Paul E.

Marik, MD, FCP(SA), FRCPC, FCCM, FCCP

Version 2.00
Copyright, P Marik 2001
Table of Contents
Intro/Preface
Daily Management
Hyperglycemia
Blood Comp Rx
DVT Prophylaxis
Nutrition
Ventilator Pneumonia
Weaning
ARDS
Sedation
Neuromuscular Blockers
EBM ICU Protocols
By Paul Marik, MD
TOC
Note to reader:
The author has checked with sources believed to be reliable and up to date in an effort
to provide information that is complete and generally in accord with standards of
practice at the time of publication. However, in view of the possibility of human error or
changes in medical science the author of this book cannot warrant that the information
contained herein is in every respect accurate or complete. Readers are encouraged to
confirm the information contained herein with other sources.
Disclaimer:
Use at your own risk! Verify all information before initiating treatment.
Feedback:
Please e-mail comments, corrections or suggestions to [email protected]
Evidence Based Critical Care Medicine:
Balancing the Evidence
Before medicine developed its scientific basis of pathophysiology, clinical practice was
learned empirically from the events of daily experience in diagnosing and treating the
maladies patients presented. Students learned as apprentices to clinicians, observing
the phenomena of disease, the skill of diagnosis and treatment, and the outcomes of
different remedies. Sir William Osler's classic textbook of medicine was based almost
entirely on his personal experience correlated with the general experience of others.
With advances in our understanding of human physiology and the pathophysiologic
basis of disease these remedies fell by the wayside and treatment became based on
modalities of treatment that were shown to interrupt or otherwise modify the disease
process. Until recently it was considered sufficient to understand the disease process in
order to prescribe a drug or other form of treatment. However, when these treatment
modalities were subjected to randomized controlled clinical trials (RCT's) examining
clinical outcomes and not physiological processes, the outcome was not always
favorable. The RCT has become the reference in medicine by which to judge the effect
of an intervention on patient outcome, because it provides the greatest justification for
conclusion of casualty, is subject to the least bias and provide the most valid data on
which to base all measures of the benefits and risk of particular therapies. Numerous
ineffective and harmful therapies have been abandoned as consequence of RCT's,
while others have become integral to the care of patients and become regarded as the
standard of care.
Many RCT's are, however, inconclusive or provide conflicting results. In this situation
systematic reviews that are based on meta-analysis of RCT's are clearly the best
strategy for appraising the available evidence. While meta-analysis have many
limitations, they provide the best means of determining the significance of the treatment
effect from inconclusive or conflicting RCT's. Although over 250,000 RCT's have been
performed, for many clinical problems there are no RCT's to which we can refer to
answer our questions. In these circumstances we need to base our clinical decisions on
the best-evidence available from experimental studies, cohort studies, case series and
systematic reviews.
Intuition, anecdotes, common sense, personal experience and personal biases can no
longer be used to justify clinical decisions or therapeutic policies. Every decision that the
clinician makes must be based on sound scientific evidence (a collection of anecdotes is
not scientific evidence). Many clinicians justify their c urrent practices by rationalizing
that's the way I've been doing it for the last 20 years. However, nothing in medicine
stands still, and its likely that the physician has been repeating the same mistakes for
the last 20 years.
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The Need for Evidence Based Protocols in the ICU
The practice of medicine is characterized by enormous variability, frequently with
opposing therapeutic strategies. Ambiguities in care may have disastrous implications
for ICU patients who are managed by a large team of health care professionals. In order
to achieve the best outcomes for these very complicated patients, it is essential that all
members of the team have a common approach based on the best available current
evidence.
The role of the ICU is to provide temporary physiologic support for patients who have
suffered acute and often catastrophic insults. The care of these patients requires the
coordinated and integrated support of all the organ systems and the prevention of the
unique complications faced by these patients. As many of the management issues are
common to most ICU patients a standardized evidence based approach to these issues
will ensure a systematic and coordinated management strategy. Evidence based
protocols prevent ambiguities in patient care, while allowing the individualization of the
management of these exceedingly complex patients.
Contradictory therapeutic approaches have a negative impact on all the members of the
team and compromise patient outcome. Changing the patients' therapy each time
different members of the team see the patient results in fragmented care and
undermines the team approach essential to achieving the best patient outcome.
Protocols help avoid these ambiguities of care.
In order for this approach to succeed the protocols must be evidence based and have
the full support of all members of the team. If disagreements exist these need to be
resolved (by reviewing the literature) prior to the implementation of a protocol.
Furthermore, protocols must evolve as clinical circumstances dictate and as new
evidence emerges.
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Daily ICU Management
TOC
Daily Exam
Neuro Exam
Labs & CXR
Presenting
Key Points
Intensive Care Units exemplify the miraculous advances of modern medicine. An ICU
provides an environment where high-quality, compassionate, physiologically orientated
and evidence based medicine can be practiced. The ICU is an exciting and challenging
place to work and provides a remarkable learning environment. The keys to a
successful rotation in the ICU are i) teamwork and ii) a systematic, disciplined and
organized approach to patient care.
Admission History and Physical Examination
It is essential that a detailed and systematic history and physical examination (H+P) be
performed on all patients admitted to the ICU. It is essential that the patients code status
and the presence of advance directives be established on admission to the ICU.
The Daily Examination
It is essential that a thorough physical examination be performed daily, the following
features should be documented:
General
Overall condition of patient
The presence of all invasive lines, tubes and devices
Vital signs:- temperature, including max. 24 hour temp, BP, pulse (rate+rhythm),
RR.
The presence of all pulses and the adequacy of peripheral perfusion
Limb symmetry and swelling (presence of venous thrombosis)
Presence of rashes and decubitus ulcers
Heart
Heart sounds and murmurs.
Chest
Symmetry of air entry and presence of rhonchi or crackles
Abdomen
The presence of distension and tenderness (esp. RUQ).
The type of enteral feeds should be recorded,evidence of reflux and the gastric
residual volumes.
Presence of diarrhoea should be noted.
CNS - A focused neurological examination is essential, particularly in patients receiving
hypnotic/sedative agents, and should include the following:
Level of consciousness and response to commands
Pupillary size and response
Eye movements
Limb movements; spontaneous and in response to noxious stimuli (pain)
Presence of deep tendon reflexes
The Ventilator: The ventilator is an extension of the patient and it is therefore essential
that the following features be recorded:
Mode of ventilation (AC, SIMV, PCV etc)
Set rate & patient rate
Tidal volume
FiO2
PEEP
Peak airway pressure and plateau airway pressure
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The importance of the daily neurological examination
Critically ill patients in the ICU are at risk of developing serious neurological
complication including, ICU psychosis, septic encephalopathy, critical illness
polyneuropathy, entrapment neuropathies, compartment syndromes, cerebral edema,
intracerebral hemorrhages (related to coagulopathies), cerebral ischemia (related to
hemodynamic instability) and cerebral embolism. These conditions can only be detected
and diagnosed by physical examination. Furthermore, these conditions may frequently
be masked in patients who are being sedated. It is therefore essential that the motor
and eye response to a noxious stimulus (pain) as well as the deep tendon reflexes be
recorded in all sedated patients. If the patient does not respond to a noxious stimuli the
sedation must immediately be stopped, in order to facilitate further neurological
evaluation.
The Glasgow Coma Scale (GCS) was developed to assess the level of consciousness
of trauma patients. The GCS is a measure of pathologic obtundation. This scale is
difficult to apply to intubated and sedated ICU patients. A description of the patients'
level of consciousness (or arousal) and response to a noxious stimuli is more useful
than documentation of the GCS. This description should include the type and power of
the motor response.
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Laboratory tests and chest-radiographs
All ICU patients require a daily CBC, and urea and electrolytes
Oxygenation - by pulse oximetry & blood gasses when appropriate
All other laboratory tests should be ordered on merit
All intubated patients require a daily chest radiograph. In all other patients chest
radiographs should be ordered when indicated.
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Presenting on Daily Rounds
The presentation must be logical, sytematic, clear and succinct. The following approach
is suggested:
1. Begin your presentation with the patient's name, sex and age.
2. List the primary medical problems responsible for ICU admission then, the list
significant secondary medical problems and chronic health problems
3. Outline the events of the past 24 hours
4. 24 hour urine output and fluid balance
5. Current Physical findings
BP, HR, RR, Temp & T.max
General
Chest
Heart
Abdomen
CNS
Extremeties
6. Ventilator settings and most recent blood gas [pH/pCO2/PO2/HCO3/Sat] or
oxygen saturation
7. Relevant Labs
8. Review of medications
9. Assessment and plan.
Top
KEY POINTS:
1. ICU patients are at a high risk for DVT and therefore all ICU patients require DVT
prophylaxis (i.e SQ heparin, s/q LMWH, compression stockings alone or in
combination).
2. All ICU patients should be evaluated for risk factors for stress ulceration and high
risk patients should receive stress ulcer prophylaxis.
3. All intubated patients require a gastric tube. The orogastric route is preferred.
Gastric tubes provide access to the GI tract for feeding, allow measurement of the
residual volumes and allow decompressions of the stomach to minimize the risk of
aspiration. Small bore tubes have no advantages over standard NG tube unless
feeding is being given into the small intestine.
4. Determine the adequacy of venous access.
5. Don't forget to feed the patient; absent bowel sounds do not preclude enteral
feeding.
6. Communicate with the patients' nurse and respiratory therapist.
7. If you don't understand something, ASK!
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Stress-induced hyperglycemia
TOC
Introduction
Sliding Scale
Infusion
Introduction
Stress-induced hyperglycemia is common in ICU patients. Hyperglycemia is associated
with an increase risk of infections complications; recent evidenece suggests that the
maintenance of euglycemia can reduce infectious complications and reduce the
mortality of ICU patients.
Long-acting insulin has no role in the management of hyperglycemia in acutely ill ICU
patients. In patients with mild stress induced hyperglycemia a s/c insulin sliding scale
maybe appropriate. However, in many patients s/c insulin prevents large fluctuations in
glucose level but rarely controls blood glucose in the 125-200 mg/dl range. For this
reason a continuous insulin infusion is suggested. The target blood glucose is 125 to
200 mg/dl
6 Hourly Sliding Scale
BG ......... U s/c insulin
<150 ............. 0
150-200 ........ 2 (or 4)
201-250 ........ 4 (or 6)
>250 ............. insulin infusion
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Insulin Infusion Protocol
1. Mix 200 units regular insulin in 200 cc NS (=1 U/cc)
2. Flush tubing with 50 cc of insulin saline infusion
3. Begin IV insulin infusion at a rate of 2 U/hr
4. Check capillary blood 1 to 2 hourly until stable then 4 to 6 hourly
5. Adjust infusion rate as follows:
i. If BG 80-124 mg/dl or if BG falls by >50 mg/dl/hr
Rate(U/hr) ... DECR. by U/hr
<2 ............................. 0.5
2-10 .......................... 1
10-20 ........................ 2
>20 .......................... 4
ii. If BG 125 to 200 mg/dl,continue current drip rate
iii. If BG >200 mg/dl
Rate (U/hr) ... INCR. by U/hr
<2........................... 0.5
2-10 ........................ 1
10-20 ...................... 2
>20 ........................ 4
iv. For hypoglycemia
BG <80 mg/dl
STOP infusion, give amp D50
BG <60 mg/dl
STOP infusion, give 1 amp D50
Repeat finger stick in 15 minutes and repeat D50 until BG >100
When BG >100, resume insulin infusion at 50% of prior rate
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BLOOD COMPONENT THERAPY
TOC
RBC
Platelet
FFP
Cryoprecipitate
Dosing
DIC
EPO
Notes
Indications for red blood cell transfusion (See note 1)
Hb <9 in patients with evidence of cardiac decompensation, unstable CAD, or Hx
of CAD and preop
Acute GI tract bleed with Hct <30
Hb <7.5 in all other ICU patients
Indications for platelet transfusion (See note 2)
Chronic thrombocytopenia (<5000) and patient bleeding
Acute or chronic thrombocytopenia (<10,000) and patient on chemotherapy
Acute or chronic thrombocytopenia (<50,000) and patient bleeding
Acute or chronic thrombocytopenia (<100,000) and operative bleeding
Acute or chronic thrombocytopenia (<50 -100,000 depending on procedure)
undergoing invasive or operative procedure
CONTRAINDICATED IN TTP
Indications for fresh frozen plasma (See note 3)
Replacement of clotting factors when PT and or PTT 1.5 X control or greater and
patient bleeding or facing hemostatic challenge
Treatment of thrombocytopenic purpura (TTP)
Treatment of ATIII deficiency
Rapid reversal of warfarin effect
C1 esterase inhibitor deficiency
Indications for cryoprecipitate (See note 4)
Fibrinogen <100 mg/dl and patient bleeding
Hemophilia A or von Willebrand's disease
Dosing Guidelines for Blood Components
Fresh frozen plasma: 2 - 4 units (400-1000 ml) over 1 hour
Platelets:Use whatever dose is necessary to increase platelet count above 50 000;
6 units is usually sufficient; or 1 unit or random platelets per 10 kg over 30 minutes
Cryoprecipitate:desired increase in g/L=(0.2 X number bags)/plasma volume in L;
or use 1 bag/5kg, IV push or 1000u/10 min
Packed red blood cells; 1 unit increases hemoglobin by 1.0-1.5 g/dL; give over 2-3
hours
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Rx of DIC
DIC is characterized by bleeding and widespread microvascular thrombosis. While the
bleeding manifestations usually receive the most attention, the microvascular
thrombosis are pathologically more important and strongly implicated in the
development of organ failure.
Blood component therapy is a potentially hazardous in patients with DIC as it adds fuel
(thrombin & fibrinogen) to the fire. The administration of FFP and platelets should be
restricted to patients with active hemorrhage and severe decreases in PT and platelet
count AND should be coadministered with activated Protein C. Fibrinogen concentrates
should be avoided.
Erythropoeitin (EPO) & ICU anemia
Anemia is common in ICU pateints. The casues are multifactorial, including low
erythropoietin, blunted response to EPO, and venesection. rhEPO has been
demonstrated to decrease the transfusion requirements of ICU patients.
Indications
Pts expected to be in ICU >3 days
Hct <36
Regimen
On 2nd ICU day or when Hct <36
40 000u s/c weekly
PO iron daily (150 mg of elemental iron)
IV iron should be considered if ferritin <100 ng/ml despite PO iron
Monioring
Baseline: Retic's, Fe, TIBC,ferritin
Twice weely: Retics's, ferritin
Top
Notes:
1. There is a lack of reliable data to define "the ideal" hemoglobin concentration in
critically ill patients. However, blood transfusion is associated with signifincat
compliations, the most important being immunosupression. recent data suggests
that the number of units of transfused blood may be an independent predictor of
MSOF and death. Currently a transfusion "trigger" of 7-8 g/dl is reccommended.
However, patients with unstbale coronary artery disease or "cardiac
decompensation" maybe at risk of silent ischemia at this level, and a transfusion
trigger of 9-10 g/dl may be more appropriate in this group of patients.(Back to text)

2. Platelets should generally be reserved for thrombocytopenic patients who are
BLEEDING and thrombocytopenic patients undergoing invasive or operative
procedures.(Back to text)
3. Fresh frozen plasma contains all the stable and labile plasma constituents. One
unit of FFP contains approximately 400 mg of fibrinogen and 1 U clotting activity
per milliliter.(Back to text)
4. Cryoprecipitate is prepared from a cold insoluble precipitate of plasma. It contains
high levels of factor VIII (both procoagulant activity and von Willebrand factor) and
fibrinogen. Insufficient amounts of the other clotting factors are present to be of
therapeutic value.(Back to text)
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DVT Prophylaxis
TOC
Introduction
Risk 1
Risk 2
Risk 3
Risk 4
N/S
Introduction
ICU patients have many of the risk factors for DVT. ICU patients who do not receive
DVT prophylaxis have a high incidence of thromboembolic disease. Consequently
routine DVT prophylaxis is recommended in all ICU patients. Within the ICU population
a number of risk factors significancantly increase the risk of DVT, including obesity,
trauma, neurosurgery and hip and knee surgery. The prophylactic strategy therefore
depends upon the patients risk profile. While the optimal prophylactic approach for
certain groups has yet to be determined, the results of recent RCT's form the basis for
the current recommendations in specific risk groups. The recommendations in those risk
groups which have not been subject to well conducted RCT's are based on the
recommendations of "expert panels."
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Risk Group 1
ICU patient NOT represented below
5000 U heparin s/c q 8 hourly
.. Or
External pneumatic compression
Risk Group 2
Obesity (BMI >30)
Deep sedation/paralysis
GBS/M.gravis/Stroke
Spinal cord injury
Urological surgery
Femoral catheters
External pneumatic compression and 5000 heparin s/c q 8 hourly
.. Or
Lovenox 40 mg s/c daily
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Risk Group 3
Total hip replacement
Total knee replacement
Fracture hip/femur
Trauma (excluding TBI)
Lovenox 30mg s/c q 12 hourly
.. Or
Lovenox 30mg s/c q 12 hourly and external pneumatic compression (if feasible)
Risk Group 4
Intracerebral hemorrhage
TBI
Coagulopathy (PT or PTT >1.5 x control)
Active bleeding
External pneumatic compression
Neurosurgery
Lovenox 40 mg s/c daily (started post-op) and external pneumatic
compression/compression stockings
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Nutrition in the ICU
TOC
Principles
Protocol
Notes
Liver failure
Pancreatitis
Renal failure
"If The Bowel Works, Use It" ....
"There is no disease process that benefits from starvation"
Principle of nutritional support in the ICU
1. Nutritional support is an essential component in the management of critically ill
patients.
2. There is no data that TPN is of any benefit in critically ill patients. The available
evidence suggests that TPN increases complications and mortality rates (see note
1). TPN should therefore be limited to patients, who after 5-7 days of starvation,
are unable to tolerate even small volumes of enteral nutrition (EN). The addition of
"trickle feeds" reduce the complications associated with TPN. Despite this data,
patients with a functional gut continue to receive TPN!
3. Early EN (within 24 hours of admission to the ICU) has been shown to reduce
complications and improve the outcome of critically ill patients when compared to
delayed EN.No studies demonstrate an advantage to delaying nutritional support
in seriously ill patients.
4. Over 20 RCT's have demonstrated that "immune enhancing diets" (IED) decrease
indices of inflammation, improve cell mediated immunity, decrease organ failure
and ICU complications, and reduce LOS. Immune enhancing diets should
therefore be given to all patients with ALI/ARDS, sepsis, poly-trauma and other
"high risk" patients with an anticipated ICU stay in excess of 5 days.
5. Overfeeding patients is associated with significant complications including
hyperglycemia, hepatic steatosis with hepatic dysfunction, elevated BUN and
excessive CO2 production.
6. There is no data to suggest that accurately measuring energy expenditure and
nutritional requirements improves outcome.
Summary: "Do It early, Do It slowly and Do It with an IED"
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Nutrition Protocol
EN should be initiated within 12 hours of admission to the ICU.
Use IED in high risk patients
Place NG tube. If a patient is at high risk for poor gastric emptying then a small
bowel tube should be placed.
The head of the bed should be elevated to 30o to decrease the risk of aspiration.
Feeding may be administered by boluses of 100-250 ml every two to four hours or
by continuous infusion started at 25 to 30 ml/hr and increased by 10 to 25ml/hr
every six hours as tolerated (i.e gastric residual volumes <150 ml) until caloric
goal is achieved (25 to 30 kcal/day).
Gastric residuals should be measured every 6 hours with continuous feeding or
prior to each bolus. If the gastric residual is >150 ml and/or should the patient
reflux, the stomach should be emptied, feedings held for 2 hours, and then
restated at one-half the volume. Erythromycin (250 mg IV q 8 hourly) improves
gastric emptying and should be started.
Should the residual volumes remain high and/or the patient tolerate tube feeding
poorly, post pyloric access should be obtained.
In patients with discontinuity of the bowel TPN maybe indiated.TPN should be
initiated slowly; 50% of goal first day, 75% second day, 100% 3-4th day. In
addition TPN should not be suddenly stopped (may cause profound
hypoglycemia). Standard TPN orders include:
Non protein calories:25-30 kcals/kg/day
CHO: MAX 4mg/kg/day (1600 cals)
Lipid: 4-12 kcals/kg/day
Protein ~1.5 g/kg/day
Vitamins and trace elements
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Notes:
1. TPN is associated with significant complications, including an increased incidence
of infections, metabolic disturbances such as hyperglycemia, hypophosphatemia,
hypokalemia and trace element deficiency; atrophy of the GIT mucosa and
lymphoid system predisposing to bacterial translocation; immune suppression and
hepatic dysfunction.(back to text)
2. Propofol emulsion contains 0.1g of fat (1.1 Kcal) for every milliliter. An infusion of
propofol may therefore provide a significant caloric load. In patients receiving high
dose propofol infusions, the enteral feeds need to be adjusted to take into account
the added caloric load. A low-fat enteral formulation, such as Vivonex (10g fat/L)
may be used.
3. The refeeding syndrome: Feeding malnourished patients, particularly after a
period of starvation may result in severe metabolic disturbances, most notably
hypophosphatemia. Hypophosphatemia developing after initiating parenteral or
enteral nutrition has been termed the refeeding syndrome. In addition to
hypophosphatemia, changes in potassium, magnesium and glucose metabolism
occur during refeeding. Although classically described in cachectic patients after
prolonged starvation, this syndrome has been reported to occur commonly in
poorly nourished ICU patients who have been starved for as short as 48 hours.
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Nutrition in specific disease states
Liver Failure
The use of protein restriction in hepatic encephalopathy/liver failure is controversial.
Intolerance of dietary protein should be balanced against the increasing evidence that
adequate nutrition, including fair amounts of protein, can improve clinical outcome in
patients with hepatic encephalopathy. Therefore, in patients with liver cirrhosis and
hepatic encephalopathy, one should initially restrict daily protein intake to 0.5 g/kg/day
and slowly increasing the intake to 1.0 g/kg per day. Zinc deficiency is common in
patients with cirrhosis; supplement with 600mg zinc sulphate daily.
Pancreatitis
Despite the lack of prospective data, "conventional wisdom" dictates that gut rest with or
without the provision of parenteral nutrition remains the treatment of choice in acute
pancreatis. However, the results of a number of RCT's has disproved this standard
dogma. These studies have clearly demonstrated that oral feeds in mild/moderate
pancreatitis and enteral feeding via a nasoenteric tube placed distal to the ligament of
Treitz in patients with severe pancreatitis reduces indices of pancreatic and systemic
inflammation and reduces the incidence of intra-abdominal sepsis, multiple organ
failure, need for operative intervention, and mortality when compared with the
parenterally fed patients. TPN consequently appears to have little (NO) role in the
management of patients with acute pancreatitis. Oral refeeding is only recommended
once pain has subsided and the serum amylase has approached normal levels.
Renal Failure
Most patients with ARF are hypercatabolic and require increased quantities of nutrients.
Patients with ARF should receive a minimum of 1g protein/kg/day and optimal
non-protein calories. Protein intake in critically patients should not be limited in an
attempt to avoid initiation of dialysis.
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Approach to Suspected VAP
TOC
Introduction
PSB sampling
Bacteriology
Empiric Rx
PSB Results
Introduction: Clinical criteria alone are notoriously unreliable in the diagnosis of VAP;
consequently many patients without pneumonia are needlessly treated with antibiotics.
Sputum culture (tracheal aspirate-T/A) should not be used to diagnose VAP as this test
is plagued by both high false-positive and false-negative results; the specificity of
sputum culture is only 50% (no better than flipping a coin).
Consequently, lower respiratory tract sampling together with quantitative culture is
recommended to diagnose VAP. This can be performed bronchoscopically or blindly;
the blind technique (B-PSB) has operating characteristics similar to the bronchoscopic
technique; however, it is quicker, safer, more cost effective and easier to perform.
Patients with suspected PCP, immunocompromised and/or neutropenic patients should
undergo formal bronchoscopy with PSB and BAL. T/A are suitable specimens in
patients with suspected tuberculosis. Post-intubation T/A's may be useful for the
diagnosis of community acquired pneumonia.
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Indications for PSB sampling:
1. Patient intubated for greater than 24 hours
2. New or progressive pulmonary infiltrate on the chest radiograph (NO infiltrate, NO
VAP)
3. At least two of the following clinical criteria:
Fever >38.3C (101F)
Leukocytosis (>10 x 109/L)
Purulent tracheal secretions
Contraindications to Blind PSB:
1. Non intubated patients
2. Patients with uncontrolled bleeding
3. Ptients with PT/PTT greater than twice normal or a platelet count <60 000
4. Ptients with known or suspected intrabronchial lesions
5. Patients who have recently undergone a pneumonectomy or lobectomy
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Blind PSB Procedure:
1. Administer 80 to 100% oxygen throughout the procedure and monitor O2 sats.
2. Midazolam/propofol should be administered to non-sedated patients to limit
coughing during the procedure.
3. A standard microbiology specimen brush is inserted through the ET tube until
approximately 35cm or until resistance is met.
4. A specimen is obtained by advancing the inner canula (expressing the wax plug),
advancing the brush, twisting the brush then retracting the brush into the inner
canula.
5. The entire catheter is then removed from the ET tube.
6. The brush is then cut and placed in 1 ml of ringers lactate and processed by the
microbiology laboratory within 30 minutes.
7. Quantitative culture should be performed using standardized techniques.
Bacteriology of VAP
A consistent pattern of pathogens has been reported in patients with VAP. The
commonest pathogens are:
S. aureus
P. aeruginosa
Enterobacter spp.
S. pneumonia
H. influenzae
E. coli
Klebsiella spp
A. baumannii.
P. aeruginosa and A. baumannii are more common in patients intubated >4 days while
S. pneumonia and H. influenzae are more common in patients intubated for <4 days.
Anaerobes have been shown to be unimportant in most patients with VAP.
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Empiric antibiotics until culture data available
The choice of empiric antibiotics is extremely important in determining the outcome of
patients with VAP and should be based on local epidemiological data. The empiric
regimen must be broad to cover the most likely pathogens; the appropriateness of the
initial regimen determines outcome. This regimen is then tailed once culture data are
available. A number of studies have demonstrated that the scheduled change (every 4-6
months) of antibiotic class can reduce both the incidence of VAP and the incidence of
VAP attributed to antibiotic-resistant bacteria.
The following antibiotic(s) are reccommended. These reccommendations require
modification depending on the importance of MRSA and pseudomonas in individual
ICU's. Rotating antibiotics is reccommended.
Piperacillin/Tazobactam vancomycin gentamycin
Imipenem vancomycin gentamycin
Ciprofloxacin vancomycin gentamycin
The use of 3rd generation cephalosporins should be limited due to the induction of
ESBL and VRE.
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Interpretation of PSB results
The results of the b-PSB should be recorded and interpreted as follows:
1. no growth
2. <500 cfu/ml (contaminant)
3. 500-1000 cfu/ml (borderline +ve)
4. >1000 cfu/ml (positive)
Patients with borderline +ve or +ve culture should be considered to have VAP.
Candida or coagulase negative staphylococci should be ignored.
In patients with +ve and borderline +ve cultures the antibiotic regimen MUST be
tailored/narrowed according to the sensitivities of the pathogen(s) isolated.
In patients with negative cultures, the decision to continue or stop the antibiotics
should be made by the patients' attending physicians based on his/her
assessment of the risk of stopping antibiotics. However, it is recommended that
unless VAP is strongly suspected, antibiotics be stopped and the patient
re-cultured if a strong index of suspicion for VAP still exists.
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ARDS
TOC
Definitions
Low TV
PCV
Hemo support
Sedation
Other Rx
Chronic
Lung Protection
Definitions
ARDS/ALI is a condition characterized by:
An oxygenation defect with bilateral alveolar infiltrates
A patient who has suffered an acute catastrophic event
A patient with a PCWP <18 mmHg and/or no clinical evidence of an elevated left
atrial pressure
ALI:- PO2/FiO2 <300
ARDS:- PO2/FiO2 <200
Rx of acute phase
The management of ARDS is essentially supportive and includes:
Cardio-respiratory and nutritional support
The prevention of further lung injury
The prevention of complications
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Ventilation
See Lung Protective Strategy
Initiating a Lung Protective Strategy
Patients with bilateral pulmonary infiltrates and any of the following ventilator
parameters on standard assist-controlled ventilation should be be switched to PCV/low
TV vent.:
Plateau pressure >35 cmH2O
PEEP >10 cmH2O
FiO2 >60%
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Low TV ventilation
Initial settings:
Adequate sedation must be achieved
Mode: AC
Tidal volume: 8ml/kg reduced by 1ml/kg to 4-6 ml/kg
Rate: Set to match initial MV (max 30/min)
FiO2: Original setting titrate Sats >88%
PEEP: Best determine by static PV curve, else by FiO2
FiO2 40 -- 8
FiO2 50 -- 10
FiO2 60 -- 12
FiO2 >60 -- 15
Flow rate (I:E): Flow rate adjusted to achieve I:E of 1:1 - 1:1.3
Goals:
Plateau Press <35 cmH2O
Sat >88%
pH >7.15
Top
Pressure Controlled Vent.
Required equip:
Ventilator that supports PCV
Ventilator with wave-form capabilities
Ventilator that can measure auto-PEEP
Continuous pulse oximetry
End-tidal CO2 monitoring
Initial PCV settings:
Adequate sedation must be achieved
An inspiratory pressure of 20 cmH2O
PEEP 15 cmH2O (if possible obtain a static pressure/volume curve and set PEEP
above the lower inflection point)
Same FiO2 as on A/C ventilation
Rate 14/minute
Set inspiratory time such that the initial I:E is 1:1.5
Top
Refining the initial settings:
The inspiratory and expiratory times ( I:E ratio) and respiratory rate are best
adjusted by analyzing the Flow vs. Time Waveform. It is essential that adequate
inspiratory time be given so that all the airways, both healthy and diseased, have
time to reach the preset pressure level. If expiration begins before flow has
reached zero the inspiritary time needs to be increased. This will therefore
increase mean alveolar pressure and improve oxygenation. The inspiratory time
can be lengthened in 2 ways;
Increase the inspiratory time until the inspiratory flow reaches zero
(recommended method)
Reducing the "E" part of the I/E ratio will increase "I".
If flow reaches zero and there is a long inspiratory pause, this is an indication that
inspiratory time is too long. Setting inspiratory time longer than that which is
required to open recruitable airways increases the likelihood of significant
auto-peep.
To evaluate the adequacy of the expiratory time, the Flow vs. Time Waveform
needs to be studied again. This waveform shows whether the patient has enough
time to exhale to the pre-set PEEP level before the ventilator gives the next
breath. Should inspiration begin before flow reaches zero air trapping will occur
with the development of auto-PEEP. There is no data that intrinsic PEEP has any
advantage over extrinsic (ie applied) PEEP. However, the unrecognized
development of auto-PEEP may result in hemodynamic compromise leading to the
inappropriate use of fluid and vasopressor therapy. Air trapping is corrected by
either reducing the respiratory rate or inspiratory time. Each should both be
independently and sequentially reduced, in order to determine which maneuver
affects ventilation the least.
Top
Monitoring PCV
It is essential that the e TV be monitored and the ventilator alarms set at the
appropriate level
Continuous end-tidal CO2 monitoring is essential.These measures are important
as changes in airway/lung compliance will result in a fall in tidal volume and
increase in PaCO2 without this being clinically obvious.
It is essential that the level of auto-PEEP be measured.
Continuous pulse oximetry is essential with the arterial saturation kept above 88%.
The Flow vs Time waveform should be monitored regularly. As the patients
pulmonary mechanics change the inspiratory time and respiratory rate may need
to be altered.
Arterial blood gas analysis should be performed at least once daily.
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Hemodynamic support
The optimal fluid strategy in patients with ARDS is a hotly debated subject with a "wet
lung" and a "dry lung" camp. These two approaches have as yet to been compared in
an adequately powered RCT. In the absence of such data, "experts in the field" suggest
a strategy that maintains the lowest intravascular volume (or PCWP) that sustains an
adequate cardiac output (and renal perfusion). Inotropic agents may be required to
maintain an adequate cardiac output and perfusion pressure (MAP >75-80 mmHg). If
hemodynamics allow the patient should be kept in a negative fluid balance. Once
hemodynamic stability is achieved the patient should be actively diuresed (until the BUN
climbs to approximately 30 mg/dl).
Sedation
All patients receiving low-volume/high PEEP ventilation require deep sedation to
achieve ventilator synchrony. Sedation is best achieved with a continuous infusion of
propofol and lorazepam supplemented with fentanyl as required.
Neuromuscular blocking agents are associated with signifincat complications are their
use is strongly discouraged.
Top
Other supportive measures:
GI prophylaxis
DVT prophylaxis
Early initiation of enteral nutrition with an immune enhancing formula
Screen for nosocomial infection esp VAP
Top
Rx of Chronic Phase
Patients who after 10-14 days of aggressive supportive therapy require high levels of
ventilatory support (FiO2 50%) are candidates for corticosteroid therapy. Corticosteroids
should only be considered if lower respiratory tract sampling can be performed to
diagnose and treat pulmonary sepsis. Prior to embarking on corticosteroid therapy
sepsis should be excluded. Once corticosteroids are commenced surveillance cultures
and protected lower respiratory tract sampling performed every 4th day.
Corticosteroid Protocol (methylprednisolone):
Days 1-14:
Loading dose of 2mg/kg then 0.5 mg/kg q 6 hourly
Days 15 -21
1 mg/kg/day
Days 22-28
0.5 mg/kg/day
If patient extubated prior to day 14, treatment is tapered after day 15.
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Lung Protective Strategy
Because a significant portion of the lung is consolidated and not recruitable, only a small
amount of aerated lung receives the total tidal volume - ARDS leads to "baby lungs".
The use of traditional tidal volumes (12 to 15 ml/kg) in these patients will result in high
inspiratory pressures with overdistension of the normally aerated lung units. An
impressive body of experimental and clinical evidence has clearly demonstrated that
mechanical ventilation that results in high trans-pulmonary pressure gradients and
overdistension of lung units will cause acute lung injury. Animal studies have
demonstrated that a trans-pulmonary pressure in excess of 35 cmH2O will lead to
alveolar damage. Furthermore the cyclic opening and closing of lung units (recruitment
and derecruitment) in patients with ARDS who are ventilated with insufficient PEEP will
further potentiate this iatrogenic lung injury. It has clearly demonstrated that ventilatory
strategies that avoid overdistension of lung units and also avoids end-expiratory alveolar
collapse limits the degree of lung injury in ARDS, reduces complications and improves
survival.
A relative form of "lung rest" using low tidal volume mechanical ventilation is therefore
recommended. This may be achieved with low-volume, volume-cycled ventilation with a
decelerating inspiratory flow or pressure controlled ventilation (PCV).
Permissive hypercapnia.The strategy to reduce volume induced lung injury by using
small tidal volumes may lead to CO2 retention. The term "permissive hypercapnia" has
been used to the describe this ventilatory strategy. Hypercapnic acidosis is generally
well tolerated by the patients, especially when it develops gradually over 1 to 2 days.
Aministration of bicarbonate to correct the acidosis is not reccommended. Permissive
hypercapnia should not be used in patients with acute intracranial pathology.
Top
Protocol for Liberation/Weaning From Mechanical
Ventilation
TOC
Step 1
Step 2
Step 3
Failure to wean
Notes
Introduction
A number of different approaches to ventilator liberation have been reported (See note
1). The most popular and efficient method is described. According to this approach:
1. All ICU patients are screened daily by the RT (See note 2)
2. Suitable patients undergo a 3 minute spontaneous breathing trial
3. This is followed by a 30 minute to 2 hour spontaneous breathing trial in those who
pass the 3 minute test
Step 1. Screening of patients
Candidates for the 3 minute spontaneous breathing trial: (See note 3)
Adequate gas exchange
Non COPD: a PaO2 >60mmHg with a FiO2 of 0.4 or less (PaO2/FiO2>150)
COPD: pH >7.30, PaO2 >50mmHg with a FiO2 of 0.35 or less
PEEP <6 cmH2O
Alert and cooperative patient.
Patient not on a continuous infusion of sedatives/narcotics
Temperature <38C and >36.5C
No requirement for vasopressor agents
dopamine >10 ug/kg/min
norepinephrine
Minute ventilation <15 L/min and RR <30
Adequate cough during suctioning
Heart rate less 100 beats/min
Systolic blood pressure >90 and <180 mmHg
Top
Step 2. Three minute spontaneous breathing trial
Patients who meet all the above criteria then undergo a 3 minute spontaneous breathing
trial.
The patient will be placed on one of the following trial modes:
CPAP with auto-flow
CPAP with pressure support of 5cm/H20 (See note 4)
The FiO2 is set at the same level as that used during mechanical ventilation. Trial must
be monitored by pulse oximetry and electrocardiography. The trial must be stopped
immediately when the patient meets any of the following criteria:
Resp Rate/Tidal Volume (Liters) >105
Respiratory rate <8 or >35
Spontaneous tidal volume <4cc/kg
Arterial saturation <90%
Heart rate >140 or heart rate change (either direction ) >20%; no arrhythmia
Top
Step 3. Trial of Liberation
Patients continue to breath through the CPAP circuit. The FiO2 may be increased up to
50%.
Back-up apnea parameters must be set on the ventilator to activate at a 20 second
apneic interval.
Trial terminated when:
Respiratory rate >35/min
Arterial saturation <90
Heart rate >140 or heart rate change (either direction ) >20% or arrhythmias
SBP >180 and <90
Increased anxiety and diaphoresis
Should the patient tolerate the CPAP trial for 2 hours (some studies have used 30
minutes) then the patient may be extubated.
The trial is repeated daily in those patients who fail to tolerate this spontaneous
breathing trial.
The time to liberation is not shortened by repeating the spontaneous breathing trial
multiple times per day.
The ICU team must be notified should the patient pass this phase of the liberation
process and an order obtained to extubate the patient.
Orogastric tubes, if present should be removed to reduce the risk of aspiration. If gastric
access is required a naso-gastric tube should be placed. The tube feeds should be
stopped at this point in time. Intravenous glucose must be given to prevent
hypoglycemia.
Top
Treatable causes of " failure to wean"
Hypophosphatemia
Hypokalemia
Hypomagnesemia
Hypocalcemia (ionized)
Pulmonary edema
Angina
Anemia
Malnutrition
Overfeeding with excessive carbohydrate (increased CO2 production)
Notes:
1. Weaning/liberation is the process by which a patient is removed from the
ventilator. In many patients ventilatory assistance need not be decreased
gradually, mechanical ventilation and artificial airways can simply be removed
(liberated). According to this thesis patients can simply be removed from the
ventilator once the disease process which led to intubation and mechanical
ventilation has improved or resolved; a prolonged "weaning process"is therefore
not required."
Several studies have been performed comparing the efficacy of SIMV,
T-piece/CPAP, and PSV weaning. No technique has proven superior to
T-piece/CPAP weaning.
Cinical judgement alone does not accurately predict whether mechanical
ventilation can be discontinued successfully.It has recently been demonstrated
that screening patients daily to identify those who can breathe spontaneously will
promote earlier weaning from mechanical ventilation.(Return to text)
2. These are screening criteria; some patients who fail to meet these criteria may be
candidates for the "three minute trial" if approved by the ICU medical team.(Return
to text)
3. Patient evaluations should begin early in the morning (around 5:00 am) and the
patients who meet the inclusion criteria will then immediately begin this protocol.
Attending physicians will be notified during morning rounds with an update of all
evaluated patients.(Return to text)
4. Patients with cardiac disease are best weaned with CPAP and pressure support;
this includes patients with cardiac failure and patients with significant coronary
artery disease. The level of pressure support should initially be set at between
10-12 cmH20 and reduced by 2 cmH20 until the patient is able to tolerate a PSV
of 5 cm H20 for 2 or more hours. An electrocardiogram should be obtained prior to
extubation in patients with a history of coronary artery disease.(Return to text)
Top
Sedation in the ICU
TOC
Introduction
Assessment
SAS Scale
Agents
Protocol
Introduction
Anxiety is an almost universal feature of ICU patients. Consequently, sedation is an
integral component of the management of the ICU patient. The primary objectives of
sedation is too allay anxiety, enhance patient comfort, promote sleep, reduce O2
consumption, reduce the stress response, and facilitate mechanical ventilation. The
desirable level of sedation/hypnosis will depend in large part upon the patient's acute
disease process as well as the need for mechanical ventilation.
In anxious patients it is important to exclude treatable causes of anxiety and not just
increase the amount of sedative drugs being used. Treatable causes of anxiety include:
Uncontrolled pain (NB)
Ventilator settings inappropriate (esp inadequate flow rate) - respiratory
incoordination
Drug or alcohol withdrawal syndrome
Increased work breathing, e.g. pneumothorax, kinked/blocked tube
Pulmonary edema
Loud ventilator alarms and monitors
Poor communication with patient as regards diagnosis, therapy etc.
Top Assessing the degree of sedation and titrating the drug regimen to predetermined
end-points is essential as both over sedation and inadequate sedation are associated
with significant complications.
Complications of under-sedation include:
Severe anxiety with delusional behavior
nterference with medical and nursing care
Sympathetic over-activity with increased myocardial oxygen consumption
Self-injury
Self-extubation
Complications of over-sedation include:
Prolonged intubation with an increased risk of pulmonary complications
Disorientation and "ICU-psychosis" following emergence
Masking of significant neurological and neuromuscular complications
Top
Assessing the level of sedation
Ongoing clinical evaluation is the most effective method of assessing sedation. In order
to provide a more consistent and objective means of assessing the degree of sedation a
number of "sedation scales" have been used. The Glasgow Coma Scale (GCS) was
developed to assess the level of consciousness of trauma patients. This scale is
commonly used to monitor the level of sedation in ICU patients. The GCS is, however,
essentially a measure of pathologic obtundation and cannot be recommended for
monitoring sedation. The Sedation-Agitation Scale (SAS) was developed and tested on
ICU patients and designed specifically for evaluating the level of sedation in the ICU.
This is the preferred assessment scale.
Top
The Sedation-Agitation Scale (SAS)
1. Unarousable - deep hypnosis, non-rousable, no spontaneous movement, no
coughing
2. Very sedated - rousable with strong tactile stimulus, occasional spontaneous and
non-purposeful movements, does not respond to commands
3. Sedated - Asleep/sedated but rousable with tactile stimulus and displays
purposeful movements and follows simple commands
4. Calm cooperative - Calm, awakens easily, follows commands ------------------
5. Agitated - Anxious or mildly agitated, attempting to sit up, calms down to verbal
instructions
6. Very agitated - Does not calm despite frequent verbal remind; requires physical
restraints, biting ET tube
7. Dangerous agitation - Severe anxiety, diaphoresis, frequent vigorous movements,
pulling on ET tube , trying to remove catheters, climbing over bed rails, striking at
staff, thrashing side to side
Goals of Sedation
Non-ventilated patients
SAS 3-4
Ventilated pts: AC, SIMV, PS
SAS 2-4
Ventilated pts: PCV, low TV AC
SAS 1-2
Top
Sedative/Hypnotic agents of choice
The following drugs have been selected based on cost, efficacy, tolerance,
pharmacokinetics and pharmacodynamics and side-effects.
1. Long term sedation
Lorazepam is the drug of choice for non-intubated patients and patients who will
require long term sedation/hypnosis in the ICU (>48 hours). Benzodiazepines
should be avoided in patients with liver disease. Lorazepam and propofol act
synergistically; the addition of propofol should be considered to prevent
oversedation and long waking time.
2. Short term sedation, neurological/neurosurgical patients
Propofol is the drug of choice due to the rapid emergence once discontinued
3. Deep hypnosis to facilitate "lung protective ventilation"
This may be achieved with propofol alone. However, propofol and lorazepam
have synergistic effects and the combination may achieve the desired level of
hypnosis at a lower cost.
4. Treatment of Delirium or sedation without respiratory depression
Haloperidol
5. Sedation for invasive procedures
Midazolam alone or in combination with fentanyl
The daily interruption of sedative-drug infusions is recommended in patients receiving
mechanical ventilation. This approach allows daily assessment of neurological function
that would otherwise not be possible and prevents oversedation and reduction of total
sedative dosages.
Top
Sedation Protocol
1. To treat SAS 7, sedation for PCV, neurosurgical/neurology patients , patients with
hepatic dysfunction and short term sedation (<24 hours)
Propofol: Start IV drip at 10ug/kg/min, titrate dose by increments of 5-10
mcg/kg/min at 10 minute intervals
Lorazepam 2-4 mg IV Q4 hour; hold if patient requiring <50 mcg/kg/min
propofol
Hold propofol drip Q AM to assess neuro status, restart drip at previous level
Check triglyceride Monday and Thursday: if >400 mg/dl halve propofol dose
and start lorazepam infusion at XX mg/hr (if >600 mg/dl stop propfol)
2. To treat SAS 5 or 6 or for any patient for whom sedation is required
Non Intubated patient
Lorazepam 2-4 mg IV Q 6 hours. Hold for SAS <3
Intubated Patient
SAS 6. Lorazepam infusion - start at 2mg/hr and then titrate to SAS level XX
increasing by 2mg/hr no more frequently than every 15 minutes.
SAS <6. Lorazepam 2-4 mg Q 4 hourly IV. If poor response change to an
infusion of lorazepam at 2mg/hr and then titrate to SAS level XX increasing by
1mg/hr no more frequently than every 15 minutes.
Hold lorazepam drip Q AM to assess neuro status, restart drip at previous
level.
3. Delerium
Haloperidol 5-25 mg IV Q 10 minutes PRN for SAS 6 or 7. DO not exceed 80
mg over 2 hours
Haloperidol 5-25 mg IV Q 4 hours. Hold for SAS <3
Note: Propofol should only be used in intubated patients
Weaning propofol
Decrease propofol by 10ug/kg/min q 2 hour
IF SAS >4 choose from:
Lorazepam 2-4 mg IV Q 4 hours. Hold for SAS <3
Haloperidol 10 mg IV Q 10 minutes PRN for SAS 6 or 7. DO not exceed 80 mg
over 2 hours
Haloperidol 5 mg IV Q 4 hours. Hold for SAS <3
Top
Neuro-muscular blockers in the ICU
TOC
Introduction
NMBA's
TOF
Introduction
NMBA have historically been used in the OR where they have been found to be
remarkably safe. The safety of these drugs in the ICU has been questioned, due to the
increasing number of case reports of prolonged paralysis following their use. In
particular, the concomitant use of NMBA and corticosteroids has been linked to a
syndrome known as "acute quadriplegic myopathy". This syndrome may occur after use
for as short as 8 hours and without the concomitant use of corticosteroids. Acute
quadriplegic myopathy has been associated with the use of both steroid and non-steroid
based NMBA. NMBA's should, therefore, be used only when absolutely indicated (and
only when high dose propofol has failed) and then only for the shortest possible period
of time. Neuromuscular blockade should NEVER be used for the treatment of anxiety or
restlessness.
The major indication for NMBA in the ICU is to facilitate ventilation in the following
circumstances:
High PEEP
When peak airway pressures are high
PCV
Low tidal volume ventilation
To prevent excessive and prolonged neuromuscular blockade all patients receiving
NMBA should be monitored using a nerve stimulator. For practical purposes the
Train-Of-Four (TOF) should be used to access the degree of neuromuscular blockade.
The goal is to achieve one to two twitches.
Top
Choice of NMBA
Long term paralysis
Vecuronium - duration 60-75 minutes
Intubation: 0.07-0.1 mg/kg
Maintenance: 4-10 mg/hr
Renal failure
Atracurium - duration 45-60 minutes
Intubation: 0.4-0.5 mg/kg
Maintenance: 20-50 mg/hr
Intubation
Rocuronium - acts 1 min, duration minutes
0.6-1.2 mg/kg
Succinylcholine - acts 30s, duration 5-15 minutes.
1mg/kg
CONTRAINDICATIONS to the use of Succinylcholine include:
Renal failure
Burns
Severe trauma with muscle injury
Severe sepsis
Ocular injuries
severe acidosis
Top
Train of Four (TOF) Monitoring
The train of four (4 stimuli 0.5s apart) is a convenient way of monitoring the degree of
neuromuscular blockade and roughly correlates with the degree of neuro-muscular
junction receptor occupation:
4 twitches ... 0-70% receptors occupied
3 twitches ... 70-80% receptors occupied
2 twitches ... 80-90% receptors occupied
1 twitch ... >95% receptors occupied
0 twitches ... 100% receptors occupied
In principle, any superficially located peripheral motor nerve can be stimulated. The
ulnar nerve is however the most popular site. The electrodes are best applied on the
volar side of the wrist.
From a practical point of view 1 to 2 twitches (of TOF) of the adductor pollicis muscle
will result in sufficient diaphragmatic paralysis to prevent the patient from coughing,
hiccoughing and breathing during mechanical ventilation.
Prior to paralysis the supramaximal stimulation (SMS) must be determined. The SMS is
defined as the level at which additional stimulation current does not increase the twitch
response. It is important to note that each nerve may have a different SMS and
inadequate stimulation may lead the clinician to overestimate the degree of
neuromuscular blockade present. The SMS is usually in the range of 20-60 mA.
Starting at 10 mA, increase the TOF current by 10mA until four equal responses are
obtained. Continue to increase the current until the intensity of the response does not
increase any further. When this occurs the prior setting will be the SMS for that nerve.
Once the patient is paralyzed the TOF is then performed using the SMS.
Top
The TOF test should be performed hourly until the goal is achieved (1-2 twitches) and
then 6 hourly. The rate of the infusion should be adjusted as follows:
0 twitches
Stop infusion, restart when 2 twitches are present. Restart infusion rate at:
80% if takes 1 hour for 2 twitches
75% if takes 2 hour for 2 twitches
50% if takes 3 hour for 2 twitches
25% if takes 4 hour for 2 twitches
1 twitch
Reduce to 80% of present infusion rate
2 twitches
Maintain present infusion rate
3 twitches
Reload with 25% of loading dose
Increase infusion rate by 25%
4 twitches
Reload with 50% of loading dose
Increase infusion rate by 50%
Top