threat

Threat from telephone, letter or suspicious object

Bomb or arson

Radiation spill

Dialling 4444 and thereby contacting the switchboard will in most

circumstances allow you to initiate an emergency response that is

appropriate to the threat.

1.11.1 Fire and building emergencies

Attend formal fire training sessions

Become familiar with location of fire exits


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Assess medical condition of persons in an emergency area, and the likely

effects of evacuation on them.

Follow instructions of trained accredited staff.


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2 CLINICAL PROCEDURES

2 Clinical Procedures

Introduction It is inevitable that during your stay in the Intensive Care Unit

you will be exposed to a number of procedures with which you are not

familiar. All staff are encouraged to become proficient with routine

procedures:

2.0.2 ICU Procedures

Endotracheal intubation

Peripheral venous catheterisation

Central venous catheterisation

Arterial cannulation / PiCCO insertion

Pulmonary artery catheterisation

Urinary catheterisation

Lumbar puncture

Intercostal drain insertion or pleurocentesis

Naso-gastric / jejunal tube insertion

Patient consent should be obtained if appropriate as outlined elsewhere in

these guidelines.

No member of staff is permitted to attempt a procedure without adequate

training. Staff with previous experience must affirm this with the Senior

Anaesthetist or Consultant Intensivist prior to attempting unsupervised

procedures. All junior staff should be supervised for their first 2 arterial

cannulations and at least 5 central venous access procedures prior to

performing these procedures unsupervised.


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No matter how experienced you are, repeated unsuccessful vascular

punctures are unacceptable and a more experienced member of staff should

be asked to help.

All procedures must be annotated in the case notes, including the

indication / complications for the procedures.

2.0.3 Restricted procedures

Specialised procedures should only be performed by the Senior Anaesthetist

or Consultant Intensivist. They may not be attempted prior to discussion

with the Consultant.

Percutaneous tracheostomy

Fibreoptic bronchoscopy

2.1 Peripheral IV Catheter

2.1.0.1 Indications


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2.2 Arterial Cannulae 2 CLINICAL PROCEDURES

Initial IVI access for resuscitation

Stable or convalescent patients where more invasive access is not

warranted.

2.1.0.2 Management All lines placed in situations where aseptic technique

was not followed must be removed (eg. Placement by emergency staff at the

roadside). Peripheral lines must be removed after 72 hours (or before, if not

required), and replaced if there is a continuing need for peripheral IV access.

Acceptable aseptic technique must be followed including:

Thorough hand-washing

Skin preparation with alcohol swab

Occlusive but transparent dressing

All lines should be removed if not being actively used, or if > 2 days old.

An exception may be made where venous access is challenging (eg. IV drug

abusers).

2.1.0.3 Complications

Infection

Thrombosis

Extravasation

2.2 Arterial Cannulae

2.2.0.4 Indications

Invasive measurement of systemic blood pressure in ICU or during patient

transport / retrieval.

Multiple blood gas sampling and laboratory analysis

2.2.0.5 Site and catheter choice


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1st choice: Radial artery

2nd choice: Femoral.

Site of choice for PiCCO catheter monitoring (Pulsiocath 5F 16 cm catheter)

is generally the femoral artery.

The axillary artery may be considered after consultation with the Consultant

(usually 4F catheter).

The Brachial artery is an end-artery, and catheterisation has been

considered a risk for distal arterial complication (although this has also been

disputed). It may be used if there are no alternatives.


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2 CLINICAL PROCEDURES 2.3 Central Venous Cannulae

2.2.0.6 Technique

All catheters should be inserted with full sterile technique (gown, sterile

gloves, topical antiseptic)

The arterial line must be firmly anchored (suturing is not recommended)

The insertion site and all connectors must be visible through the applied

dressing.


Infection

Thrombosis

Digital Ischaemia

Vessel trauma and fistula formation.

NB: Interpretation of arterial waveforms requires familiarity with normal

arterial waveforms as well as trace damping, amplification and arterial

harmonics. If you are unsure as to the reliability of a trace / reading you

must seek assistance before removing the arterial cannula.

2.3 Central Venous Cannulae

2.3.1 Introduction

The use of CVCs is associated with adverse effects both hazardous to

patients and expensive to treat. More than 15% of patients with CVCs have

some complication from them:

Mechanical 5-19%

Infectious 5-26%use

Thrombotic 2-26%


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The first 5 CVC insertions performed by the trainee should be performed

under direct supervision and then (if the competency is signed off) the

trainee may insert the lines without supervision, on the understanding that

when a difficult catheterisation is anticipated, they will ask for senior

assistance.Failure to insert the catheter after 3 attempts, should prompt the clinician to

seek help rather than continue to attempt the procedure, as the incidence of

mechanical complications after three or more insertion attempts is six times

the rate after one attempt.

2.3.2 Types of catheter

2.3.2.1 Anti-microbial-Impregnated Catheters These catheters have been

shown to lower the rate of catheter-related bloodstream infections.

Consider the use of an Anti-microbial-Impregnated CVC for adult patients

who require shortterm (1-3 weeks) CVC and who are at high risk for

catheter-related blood stream infection (CR-BSI)

It may be appropriate to use this type of CVP in selected patients, ie those

with neutropaenic sepsis.


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2.3 Central Venous Cannulae 2 CLINICAL PROCEDURES

2.3.2.2 Single-lumen and Multi-lumen catheters The number of lumina does

not directly affect the rate of catheter-related complications, so the choice of

either single- or multilumen catheter should be dictated by clinical need.

2.3.3 Indications

2.3.3.1 Monitoring haemodynamic variables

Fluid administration (particularly if large volumes of fluids or blood

products are required)

Infusions of

TPN

Inotropes

Hypertonic solutions

Irritant solutions

Chemotherapy

Potassium solutions

For haemofiltration or haemodiafiltration

2.3.4 Site

Subclavian

Internal Jugular

Femoral

Internal jugular catheterisation can be difficult in morbidly obese patients,

although with ultrasound may be made easier.


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Subclavian venous catheterisation should be avoided in patients with severe

hypoxaemia, as the risks and complications of pneumothorax and

haemothorax are greater than with internal jugular approach.

Femoral catheterisation should be avoided in patients with grossly

contaminated inguinal regions, as the risk of development of catheter-related infections is increased.

If central venous access is needed rapidly in the shocked patient, the

femoral approach may be the fastest technique and used for the initial

resuscitation.

2.3.5 Technique

Asepsis

Full scrub

Sterile gown

Sterile gloves


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2 CLINICAL PROCEDURES 2.3 Central Venous Cannulae

Large sterile drape

Skin decontamination

Alcoholic chlorhexidine gluconate for skin

Allow to dry before cannulation

Use Seldinger technique to access vein

NICE guidance on use of ultrasound for placing CVCs

1.1 Two-dimensional (2-D) imaging ultrasound guidance is recommended as

the preferred method for insertion of central venous catheters (CVCs) into

the internal jugular vein (IJV) in adults and children in elective situations.

1.2 The use of two-dimensional (2-D) imaging ultrasound guidance should

be considered in most clinical circumstances where CVC insertion is

necessary either electively or in an emergency situation.

1.3 It is recommended that all those involved in placing CVCs using two

dimensional (2-D) imaging ultrasound guidance should undertakeappropriate training to achieve competence.

1.4 Audio-guided Doppler ultrasound guidance is not recommended for CVC

insertion.

Flush all parts of catheter with heplock prior to insertion

Trendelenburg tilt for internal jugular or subclavian routes

Use blade to ensure insertion site on skin will allow passage of dilator and

catheter

Insert catheter to estimated appropriate depth, according to insertion site

and patient anatomy


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Aspirate from each port. Easy aspiration of blood should be possible from

each line, and then flush each line with heplock, and the the catheter ports

must then be closed with caps.

Secure the catheter to the skin by suturing the holder on the catheter to

the skin (not the clip for adjusting the catheter position)

Apply a sterile semi-permeable polyurethane dressing to the catheter

insertion site eg Tegaderm. If the insertion site is bleeding or oozing, a

sterile gauze dressing may be used.

Chest X-Ray when the catheter is secure, to look for pneumothorax and

assess catheter tip position

2.3.6 Complications

At Insertion


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2.3 Central Venous Cannulae 2 CLINICAL PROCEDURES

Arterial puncture

Pneumothorax

Neural injury

Guidewire induced arrhythmia

Air embolus

During catheter presence

Infection

Thrombosis

Embolism

Pulmonary infarct or PA rupture (with PAF catheter)

Arterio-venous fistula

2.3.6.1 Mechanical complications Arterial puncture, haematoma andpneumothorax are the commonest Frequency of mechanical complications,

according to approach :

Internal Jugular Subclavian Femoral

Arterial Punture 6.3-9.4% 3.1-4.9% 9-15%

Haematoma


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Data from a systematic review of complications of CVS has shown the rate of

bloodstream infections may be as high as 8.6% with jugular access, and

4.0% with subclavian access.

2.3.6.3 Thrombotic complications The risk of catheter-related thrombosis

varies according to site of catheter.

Approximate figures are:

21% of patients with femoral catheters

2% of patients with subclavian venous catheters

8% of patients with internal jugular

The clinical importance of catheter-related thrombosis remains undefined,

although all thromboses have the potential to embolize.


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2 CLINICAL PROCEDURES 2.4 Pulmonary artery catheterisation

2.3.7 Documentation

Documentation of the procedure undertaken should appear in the patient

case notes using a procedure sticker. ALL complications or difficulties

encountered, should be documented beneath the sticker.

2.3.8 Line Management

Routine line replacement is not necessary

The practice of changing the central line over a guidewire should beavoided unless it is the only option

Lines should be removed

as soon as a clinical indication no longer exists

if patient shows signs of unexplained systemic infection

if insertion site appears infected or blood cultures suggest infection with a

skin organism (eg staph epidermidis). The catheter-tip should be sent to

microbiology for culture and sensitivities

If suspecting catheter-related bloodstream infection, a wound swab should

be taken from the catheter insertion site, and blood should cultured from the

suspect line and from a sample taken from a peripheral stab.

References

1. NICE Technology Appraisal Guidance No.49, ultrasound locating devices

for placing central venous catheters - September 2002. Moved to static list

of guidance November 2005 following period of consultation.2. Guidelines for the prevention of intravascular catheter-related infections.

Centers for Disease Control and Prevention. MMWR 2002;51(NoRR-10):1-33

3. Preventing Complications of Central Venous Catheterization. McGee DC,

Gould MK The New England Journal of Medicine. 2003 Vol 348:1123-1133


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4. National Evidence-based guidelines for preventing healthcare associated

infections in NHS hospitals in England. London. Richard Wells Research

Centre, Thames Valley University, 2006 epic2.

5. Complications of central venous catheters: Internal jugular versus

subclavian access A systematic review. Ruesch S, Walder B, Tramer M.Critical Care Medicine 30(2):454-460, February 2002

2.4 Pulmonary artery catheterisation

The PA Catheter is not a resuscitation tool and should only be inserted in a

controlled environment after discussion with the senior Anaesthetist.

Dwindling use of the PA catheter has resulted in a loss of familiarity with its

use. Junior medical staff and nursing staff not familiar with this instrument

should not manipulate / advance / inflate the PA catheter balloon.


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2.5 Pleural Procedures 2 CLINICAL PROCEDURES

2.4.1 Indications

Haemodynamic measurement: (cardiac output, stroke volume, systemic

vascular resistance)

Measurement of right heart pressures (pulmonary hypertension,

pulmonary embolus)

Estimation of preload to the left ventricle - controversial.

2.4.2 Insertion

PA Catheter insertion is technically difficult and requires a working

knowledge of right heart pressures and waveforms. They should only be

inserted by accredited staff. See appendix on pulmonary artery

catheterisation

2.4.3 Monitoring PA trace

An adequate tracing should be visible on the monitor at all times. A damped

tracing may represent a wedged catheter, clot at the catheter tip or

inappropriate equipment set-up (wrong monitor calibration, faulty pressure

transducer).

Flush the distal lumen generously (using closed mechanism)

Withdraw catheter until a trace is present. NB: Never withdraw the

catheter with an inflated ballon.

2.4.4 Measurement of pressures

Pressure should be referenced to the mid-axillary line The true wedge pressure is measured at end-expiration

PEEP may influence wedge pressures, however this is not a factor at PEEP 10% from average discarded.

2.5 Pleural Procedures

As with all invasive procedures this should not be attempted by

inexperienced staff.


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2 CLINICAL PROCEDURES 2.5 Pleural Procedures

Indications for accessing pleural space

Pneumothorax ( temporising procedure if under tension)

Haemothorax

Symptomatic or infected pleural effusion

Needle Thoracostomy for Tension Pneumothorax

16G cannula placed in mid clavicular line, 2nd intercostal space

Proceed to formal intercostal drain insertion.

2.5.1 Pleurocentesis

2.5.1.1 Indications

Diagnostic procedure: Exudate vs Transudate, or to exclude infected

collection or malignancy.

Therapeutic procedure: Drainage of an infected collection requires an

underwater sealed drain. It is not appropriate to perform one-off drainage.The practice of draining non-infected pleural collections by pleurocentesis is

controversial and should not be performed without direction by the senior

Anaesthetist.

2.5.1.2 Technique Local anaesthesia and sterile technique.

Unless the fluid collection is grossly detectable on clinical examination and

on plain radiology, pleurocentesis should be ultrasound directed.

Investigation of pleurocentesis fluid Aspirated fluid should , at the very least,be submitted for pH or analysed in ICU blood gas analyser (pH < 7.20 =

empyema, 7.20-7.25 = equivocal)

2.5.2 IntercostalCatheter / Underwater Sealed Drain

2.5.2.1 Insertion


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Local Anaesthesia is mandatory in awake patients, and should be used in

sedated patients

Strict aseptic technique

28F catheter inserted into 3-4th intercostal space, mid-axillary line, usingblunt dissection as described and recommended in the ATLS guidelines.

The Catheter must be guided through the ribs without use of sharp

instruments (preferably finger). Trochar aided insertion techniques are not

acceptable.


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2.6 Endotracheal Intubation 2 CLINICAL PROCEDURES

2.5.2.2 Maintenance Drains placed in un-sterile environs should be removed

as soon as possible.

Drains should remain in-situ until radiological resolution has occurred and

there is no further bubbling or drainage of significance ( < 150 ml.24-hr)

In patients at risk (due previous large air leak, or multiple rib fractures) who

remain on positive pressure ventilation, the drain may be clamped for 4hrs

prior to removal as a safety measure, although this is by no means

universally practiced. Drains placed electively in theatre are the

responsibility of the surgeon


Incorrect placement

Pulmonary laceration

Pneumothorax

Bleeding as a result traumatic drain insertion (intercostal or, lateral

thoracic artery, lung etc)

Microbial innocculation

2.6 Endotracheal Intubation

2.6.0.4 Introduction Endotracheal intubation in ICU patients is a high risk

but vital emergency procedure in patients who often have limited reserve,

are difficult to position and may have a difficult airway. All staff should

familiarise themselves with the intubation trolley and equipment. Whenever

possible make sure that you have capable and trained staff to assist you. Ifyou are alone or inexperienced always call for assistance. If the senior

anaesthetist cannot be reached for some reason, or is detained, then

assistance should be sought from an anaesthetic colleague.

Rapid sequence induction is the rule in ICU patients unless previously

discussed with senior medical staff.


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2.6.0.5 Indications

Institution of mechanical ventilation

To maintain an airway

Upper airway obstruction or threat

Control of arterial carbon dioxide content (eg. in the setting of traumatic

brain injury)

Patient transportation

To protect an airway

Patients at risk of aspiration


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2 CLINICAL PROCEDURES 2.6 Endotracheal Intubation

Altered conscious state

Tracheal toilet

2.6.0.6 Techniques Orotracheal intubation is the rule.

Blind nasal awake intubation, or fibreoptic awake intubation, may be

indicated in selected patients with cervical spine injury, limited mouth

opening or oro-facial surgery / trauma. These techniques should only be

undertaken by staff with current experience of these techniques, and only

after discussion with and the presence of the Consultant Intensivist.

2.6.0.7 Standard endotracheal tube choice All patients in the Intensive Care

Unit should be intubated with a low pressure high volume PVC tube (eg

Portex blue line oral/nasal tube)

2.6.0.8 Non-standard tubes Patients returning from theatre (or transported

from another centre) may have a different ET tube (eg. armoured ETT) in

situ. Where there is no good reason for this to remain it should be changed

to the standard ETT if it is anticipated that the patient will require intubation

> 48 hrs, and would not be exposed to significant risk during the ETTchange.

2.6.1 Intubation Guideline

2.6.1.1 Personnel

Skilled assistance is mandatory, where possible a team of 4 is required.

Intubator who controls and co-ordinates the procedure.

Drug administration

A person to apply in-line traction where the stability of the cervical spine is

unclear.

Cricoid Pressure: Cricoid pressure is recommended in all emergency

situations and should be applied at the commencement of induction. Cricoid


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pressure may distort the larynx so that intubation is made more difficult. It

should be modified at the discretion of the intubator, and requires an

understanding of the procedure.

2.6.1.2 Preparation

Secure adequate IVI access

Check all equipment prior to intubation:

Adequate lighting

Selection of oropharyngeal airways

Working suction with Yankauer attachment

AMBU bag assembly and appropriate mask

100% oxygen with flow capability > 15 l/min


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2 working laryngoscopes with appropriate choice of blade

Magill forceps

Malleable introducer and gum-elastic bougie

2 ETT: estimated patient size and one smaller size. (Female = 7-8 mm,

Male = 8-9 mm)

A selection of laryngeal masks

Emergency cricothyrotomy kit: (#15 scalpel and 6.0mm cuffed ETT)

Ensure adequate monitoring

Pulse oximetry

Reliable blood pressure monitoring (eg. invasive if necessary)

ECG telemetery

Difficult intubationKit A difficult intubation kit can be found on the side of

the intubation trolley. This contains:

An intubating LMA

McCoy laryngoscopes

Light wands

Emergency cricothyrotomy kit

Jet ventilation system

2.6.1.3 Drugs

Induction agent

eg. Thiopentone, Fentanyl, Ketamine, Midazolam

Muscle relaxant


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Suxamethonium 1-2 mg/kg

Consider Rocuronium 1-2 mg/kg if Suxemethonium contra-indicated ie:

Burns patients > 48 hrs post injury

Spinal injury patients where spasticity is present

Chronic neuromuscular disease (Myasthenia Gravis, GBS)

Hyperkalaemic states

Miscellaneous

Atropine 0.6-1.2 mg

Adrenaline 10 ml of 1:10 000 solution.

Metaraminol 0.5 mg/ml (usually in 10 ml)


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2 CLINICAL PROCEDURES 2.6 Endotracheal Intubation

2.6.1.4 Procedure: Rapid sequence induction and orotracheal intubation

Pre-oxygenate for 3-4 minutes with 100% oxygen. Patients receiving non-

invasive ventilation should continue on this form of ventilation until the point

of induction, and a PEEP valve applied to the AMBU-bag mask assembly.

Administer induction agent and suxamethonium

Apply cricoid pressure

Intubation under direct visualisation

Inflate ETT cuff until there is no air leak during ventilation

Confirm ETT placement with capnograph and chest auscultation with

manual ventilation.

Release cricoid pressure

Secure ETT at correct length (Female = 19-21cm at incisors, Males = 21-

23 cm at incisors)

Do not cut ETT at less than 26 cm (if at all).

Connect patient to ventilator

Ensure adequate sedation and analgesia to cover period of muscle relaxant

and continue as indicated by clinical scenario.

Insert naso-/-orogastric tube or naso-jejunal tube if not already present.

A follow-up CXR should be performed as soon as convenient.

2.6.1.5 Maintenance of endotracheal tubes

Tapes ETT are generally secured with white tape.

Tapes are changed daily or PRN by nursing staff.

In certain circumstances personalised ETT security may be required.


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Cuff integrity Sufficient air should be placed into the cuff to prevent an air

leak, as assessed by auscultating over the trachea.

ETT manometry is not routinely required, and may be misleading as the

correlation with mucosal pressure is unreliable.

Persistent cuff leakage Any ETT that constantly requires additional air

instilled into the cuff should be reviewed for:

Herniation above the cords

Cuff damage (rare)

Malfunctioning pilot tube valve (which can be excluded by placing distal

pilot tube into container of water and observing for bubbling)


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Airway suctioning Airway suction may be performed every 2-3 hrs prn

Routine suctioning should be avoided where:

it requires disconnection of PEEP (open suction system)

may exacerbate the patients condition (asthma, reactive Intra-cranial

pressure, florid pulmonary oedema).

2.6.1.6 Endotracheal tube change

Equipment and assistance The procedure / setup is the same as for

intubation de novo

Ensure patient is adequately oxygenated (Saturation 98-100%). An FiO2 of

1.0 may be excessive and promote atelectasis.

Ensure adequate anaesthesia and muscle relaxation

Procedure Perform direct laryngoscopy:

If a good view of the larynx and vocal cords is obtained then proceed to

manual exchange of ETT with application of cricoid pressure, or proceed as

below using gum-elastic bougie.

If direct laryngoscopy reveals abnormal or swollen anatomy, or only partial

view of anatomy, then proceed as follows:

Place gum elastic or ventilating bougie through the ETT and insert to a

length corresponding to a few cm distal to the end of the ETT.

With an assistant stabilising the bougie, and applying cricoid pressure,

remove faulty ETT under direct laryngoscopy, while maintaining bougie inthe same position.

Confirm the bougie is still in place through cords once ETT removed, and

then replace new ETT over the top of the bougie apparatus.


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If the ETT does not progress smoothly through the cords, rotate 90 deg

anti-clockwise and attempt again (ie. realign beveled edge of ETT along

upper border of bougie)

Check position of ETT and secure as for de novo intubation procedure.

2.6.1.7 Extubation guideline Ensure

the intensive care unit maual

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