Current Guidelines in Critical Care Session 2: 2014 Critical Care Boot Camp

1. Current Guidelines in Critical CareSession 2: 2014 Critical Care Boot Camp Billy Cameron, MSN, ACNP-BC Assistant in Surgery, Dept of Surgery Acute Care Nurse Practitioner Surgical Intensive Care Unit

2. Current Guidelines in Critical CareSeptember 9, 2014 • Rapid Response Teams • Use of Corticosteroids in Septic Shock • Central Venous Catheter Infection Prevention • Critical Care of the Organ Donor • Advanced Cardiac Life Support Algorithms

3. Objectives • Identify background of previous evidence based critical care practice guidelines • Identify and apply most recent evidence based guidelines for critical care practice • Be able to identify areas in which critical care practice may be impacted by most recent guidelines

4. Rapid Response Teams Background: • Literature supports Rapid Response Teams in reducing mortality of patients, reducing lengths of stay, reducing unplanned transfers to ICUs, and increasing patient satisfaction • Rapid Response Teams can intervene prior to an acute cardiac event, or other deterioration of clinical status (ie; early intervention for sepsis)

5. Rapid Response Teams Goals of Rapid Response Teams: • Increase early intervention and stabilization to prevent clinical deterioration prior to cardiac arrest or other life-threatening event • Decrease the number of cardiopulmonary arrests that occur outside of the ICU and ED • Decrease hospital mortality • Increase patient, family, and staff satisfaction

6. Rapid Response Teams Guideline: Develop an Early Warning System: • “Something isn’t right” • Heart rate: <40/>160 (some systems use 120); new onset chest pain • Blood pressure: Consider range of SBP <80/>180 or DBP >100 • Respiratory status: Consider rate <8/>28 bpm • consider SpO2 <85-90% for more than 5 minutes • increasing O2 demand to maintain baseline SpO2 evidenced by increased work of breathing or change in breathing pattern • Neurological status: Acute change in baseline neuro status • Alteration in LOC; AMS • Unexplained lethargy and/or agitation; new delirium • Seizure • Symptoms of stroke: change in speech, facial/extremity weakness, numbness/tingling

7. Rapid Response Teams Guideline: Develop an Early Warning System: Some institutions use Early Warning Score: 3 or more institutes activation of RRT

8. Rapid Response Teams Guideline: Other Considerations • RRT should consist of qualified individual providers with excellent assessment, communication, and clinical skills • Have a means by which to active an ACS protocol with qualified cardiopulmonary providers should the event be an ACS event; have an algorithm that drives activity • Encourage family members to be educated and feel comfortable activating the RRT • Bedside report upon arrival of the RRT should include SBAR (situation, background, assessment, recommendation) in a concise, brief exchange in order to give the providers on the RRT enough information to begin piecing the events together

9. Rapid Response Teams Guideline: Other Considerations • Provide ongoing simulation training to the RRT members • Provide ongoing evaluation of RRT events and problems that arise • Post early warning signs for activation of the RRT with clear visibility for patients, their family members, and healthcare staff (ie; posters)

10. Rapid Response Teams

11. Rapid Response Teams • Algorithm example at: https://www.icsi.org/_asset/8snj28/rrt.pdf

12. Rapid Response Teams References: Health care protocol: rapid response teams. Institute for Clinical Systems Improvement. Retrieved from internet on 8/11/2014 at https://www.icsi.org/_asset/8snj28/rrt.pdf Romero-Brufau, S., et al. (2014). Widely used track and trigger scores: Are they ready for automation in practice? Resuscitation 85 (2014) 549-552. Pliego, J., Sheather, S., Villamaria, F. Wehbe-Janek, H., (2014). System-based interprofessional simulation-based training program increases awareness and use of rapid response teams. TheJoint Commission on Quality and Patient Safety. Vol 40; No 6.

13. Use of Corticosteroids in Septic Shock Background: • The use of corticosteroids as an adjunctive therapy has been used for decades, controversial and often misunderstood. • High-dose corticosteroids have been shown to provide no real benefit in septic shock • Hypothetically, severely prolonged systemic inflammation can lead to adrenal insufficiency resulting in “critical illness-related corticosteroid insufficiency”; which, can be treated with physiologic doses of corticosteroid (hydrocortisone 200mg – 300 mg per day) • Studies have shown reduction in mortality in patients with relative adrenal insufficiency when treated with physiologic doses of corticosteroid • The 2012 Surviving Sepsis Guidelines attempted to clarify often misunderstood guidelines from 2008.

14. Use of Corticosteroids in Septic Shock Barriers to Guideline Implementation: • No specific dosing recommendations beyond stating a limit of 300mg/day • Intensivists “individualizing” treatment • Different interpretations of the guidelines • Discrepancy between a clinician’s interpretation of guidelines and the reality of their clinical practice • Lack of support from institution to implement prevention and treatment “bundles” based on evidence

15. Use of Corticosteroids in Septic Shock 2008 Surviving Sepsis Guidelines for Corticosteroids: • Hydrocortisone IV should be given only to adult patients in septic shock after it has been confirmed that their blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy. • ACTH stimulation test should not be used to identify the subset of adults with septic shock, who should receive hydrocortisone • Steroids need to be weaned by the clinician when vasopressors are no long required

16. Use of Corticosteroids in Septic Shock 2012 Surviving Sepsis Guidelines for Corticosteroids: • Do not administer IV hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, the suggestion is IV hydrocortisone alone at a dose of 200mg per day RATIONALE: Several studies have shown benefit on mortality with the use of hydrocortisone in patients who exhibit shock, as well as low results. Because of study design and patient population differences, disparity continues in the research. So, it is best to use fluid resuscitation and vasopressors when the patient is responsive to such treatments.

17. Use of Corticosteroids in Septic Shock 2012 Surviving Sepsis Guidelines for Corticosteroids: • Do not use the ACTH stimulation test to identify the subset of adults with septic shock who should receive hydrocortisone RATIONALE: Observations have been made in multicenter trials regarding responders and nonresponders to hydrocortisone in septic shock and ACTH stimulation tests are not significant predictors of adrenal insufficiency. Random cortisol tests may still be useful for absolute adrenal insufficiency , but not relative adrenal insufficiency (no absolute stress response). A random cortisol level of less than 15 μg/dl in critical illness is where most literature sets the limit to treat relative adrenal insufficiency; some studies suggest as high as 20 – 25 μg/dlOf note, etomidate when used for intubation, can suppress the hypothalamic-pituitary-adrenal axis; therefore, reducing levels of cortisol.

18. Use of Corticosteroids in Septic Shock 2012 Surviving Sepsis Guidelines for Corticosteroids: 3) Taper treated patients from steroid therapy when vasopressors are no longer being used RATIONALE: There has been no comparative study between fixed-duration and clinically guided regimen or between tapering and abrupt cessation of steroids. There have been randomized controlled trials that have shown good results in a weaning regimen, abrupt cessation (however, one study showed hemodynamic and immunologic rebound effects after abrupt cessation), and no difference in outcome with regimens of low dose steroids for 3 or 7 days.  This leads to a barrier in practice giving rise of clinicians to implement their own practice biases. More large center trials are needed.

19. Use of Corticosteroids in Septic Shock 2012 Surviving Sepsis Guidelines for Corticosteroids: 4) Do not administer steroids for the treatment of sepsis in the absence of shock RATIONALE: There is no sufficient evidence to show that steroid treatment has benefit in treating patients who have sepsis; but, who do not have shock. In this case, steroids may be considered for adrenal dysfunction, but no evidence supports steroid treatment for a preventive potency in reducing the incidence of severe sepsis and shock in critically ill patients. • When low-dose hydrocortisone is given, use continuous infusion rather than bolus injections RATIONALE: Several randomized trials show an increase in hyperglycemia and hypernatremia with the use of bolus high-dose steroids.

20. Use of Corticosteroids in Septic Shock References: Contrael, K., et al. (2013). Prescribing patterns of hydrocortisone in septic shock: a single-center experience of how surviving sepsis guidelines are interpreted and translated into bedside practice. Critical Care Medicine. 41:10. Dellinger, R., et al. (2013). Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine. 41:2. Pastores, S., Rajendram, P., (2013). Prescribing patterns for corticosteroids in septic shock: translating guidelines into bedside practice. Critical Care Medicine. 41:10.

21. Central Venous Catheter Infection Prevention Background • Central venous catheters (CVC) are routinely used in the ICU and bloodstream infections are a major complication in those patients with indwelling CVC. • CVC tubing may contribute to bacteremia and other infections. • Healthcare associated infections can contribute to increased mortality and morbidity when hospital staff do not adhere to proper aseptic technique when inserting CVCs and caring for them • Over 80,000 CVC-related blood stream infections occur annually in ICUs and increase LOS.

22. Central Venous Catheter Infection Prevention Current 2011 CDC Guidelines: Summary 1) Educate clinicians regarding the indications of CVC use, proper procedures to insertion and maintenance, and appropriate infection control measures 2) Periodically assess knowledge of and adherence to guidelines for all involved with insertion and care of CVCs. 3) Designate only trained personnel who demonstrate competence for insertion and maintenance of CVCs 4) Ensure appropriate nursing staff levels in ICUs. Studies suggest that a higher proportion of “pool nurses” or elevated patient-to-nurse ratio is associated in increased occurrence of CVC-related infections

23. Central Venous Catheter Infection Prevention Current 2011 CDC Guidelines: • Use maximal sterile barriers during CVC insertion • Use >0.5% chlorhexidine skin preparation with alcohol for skin antisepsis • Avoid routine placement of CVC as a strategy to prevent infection • Avoid femoral vein placement of CVC (higher risk for infection due to location) • Change dressings using aseptic technique • Perform daily audits to assess whether central line is still needed • Promote hand hygiene

24. Central Venous Catheter Infection Prevention Current 2011 CDC Guidelines: • Promote evidence based bundles for prevention of CVC infections • Avoid subclavian site in patients receiving hemodialysis to avoid subclavian vein stenosis • Use ultrasound guidance to place CVCs to reduce number of cannulation attempts and mechanical complications • Promptly remove any CVC that is no longer deemed necessary • When adherence to aseptic technique cannot be ensured, replace catheter as soon as possible (outside hospital admisisons)

25. Central Venous Catheter Infection Prevention Current 2011 CDC Guidelines: • Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgement • Do not use guidewire exchange routinely for non-tunneled CVCs to prevent infection, or for CVC that is suspicious of infection • Replace administration tubing no more frequently than 96 hours for those sets not infusing blood, blood products, or fat emulsions (ie; TPN, propofol, lipids), but at least every 7 days • Replace administration tubing for blood, blood products, and fat emulsions every 24 hours • Replace tubing for propofol every 6-12 hours or with each new bottle of medication

26. Central Venous Catheter Infection Prevention Suggested Updates to Guidelines: • Use antimicrobial CVCs (no significant difference between non-impregnated or impregnated) to reduce line infections, especially in ICUs, where the primary evidence shows to be most effective. Use caution outside the ICU where nursing staff may be less aware of CVC-related infection precautions. • Provide ongoing education to hospital staff regarding infection prevention in order to assess knowledge and adherence to guidelines • When introducing bundles for prevention of infection, introduce one new intervention at a time to decrease confusion and/or overwhelming the hospital staff to increase adherence

27. Central Venous Catheter Infection Prevention References Flodgren, G., et al. (2013). Interventions to improve professional adherence to guidelines for prevention of device-related infections. Cochrane Database of Systematic Reviews, Issue 3. CD 006559 O’Grady, N., et al. (2011). Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Lai, NM., et al. (2013). Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database of Systematic Reviews, Issue 6. CD 007878 Ullman, AJ., et al. (2013). Optimal timing for intravascular administration set replacement. Cochrane Database of Systematic Reviews, Issue 9. CD 003588

28. Critical Care of the Organ Donor Background: • Organ donation is often surrounded by ethical and policy issues that require strict adherence • Donation after circulatory determination of death (DCDD: Formerly known as donation after cardiac death) has the potential to increase the number of organs available for transplantation. • Consent and management of potential donors must occur before death; therefore, unique ethical considerations exist

29. Critical Care of the Organ Donor Background: • DCDD organs are accounting for more available organs across the Organ Procurement Organizations (OPO), allowing for more policies to be enacted in hospitals to consider ethical principles and advanced directives regarding organ donation • Care of the DCDD donor/patient requires dedicated and informed hospital staff along with OPO staff

30. Critical Care of the Organ Donor Underlying Ethical Principles: • Acts that promote the opportunity to donate viable organs respect the patient’s potential interest in becoming an organ donor. RATIONALE: In controlled DCDD, actions must be taken on living persons which are more for the intent of organ preservation for donation. It becomes imperative to promote the donor’s legitimate interests in what becomes of their bodies after death

31. Critical Care of the Organ Donor Underlying Ethical Principles: • The legitimacy of surrogate decision making for critically ill patients whose wishes are unknown extends to decisions regarding organ donation: RATIONALE: Critically ill patients are often incapacitated of decision making. Surrogates are viable decision makers; however, care must be taken that the wishes of the surrogate do not overshadow the wishes of the donor prior to critical illness

32. Critical Care of the Organ Donor Underlying Ethical Principles: 3) If real or perceived conflicts arise between the goals of providing optimal end-of-life care and the goals of procuring organs, delivery of quality end-of-life care should take priority RATIONALE: Patients or their surrogates must be well informed of how certain end-of-life treatment strategies may impact opportunities for donation before they are initiated.

33. Critical Care of the Organ Donor Treatment Guidelines for Organ Optimization with DCDD: • Hemodynamics: Immediate attention should be given to correcting hypotension; resulting in maximized organ perfusion. - Use volume - Use vasoactive drugs cautiously; vasopressin has become the drug of choice in lieu of high dose vasopressors

34. Critical Care of the Organ Donor Treatment Guidelines for Organ Optimization with DCDD: • Pulmonary: Lungs are transplanted most rarely (15-25% of donors); therefore, care should be taken to optimize if viable: - Adequate gas exchange is imperative - Mechanical ventilation should focus short periods of PEEP of 15 cm H2O for 2 hours followed by lower PEEP of 5 cm H2O to prevent atelectasis and open alveoli. - Avoid excess fluid administration

35. Critical Care of the Organ Donor Treatment Guidelines for Organ Optimization with DCDD: 3) Hormonal Therapy: - Catecholamine surges following DCDD are common. These need to be avoided by doing the following: • Exogenous replacement of ADH following posterior pituitary insufficiency; this has been shown to improve graft function of kidneys, liver, and cardiac recipients • Volume replacement is essential to treat Diabetes Incipidus • Correct Hypernatremia • Deficiencies of pituitary hormones need to be corrected: TSH, T4, HGH. UNOS has done research hormone replacement and has been shown to increase donation of organs by 22.5% • Correct hyperglycemia using insulin infusion, if needed

36. Critical Care of the Organ Donor Guidelines for Organ Optimization with DCDD: • Organ procurement can only occur once death has been certified by a physician • To decrease warm ischemic time, withdrawal of life support should occur in the OR where procurement can begin immediately thereafter. • Consideration for Extracorporeal Membrane Oxygenation (ECMO) to increase oxygenation and organ preservation is controversial and an extreme measure that must be understood by those involved in premortem care

37. Critical Care of the Organ Donor References: Baumann, A., et al. (2013). Elective non-therapeutic intensive care and the four principles of medical ethics. Journal of Medical Ethics. 39: 139-142 Dare, A., Bartlett, A., Fraser, J. (2012). Critical care of the potential organ donor. Curr Neurol Neurosci Rep. 12: 456-465 Gries, C., et al. (2013). An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: Ethical and policy considerations in organ donation after circulatory determination of death. American Journal of Respiratory Critical Care. 188: 1, 103-109

38. Advanced Cardiac Life Support Simplified Algorithms for Easy Memorization and Use in Acute Events TOO FAST: VT, VF • Determine whether stable or unstable Stable: Narrow complex (SVT) Wide complex (VT) • Vagal Amiodarone150mg bolus; Sotalol • Drugs: • Adenosine 6mg  12mg/12mg Then, consider betablocker, CCB Unstable: (hypotension/shock/ACS/AMS/CP)  Cardioversion

39. Advanced Cardiac Life Support Simplified Algorithms for Easy Memorization and Use in Acute Events TOO SLOW: sinus brady/heart blocks • Determine whether symptomatic (unstable) or asymptomatic Symptomatic: • Atropine 0.5mg q3-5 mins (max 3mg)…only use for atropine now • Call for TCP • Epinephrine/domamine infusion Asymptomatic: 1) Monitor; identify causes

40. Advanced Cardiac Life Support Simplified Algorithms for Easy Memorization and Use in Acute Events Pulseless VT/VF: SHOCK (Defib VF) @ 200 J  CPR 2 mins. (prep meds)  Rhythm check SHOCK if still no pulse; VF/VT  CPR 2 mins. (give meds; epi; call for amio)  Rhythm check Consider H’s/T’s (hypoxia, hypothermia, hypovolemia, hypo/hyperK, Hydrogen ion acidosis) (Toxins, Thromboses (cardiac/pulmonary), Tamponade [Mg], Tension pthx)  Continue cycles of CPR

41. Advanced Cardiac Life Support Simplified Algorithms for Easy Memorization and Use in Acute Events Pulseless Electrical Activity/Asystole: • CPR • Epinephrine 1mg q3-5 mins • H/T’s Return of Spontaneous Circulation: V: VS, values (labs) O: O2; ETT with capnography M: Mentation (candidate for hypothermia?) I: IVs, ICE T: Twelve lead; transport (either cath lab for STEMI; ICU for NSTEMI)