Current Guidelines in Critical Care Session 1: 2014 Critical Care Boot Camp

1. Current Guidelines in Critical CareSession 1: 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 8, 2014 • Ventilator Associated Events • Resuscitative Fluid • ICU Delirium Bundle • Glucose Management in the ICU • Antibiotic Rotation in the ICU

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. Ventilator Associated Events in Adults • Background: • Formerly known as VAP (Ventilator Associated Pneumonia); last updated in 2002 • VAEs reported to National Healthcare Safety Network (NHSN); the CDC’s Healthcare Associated Infection (HAI) surveillance system; newly updated in 2011 • Prior reporting systems were too subjective; CDC’s Division of Healthcare Quality Promotion teamed with CDC Prevention Epicenters to develop more objective reporting

5. Ventilator Associated Events in Adults • Background continued: • Previous reportable data: • 1) Xray component • 2) Signs and Symptoms component • 3) Laboratory component - Previous reports too subjective and variable across institutions based on resources and lack of standardization

6. Ventilator Associated Events in Adults New Algorithim Created: • Created in cooperation with critical care professionals and organizations involved in the care of mechanically ventilated patients • More objective • Requires engagement across disciplines

7. Ventilator Associated Events in Adults New Algorithm for Surveillance: - Patients >/= 18 years of age - Patients who have been intubated/mechanically ventilated for at least 3 calendar days - Include patients in acute and long-term acute care hospitals and inpatient rehabilitation facilities (ECMO, HFV, Prone patients are excluded)

8. Ventilator Associated Events in Adults New Algorithim vs Old Algorithm: What’s Different?: - Xray: No radiographic reporting is required due to inconsistency in ordering practices and variability in resources/techinique. Do not adequately identify patients with VAP - Will detect ventilator associated conditions and complications - Focuses on readily available, objective clinical data - Requires a minimum period of time on the ventilator

9. Ventilator Associated Events in Adults • Minimum daily FiO2 increase >/= .20 over baseline >2 days • Minimum PEEP increase >/= 3 cmH20 over baseline > 2 days

10. Ventilator Associated Events in Adults Infection- Related Ventilator Associated Complication (IVAC): Definition: On or after calendar day 3 of mechanical ventilation within 2 calendar days of onset of worsening oxygenation, ONE of the following criteria is met: • Purulent respiratory secretions (>25 neutrophils and <10 squamous epithelial cells per lpf) or be above quantitative thresholds • Positive culture of sputum, BAL, lung tissue, histopathology, + pleural fluid

11. Ventilator Associated Events in Adults The events on previous slide are reportable events: Break Down: • VAC: Temp, signs of infection, lab data of infection, new antimicrobial agent >4 days • IVAC: The above with the addition of positive cultures from lungs, lung tissue, purulent secretions • More objective data • VAP no longer used as the event; it is the result of the event Reference: 2011. Improving surveillance for ventilator-associated events in adults. Centers for Disease Control and Prevention

12. Ventilator Associated Events in Adults Prevention: • Oral chlorhexadine rinse reduces opportunistic VAP by 40% when performed consistently by nursing and care staff q6-8 hours(1) • Elevate the head of the bed at an angle of 30-45 degrees for a patient at high risk for aspiration in the absence of medical contraindications. • Use a dedicated suction line for endotracheal tube suctioning of respiratory secretions or use ETT with subglottic secretion drainage • Cuff pressure should be maintained at 20-25 cm H2O. • Circuit changes should occur when visibly soiled rather than routinely. • Heat and moisture exchangers should not be changed more frequently than every 48 hours or when they become visibly soiled or mechanically malfunction. • Assess patient for daily sedation reduction/discontinuation and implement per institution's guidelines. Reduce or discontinue sedation until patient is awake and can follow simple commands OR patient becomes agitated. • Assess eligibility for daily weaning trials unless contraindicated (2)

13. Ventilator Associated Events in Adults References: Shi, et al. 2013. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Systematic Review. Sinuff, et al. 2013. Implementation of clinical practice guidelines for ventilator-Associated pneumonia prospective study. Critical Care Medicine. Vol 41-1; 15-23 2011, 2014. Prevention of ventilator-associated pneumonia. Health care protocol. National Guideline Clearinghouse. Agency for Healthcare Research and Quality.

14. Resuscitative Fluid in ICU Background: • Recent evidence has shown that hyperchloremic crystalloid solutions, such as Normal Saline, can induce and/or exacerbate hyperchloremia, acute kidney injury (causes renal vasoconstriction and decreased GFR), and metabolic acidosis in the critically ill patient.

15. Resuscitative Fluid • Recommendations: • In the critically ill adult, it has been shown that by using nonchloride-rich fluids, that there are significant reductions in rise in SCr, AKI (using the RIFLE criteria), and the use of RRT • Choosing from the following fluids assist in lowering the risk of these conditions: • Lactated Crystalloid Solution (Cl- 109 mmol/L) • Plasma Lyte (Cl- 98 mmol/L) • 20% Albumin Solution (Cl- 19 mmol/L). Be considerate of costs and availability in your institution

16. Resuscitative Fluid References: Yunos, et al. 2012. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA, October 17, 2012 – Vol 308, No. 15

17. ICU Pain, Agitation, Delirium (PAD) Bundle • Background: • In 2013, the American College of Critical Care Medicine published a revised version of the pain, agitation, and delirium guidelines (from 2002) to include an ICU pain, agitation, and delirium care bundle designed to facilitate implementation of said guidelines. • Update the ABCDE Bundle (did not address pain management) • Link these guidelines with other evidence-based ICU practices including, SBTs, early mobility, and sleep hygiene in order to improve ICU patient outcomes and reduce costs of care/LOS

18. PAD Bundle: Pain • Assessing Pain in the PAD Bundle: • Use a numeric pain scale for patients who can self-report pain; use a behavioral pain scale for those who cannot • Pain is considered >/=4 on a NPS and >/= 6 on a BPS • Pain should be assessed at least 4 times per nursing shift and more often if changes in NPS or BPS occur

19. PAD Bundle: Agitation • Assessing agitation/sedation in the PAD Bundle: • Assess agitation/sedation with an evidence-based scale such as the Richmond Agitation and Sedation Scale (RASS) or Sedation-Agitation Scale (SAS). This will help avoid over sedation and the harmful outcomes that can occur (longer vent days, increased risk of ICU delirium and neuropsychological sequelae, increased risk of mortality)

20. PAD Bundle: Delirium • Assessing delirium in the PAD Bundle: • Assess for delirium using an evidence-based scale such as Confusion Assessment Method (CAM-ICU) at least once per shift to avoid increasing the risk of prolonged vent days, increased LOS, postdischarge institutionalization, long-term cognitive dysfunction, and increased risk of mortality

21. ICU PAD Bundle: Treatment • Treating pain: • Treat pain FIRST, then consider sedation (only if needed). May patients can manage mechanical ventilation with effective analgesia only. • Options: opioids (morphine, fentanyl, hydromorphone) for nonneuropathic pain; nonopioids (acetaminophen); nonsteroidals (ketorolac, ibuprofen); adjunctives (ketamine, catapres), epidurals (primarily with rib fractures), consider gabapentin or carbamazepine for neuropathic pain • Assess pain within 30 minutes of administering the selected pain regimen and adjust as deemed necessary based on evidence-based pain scale

22. ICU PAD Bundle: Treatment • Treating agitation: • Use the following guidelines when deciding what type of treatment plan is needed: • Specific indications for sedation and the sedative goals for each patient • Compatibility between the clinical pharmacology of a sedative, its side effect profile, and the relative contraindications for its use in the critically ill patient • Overall costs (not limited to pharmacy costs) associated with a particular sedative

23. ICU PAD Bundle: Treatment • Treating agitation: • Benzodiazepines vs Nonbenzodiazepines • Some studies (meta-analyses and Fraser, et al) suggest that use of nonbenzos over benzos reduce length of stay and reduction of ventilator days; but, no specific data suggests decreased prevalence of delirium or decreased short-term mortality • Nonbenzo options: Dexmedetomidine and diprovan • Benzo options: most common choices; lorazepam, midazolam • Use clinical judgment when selecting

24. ICU PAD Bundle: Treatment • Treating agitation: • A note about benzos: • Guidelines do not prohibit use of benzos • Still a good choice because of their anxiolytic, amnesic, and anticonvulsant properties • Still recommended for use of treating ethanol and/or benzo withdrawal • Recommended for patients needed sedation who have intractable seizures • Synergistic effects can be achieved with benzos when other sedation options have proven ineffective

25. ICU PAD Bundle: Treatment • Treating agitation: • Sedate only those patient needing sedation based on an evidence-based approach using the lightest amount of sedation tolerated by the patient (being able to perform 3 of the 5 following commands: open eyes, maintain eye contact, squeeze hand, stick out tongue, wiggle toes)

26. ICU PAD Bundle: Treatment • Treating delirium: • First steps in treating delirium: • Identify and eliminate potential contributing factors: • Sepsis • Septic shock • Glycemic dysregulation • Electrolyte disorders • Hypoxia/Hypercarbia • Treat untreated pain • Treat drug withdrawal • Discontinuation of psychiatric medications • Decrease exposure to deliriogenic medications (ie; benzos) • Eliminate adverse drug reactions • Improve environmental factors (ie; sleep deprivation, disorientation, prolonged immobilization, use of restraints)

27. ICU PAD Bundle: Treatment • Treating delirium: • Nonpharmacologic: • Frequent reorientation • Allowing for eyeglasses and hearing aids • Maintaining sleep-wake cycles • Minimizing nursing activities at night to increase quality sleep • Mobilizing patients (even ventilated patients) • Pharmacologic: • Adequate analgesia (opioid/nonopioid; infusions; pca; prn) • Discontinue benzos (except in patients with benzo/alcohol withdrawal) • Resumption of patient’s psychiatric medications • Treat withdrawal syndromes • Antipsychotics if needed (olanzapine, quetiapine, haloperidol): Be careful to monitor Q-T intervals

28. ICU PAD Bundle: Prevention • Pain • Take specific care to prevent procedural pain, especially in the ICU • Treat sleep deprivation to decrease long term effects such as PTSD • Agitation • Reduce the need for sedation; highest reported reason is for mechanical ventilation; use SBTs; SATs; DSIs to reduce ventilator days • Delirium • Improve sleep quality • Normalize (increased mobility, remove lines and catheters)

29. ICU PAD Bundle: Big Picture • Optimize pain management first • Make light sedation the norm • Move away from routinely using benzodiazepines , especially in ICU patients who are at high risk for delirium • Implement more effective delirium prevention and treatment strategies using both pharmacologic and nonpharmacologic methods • Use antipsychotics judiciously and be aware of clinical effects

30. ICU PAD Bundle

31. ICU PAD Bundle References: Barr, J., Pandharipande, P. 2013. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 pain, agitation, and delirium guidelines in an integrated and interdisciplinary fashion. Critical Care Medicine 2013; 41: S99-115 Barr, et al. 2013. Clinical practrice guidelines for the management of pain, agitation, and delirium in the intensive care unit. Critical Care Medicine. 2013; 41: 263-306

32. Glucose Management in the ICU • Background: • Untreated hyperglycemia and/or hypoglycemia contributes to increased mortality in critically ill patients; with specific research available for unstable angina, AMI, CHF, arrhythmia, ischemic and hemorrhagic stroke, GIB, ARF, pneumonia, PE, and sepsis • Morbidity/Mortality can be increased with those patients with pre-existing diabetes • There was an established need to define a more specific glycemic range for target glucose goal.

33. Glucose Management in the ICU • Background: General ADA recommendations: • Patients with diabetes should have their disease clearly marked in their chart when entering the hospital • Sole use of sliding scale insulin is discouraged in the inpatient setting • All patients with diabetes should have an order to check their blood glucose with results reported to their primary healthcare team • Consider ordering a HgA1C for patients who are suspected to be poorly controlled diabetics or who have significant risk factors for diabetes when being hospitalized

34. Glucose Management in the ICU Guidelines: (Clinical Practice Guideline Study) • A BG >150 mg/dL should trigger initiation of insulin therapy; titrated to keep BG <150 mg/dL: ADA recommends 140-180 mg/dL for “tight” glycemic control NICE-SUGAR RCT showed higher incidence of hypoglycemia in “intensive” BG target range of 81-108 mg/dL 2) Maintain BG absolutely <180 mg/dL 3) Avoid hypoglycemia; defined <70 mg/dL; better achieved with intravenous insulin infusion with a glucose source 4) Avoid or minimize dextrose infusions when patient have another source of nutrition such as enteral tube feeds or parenteral nutrition

35. Glucose Management in the ICU Guidelines: (Clinical Practice Guideline Study) 5) Avoid BG <100 mg/dL in patients with brain injury (can produce or exacerbate neurological deficits, encephalopathy, seizures, permanent cognitive dysfunction, death)

36. Glucose Management in the ICU Guidelines: (Clinical Practice GuidelineStudy) 6)Treatment of hypoglycemia: stop insulin infusion and adminsiter 10-20 grams of hypertonic (50%) dextrose and recheck BG within 15 minutes with a goal BG >70 mg/dL achievement taking effort to avoid iatrogenic hyperglycemia • Point of Care testing: • Care should be taken to realize that glucometers have various error rates based on condition of patient. • In the critically ill, especially patients on vasopressors, in shock, or critically anemic, arterial or venous samples should be used for BG testing

37. Glucose Management in the ICU Guidelines: (Clinical Practice Guideline Study) 8)Transitioning from insulin infusion to SSI: Patients in the ICU should be started on SSI of a protocol-driven basal/bolus regimen before the insulin infusion is discontinued to avoid loss of glycemic control • Calculate the basal/bolus regimen based on the patient’s use of IV insulin in the last 24 hours, taking into consideration carbohydrate intake

38. Glucose Management in the ICU Guidelines: Considerations out of the ICU • Antihyperglycemics: Okay to use once patient is stabilized and readied for discharge. May need to avoid metformin as increased risk for renal insufficiency and hemodynamic instability in the hospitalized patient • Use inpatient specialized diabetes providers when available for hospitalized patients who have diabetes • Self management may be agreed upon by patient and provider is they mutually agree that the patient understand the use of his/her insulin pump, insulin injections, and treatments for “sick day” management of glucose

39. Glucose Management in the ICU Guidelines: Considerations out of the ICU Note: There are more specific recommendation/suggestions in this study, but address metrics and calculation formulae of insulin infusion protocols that were outside the scope of this lecture References: Standards of medical care in diabetes – 2014. American Diabetes Association. Diabetes Care 2014 Jan; 37 S 14-80 Jacobi, et al. 2012. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Critical Care Medicine. Vol 40, No 12 3251-3276.

40. Antibiotic Rotation in the ICU Background: • Patients in the ICU are at an increased risk for hospital-acquired infections (HAI) • Gram-negative pathogen resistance to broad-spectrum antibiotics poses increase to morbidity and mortality • Gram-negative pathogen infections increase institutional resource utilization and consumption • Use of antibiotic cycling is proposed to reduce resistance of gram-negative pathogens

41. Antibiotic Rotation in the ICU Background: Definitions • Antibiotic resistant pathogen: Any pathogen that is resistant to at least one class of antibiotics (ie; fluoroquinolones) • Multidrug resistant pathogen: Any pathogen that is resistant to 3 or more classes of antibiotics (ie; aminoglycosides, fluroquinolones, carbapenems)

42. Antibiotic Rotation in the ICU Cycling vs Mixing Antibiotics • Cycling antibiotics allows for a resistance strain of pathogen to decrease in frequency or perhaps even disappear in the off-period • Mixing antibiotics (using randomly selected antibiotics on different patients) The majority of research favors cycling in large populations of patients

43. Antibiotic Rotation in the ICU Example antibiotic cycling for HAIs based on annual quarters: Pneumonia (Day 1-3) Pneumonia >/= Day 4 a Non-pneumonia b Excluded Class 1st Qtr: Ceftriaxone Levofloxacin Piperacillin/tazobactam CARB 2nd Qtr: Ampicillin/sulbactam Doripenem Cefepime/metronidazole FQ Imipenem-cilastatin 3rd Qtr: Levofloxacin Cefepime Doripenem BLIC 4th Qtr: Ertapenem Piperacilline/tazobactam Levofloxacin/metronidazole ¾ CEPH aEmpiric coverage includes vancomycin and aminoglycoside until culture data is available bVancomycin included except in secondary peritonitis; fluconazole included for high risk patients and tertiary peritonitis BLIC: beta-lactamase inhibitor combinations FQ: fluoroquinolones CARB: carbapenems ¾ CEPH: 3rd and 4th generation cephalosporins

44. Antibiotic Rotation in the ICU Guidelines: • Incorporate multiple disciplines to reduce infection risks (nursing, pharmacy, physician, infectious disease, pathology, advanced practice nurses/PAs, nutrition, IT). Terminal room cleans after discharge of patient with resistant pathogen(s) • Narrow antibiotics to pathogen-specific drug as soon as known (de-escalate) • Pneumonia: early and late onset • Non-pneumonia: blood stream, surgical site, urinary tract, body fluid • Avoid prophylactic antibiotics except in certain patient populations (abdominal trauma, orthopedic fractures, craniofacial trauma) • Rotate antibiotic classes on a quarterly basis to reduce resistance and maintain heterogeneity • Aggressively empirically treat suspected pathogens and de-escalate as cultures are speciated (ie; suspected necrotizing soft tissue infections [use of clindamycin])

45. Antibiotic Rotation in the ICU References: Dortch, M., et al. 2011. Infection reduction strategies including antibiotic stewardship protocols in surgical and trauma intensive care units are associated with reduced resistant gram-negative healthcare-associated infections. Surgical Infections. 2011; 12; 15-25 Kouyos, R., Abel zur Wiesch, P., Bonhoeffer, S. 2011. Informed switching strongly decreases the prevalence of antibiotic resistance in hospital wards. PLoS Computational Biology. 7(3); e1001094. May, A., et al. 2006. Influence of broad-spectrum antibiotic prophylaxsis on intracranial pressure monitor infecitons and subsequent infectious complications in head-injured patients. Surgical Infections. 2006; 7: 409-417 May, A., 2014. Antibiotic stewardship program; multidisciplinary surgical critical care guidelines. Vanderbilt Medical Center. www.traumaburn.com. .