DRUGS IN INTENSIVE CARE UNIT

Uses

 Pressors
 Sedatives
 Analgesics
 Paralytic agent

Dopamine

 Renal (2-5 mcg/kg/min)

o Increase in mesenteric blood flow
 Beta (5-10 mcg/kg/min)
o Positive inotrope
 Alpha (10-20 mcg/kg/min)
o vasoconstriction
 “Renal dose” dopamine only transiently increases urine output
 Adverse effects - Tachyarrhythmias .

Dobutamine

Primarily beta 1, mild beta 2.

 Dose dependent increase in stroke volume, accompanied by decreased filling

pressures.
 Systemis vascular resistance may decrease
 Useful in heart failure.
 Should be used only if systolic pressure >90
 Dose- 5-15 mcg/kg/min.
 Adverse effects- Tachyarrhythmias.

Epinephrine

 Alphaagonist - arterial vasoconstriction

o Increased systemic vascular resistance
o cerebral and coronary blood flow
  Beta agonist
o Increased heart rate
o Increased force of contraction
o Increased myocardial O2 demand (may increase ischaemia)
 Beta at very low doses, a at higher doses.
 Useful in cardiac arrest ,anaphylaxis and bronchial asthma
 Side effects –Arrhythmogenic, coronary ischemia, renal vasoconstriction, 
metabolic rate.

Recommended Dose

 1.0 mg (10mL of 1: 10,000 solution) administered iv every 3 to 5 minutes.

 3-5 ml 1:10,000 i.v. in anaphylaxis, depending on severity

Norepinephrine

 Potent alpha agent, some beta

 Vasoconstriction (that tends to spare the brain and heart).
 SVR in high output shock.

 Dose 1-12 mcg/min

 Can cause reflex bradycardia (vagal).

Vasopressin

 Vasoconstrictor that may be useful in septic shock - 0.4 units/min

 Used as an alternative pressor to epinephrine in refractory VF

Nitroglycerine

 Venodilator at low doses (<40mcg/min)

 Arteriolar dilation at high doses (>200 mcg/min).
 Rapid onset, short duration, tolerance.
 AE- inhibits platelet aggregation,  ICP, headache.

Nitroprusside

 Balanced vasodilator
 Rapid onset, short elimination time
  Useful in hypertensive emergency, severe CHF, aortic dissection
 Accumulates in renal and liver dysfunction.
 Toxicity= CN poisoning (decreased CO, lactic acidosis, seizures).

Dosing

 0.2- 10 mcg/kg/min
 Other AE-  ICP

Labetolol

 Dose related decrease in SVR and BP without tachycardia.

 Does not ICP
 Useful in the treatment of hypertensive emergencies, aortic dissection.
 Bolus= 20mg, infusion= 2mg/min.

Sedation

 Relieve pain, decrease anxiety and agitation, provide amnesia, reduce patient-
ventilator dysynchrony, decrease respiratory muscle oxygen consumption, facilitate
nursing care.
 May prolong mechanical ventilation and increase costs.

Goals of Sedation

 Old- Obtundation
 New- Sleepy but arousable patient
 Almost always a combination of anxiolytics and analgesics.

Benzodiazepines

 Act as sedative, hypnotic, amnestic, anticonvulsant, anxiolytic.

 No analgesia.
 Develope tolerance.
 Synergistic effect with opiates.
 Lipid soluble, metabolized in the liver, excreted in the urine.
 Interact with erythromycin, propranolol, theophylin
 Diazepam
 o Repeated dosing leads to accumulation
o Difficult to use in continuous infusion
 Lorazepam
o Slow onset, longest acting
o Metabolism not affected by liver disease
 Midazolam
o Fast onset, short duration
o Accumulates when given in infusion >48 hours.

Propofol

 Sedative, anesthetic, amnestic, anticonvulsant

 Respiratory and CV depression
 Highly lipid soluble
 Rapid onset, short duration
o Onset <1 min, peak 2 min, duration 4-8 min
 Clearance not changed in liver or kidney disease.

Side effects

 Unpredictable respiratory depression

o Use only in mechanically ventilated patients
 Hypotension
o First described in post-op cardiac patients
 Increased triglycerides
o 1% solution of 10% intralipids
o Daily tubing changes, dedicated port

Butyrophenones

 Haloperidol
o Anti-psychotic tranquilizer
o Slow onset (20 min)
o Not approved for IV use, but is probably safe
o No respiratory depression or hypotension.
 o Useful in agitated, delirious, psychotic patients
o Side effects- QT prolongation, NMS, EPS

Analgesics

 Relieve Pain
 Opioides
 Non-opiodes
 Can be given PRN or continuous infusion
o PRN avoids over sedation, but also has peaks and valleys and is more labor
intensive.

Opiodes

 Metabolized by the liver, excreted in the urine.

o Morphine- Potential for histamine release and hypotension.
o Fentanyl- Lipid soluble, more potent, more rapid onset, no histamine release,
 Adverse effects
o Respiratory depression
o Hypotension (sympatholysis, histamine release)
o Decreased GI motility (peripheral effect)
o Pruritis

Non-opiodes

 Ketamine
 Analog of phencyclidine, sedative and anesthetic, dissociative anesthesia.
 Hypertension, hypertonicity, hallucinations, nightmares.
 Potent bronchodilator

Paralytics

 Paralyze skeletal muscle at the neuromuscular junction.

 They do not provide any analgesia or sedation.
 Prevent examination of the CNS
 Increase risks of DVT, pressure ulcers, nerve compression syndromes.
Use of Paralytics

 Intubation
 Facilitation of mechanical ventilation
 Preventing increases in ICP
 Decreasing metabolic demands (shivering)
 Decreasing lactic acidosis in tetanus, NMS.

Atropine

 Parasympathetic blocking (vagolytic) agent.

  heart rate, A-V conduction

 May restore cardiac rhythm in asystole if due to increase parasympathetic tone.

Atropine

 Indications

 Symptomatic bradycardias
 Asystole
 PEA (rate < 60 beats min)
 May be beneficial in presence of AV block at the nodal level.

Dose

 1.0 mg IV every 3 to 5 minutes for asystolic cardiac arrest.

 0.5 to 1.0 mg IV every 3 to 5 minutes for bradycardia.

Maximum dose

 Upto a total dose of 0.04mg/kg. (asystolic cardiac arrest)

 Upto a total dose of 0.03mg/kg. (Bradycardia)

Lidocaine

 Suppresses ventricular ectopy

 Decrease excitability in ischemic tissue
  VF threshold

Indications
  Refractory VF / Pulseless VT 
o when amiodarone is unavailable
 Haemodynamically stable VT 
o as an alternative to amiodarone

Dose

 Refractory VF / Pulseless VT
 1 to 1.5 mg/kg as bolus and ½ the dose incrementally up to max of 3 mg/kg.
 Drip – 2mg/min

Adenosine

 Paroxysmal supraventricular tachycardia

 Broad complex tachycardia of uncertain etiology

Actions

 Decreases the sinus rate

 Slows conduction across the AV node
 Half- life is <5 seconds

Dose

 6 mg by rapid I.V push.

 If necessary, two further doses of 12 mg each can be administered every 1–2
mins(saline chase)

Sodium Bicarbonate

Alkalinizing agent (increases pH)

Used in

 Severe metabolic acidosis (pH < 7.1)

 Hyperkalaemia
 Special circumstance
o Tricyclic antidepressant poisoning

Dose
  1 - 2 mmols / Kg i.v.
o Paradoxical intracellular acidosis
o Increases carbon dioxide load
o Inhibits release of oxygen to tissues
o Impairs myocardial contractility
o Hypernatremia.

TRANSITIONAL CARE MANAGEMENT(TCM)

Definition

 The assistance and service provided to senior patients as they move from their
“inpatient hospital setting”to their residence setting (personal home, rest home or
assisted living).
 There are several specifics healthcare providers must be aware of in order to bill for
Transitional Care Management under Medicare and Medicaid:

Specific time frame

 TCM starts the day after a patient is discharged

 Concludes 29 days after start date

Must be a qualified professional

 TCM services must be rendered by a qualified professional

 That is a: physician, nurse practitioner, physician assistant, or nurse specialist

Initial contact

 Initial contact must occur within 2 business days

 Qualified Professional is in charge of documenting time & providing written
summary of encounter

Read adjustment of medication

 Pre-admittance medication must be documented and compared to post-release

medication
 Prescriptions can only come from QPs with prescription authority

In person visit
  There must be a face-to- face visit within the first 7 or 14 calendar days of the
transitional care
 The number of days depends on the code being billed for

Non- face to face interaction

 The Center for Medicare and Medicaid has a list of required services that must take
place within the 30 days
 Each service must be properly documented in order to be billed.

CRISIS INTERVENTION

Introduction

 Stressful situations are a part of everyday life. Any stressful situation can precipitate a crisis.
Crises result in a disequilibrium from which many individuals require assistance to recover.
Crisis intervention requires problem- solving skills that are often diminished by the level of
anxiety accompanying disequilibrium. Assistance with problem solving during the crisis
period preserves self esteem and promotes growth with resolution.

Meaning

 The dictionary meaning of crisis is a crucial or decisive point or situation; a turning

point.
 A crisis (derived from the “krisis” which means critical) is any event that is, or is
expected to lead to, an unstable and dangerous situation affecting an individual,
group, community, or whole society.

Definition

 “A sudden event in one’s life that disturbs homeostasis, during which usual coping
mechanisms cannot resolve the problem.” -LAGERQUIST, 2006
 “It is the situation of a complex system (family, economy, society) when the system
functions poorly, an immediate decision is necessary, but the causes of the
dysfunction are not known.”
 “It occurs when individuals are confronted with problems that can’t be solved. These
irresolvable issues result in an increase in tension, signs of anxiety, a subsequent state
of emotional unrest, and an in ability to function for extended periods.”
  Event or situation perceived as intolerably difficult that exceed an individual’s
available resources and coping mechanisms.” -JAMES & GILILAND (2005)

Types

Class 1 : Dispositional Crises

 An acute response to an external situational stressor.

Class 2: Crises of anticipated life transitions

 Normal life cycle transitions that may be anticipated but over which the individual
may feel a lack of control.

Class 3: Crises resulting from traumatic stress

 Crises precipitated by unexpected external stresses over which the individual has little
or no control and from which he or she feels emotionally overwhelmed and defeated.

Class 4: Maturational/Developmental crises

Crises that occur in response to situations that trigger emotions related to unresolved conflicts
in one’s life.

Class 5: Crises reflecting psychopathology

Emotional crises in which pre existing psychopathology has been instrumental in

precipitating the crisis or in which psychopathology significantly impairs or complicates
adaptive resolution. Examples of psychopathology that may precipitate crises include
borderline personality, severe neuroses, character logical disorders, or schizophrenia.

Class 6: Psychiatric emergencies

Crisis situations in which general functioning has been severely impaired and the individual
rendered incompetent or unable to assume personal responsibility. Examples include acutely
suicidal individuals, drug overdoses, and reactions to hallucinogenic drugs, acute psychoses,
uncontrollable anger, and alcohol intoxication.

Crisis intervention

 Individuals experiencing crises have an urgent need for assistance. In crisis

intervention the therapist, or other intervener, becomes a part of the individual’s life
 situation. Because of the individual’s emotional state, he or she is unable to problem
solve, so requires guidance and support from another to help mobilize the resources
needed to resolve the crises.
 Crisis intervention takes place in both inpatient and outpatient settings. The basic
methodology relies heavily on orderly problem solving techniques and structured
activities that are focused on change. Through adaptive change, crises are resolved
and growth occurs. Because of the time limitation of crisis intervention, the individual
must experience some degree of relief almost from the first interaction.
 Crisis intervention, then, isn’t aimed at major personality change or reconstruction,
but rather at using a given crisis situation, at the very least, to restore functioning and,
at most, to enhance personal growth.
 Crisis intervention is emergency first aid for mental health & domestic violence. It
requires that the person experiencing the crisis receive timely and skillful support to
help cope with his/her situation before physical or emotional deterioration occurs.
 Crisis intervention therefore involves three major components:
 The actual crisis – victim’s perception of an unmanageable situation,
 The individual in crisis, and
 The helper who provides aid.
 Goal is to stabilize the family situation and restore to their pre-crisis level of
functioning.
 Opportunity to develop new ways of perceiving, coping, and problem-solving.
 The intervention is time limited and fast paced.
 Planning occurs simultaneously as assessment is made about how much time has
elapsed between the occurrence of the stressor event and this initial interview.
 How much the crisis has interrupted the person’s life?
 The effect of this disruption on others in the family.
 Level of functioning prior to crisis and what resources can be mobilized.
 The goal of intervention is to restore the person to pre-crisis level of equilibrium, not
of personality changes.
 Worker attempts to mobilize the client’s internal and external resources.
 Exact nature of the intervention will depend on the client’s pre-existing strengths and
supports and the worker’s level of creativity and flexibility.
Warnings

 Danger of misunderstanding the client’s nonverbal behavior as well as spoken words

due to cultural differences or the client’s state of disorganization.
 Imperative for the worker not to assume that they understand what the client means
by his spoken word or non-verbal behavior and vice versa.
 It is best to clarify and make sure

Phases of crisis intervention : The role of a nurse

Phase I. Assessment 1

 Ask the individual to describe the event that precipitated this crisis.
 Determine when it occurred.
 Assess the individual’s physical and mental status.
 Determine if the individual has experienced this stressor before. If so, what method
of coping was used? Have these methods been tried this time?
 If previous coping methods were tried, what was the result?
 If new coping methods were tried, what was the result?
 Assess suicide or homicide potential, plan, and means.
 Assess the adequacy of support systems.
 Determine level of precrisis functioning. Assess the usual coping methods, available
support systems and ability to problem solve.
 Assess the individual’s perception of personal strengths and limitations.

Phase II. Planning of therapeutic intervention

 In the planning phase of the nursing process, the nurse selects the appropriate nursing
actions for the identified nursing diagnoses.
 In planning the interventions, the type of crisis, as well as the individual’s strengths
and available resources for support, are taken into consideration.
 Goals are established for crisis resolution and a return to, or increase in, the precrisis
level of functioning.

Phase III. Intervention

 Use a reality oriented approach. The focus of the problem is on the here and now.
  Remain with the individual who is experiencing panic anxiety.
 Establish a rapid working relationship by showing unconditional acceptance, by
active listening, and by attending to immediate needs.
 Discourage lengthy explanations or rationalizations of the situations; promote an
atmosphere for verbalization of true feelings.
 Set firm limits on aggressive, destructive behaviors. At high levels of anxiety,
behavior is likely to be impulsive and regressive. Establish at the outset what is
acceptable and what is not, maintain consistency.
 Clarify the problem that the individual is facing. The nurse does this by describing
his/her perception of the problem and comparing it with the individual’s perception of
the problem.
 Help the individual determine what he or she believes precipitated the crisis.

Phase IV. Evaluation of crisis resolution and anticipatory planning

 Have positive behavioral changes occurred?

 Has the individual developed more adaptive coping strategies? Have they been
effective?
 Has the individual grown from the experience by gaining insight into his or her
responses to crisis situations?
 Does the individual believe that he or she could respond with healthy adaptation in
future stressful situations to prevent crises development?
 Can the individual describe a plan of action for dealing with stressors similar to the
one that participated this crisis?

ADVANCED CARDIAC LIFE SUPPORT

Definition

Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set
of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-
threatening medical emergencies, as well as the knowledge and skills to deploy those
interventions.

Component of high quality cpr in bls

 Scene safety
 o Make sure the environment is safe for rescuers and victim
 Recognition of cardiac arrest
o Check for responsiveness
o No breathing or only gasping ( ie, no normal breathing)
o No definite pulse felt within 10 secs ( Carotid or femoral pulse)
o (Breathing and pulse check can be performed simultaneously within 10 secs)
 Activation of emergency response system
o If alone with no mobile phone, leave the victim to activate the emergency
response system and get the AED before beginning CPR
o Otherwise, send someone and begin CPR immediately; use the AED as soon
as it is available
o In case of unwitnessed collapse of children or infant give CPR for 2 mins
before leaving the victim and getting the AED then resume CPR
 Chest compression
o Adult- 30:2
o Children or infant- 30:2 if one rescuer
o 15:2 if more than one rescuer
 Compression rate: 100-120/ min
 Compression depth
o Adult- at least 5 cm
o Children or infant- at least 1/3rd AP diameter of chest
 Hand placement
o Adult - 2 hands on the lower half of the sternum
o Children – 1 or 2 hands on the lower half of the sternum
o Infants – 2 fingers or 2 thumb defending of the number of rescuers
 Chest recoil
o allow full recoil of chest after each compression; do not lean on the chest after
each compression.
 Minimizing interruption: Limit interruptions in chest compressions to less than 10
secs.

Adult advanced cardiovascular life support

Recongnition of arrythmia

 Lethal or non lethal

 Symptomatic or asymptomatic
 Stable or unstable
 Shockable or unshockable

Shockable

 Ventricular tachycardia
o Monomorphic or polymorphic
 Ventricular fibrillation
o Fine or Coarse VF

Unshockable

 Asystole
 PEA- pulseless electrical activity or EMD- electromechanical dissociation

Meanwhil

 Minimize interruption in CPR- alternate CPR provider every 2 minutes as continued

Chest compression may fatigue the provider leading to ineffective compression
 Maintain an orchestra of activity between physician, nurse and other health care
provider (Ward boy)
 Check airway patency- consider oropharyngeal tube placement if tongue fell back.
 Arrange for endotracheal tube/ maximize oxygen delivery

Electrode placement

 4 pad positions
o Anterolateral
o Anteroposterior
o anterior-left infrascapular,
o anterior-rightinfrascapular
 For adults, an electrode size of 8 to 12 cm is reasonable (Class IIa, LOE B)
 Any of the 4 pad positions is reasonable for defibrillation (Class IIa, LOE B).
Defibrillation

 Biphasic wave form: 120- 200 J

 Monophasic wave form: 360 J
 AED- device specific
 Failure of a single adequate shock to restore a pulse should be followed by continued
CPR and second shock delivered after five cycles of CPR
 If cardiac arrest still persist- patient is intubated and IV/IO access achieved

Defibrillation Sequence

 Turn the AED on

 Follow the AED prompts
 Resume chest compressions immediately after the shock(minimize interruptions).

1-shock protocol versus 3-shock sequence

 Evidence from 2 well-conducted pre/post design studies suggested significant survival

benefit with the single shock defibrillation protocol compared with 3-stacked-shock
protocols
 If 1 shock fails to eliminate VF, the incremental benefit of another shock is low, and
resumption of CPR is likely to confer a greater value than another shock

Treatable causes of cardiac arrest

The H’S AND T’S H’s T’s

 Hypoxia Toxins
 Hypovolemia Tamponade (cardiac)
 Hydrogen ion(acidosis) Tension pneumothorax
 Hypo-/hyperkalemia Thrombosis, pulmonary
 Hypothermia Thrombosis, coronary

Airway and ventilations

 Opening airway – Head tilt, chin lift or jaw thrust, in addition explore the airway for
foreign bodies, dentures and remove them. Consider oropharyngeal tube placement.
  The Health care provider should open the airway and give rescue breaths with chest
compressions

Rescue breaths

 By mouth-to-mouth or bag-mask
 Deliver each rescue breath over 1 second
 Give a sufficient tidal volume to produce visible chest rise
 Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations
 After advanced airway is placed, rescue breaths given asynchronus with ventilation
 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute)

Breathing devices

 Plastic oropharyngeal airways

 Esophageal obturators
 Ambu bag- usual method for continuing breathing in hospital before ET tube can be
inserted.
 Endotracheal tube

Pharmacotherapy

 Routes of administration
o Peripheral IV – easiest to insert during CPR, must followed by 20 ml NS push
o Central IV – fast onset of action, but do not wait or waste time for CV line
o Intraosseous – alternative IV route in peds, also in Adult
o Intratracheally (down an ET tube)- not recommended now a days
 Oxygen
o FIO2 100%
o Assist Ventilation
o O2 Toxicity should not be a concern during ACLS
 IV Fluids
o Volume Expanders
o crystalloids , e.g. Ringer’s lactate, N/S

Amiodarone (Cordarone)
  Indications
o Like Lidocaine – Vtach, Vfib
 IV Dose
o 300 mg in 20-30 ml of N/S or D5W
o Supplemental dose of 150 mg in 20-30 ml of N/S or D5W
o Followed with continuous infusion of 1 mg/min for 6 hours than .5mg/min to
a maximum daily dose of 2 grams

Lidocaine

 Indications
o PVCs, Vtach, Vfib
o Can be toxic so no longer given prophylactically
 IV dose
o 1-1.5 mg/kg bolus then continuous infusion of 2-4 mg/min
o Can be given down ET tube
 Signs of toxicity
o slurred speech, seizures, altered consciousness

Monitoring during cpr

 Physiologic parameters
o Monitoring of PETCO2 (35 to 40 mmHg)
o Coronary perfusion pressure (CPP) (15mmHg)
o Central venous oxygen saturation (ScvO2)
o Abrupt increase in any of these parameters is a sensitive indicator of ROSC
that can be monitored without interrupting chest compressions
 Quantitative waveform capnography
o If Petco2 <10 mm Hg, attempt to improve CPR quality
 Intra-arterial pressure
o If diastolic pressure <20 mm Hg, attempt to improve CPR quality
o If ScvO2 is < 30%, consider trying to improve the quality of CPR
Initial objectives of post– cardiac arrest care

 Optimize cardiopulmonary function and vital organ perfusion.

 After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a
comprehensive post–cardiac arrest treatment
 Transport the in-hospital post– cardiac arrest patient to an appropriate critical-care
unit
 Try to identify and treat the precipitating causes of the arrest and prevent recurrent
arrest

DEFIBRILLATOR

Definition

 Defibrillation is a process in which an electronic device sends an electric shock to the

heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart
rhythm.
 Defibrillation is a common treatment for life threatening cardiac dysrhythmias,
ventricular fibrillation, and pulse less ventricular tachycardia.

Need for a defibrillator

 Ventricular fibrillation is a serious cardiac emergency resulting from asynchronous

contraction of the heart muscles.
 Due to ventricular fibrillation, there is an irregular rapid heart rhythm. Fig.
Ventricular fibrillation Fig. Normal heart beat
 Ventricular fibrillation can be converted into a more efficient rhythm by applying a
high energy shock to the heart.
 This sudden surge across the heart causes all muscle fibres to contract simultaneously.
 Possibly, the fibres may then respond to normal physiological pace making pulses.
 The instrument for administering the shock is called a DEFIBRILLATOR.

Purpose

 Defibrillation is performed to correct lifethreatening fibrillations of the heart, which

could result in cardiac arrest. It should be performed immediately after identifying
 that the patient is experiencing a cardiac emergency, has no pulse, and is
unresponsive.

History

 Defibrillation was invented in by Prevost and Batelli, two Italian physiologists. They
discovered that electric shocks could convert ventricular fibrillation to sinus rhythm in
dogs.The first case of a human life saved by defibrillation was reported by Beck in
1947 .

Principle

 Energy storage capacitor is charged at relatively slow rate from AC line.

 Energy stored in capacitor is then delivered at a relatively rapid rate to chest of the
patient.
 Simple arrangement involve the discharge of capacitor energy through the patient‟s
own resistance.
 The discharge resistance which the patient represents as purely ohmic resistance of 50
to 100Ω approximately for a typical electrode size of 80cm2.
 This particular waveform Fig is called „ Lown‟ waveform.
 The pulse width of this waveform is generally 10 ms.

Strength duration curve

 minimum defibrillation energy occurs for pulse durations of 3 - 10 ms (for most pulse
shapes)
 pulse amplitude in tens of amperes (few thousand volts).
 operator selects energy delivered: 50-360 joules, depends on
o intrinsic characteristics of patient
o patient‟s disease
o duration of arrhythmia
o patient‟s age
o type of arrhythmia (more energy required for v. fib.)

Mechanism

 Fibrillations cause the heart to stop pumping blood, leading to brain damage
  Defibrillators deliver a brief electric shock to the heart, which enables the heart's
natural pacemaker to regain control and establish a normal heart rhythm.

Power of defibrillation

 Higher voltages are required for external defibrillation than for internal defibrillation.
 A corrective shock of 750-800 volts is applied within a tenth of a second.
 That is the same voltage as 500-533 no of AA batteries!

Defibrillator electrodes

 Types of Defibrillator electrodes

o Spoon shaped electrode - Applied directly to the heart.
o Paddle type electrode - Applied against the chest wall
o Pad type electrode - Applied directly on chest wall

Classes of discharge waveform

There are two general classes of waveform

 mono-phasic waveform
o Energy delivered in one direction through the patient‟s heart a
 Biphasic waveform
o Energy delivered in both direction through the patient‟s heart
 A monophasic type, give a high-energy shock, up to 360 to 400 joules due to which
increased cardiac injury and in burns the chest around the shock pad sites.
 A biphasic type, give two sequential lowerenergy shocks of 120 - 200 joules, with
each shock moving in an opposite polarity between the pads.

Types of defibrillators

 Internal defibrillator
o Electrodes placed directly to the heart
o e.g..-Pacemaker
 External defibrillator
o Electrodes placed directly on the heart
o e.g..-AED
External defibrillator

 For each minute elapsing between onset of ventricular fibrillation and first
defibrillation, survival decreases by 10%.
 defibrillators should be portable, battery operated, small size.
 energy in defibrillators usually stored in large capacitors

Automatic external defibrillator

 AED is a portable electronic device that automatically diagnoses the ventricular

fibrillation in a patient.
 Automatic refers to the ability to autonomously analyse the patient's condition.
 AED is a type of external defibrillation process
 AEDs require self-adhesive electrodes instead of hand held paddles.
 The AED uses voice prompts, lights and text tell the rescuer what steps have to take
next. messages to

Working of AED

 Turned on or opened AED.

 AED will instruct the user to
o Connect the electrodes (pads) to the patient.
o Avoid touching the patient to avoid false readings by the unit.
o The AED examine the electrical output from the heart and determine the
patient is in a shock able rhythm or not
o When device determined that shock is warranted, it will charge its internal
capacitor in preparation to deliver the shock.
o When charged, the device instructs the user to ensure no one is touching the
victim and then to press a red button to deliver the shock.
o Many AED units have an 'event memory' which store the ECG of the patient
along with details of the time the unit was activated and the number and
strength of any shocks delivered.

Precaution

 The paddles used in the procedure should not be placed

o on a woman's breasts
 o overan internal pacemaker patients.
 Before the paddle is used, a gel must be applied to the patient's skin

Risk of defibrillators

 Skin burns from the defibrillator paddles are the most common complication of
defibrillation.
 Other risks include injury to the heart muscle, abnormal heart rhythms, and blood
clots.

CARDIAC MONITORING

Definition

 “Finger on pulse” is the easiest and quickest method to assess heart rate.
 ECG is most common method to detect heart rate in ot, by measurement of r-r
interval.
 ECG can get confounded by electrosurgical instruments, power line noises,
twitchings and fasciculations, lithotripsy machine, cardiopul bypass, and fluid
warmers.
 Direct ECG monitoring is better than monitoring of derived heart rate.

Pulse Rate monitoring

 Difference between pulse rate and heart rate is the difference between electrical
depolarization and mechanical contraction of heart.
 Pulse deficit arises in conditions such as AF , PEA( in Cardiac tamponade, extreme
hypovolemia, and conditions where electrical activity is present but not capable of
producing pulse).
 Pulse oxymetery gives PR. Although it seems redundant to measure both HR and PR
but its important to avoid error.

Arteial blood pressure monitoring

  Sphygmomanometer use for systolic blood pressure first described by Riva and Rocci
in 1896(palpatory method). Korotkoff in 1905 described measurement of diastolic as
well.(auscultatory method).
 Any condition causing decrease in blood flow below the level of detection, or
conditions needing excessive pressure to occlude artery.
 Size of cuff 40% and 80%of circumference and length of arm. Too large can still be
accepted but too small will give spuriously high reading. Pressure should be released
slowly to assess korotkofs sounds properly. Rapid deflation results in falsely low
readings.

Automated NIBP

 Intermittent based on oscillometery method, first described by marey 1876.

 Assess MAP most accurately and SBP and DBP are derived. DBP is least reliable by
this method.
 This method is although highly unrelialable, its still most used in critical care settings
but its use other than upper arm is not validated.
 Complications may occur due to continuous use and use in patients with
coagulopathies, arterial and venous insufficiency, thrombolytic therapy and peripheral
neuropathies.
 Automated continuous techniqes(eg:finger BP by arterial volume clamp method) are
also available but with several disadvantages.

Complications of Noninvasive Blood Pressure Measurement

 Pain
 Petechiae and ecchymoses
 Limb edema
 Venous stasis and thrombophlebitis
 Peripheral neuropathy
 Compartment syndrome

IBP/ Direct blood pressure monitoring

 Despite various complications and need of expertise IBP monitoring is ideal

reference standard for BP monitoring ,which provide timely and crucial information
  Arterial cannulation can be done in radial, ulnar, brachial, axillary or femoral artery.
 More central the artery is more are the chances of embolism. Axillary and femoral
arterial cannulation results waveforms that resembles change in pressure in aortic
arch more closely.
 In radial artery cannulation hyperextension is avoided to prevent median nerve injury
and in femoral artery cannulation must be done below the inguinal ligament.

Arterial Blood Pressure Waveform Abnormalities

 Condition Characteristics
 Aortic stenosis Pulsusparvus (narrow pulse pressure)
 Pulsustardus (delayed upstroke)
 Aortic regurgitation Bisferiens pulse (double peak)
 Wide pulse pressure
 Hypertrophic cardiomyopathy Spike-and-dome pattern (midsystolic obstruction)
 Systolic left ventricular failure Pulsusalternans (alternating pulse pressure amplitude)
 Cardiac tamponadePulsusparadoxus (exaggerated decrease in systolic blood pressure
during spontaneous inspiration

Central venous Pressure monitoring

 Central vein is catheterized for various purposes.

 Measurement of CVP is often necessary in heamodynamically unstable and patietns
undergoing major surgeries.
 Rt IJV is most commonly catheterised central vein. Others are left IJV , right and left
subclavian, femoral, external jugulars and axillary.
 Most commonly used size is 7 French , 20 cm catheter with a 18 g introducer needle
and guide wire.

Indications for Central Venous Cannulation

 Central venous pressure monitoring

 Pulmonary artery catheterization and monitoring
 Transvenous cardiac pacing
 Temporary hemodialysis
 Drug administration -Concentrated vasoactive drugs
  Hyperalimentation
 Chemotherapy
 Agents irritating to peripheral veins Prolonged antibiotic therapy (e.g., endocarditis)
 Rapid infusion of fluids (via large cannulas) Trauma
 Major surgery
 Aspiration of air emboli
 Inadequate peripheral intravenous access
 Sampling site for repeated blood testing

Complications of CVP

 Mechanical Vascular injury Arterial VenousHemothorax Cardiac tamponade

 Respiratory compromise Airway compression from hematoma Tracheal, laryngeal
injury Pneumothorax
 Nerve injury
 Arrhythmias
 Subcutaneous/mediastinal emphysema
 Thromboembolic Venous thrombosis Pulmonary embolism Arterial thrombosis and
embolism (air, clot) Catheter or guidewire embolism
 Infectious Insertion site infection Catheter infection Bloodstream infection
Endocarditis
 Misinterpretation of data
 Misuse of equipment

VENTILATOR AND NURSING MANAGEMENT OF MECHANICALLY

VENTILATED PATIENTS

Introduction:

Breathing plays an very important role in the human being by the way of providence
& delivery of oxygen to the cells in the condition of deprivation of oxygen cells will go for an
state called anoxia where the normal functions of the human body will be get affected thus
the mechanical ventilators are the machines which are responsible for providing the oxygen
to the client in the absence of normal respiratory functions. Thus during the state of
respiratory arrest or unconscious the ventilator plays an greater role in maintain the normal
functioning of the lungs .

Spontaneous respiration vs. Mechanical ventilation

Natural Breathing – Negative inspiratory force – Air pulled into lungs

Mechanical Ventilation – Positive inspiratory pressure – Air pushed into lungs

Types of ventilation

 Noninvasive
 Invasive
 Mechanical ventilation
 Negative pressure
 Positive pressure
 Negative-Pressure Ventilators

Negative pressure ventilator

Early negative-pressure ventilators were known as “iron lungs.” The patient’s body was
encased in an iron cylinder and negative pressure was generated . The iron lung are still
occasionally used today. Intermittent short-term negative-pressure ventilation is sometimes
used in patients with chronic diseases. The use of negative-pressure ventilators is restricted
in clinical practice, however, because they limit positioning and movement and they lack
adaptability to large or small body torsos (chests) . Our focus will be on the positive-pressure
ventilators.

Positive pressure ventilation (invasive)

 Indications for Ventilatory Support

 Acute Respiratory Failure
 Prophylactic Ventilatory Support
 Hyperventilation Therapy

Initiation of Mechanical Ventilation

Indications

 Acute Respiratory Failure (ARF)

 Hypoxic lung failure (Type I)
 Ventilation/perfusion mismatch
 Diffusion defect
 Right-to-left shunt
 Alveolar hypoventilation
 Decreased inspired oxygen
 Acute life-threatening or vital organ-threatening tissue hypoxia CO2 production)
 metabolic acidosis
 anxiety associated with dyspnea
 Acute Respiratory Failure (ARF)
 Acute Hypercapnic Respiratory Failure (Type II) –
 CNS Disorders : Reduced Drive To Breathe ,depressant drugs, brain or brainstem
lesions (stroke, trauma, tumors), hypothyroidism
 Increased Drive to Breathe: increased metabolic rate
 Paralytic Disorders: Myasthenia Gravis, Guillain- Barre poliomyelitis, etc. Paralytic
Drugs: Curare, nerve gas, succinylcholine, insecticides
 Drugs that affect neuromuscular transmission; calcium channel blockers, long-term
adenocorticosteroids, etc.
 Impaired Muscle Function: electrolyte imbalance, malnutrition, chronic pulmonary
disease, etc.
 Increased Work of Breathing Pleural Occupying Lesions: pleural effusions,
hemothorax, empyema, pneumothorax
 Chest Wall Deformities: flail chest, kyphoscoliosis,
 obesity Increased Airway Resistance: secretions, mucosal edema,
bronchoconstriction, foreign body
 Lung Tissue Involvement: interstitial pulmonary fibrotic diseases
 Pulmonary Vascular Problems: pulmonary thromboembolism, pulmonary vascular
damage
 Dynamic Hyperinflation (air trapping)
 Postoperative Pulmonary Complications
 Ventilatory support is instituted to: –Decrease the WOB –Minimize O2 consumption
and hypoxemia
 Reduce cardiopulmonary stress
 Control airway with sedation
  Hyperventilation Therapy : Ventilatory support is instituted to control and manipulate
PaCO2 to lower than normal levels

Criteria for institution of ventilatory support:

Normal range Ventilation indicated Parameters

Pulmonary function studies

 Respiratory rate (breaths/min).

 Tidal volume (ml/kg body wt)
 Vital capacity (ml/kg body wt)
 Maximum Inspiratory Force (cm HO2)

Normal range Ventilation indicated Parameters

 Arterial blood Gases

 PH
 PaO2 (mmHg)
 PaCO2 (mmHg) 17

Contraindications

 Untreated pneumothorax
 Patient’s informed consent
 Medical futility
 Reduction or termination of patient pain and suffering

Essential components in mechanical ventilation

 Patient
 Artificial airway
 Ventilator circuit
 Mechanical ventilator
 A/c or D/c power source
 O2 cylinder or central oxygen supply

Artificial airways

 Tracheal intubation : Nasal or Oral

  Supraglottic airway
 Cricothyrotomy
 Tracheostomy
 Laryngeal airway

Articles required :

 Sterile gloves
 Syringe
 Tape
 Stethoscope
 Stillet
 3 sizes of ET tubes
 Laryngoscope with assorted blades
 Ambu bag and mask
 Suction catheter
 Suction apparatus and tubing
 Oxygen flowmeter and O2 tubing
 Intubation Procedure Check and Assemble Equipment

Procedure:

 Intubation Procedure Position your patient into the sniffing position

 Intubation Procedure Preoxygenate with 100% oxygen to provide apneic or distressed
patient with reserve while attempting to intubate. Do not allow more than 30 seconds
to any intubation attempt. If intubation is unsuccessful, ventilate with 100% oxygen
for 3-5 minutes before a reattempt.
 Intubation Procedure Insert Laryngoscope
 Intubation Procedure After displacing the epiglottis insert the ETT. The depth of the
tube for a male patient on average is 21-23 cm at teeth The depth of the tube on
average for a female patient is 19-21 at teeth. CO2 detector – (esophageal detection
device or by capnography)Tube location at teeth Bilateral chest rise By auscultation
of the chest Intubation Procedure Confirm tube position . Stabilize the ETT
 Ventilator circuit : Breathing System Plain Breathing System with Single Water Trap
Breathing System with Double Water Trap. Breathing Filters HME Filter . Flexible
Catheter Mount
Mechanical ventilator :

A mechanical ventilator is a machine that generates a controlled flow of gas into a

patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is
pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2),
accumulated in a receptacle within the machine, and delivered to the patient using one of
many available modes of ventilation.

Types of Mechanical ventilators

 Transport ventilators
 Intensive-care ventilators
 Neonatal ventilators
 Positive airway pressure ventilators for NIV

Classification of positive-pressure ventilators : Ventilators are classified according to how

the inspiratory phase ends. The factor which terminates the inspiratory cycle reflects the
machine type. They are classified as:

 Pressure cycled ventilator

 Volume cycled ventilator
 Time cycled ventilator

Volume-cycled ventilator

Inspiration is terminated after a preset tidal volume has been delivered by the ventilator.
The ventilator delivers a preset tidal volume (VT), and inspiration stops when the preset tidal
volume is achieved.

Pressure-cycled ventilator

In which inspiration is terminated when a specific airway pressure has been reached.
The ventilator delivers a preset pressure; once this pressure is achieved, end inspiration
occurs.

Time-cycled ventilator

In which inspiration is terminated when a preset inspiratory time, has elapsed. Time
cycled machines are not used in adult critical care settings. They are used in pediatric
intensive care areas.
  Savina by Drager
 Servo S by Maquet

Mechanical Ventilators Different Types of Ventilators Available: Will depend on your

place of employment Ventilators in use in MCH

Modes of ventilation

The way the machine ventilates the patient .How much the patient will participate in his
own ventilatory pattern. Each mode is different in determining how much work of breathing
the patient has to do.

Volume Modes

 CMV or CV
 AMV or AV
 IMV
 SIMV

Pressure Modes

 Pressure-controlled ventilation (PCV)

 Pressure support ventilation
 Continuous positive airway pressure (CPAP)
 Positive end expiratory pressure (PEEP)
 Noninvasive bi-level positive airway pressure ventilation (BiPAP)

Control Mode Delivers pre-set volumes at a pre-set rate and a pre-set flow rate. The
patient CANNOT generate spontaneous breaths, volumes, or flow rates in this mode.

Assist/Control Mode Delivers pre-set volumes at a pre-set rate and a pre-set flow rate.
The patient CANNOT generate spontaneous volumes, or flow rates in this mode. Each
patient generated respiratory effort over and above the set rate are delivered at the set
volume and flow rate.Volume or Pressure control mode Parameters to set: Volume or
pressure, Rate , time,FiO2 51

Machine breaths: Delivers the set volume or pressure , Patient’s spontaneous breath:
Ventilator delivers full set volume or pressure & I-time ,Mode of ventilation provides the
most support ,Negative deflection, triggering assisted breath Assist Control .
 Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilator
breath

 prevents breath stacking

 Allows the patient to generate spontaneous breaths, volumes, and flow rates
between the set breaths.
 Delivers a pre-set number of breaths at a set volume and flow rate.

synchronized intermittent mandatory ventilation (simv):

 SIMV Synchronized intermittent mandatory ventilation

 Machine breaths: – Delivers the set volume or pressure
 Patient’s spontaneous breath: – Set pressure support delivered
 Mode of ventilation provides moderate amount of support
 Works well as weaning mode

Pressure regulated volume control (prvc): •

This is a volume targeted, pressure limited mode. (available in SIMV or AC) . Each
breath is delivered at a set volume with a variable flow rate and an absolute pressure limit.
The vent delivers this pre-set volume at the LOWEST required peak pressure and adjust with
each breath.delivers a set tidal volume with each breath at the lowest possible peak pressure.
Delivers the breath with a decelerating flow pattern that is thought to be less injurious to the
lung…… “the guided hand”

Advantages Decelerating inspiratory flow pattern Pressure automatically adjusted for

changes in compliance and resistance within a set range Tidal volume guaranteed Limits
volutrauma Prevents hypoventilation

variable tidal volumes Volume Flow Pressure Set tidal volume 62 © Charles
Gomersall 2003PRVC: Disadvantages Pressure delivered is dependent on tidal volume
achieved on last breath Intermittent patient effort

Positive end expiratory pressure (PEEP):

This is NOT a specific mode, but is rather an adjunct to any of the vent modes. PEEP is
the amount of pressure remaining in the lung at the END of the expiratory phase. Utilized to
keep otherwise collapsing lung units open while hopefully also improving oxygenation.
Usually, 5-10 cmH2O 65
 Pplat Measured by occluding the ventilator 3-5 sec at the end of inspiration Should not
exceed 30 cmH2O 67

Peak Pressure (Ppeak) Ppeak = Pplat + Pres Where Pres reflects the resistive element of
the respiratory system (ET tube and airway)

Ppeak :Pressure measured at the end of inspiration , Should not exceed 50cmH2O? 69

Auto-PEEP or Intrinsic PEEP :Normally, at end expiration, the lung volume is equal to
the FRC – When PEEPi occurs, the lung volume at end expiration is greater than the FRC
70 .

Pathology behind the hyperinflation

 Airflow limitation because of dynamic collapse

 No time to expire all the lung volume (high RR or Vt)
 Decreased Expiratory muscle activity
 Lesions that increase expiratory resistance

Adverse effects:

 Predisposes to barotrauma
 Predisposes hemodynamic compromises
 Diminishes the efficiency of the force generated by respiratory muscles
 Augments the work of breathing
 Augments the effort to trigger the ventilator

Continuous Positive Airway Pressure (CPAP):

This is a mode and simply means that a pre-set pressure is present in the circuit and lungs
throughout both the inspiratory and expiratory phases of the breath. CPAP serves to keep
alveoli from collapsing, resulting in better oxygenation and less WOB. The CPAP mode is
very commonly used as a mode to evaluate the patients readiness for extubation.
Combination “Dual Control” Modes Combination or “dual control” modes combine features
of pressure and volume targeting to accomplish ventilatory objectives which might remain
unmet by either used independently. Combination modes are pressure targeted Partial support
is generally provided by pressure support Full support is provided by Pressure Control
 Combination “Dual Control” Modes Volume Assured Pressure Support (Pressure
Augmentation) Volume Support (Variable Pressure Support) Pressure Regulated Volume
Control (Variable Pressure Control, or Autoflow) Airway Pressure Release (Bi-Level, Bi-
PAP)

Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory time is equal to,
or longer than, expiratory time (1:1 to 4:1). Inverse I:E ratios are used in conjunction with
pressure control to improve oxygenation by expanding stiff alveoli by using longer distending
times, thereby providing more opportunity for gas exchange and preventing alveolar collapse.

As expiratory time is decreased, one must monitor for the development of hyperinflation
or auto-PEEP. Regional alveolar overdistension and barotrauma may occur owing to
excessive total PEEP. When the PCV mode is used, the mean airway and intrathoracic
pressures rise, potentially resulting in a decrease in cardiac output and oxygen delivery.
Therefore, the patient’s hemodynamic status must be monitored closely. Used to limit
plateau pressures that can cause barotrauma & Severe ARDS

High frequency oscillatory ventilation

HIFI - Theory : Resonant frequency phenomena: Lungs have a natural resonant

frequency – Outside force used to overcome airway resistance , Use of high velocity
inspiratory gas flow: reduction of effective dead space ,Increased bulk flow: secondary to
active expiration

Advantages:

 Decreased barotrauma / volutrauma: reduced swings in pressure and volume

 Improve V/Q matching: secondary to different flow delivery characteristics

Disadvantages:

 Greater potential of air trapping

 Hemodynamic compromise
 Physical airway damage: necrotizing tracheobronchitis
 Difficult to suction
 Often require paralysis

Clinical Application
  Adjustable Parameters :Mean Airway Pressure: usually set 2-4 higher than MAP on
conventional ventilator
 Amplitude: monitor chest rise
 Hertz: number of cycles per second
 FiO2 I-time: usually set at 33%
 Comparison of HFOV & Conventional Ventilation Differences CMV HFOV Rates 0
– 150 180 – 900 Tidal Volume 4 – 20 ml/kg 0.1 – 3 ml/kg Alveolar Press 0 - > 50
cmH2O 0.1 – 5 cmH2O End Exp Volume Low Normalized Gas Flow Low High

Initial settings

 Select your mode of ventilation

 Set sensitivity at Flow trigger mode
 Set Tidal Volume
 Set Rate
 Set Inspiratory Flow (if necessary)
 Set PEEP
 Set Pressure Limit
 Inspiratory time
 Fraction of inspired oxygen

When flow-by triggering is used, a continuous flow of gas through the ventilator circuit is
monitored. A ventilator-delivered breath is initiated when the return flow is less than the
delivered flow, a consequence of the patient's effort to initiate a breath 85 When pressure
triggering is used, a ventilator-delivered breath is initiated if the demand valve senses a
negative airway pressure deflection (generated by the patient trying to initiate a breath)
greater than the trigger sensitivity. There are two ways to initiate a ventilator-delivered
breath: pressure triggering or flow-by triggering

Post Initial Settings

Obtain an ABG (arterial blood gas) about 30 minutes after you set your patient up on the
ventilator. An ABG will give you information about any changes that may need to be made to
keep the patient’s oxygenation and ventilation status within a physiological range.

ABG Goal:
 Keep patient’s acid/base balance within normal range pH 7.35 – 7.45, PCO2 35-45
mmHg , PO2 80-100 mmHg

Initial Ventilator Settings

Tidal Volume: Spontaneous VT for an adult is 5 – 7 ml/kg of IBW Determining VT

for Ventilated Patients

A range of 6 – 12 ml/kg IBW is used for adults – 10 – 12 ml/kg IBW (normal lung
function) – 8 – 10 ml/kg IBW (obstructive lung disease) – 6 – 8 ml/kg IBW (ARDS) – can be
as low as 4 ml/kg ,A range of 5 – 10 ml/kg IBW is used for infants and children , Respiratory
Rate Normal respiratory rate is 12-18 breaths/min. A range of 8 – 12 breaths per minute
(BPM) Rates should be adjusted to try and minimize auto- PEEP

Minute Ventilation : Respiratory rate is chosen in conjunction with tidal volume to

provide an acceptable minute ventilation = VT x f , Normal minute ventilation is 5-10 L/min ,
Estimated by using 100 mL/kg IBW ,ABG needed to assess effectiveness of initial settings –
If PaCO2 > minute ventilation via f or VT) – If PaCO245 ( < minute ventilation via f or
VT) 9035

Rate of Gas Flow – As a beginning point, flow is normal set to deliver inspiration in
about 1 second (range 0.8 to 1.2 sec.), producing an I:E ratio of approximately 1:2 or less
(usually about 1:4) – This can be achieved with an initial peak flow of about 60 L/min (range
of 40 to 80 L/min) Most importantly, flows are set to meet a patient’s inspiratory demand

Inspiration Expiration Time (sec) Flow (L/min) Beginning of expiration exhalation valve
opens Peak Expiratory Flow Rate PEFR Duration of expiratory flow Expiratory time TE

Flow Patterns Selection of flow pattern and flow rate may depend on the patient’s lung
condition, e.g., Post operative patient recovering from anesthesia may have very modest flow
demands ,Young adult with pneumonia and a strong hypoxemic drive would have very strong
flow demands , Normal lungs: Not of key importance, Constant Flow (rectangular or square
waveform) Generally provides the shortest TI – Some clinician choose to use a constant
(square) flow pattern initially because it enables them to obtain baseline measurements of
lung compliance and airway resistance

Sine Flow May contribute to a more even distribution of gas in the lungs Peak
pressures and mean airway pressure are about the same for sine and square wave patterns
 Descending (decelerating) Ramp Improves distribution of ventilation, results in a
longer TI, decreased peak pressure, and increased mean airway pressure (which increases
oxygenation)

Positive End Expiratory Pressure (PEEP) :Initially set at 3 – 5 cm H2O , Restores FRC
and physiological PEEP that existed prior to intubation , Subsequent changes are based on
ABG results , Useful to treat refractory hypoxemia

Contraindications for therapeutic PEEP (>5 cm H2O)

 Hypotension ,
 Elevated ICP
 Uncontrolled pneumothorax

FiO2 Initially 100% during Severe hypoxemia , Abnormal cardiopulmonary functions Post-
resuscitation, Smoke inhalation , ARDS , After stabilization, attempt to keep FiO2 <50% ,
Avoids oxygen-induced lung injuries, Absorption atelectasis , Oxygen toxicity

FiO2 of 40% or Same FiO2 prior to mechanical ventilationduring Patients with mild
hypoxemia or normal cardiopulmonary function ,Drug overdose ,Uncomplicated
postoperative recovery

Initial Ventilator Settings For PCV – Rate, TI, and I:E ratio are set in PCV as they are in
Volume mode The pressure gradient (PIP-PEEP) is adjusted to establish volume delivery
Remember: Volume delivery changes as lung characteristics change and can vary breath to
breath 100 .PCV provides a descending ramp waveform Note: The patient can vary the
inspiratory flow on demand . Rise time is the amount of TI it takes for the ventilator to reach
the set pressure at the beginning of inspiration . Inspiratory flow delivery during PCV can be
adjusted with an inspiratory rise time control . Ventilator graphics can be used to set the rise
time

Sigh

 A deep breath.
 A breath that has a greater volume than the tidal volume.
 It provides hyperinflation and prevents atelectasis.
 Sigh volume :Usual volume is 1.5 –2 times tidal volume.
 Sigh rate/ frequency :Usual rate is 4 to 8 times per hour.
Ensuring humidification and thermoregulation

All air delivered by the ventilator passes through the water in the humidifier, where it is
warmed and saturated or through an HME filter ,Humidifier temperatures should be kept
close to body temperature 35 ºC- 37ºC. , In some rare instances (severe hypothermia), the air
temperatures can be increased. The humidifier should be checked for adequate water levels

Ventilator Alarm Settings : High Minute Ventilation , Set at 2 L/min or 10%-15%

above baseline minute ventilation , Patient is becoming tachypneic (respiratory distress)
High Respiratory Rate Alarm Set 10 – 15 BPM over observed respiratory rate Patient is
becoming tachypneic (respiratory distress)

Low Exhaled Tidal Volume Alarm :Set 100 ml or 10%-15% lower than expired
mechanical tidal volume Causes : System leak ,Circuit disconnection ,ET Tube cuff leak

High Inspiratory Pressure Alarm : Set 10 – 15 cm H2O above PIP Common causes:
Water in circuit ,Kinking or biting of ET Tube , Secretions in the airway , Bronchospasm ,
Tension pneumothorax , Decrease in lung compliance , Increase in airway resistance ,
Coughing

Low Inspiratory Pressure Alarm : Set 10 – 15 cm H2O below observed PIP Causes
:System leak ,Circuit disconnection ,ET Tube cuff leak , High/Low PEEP/CPAP Alarm
(baseline alarm) High: Set 3-5 cm H2O above PEEP, Circuit or exhalation manifold
obstruction ,Auto – PEEP • Low: Set 2-5 cm H2O below PEEP Circuit disconnect

High/Low FiO2 Alarm , High: 5% over the analyzed FiO2 , Low: 5% below the
analyzed FiO2 – High/Low Temperature Alarm , Heated humidification ,High: No higher
than 37

Apnea Alarm : Set with a 15 – 20 second time delay , In some ventilators, this triggers
an apnea ventilation mode , Apnea Ventilation Settings , Provide full ventilatory support if
the patient become apneic , VT 8 – 12 mL/kg ideal body weight , Rate 10 – 12 breaths/min ,
FiO2 100% 110

Trouble Shooting the Vent • Common problems

 High peak pressures

 Patient with COPD
 Ventilator asynchrony
 ARDS
 If peak pressures are increasing: Check plateau pressures by allowing for an inspiratory
pause (this gives you the pressure in the lung itself without the addition of resistance)
 If peak pressures are high and plateau pressures are low then you have an obstruction , If
both peak pressures and plateau pressures are high then you have a lung compliance issue
 High peak pressure differential: High Peak Pressures Low Plateau Pressures High Peak
Pressures High Plateau Pressures Mucus Plug ARDS Bronchospasm Pulmonary Edema
ET tube blockage Pneumothorax Biting ET tube migration to a single bronchus Effusion
 COPD : If you have a patient with history of COPD/asthma with worsening oxygen
saturation and increasing hypercapnia differential includes: Must be concern with breath
stacking or auto- PEEP Low VT with increased exhalation time is advisable . Baseline
ABGs reflect an elevated PaCO2 should not hyperventilated. Instead, the goal should be
restoration of the baseline PaCO2. These patients usually have a large carbonic acid load,
and lowering their carbon dioxide levels rapidly may result in seizures.
 COPD and Asthma , Goals: Diminish dynamic hyperinflation , Diminish work of
breathing ,Controlled hypoventilation (permissive hypercapnia)
 Increase in patient agitation and dis-synchrony on the ventilator: Could be secondary to
overall discomfort • Increase sedation :Could be secondary to feelings of air hunger •
Options include increasing tidal volume, increasing flow rate, adjusting I:E ratio,
increasing sedation
 If you are concern for acute respiratory distress syndrome (ARDS) ,Correlate clinically
with radiologic findings of diffuse patchy infiltrate on CXR , Obtain a PaO2/FiO2 ratio
(if < 200 likely ARDS) ,Begin ARDSnet protocol: • Low tidal volumes • Increase PEEP
rather than FiO2 • Consider increasing sedation to promote synchrony with ventilator
 Accidental Extubation : Role of the Nurse: – Ensure the Ambu bag is attached to the
oxygen flowmeter and it is on! – Attach the face mask to the Ambu bag and after
ensuring a good seal on the patient’s face; supply the patient with ventilation.
 Obstructive Airway obstruction causing increase resistance to airflow: e.g. asthma •
Optimize expiratory time by minimizing minute ventilation • Bag slowly after intubation
• Don’t increase ventilator rate for increased CO2
 Restrictive Compromised lung volume: – Intrinsic lung disease – External compression of
lung • Recruit alveolia, optimize V/Q matching
 Lung protective strategies – High PEEP – Pressure limiting PIP: 30-35 cmH2O – Low
tidal volume: 4-8 ml/kg – FiO2 <60% – Permissive hypercarbia Permissive hypoxia
 In a patient with head injury, Respiratory alkalosis may be required to promote cerebral
vasoconstriction, with a resultant decrease in ICP. In this case, the tidal volume and
respiratory rate are increased ( hyperventilation) to achieve the desired alkalotic pH by
manipulating the PaCO2.

Complications of Mechanical Ventilation:-

 Airway Complications
 Mechanical complications
 Physiological Complications
 Artificial Airway Complications

Airway Complications

 Aspiration
 Decreased clearance of secretions
 Nosocomial or ventilator-acquired pneumonia

What is suctioning? The patient with an artificial airway is not capable of effectively
coughing, the mobilization of secretions from the trachea must be facilitated by aspiration.
This is called as suctioning.

Indications for suctioning:

 Decreased SpO2 in the pulse oximeter

 Visible secretions in the airway
 Noisy breathing
 Coarse breath sounds
 Indications & Increased PIP; decreased Vt during ventilation
 Changes in monitored flow/pressure graphics
 Clinically increased work of breathing
 Deterioration of arterial blood gas values

Articles Required:

 Clear protective goggles, apron

 Sterile catheter
 Clean gloves for closed suctioning method
 Sterile gloves for open suctioning method
  stethoscope
 Vaccum source with adjustable regulator suction jar

Necessary equipment:

 Suction tray with hot water for flushing

 Bain’s circuit or ambu bag for preoxygenate the patient
 Sterile normal saline
 mask

Types of suctioning:

 open suction
 closed suction

Closed suctioning is also indicated when PEEP level above 10cmH2O. This is used to
facilitate continuous mechanical ventilation and oxygenation during the suctioning.

 The patient should receive hyper oxygenation by the delivery of 100% oxygen for
Explain the procedure to the patient (If patient is concious).
 Patient Preparation Auscultate the breath sounds.
 Position the patient in supine position. 30 seconds prior to the suctioning (by
increasing the FiO2 by mechanical ventilator).
 Turn on suction apparatus and set vacuum regulator to appropriate negative pressure.
For adult a pressure of 100-120 mmHg, 80-100mmhg for children
 Perform hand hygiene, wash hands. It reduces transmission of microorganisms.

Procedure :

 Goggles, maskContinue….. & Open the end of the suction catheter package
 Preoxygenate with 100% O2
 apron should be worn to prevent splash from secretions & With a help of an assistant
open suction catheter package
 Wear sterile gloves with sterile technique
 connect it to suction tubing (If you are alone) & connect it to suction tubing
 Kink the suction tubeWith a help of an assistant disconnect the ventilator
  Continue….. & Resistance is felt when the catheter impacts the carina or bronchial
mucosa, the suction catheter should be withdrawn 1cm out before applying
suctioninsert the catheter in to the ETtube until resistance is felt
 Give four to five manual breaths with bag or ventilator
 Assistant resumes the ventilator
 Instill 3 to 5ml of sterile normal saline in to the artificial airway, if required
 The duration of each suctioning should be less the 15sec.
 Apply continuous suction while rotating the suction catheter during removal
 Flush the catheter with hot water in the suction tray
 Return patient to ventilator
 Continue making suction passes, bagging patient between passes, until clear of
secretions, but no more than four passes
 Document including indications for suctioning
 Wash hands
 Auscultate chest
 Flush the suction tube with hot water
 Discard used equipments
 oropharynx above the artificial airway & any changes in vitals & patient’s tolerance

Closed suction procedure:

 Wash hands
 Suction oropharynx above the artificial airway
 Clean suction catheter with sterile saline until clear; being careful not to instill
solution into the ETtube
 Repeat steps above if needed
 Place the dominant thumb over the control vent of the suction port, applying
continuous or intermittent suction for no more than 10 sec as you withdraw the
catheter into the sterile sleeve of the closed suction device
 Removal of pulmonary secretions.Improvement in arterial blood gas values or
saturation as reflected by pulse oximetry. (SpO2) Decreased peak inspiratory
pressure; Increased tidal volume delivery during ventilation. Improvement in breath
sounds.

Assessment of outcome:
 When indicated, there is no absolute contraindication to endotracheal suctioning because
the decision to abstain from suctioning in order to avoid a possible adverse reaction may, in
fact, be lethal. Suctioning is contraindicated when there is fresh bleeding. Most
contraindications are relative to the patient's risk of developing adverse reactions or
worsening clinical condition as result of the procedure.

Contraindications :

The need for suctioning should be assessed at least every 2hrs or more frequently as need
arises.Suctioning should be done when clinically necessary (not routinely). Suctioning is
potentially an harmful procedure if carriedout improperly.

Mechanical complications 1- Hypoventilation with atelectasis with respiratory acidosis

or hypoxemia. 2- Hyperventilation with hypocapnia and respiratory alkalosis 3- Barotrauma
a- Closed pneumothorax, b- Tension pneumothorax, c- Pneumomediastinum, d-
Subcutaneous emphysema. 4- Alarm “turned off” 5- Failure of alarms or ventilator 6-
Inadequate nebulization or humidification 7- Overheated inspired air, resulting in
hyperthermia

Physiological Complications 1- Fluid overload with humidified air and sodium chloride
(NaCl) retention 2- Depressed cardiac function and hypotension 3- Stress ulcers 4- Paralytic
ileus 5- Gastric distension 6- Starvation 7- Dyssynchronous breathing pattern 146

Artificial Airway Complications A- Complications related to Endotracheal Tube:- 1-

Tube kinked or plugged 2- Tracheal stenosis or tracheomalacia 3- Mainstem intubation with
contralateral (located on or affecting the opposite side of the • Lung) lung atelectasis 5- Cuff
failure 6- Sinusitis 7- Otitis media 8- Laryngeal edema

Complications related to Tracheostomy tube:- 1- Acute hemorrhage at the site 2- Air

embolism 3- Aspiration 4- Tracheal stenosis 5- Failure of the tracheostomy cuff 6- Laryngeal
nerve damage 7- Obstruction of tracheostomy tube 8- Pneumothorax 9- Subcutaneous and
mediastinal emphysema 10- Swallowing dysfunction 11- Tracheoesophageal fistula 12-
Infection 14- Accidental decannulation with loss of airway

Nursing care of patients on mechanical ventilation Assessment:

 Assess the patient

 Assess the artificial airway (tracheostomy or endotracheal tube)
 Assess the ventilator
 -Maintain airway patency & oxygenation
 Promote comfort
 Maintain fluid & electrolytes balance
 Maintain nutritional state
 Maintain urinary & bowel elimination
 Maintain eye , mouth and cleanliness and integrity
 Maintain mobility/ musculoskeletal function
 Provide psychological support
 Facilitate communication
 Provide psychological support & information to family
 Responding to ventilator alarms /Troublshooting ventilator alarms
 Prevent nosocomial infection
 Documentation
 Responding To Alarms If an alarm sounds, respond immediately because the problem
could be serious. Assess the patient first, while you silence the alarm. If you can not
quickly identify the problem, take the patient off the ventilator and ventilate him with a
resuscitation bag connected to oxygen source until the physician arrives. A nurse or
respiratory therapist must respond to every ventilator alarm
 Alarms must never be ignored or disarmed. • Ventilator malfunction is a potentially
serious problem. Nursing or respiratory therapists perform ventilator checks every 2 to 4
hours, and recurrent alarms may alert the clinician to the possibility of an equipment-
related issue.
 When device malfunction is suspected, a second person manually ventilates the patient
while the nurse or therapist looks for the cause. • If a problem cannot be promptly
corrected by ventilator adjustment, a different machine is procured so the ventilator in
question can be taken out of service for analysis and repair by technical staff.

Weaning readiness Criteria

 Awake and alert

 Hemodynamically stable, adequately resuscitated, and not requiring vasoactive
support
 Arterial blood gases (ABGs) normalized or at patient’s baseline - PaCO2 acceptable -
PH of 7.35 – 7.45 - PaO2 > 60 mm Hg , - SaO2 >92% - FIO2 ≤40% 156
  Positive end-expiratory pressure (PEEP) ≤5 cm H2O • F < 25 / minute • Vt 5 ml / kg •
VE 5- 10 L/m (f x Vt)
 VC > 10- 15 ml / kg 157
 Chest x-ray reviewed for correctable factors; treated as indicated, • Major electrolytes
within normal range,
 Hematocrit >25%,
 Core temperature >36°C and <39°C,
 Adequate management of pain/anxiety/agitation,
 Adequate analgesia/ sedation (record scores on flow sheet),
 No residual neuromuscular blockade.

Methods of Weaning

 T-piece trial
 Continuous Positive Airway Pressure (CPAP) weaning
 Synchronized Intermittent Mandatory Ventilation (SIMV) weaning, 4- Pressure
Support Ventilation (PSV) weaning.

T-Piece trial

 It consists of removing the patient from the ventilator and having him / her breathe
spontaneously on a T-tube connected to oxygen source. During T-piece weaning,
periods of ventilator support are alternated with spontaneous breathing. The goal is to
progressively increase the time spent off the ventilator.
 Synchronized Intermittent Mandatory Ventilation ( SIMV) Weaning
 SIMV is the most common method of weaning.
 It consists of gradually decreasing the number of breaths delivered by the ventilator to
allow the patient to increase number of spontaneous breaths
 Continuous Positive Airway Pressure ( CPAP) Weaning When placed on CPAP, the
patient does all the work of breathing without the aid of a back up rate or tidal volume.
 No mandatory (ventilator-initiated) breaths are delivered in this mode i.e. all
ventilation is spontaneously initiated by the patient.
 Weaning by gradual decrease in pressure value
 Pressure Support Ventilation (PSV) Weaning
 The patient must initiate all pressure support breaths.
  During weaning using the PSV mode the level of pressure support is gradually
decreased based on the patient maintaining an adequate tidal volume (8 to 12 mL/kg)
and a respiratory rate of less than 25 breaths/minute.

PSV weaning is indicated for :

 Difficult to wean patients

 Small spontaneous tidal volume.

Role of nurse before weaning:

 Ensure that indications for the implementation of Mechanical ventilation have

improved
 Ensure that all factors that may interfere with successful weaning are corrected
 Acid-base abnormalities , Fluid imbalance , Electrolyte abnormalities , Infection ,
Fever Anemia ,Hyperglycemia , Sleep deprivation
 Assess readiness for weaning
 Ensure that the weaning criteria / parameters are met.
 Explain the process of weaning to the patient and offer reassurance to the patient.
 Initiate weaning in the morning when the patient is rested.
 Elevate the head of the bed & Place the patient upright
 Ensure a patent airway and suction if necessary before a weaning trial
 Provide for rest period on ventilator for 15 – 20 minutes after suctioning.
 Ensure patient’s comfort & administer pharmacological agents for comfort, such as
bronchodilators or sedatives as indicated.
 Help the patient through some of the discomfort and apprehension.
 Evaluate and document the patient’s response to weaning.
 Wean only during the day.
 Remain with the patient during initiation of weaning.
 Instruct the patient to relax and breathe normally.
 Monitor the respiratory rate, vital signs, ABGs, diaphoresis and use of accessory
muscles frequently. If signs of fatigue or respiratory distress develop. Discontinue
weaning trials.

Signs of Weaning Intolerance Criteria

 Diaphoresis
  Dyspnea & Labored respiratory pattern
 Increased anxiety ,Restlessness, Decrease in level of consciousness
 Dysrhythmia,Increase or decrease in heart rate of > 20 beats /min. or heart rate >
110b/m,Sustained heart rate >20% higher or lower than baseline 168
 Increase or decrease in blood pressure of > 20 mm Hg Systolic blood pressure >180
mm Hg or <90 mm Hg
 Increase in respiratory rate of > 10 above baseline or > 30 Sustained respiratory rate
greater than 35 breaths/minute
 Tidal volume ≤5 mL/kg, Sustained minute ventilation <200 mL/kg/minute
 SaO2 < 90%, PaO2 < 60 mmHg, decrease in PH of < 7.35. Increase in PaCO2 169

Role of nurse after weaning

 Ensure that extubation criteria are met

 Decanulate or extubate
 Documentation

Noninvasive Bilateral Positive Airway Pressure Ventilation (BiPAP)

BiPAP is a noninvasive form of mechanical ventilation provided by means of a nasal mask or

nasal prongs, or a full-face mask. The system allows the clinician to select two levels of
positive-pressure support: An inspiratory pressure support level (referred to as IPAP) An
expiratory pressure called EPAP (PEEP/CPAP level).

Absolute contraindications

 Coma
 Cardiac arrest
 Respiratory arrest
 Any condition requiring immediate intubation
 Chronic obstructive pulmonary disease
 Cardiogenic pulmonary edema
 After discontinuation of mechanical ventilation (COPD)
  Patient interfaces with full face masks, nasal pillows, Nasal masks and orofacial
masks
 Special noninvasive ventilators
  Modes of ventilation • CPAP • BiPAP

Top 10 care essentials for ventilator patients

 Review communications.
 Check ventilator settings and modes.
 Suction appropriately.
 Assess pain and sedation needs.
 Prevent infection.
 Prevent hemodynamic instability.
 Manage the airway.
 Meet the patient’s nutritional needs.
 Wean the patient from the ventilator appropriately.
 Educate the patient and family. 
Ethics and Medico-legal issues in Critical care nursing

Introduction:

Physicians often experience ethical dilemmas in the clinical field. The intensive care unit
(ICU) is the most common place of ethical conflicts, and many respiratory physicians face
with these conflicts frequently. Recently, the intensive care dedicated system was
implemented, and the critical care environment is rapidly changing in Korea. In this paper,
we will describe the impact of ethical dilemmas on the quality of care and the role of the ICU
physicians with respect to such dilemmas.

Ethics:

Ethics is the study of how one ought to behave in contrast the law defines how one must
behave to avoid punishment; Ethics is concerned with differentiating right from wrong
behavior.

Impact of ethics in ICU:

Today's health care environment is increasingly complex. The complexity of

technology-driven modern health care, value heterogeneity, individual rights, and the number
of choices according to individual values are less conductive to good decision making1.
Despite considerable technologic breakthroughs in the provision of intensive care medicine,
mortality in the ICU remains highand ethical conflicts among stakeholders occur frequently
in contemporary health care settings. These may have negative impacts on healthcare
workers, patients, and their families, and lower the quality of intensive care.

In a previous study, over 70% of ICU workers reported perceived conflicts, which
were often considered severe and were significantly associated with job strain. Nurses
perceived distressing situations more frequently than physicians did; additionally, 45% of the
registered nurses surveyed reported having left or having considered leaving a position
because of moral distres. The ICU is one of the places in the hospital where family members
suffer. More than two-thirds of family members visiting ICU patients have symptoms of
anxiety or depression. In a French study, it was found that 75.5% of family members and
82.7% of spouses had symptoms of anxiety or depression in a multicenter study including 78
ICUs and 544 family members

Components of Medical Ethics Relationship :

 healthcare practitioners and patients

 in-between healthcare practitioners
 health care practitioners and society

Ethical framework :

 Autonomy : right to self determination

 Beneficence : “doing good”
 Nonmaleficence : “primum non nocere”
 Fidelity : duties and obligations
 Distributive justice : impartiality
 Utility : most good for most

Influence of ethical issues in Critical care:

 progress in capacity and capability

 Greater demand for resources
 Life support systems : “stalemate situation”
 Not to confuse with : “financial exhaustion”
 Life is valuable : offset when it is brief, painful and non-interactive
 Death when imminent : deferment at any cost seems inappropriate
 Futile prolongation of life may challenge the rights of salvageable and in need
 Client has a Ethical right to choose access to “therapy” . The Intensivist doesn’t have
Ethical right to unilaterally select or withhold .here Communication is the “key” between
the health care provider & the client & their relatives
 Dying in discomfort
 Receiving unwanted unhelpful therapy
 Dying with lack of dignity
 Patient wishes are commonly unknown
 Variation of practice
 Gradual treatment limitation

Constraints with influence

 Nurses to participate in discussions

 Withdrawing the treatment : not the basic nursing Care but the Palliative plan
 Practical considerations: Burden vs Benefit for the health care providers
 “probability” than “certainty” : here the Decision making is an evolving process which
considers the Collaborative approach of the client & the relatives
 Advance directives is not common in all the countries
 Legal standing is variable
 Self determination : considerable Ethical validity
 Warrants respect of the self

Practical ethical issues in critical care area

Euthanasia

 Active termination of life

 Usually at the request of a patient
 Terminal / Debilitating / Incurable illness
 “Physician assisted suicide”
 Legal in small number of countries
 NOT LEGAL IN INDIA

Informed Consent

 Treatment and Research

 General consent
 Procedure / Investigation / Therapy
 Principle of Autonomy
 Voluntary : free from coercion
 Patient interest is paramount
 Teaching consent
 Waived for emergency

Rationing

Treatment must not be withdrawn or withheld because there is a “more deserving”

patient but because it would always be withdrawn or withheld under the particular clinical
circumstances

Professionalism

 Unique, usually a privileged position

 Well covered “Code of Conduct”
 Maintenance of competency
 Appropriate professional relationship
 Respect for patient and staff confidentiality
 Respect for the tenets of law

Industry and Conflict of Interest

 Doctors vs Med Tech vs Pharmaceutical

 Complex interaction
 Interdependent
 Doctors are entitled to fair consideration for their skills and effort
 Overt and scrutinized
 Diverse nature of rewards

Research

Critically ill patients are rarely in a position to consent , But in a position to derive
benefit from earlier research projects , Surrogate decision maker , “slippery slope” Ethical
conflicts most commonly arise when there is a clash of values or interests ,Resolution is often
difficult because of entrenched positions and convictions , Ethics committee has an important
role in establishing framework
The Consumers are patients with complex needs. With increased awareness of health care,
health care facilities and Consumer Protection Act, patients are getting aware about their
rights. Nurses also have now the expanded role. Issues which seem not feasible, and ideal,
may become practice with the change of time. These issues are base for the future trends in
care.

Laws- Law is a system of rules that are created and enforced through social or governmental
institutions to regulate behavior.

Values- In ethics, value denotes the degree of importance of something or action, with the
aim of determining what actions are best to do or what way is best to live.

Moral- It is concerned with the principles of right and wrong behavior.

Rights- Rights are legal, social, or ethical principles of freedom or entitlement

Ethical system

Ethics are the rules or principles that govern right conduct and are designed to
protect the rights of human beings. Code of ethics is a guideline for performance and
standards and personal responsibility. Lillie M S and Juanita Lee

Need for critical care nursing ethics

 Helps the students/ RN to practice ethically

 Helps the nurse to identify the ethical issues in her work place
 Protecting patients right and dignity
 Providing care with possible risk to the nurses health
 Staffing patterns that limit the patients access to nursing care
 Ethical reasoning Helps the nurse to respond to ethical conflicts
 Helps to differentiate right /wrong behavior
 Guide for a professional behavior
 Help teachers plan education.
 Prevent below standard practice.
 Communication & interpersonal relationship
 Valuing the human being
 Management of the resources

Types of critical care nursing ethical practice theories:

Duty-oriented ethical theories

A duty oriented ethical theory is a system of ethical thinking having the concept of
duty or obligation as foundation. Duties are strict obligations that take primary over rights
and goals. Keep in mind however each duty has corresponding rights. Duty- oriented theories
are advantages in homogeneous societies in which each person hold the service values. A
duty oriented theory would work well in a tribal society because it is easier to share values
and therefore beliefs among a small group of people. A disadvantage of a duty-oriented
theory is determining how to rank duties. For example, a nurse may be form between a duty
to support life and a duty to prevent suffering.

 Rights-Oriented Ethical theories

 Goal-oriented ethical theories
 Intuitionist ethical theory

Ethical dilemmas

A dilemma is defined as a situation requiring a choice between two equally desirable or

undesirable alternatives.

 Too many patients but scarce resources( How to provide proper care)
 Don’t resuscitate
 Euthanasia
 Treatment of terminally ill patient like end stage cancer, HIV etc
 Rights of psychiatry patient etc.

Roles and functions of administrator in ethical issues

 He or she is self aware regarding own values and basic beliefs about the rights, duties
and goals of human beings
 Accepts that some ambiguity and uncertainty be a part of all ethical decision-making
 Accepts that negative outcomes occur in ethical decision making despite high quality
problem solving and decision-making
 Demonstrates risk taking in ethical decision making
 Role models ethical decision-making which are congruent with the code of ethics and
inter respective statements
 Actively advocates for clients, subordinates and the profession
 Clearly communicates expected ethical standards of behavior
  Uses a systematic approach to problem-solving or decision making when faced with
management problems with ethical ramifications

Decision Making Process

 Collect, Analyze and interpret the data

 State the Dilemma
 Consider the choices of action
 Analyze the advantage and disadvantages of each course of action
 make the decision and act on it.

Legal system: Established by or founded upon law or official or accepted rules

Law: The law us a system of rights and obligations which the state enforces. Green

Sources of law

 Constitutional law: - it is a judgmental law. Law that governs the state. It determines
structure of state, power and duties.
 Common law:- it is a body of legal principles that evolved from court decisions
 Administrative law: - rules and regulations established by administrative agencies
made by executives of government.

Purposes:

 Safeguarding the public

 The public safety is guaranteed
 The individual is secure to the event of sickness or disability with no fear of anxiety
of being cared for by a competent person
 Counting of sponge instrument and needles correct identity Contracts &
Documentation consent for operation and other procedures Good Samaritan laws
Licensure Good rapport Standards of care standing orders Safeguarding the nurse

Laws in nursing

 Common law :Created by judicial decisions made in courts when individual cases are
decided Felony -Is a crime of serious nature that has a penalty of imprisonment for
greater than one year or even death
  Misdemeanor :Is a less serious crime that has a penalty of a fine or imprisonment of
less than one year
 Civil law :Protects the rights of individual persons within our society and encourage
fair and equitable treatment among people
 Contract Law : It is the enforcement of agreements among private individuals.
Employment Contracts is an example of contract law under civil law
 Criminal law :Prevent harm to society and provides punishment for crimes
 Comparative Law : The comparative lawyer works with international relations in
trade and commerce, travel, government business
 Family law: The most common family law attorneys are the divorce lawyers, but
other aspects of family law are represented as well. Child support claims and those
stipulations, custody

Role and functions of Nurse Manager in legal issues.

 Serves as a role model by providing nursing care that meets or exceeds accepted
standards of care.
 Reports substandard nursing care to appropriate authorities
 Practices nursing within the area of individual competence
 Prioritizes patients right and welfare first in decision making
 Delegates to subordinates wisely, looking at the managers scope of practice and that
of those they supervise.

Meaning of legal issues

Law is standard or rules of conduct established & enforced by government. Legal

issues in nursing are those in which a person led to face legal problems in which nurse face
problem when not meeting proper patient care.

Legal issues in critical care nursing:

Duty to seek medical care for the patient :

It is the legal duty of the nurse to ensure that every patient receives safe and
competent care. If a nurse determine that a patient in any setting needs medical care, and she
does not do everything within power to obtain that care for the patient, you have breached
your duty as a nurse.
Confidentiality

The law requires you to treat all such information with strict confidentiality. This is
also an ethical issue. Unless a patient has told something that indicates danger to self or
others, you are bound by legal and ethical principles to keep that information confidential.

Permission to treat

When people are admitted to hospitals, nursing homes, and home health services,
they sign a document that gives the personnel in the organization permission to treat them.

Informed consent

Negligence

Negligence occurs when a person fails to perform according to the standards of

care or as a reasonably prudent person would perform in the same situation. It is the
responsibility of the nurse to monitor the patient.

Malpractice

Malpractice specifically refers to negligence by a professional person with a

license. Nurse can be sued for malpractice once has your LPN license.

Assault & battery

Assault is the threat of unlawful touching of another, the willful attempt to harm
someone. Battery is the unlawful touching of another without consent, justification, or
exercise. In legal medicine battery occurs if a medical or surgical procedure is performed
without patient consent. Assault can be verbally threatening a patient.

False imprisonment

Preventing movement or making a person stay in a place without obtaining consent

is false imprisonment. This can be done through physical or non physical means. Physical
means include using restraints or locking a person in a room. In some situations, restraints
and locking patients in a room are acceptable behavior. This is the case when a prisoner
comes to the hospital for treatment or when a patient is a danger to self or others.

Invasion of privacy
 Clients have claims for invasion of privacy, e.g. their private affairs, with which the
public has no concern, have been publicized. Clients are entitled to confidential health care.
All aspects of care should be free from unwanted publicity or exposure to public scrutiny.
The precaution should be taken sometimes an individual right to privacy may conflict with
public‘s right to information for e.g. in case of poison case.

Report it / tort it

Allegations of abuse are serious matters. It is the duty of the nurse to report to the
proper authority when any allegations are made in regards to abuse (emotional, sexual,
physical, and mental) towards a vulnerable population (children, elderly, or domestic). If no
report is made, the nurse is liable for negligence or wrongdoing towards the victimized
patient.

Patient satisfaction

Patient satisfaction is an important and commonly used indicator for measuring the
quality in health care. Patient satisfaction affects clinical outcomes, patient retention, and
medical malpractice claims.

Assessment of quality of health care

Patient as a consumer , Today the patient sees himself as a buyer of health services.
Patient satisfaction is an important tool for the success of their organization and are regularly
monitoring patient satisfaction levels among their customers.

Service excellence : Service excellence revolves around three factors: doctor, patient, and
organization.

 Doctor- He should do following

 See the whole person
 Secure confidentiality and privacy
 Preserve dignity & Respond quickly
 Patient- Patients expect their doctors to keep up the timings, behave cordially, and
communicate in their language. They expect care, concern, and courtesy in addition to
a good professional job.

Hospital services
 Hospital There is certain areas where minimum requirements and standards have to
be maintained.

 Good Telephone service

 Good Office appearance
 Minimizing Waiting time
 More Doctor-patient interaction
 Proper Patient education
 Feedback

Issues regarding malpractice in nursing management :It can lead to several management
problems. Improper use of administration power, improper managing of supplies, staff, ward,
institution etc.

Issues of delegation and supervision :The failure to delegate and supervise within
acceptable standards of professional practice.

Issues related to staffing :

 Inadequate accreditation standards

 Inadequate staffing, i.e. short staffing.
 Floating staff from unit to unit.

Ethics : Nurses provide care, promote human rights and values, and help meet the needs
Keeping patients' information confidential. Protecting patients from negligent co-workers
who may endanger them.

Effect : Effects of reform, shortages, ethics and salaries are issues that keep nurses constantly
thinking, growing and changing. Nursing instructors make far less money than nurses in the
clinical setting. The salaries need to be increased, and colleges and universities need to see
the value in instructors.

Issues in nursing curriculum development: It includes validation of curriculum or

judgemental process Providing professional education and preparation of participants
Updating& upgrading recent knowledge.

Collaboration issues : There is increased complex health care issues driven by technological
and medical advancements Collaborative partnerships has ensured the continuing
development of the professional expertise necessary to meet these challenges.
Employment issues:

Issues related to nursing shortage National nursing organizations are making strong efforts
at stopping the shortage by mandating better nurse- to-patient ratios, eliminating mandatory
overtime, and increasing salaries and benefits for nurses.

Issues in nurse migration : Nurse migration has attracted a great deal of political as well as
media attention in recent years. In this section a discussion on the right to work and the right
to practice is, by necessity, followed by a warning that cases of exploitation and
discrimination often occur when dealing with a vulnerable migrant population.

The right to work and the right to practice : Foreign nurses also need to meet national
security and immigration criteria in-order-to enter the country and to stay on a permanent or
temporary basis, with or without access to employment.

Exploitation and discrimination : Essential Terms and Conditions in an Employment

contract A badly drafted employment contract which does not correctly express the
intentions of the employer on such matters as working hours, prolonged illness, bonus
payments, usage of office computer facilities, transfers, retirement age, confidentiality,
conflict of interest, disciplinary action and imposition of punishment, etc these items in an
employment contract can give rise to serious consequences for employers.

Unsatisfactory work performance and termination of employment : The Courts have

time and again reiterated that employees enjoy security of tenure of employment. However,
when an employee has an attitude problem or whose work performance is not up to the
expectations he cannot be terminated by the employer simply by invoking the termination
clause in the employment contract. The employer has to follow certain rules and procedures
and only at the end of it can he terminate the services of a non-performing employee

Misconduct and imposition of punishment It has long been held that the employer has the
inherent right to discipline his workers. The Courts will interfere if, the action taken by the
management was perverse, baseless or unnecessarily harsh or was not just or fair. • There
have been occasions where employers have imposed the punishment of dismissal for
misconduct which they have assessed as serious but these cases have been reviewed.

Renewal of nursing registration In this case, registration office is updated with nurses in
practice. Re- registration may qualify its periodicity and qualifications of nurses e.g. clinical
experience, attendance at continuing education etc.
Diploma vs degree in nursing for registration to practice nursing : This issue need
indepth study of merits and demerits as well as its feasibility before it could come on the
surface.

Specialization in clinical area : It could be either through clinical experience or education.

Specialization in cure and specialized care required for patients demand that nurses be highly
skilled in the unit. Standards must be laid down and followed so that clients understand the
quality of care expected from the nurses.

Infection control in critical care unit

Introduction

Nosocomial infection comes from Greek words “nosus” meaning disease and “
komeion” meaning to take care of , also called as hospital acquired infection

The need for knowing the importance of infection control in the icu occurs because of
the increasing following factors

 Public health impact of hospital acquired infections.

 epidemiology
 Indian situation of the problem
 Estimate the extent and nature of nosocomial infections in hospital 5.
 Identify the changes in the incidence of nosocomial infections and the pathogens that
cause them.

Current Climate In the health care sector

 Public Concern
 Quality Issues
 Clinical Governance
 Clinical Standards
 Accountability Reviews
 Performance Assessment Framework

Definition of nosocomial infection:

 An infection acquired in a patient in a hospital or other healthcare facility in whom it was
not present or incubating at the time of admission or the residual of an infection acquired
during a previous admission. Nosocomial infections have been recognized for over a century
as a critical problem affecting the quality of health care and a principal source of adverse
healthcare outcomes.

Background of hospital infections

Monitoring, Neurological dysfunction, Hematologic &Renal replacement therapy , renal

failure, severe acidosis ,Hemodynamic support , shock ,Ventilator support , respiratory failure
, pneumonia

 ICU Care is more Invasive

 More invasive life lines and procedures including surgeries
 Longer length of stay
 More IV and parenteral drugs
 More tube feeding and Parenteral nutrition
 More ventilation

Risk of infections in critical care unit

Patients hospitalized in ICUs are 5 to 10 times more likely to acquire nosocomial

infections than other hospital patients. The frequency of infections at different anatomic sites
and the risk of infection vary by the type of ICU, and the frequency of specific pathogens
varies by infection site. Contributing to the seriousness of nosocomial infections, especially
in ICUs, is the increasing incidence of infections caused by antibiotic-resistant pathogens

Types by origin

 Endogenous: Caused by the organisms that are present as part of normal flora of the
patient
 Exogenous: caused by organisms acquiring by exposure to hospital personnel,
medical devices or hospital environment

Types of NCI by site

  Urinary tract infections (UTI)
 Surgical Site infections (SSI)
 Lower respiratory infections (LRI)
 Blood stream infections (BSI)
 Catheter related blood stream infections(CRBSI)
 Meningitis

Epidemiological Interaction

 Intrinsic host susceptibility Age,

 Poor nutritional status,
 Co morbidity,
 severity of underlying disease Agent factors varieties of organisms Institutional and
human Reservoirs & their virulence Environmental factors hospital location,
 diagnostic procedures,
 immunosuppressive,
 chemotherapy, antibiotics, med & surgical devices,
 exposure to infected patients or health workers, asymptomatic carrier

Disease burden

 5-10% in developed countries

 10-30% IN developing countries
 Rates vary between countries, within the country, within the districts and sometimes
even within the hospital itself, due to 1) Complex mix of the patients 2) Aggressive
treatment 3) Local practices
 In the United States, the Centers for Disease Control and Prevention estimated
roughly 1.7 million hospital-associated infections, from all types of microorganisms,
including bacteria and fungi combined, cause or contribute to 99,000 deaths each
year.
 In Europe, where hospital surveys have been conducted, the category of gram-
negative infections are estimated to account for two-thirds of the 25,000 deaths each
year.
  United Kingdom ,In 2012 the Health Protection Agency reported the prevalence rate
of HAIs in England was 6.4% in 2011,

Indian scenario

Incidence

 Average Incidence - 5% to 10%, but maybe up to 28% in ICU

 Urinary Tract Infection - usually catheter related -28%
 Surgical Site Infection or wound infection -19%
 Pneumonia -17%
 Blood Stream infection - 7% to 16%

The level of incidence Depends upon

 Average level of patient risk depends upon intrinsic host factors and extrinsic
environment factors
 Sensitivity &specificity of surveillance programmers

Consequences of nosocomial infections

 Prolongation of hospital stay: Varies by site, greatest with pneumonias and wound
infections
 Additional morbidity
 Mortality increases - in order - LRI, BSI, UTI
 Long-term physical &neurological consequences
 Direct patient costs increased- Escalation of the cost of care

ECONOMICS OF NCIS

 Extra cost of NCI consequences

 Bed
 Intensive care unit stay
 Hematological, biochemical, microbiological and radiological tests
 Antibiotics & other drugs
 Extra surgical procedures
 Working hours
 Crowded hospital conditions
 New microorganism
  Increasing number of people with compromised immune system
 Increasing Bacterial resistance Rise in nosocomial infection as a result of four factor
 ICU : Factors that increase cross- infections
 Lack of Hand washing facilities
 Patient close together or sharing rooms
 Understaffing
 Preparation of IVs on the unit
 Lack of isolation facilities
 No separation of clean and dirty AREAS
 Excessive antibiotic use
 Inadequate decontamination of items & equipment's
 Inadequate cleaning of environment

Modes of transmission

There are five main modes of transmission

 Contact
 Droplet
 Vector borne
 Air borne
 Common vehicle

Contact transmission

Most important and frequent mode of transmission of nosocomial infections, is divided

into two subgroups:

 Direct-contact transmission
 Indirect-contact transmission.
 Direct-contact transmission Involves a direct body surface-to-body surface contact and
physical transfer of microorganisms between a susceptible host and an infected or
colonized person, such as occurs when a person turns a patient, gives a patient a bath
 Indirect-contact transmission Involves contact of a susceptible host with a
contaminated intermediate object, usually inanimate, such as contaminated instruments,
needles, or dressings, or contaminated gloves that are not changed between patients
 Droplet transmission Droplet generated by sneezing Coughing or respiratory tract
procedures like Broncoscopy or suction
 Vector transmission Transmitted through insects and Other invertebrates animals such
as mosquitoes and fleas.
 Air borne transmission Tiny droplet nuclei that remain (<5) suspended in air.
 Common vehicle transmission Transmitted indirectly by materials contaminated with
the infections.

Research evidence for causative pathogens

The inanimate environment is a reservoir of pathogens ~ Contaminated surfaces increase

cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with
a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. X represents a
positive Enterococcus culture The pathogens are ubiquitous

MRSA- Methicillin-resistant S. aureus (MRSA • 60% of nocosomial infection in ICU

MRSA bacteria are also able to survive for extensive periods on surfaces and objects
including door handles, floors, sinks, taps, cleaning equipment and fabric

 Cotton: 4-21 days

 Terry: 2-14 days
 Polyester blend: 1-3 days
 Polyester: 1-40 days
 Polypropylene: 40-greater than 51.

Risk factors that causes infection

A break in the skin barrier, such as a surgical wound, burn, catheter or intravenous line that
allows bacteria to enter the body •

 Older age, comorbidities or multiple complex health issues, and weakened immune
systems Those with a weakened immune system can include:
 Patients in hospital for a long period of time
 Patients on kidney dialysis (hemodialysis)
 Patients receiving cancer treatment or specific medications that affect immune
function Those who inject illegal drugs
 Individuals who have had surgery within a year of being back in hospital
  . Estimates suggest that 49-65% of health care- associated S. aureus infections are
caused by methicillin- resistant strains.

The 5 Cs can be used to remember what factors make it easier for MRSA to be
transmitted:

 Crowding
 Contact (skin-to-skin)
 Compromised skin (open wounds)
 Contaminated (items and surfaces)
 Cleanliness (lack of)

Coagulase negative staphylococci (CoNS)

 Part of the normal flora of human skin .

 Relatively low virulence but are increasingly recognized as agents of clinically
significant infection of the bloodstream and other sites.
 Risk factors for CoNS : Presence of foreign devices (such as intravascular catheters)
 Immune compromise.

Vancomycin-resistant enterococci

VRE can live in the human intestines and female genital tract without causing disease
(often called colonization). However, sometimes it can cause infections of the urinary tract,
the bloodstream, or of wounds associated with catheters or surgical procedures

Pseudomonas aeruginosa

 cause of intensive care unit (ICU)–related pneumonia

 Number 2-ranked gram-negative organism, responsible for 9% of all nosocomial
bacterial and fungal isolates
 Number 2 cause of nosocomial pneumonia
 Number 3-ranked isolate in hospital-acquired UTIs
 Number 4 cause of surgical site infections and of hospital- acquired gram-negative rod
bacteremia
 Number 5 hospital pathogen
 Number 8-ranked bloodstream isolate
 Causes 10% of nosocomial infections
Clinical pictures

 Clinical presentation is often identical to other gram- negative organisms.

 Fever is usually present, except in very young or premature infants. Fever is often
accompanied by tachycardia and tachypnea.
 Patients appear toxic and may present with apprehension, disorientation, or
obtundation.
 Signs of shock, including hypotension, azotemia, or acute renal failure, may be
observed.
 Respiratory failure occurs in the presence of bacteremicpseudomonal pneumonia or in
conjunction with airway restrictive disease syndrome.

Acinetobacterbaumanii

 Prolonged length of hospital stay

 Exposure to an intensive care unit (ICU)
 Receipt of mechanical ventilation, colonization pressure
 Exposure to antimicrobial agents, recent surgery, invasive procedures, and underlying
severity of illness .outbreaks of infection have been traced to respiratory care
equipment, wound care procedures, humidifiers, and patient care items.
 Acinetobacter infection, with environmental contamination found on curtains,
laryngoscope blades, patient lifting equipment, door handles, mops, and keyboards.

Fungi

 Due to increased antibiotic use &host susceptibility

 Candida species– most common, causing BSI (38% mortality)
 Changing bacterial & fungal spectrum in the hospital reflects the increased use,
particularly of the newer antibiotics
 Development of resistance (MRSA, VRE, MDRTB)
 Overcrowding & understaffing of nursing units increased the rates of infections

Clostridium difficile

 Causes antibiotic-associated diarrhoea and pseudo membranous colitis life threatening

illnesses
 Normally affects only the elderly, especially those on long-term broad-spectrum
antibiotics
  Produces two powerful toxins and is a spore-former difficult to eradicate, resistant to
alcohol
 Reasons for recent increases still not known

Risk factors

 Antibiotics
 Healthcare environment
 Acid suppression medication

Contamination rates after contact with CDAD patients

 Physicians medical Students -75 of the time

 Dialysis Technicians 66 of the time
 Nurses -56 of the time
 Physiotherapists 50 of the time
 Underside of fingernails 43 times
 Fingertips and Palms 37 times
 Underside of Rings 20 times C difficile spores remain in environment in

Factors that predispose to nosocomial infection    

 Length of stay    
 Urinary catheter    
 Parenteral nutrition    
 Tracheostomy    
 Diabetes    
 Recumbent position    
 Nasogastric tube    
 Chronic lung disease    
 Stress-ulcer prophylaxis
 Surgical drains    
 Heavy smoking    
 Immunosuppressive treatments    
 Extracorporeal renal support    
 Burns    
 Alcoholism    
 Recent antimicrobial therapy    
 Central venous catheterization    
 Trauma    
 Malnutrition    
 Blood transfusion    
 End tracheal or nasal intubation    
 Surgery   
 Related to underlying health status Related to acute disease process Related to
invasive procedures Related to treatment Advanced age
 Lack of Hand washing facilities
 Inadequate decontamination of items
 No separation of clean and dirty areas
 Lack of isolation facilities
 Patient to patient (busy, crowded unit, staff shortages)
 Poor aseptic practice
 Multiple changes in staff
 Changes in procedures or protocols
 Multiple or prolonged antibiotics
 ventilation
 Prolonged stay
 Multiple procedures
 Invasive devices
 open wounds
 Immunosuppression
 Nutritional state
 Underlying disease
 Severity of illness
 Patient Environment Organism & Formation of slime
 Resilience
 Resistance
 equipment's Prevalence
 Pathogenicity
 ability to adhere
Common infections which are occurring in the critical are unit

Bloodstream infections (BSI) Central line-associated BSI (CLABSI)

A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical

catheter (UC) was in place for >2 calendar days on the date of event, with day of device
placement being Day 1, AND the line was also in place on the date of event or the day
before.

 IV Catheter Biofilm 24 hours after Insertion

 Coagulase Negative Staphylococci Slime-producing, Catheter Surface
 Semi permanent Tunneled Catheters (Groshong, Hickman, Mediport)
 Dacron cuff incites inflammatory response, fibrosis at insertion site
 prevents bacteria from migrating along external catheter surface
 locations of infection: exit site, tunnel, tip
 tunnel infection always requires catheter removal which may cause septic
thrombophlebitis/pulmonary emboli
 Groshong catheter
 Intrinsic contamination of infusion fluid Connection with administration set Insertion
site Injection ports Administration set connection with IV catheter Port for additives
Sources of Infection
 EXAMPLE 1 Patient has a central line inserted on June 1. On June 3, the central line
is still in place, and the patient’s blood is collected for culture. The culture is positive
for S. aureus. . This is a CLABSI because the central line was in place for >2 calendar
days (June 1, 2, and 3), and still in place, on the date of event (June 3).
 EXAMPLE 2 Patient has a central line inserted on June 1. On June 3, the central line
is removed and on June 4 the patient’s blood is collected for culture. The culture is
positive for S. aureus. This is a CLABSI because the central line was in place for >2
calendar days (June 1, 2, and 3), and was in place the day before the date of event
(June 4).
 EXAMPLE 3 Patient has a central line inserted on June 1. On June 3, the central line
is removed. On June 5 patient spikes a fever of 38.3°C and the patient’s blood is
collected for culture. The culture is positive for S. aureus. . This meets LCBI Criterion
1 but it is not a CLABSI because the Date of Event (June 5) did not occur on the day
the central line was discontinued (June 3) nor the next day (June 4).
  The CLABSI rate per 1000 central line days is calculated by dividing the number of
CLABSIs by the number of central line days and multiplying the result by 1000. The
Central Line Utilization Ratio is calculated by dividing the number of central line
days by the number of patient days.

Surgical site infections

Epidemiology of SSI

 SSI infection generally occurs within 30 days following surgery

 Some procedures monitored up to 90 days for SSI
 2% -5% surgical patients acquire SSI (300-500K per year) 3% die (77% of deaths
directly attributable to the SSI)
 Many result in long term disability
 SSI increases hospital length of stay 7-10 days
 Cost estimates vary, ~$30,000 per SSI
 Most estimates do not account for re-hospitalization, outpatient treatment, post-
discharge expenses, quality of life for the patient, or any long term disability costs

Source of SSI Microorganisms

Surgery Incidence (n/N) Gram+ve Gram-ve Type (%SSI) Bhatia 2003 18.7%
(116/615) S. Epidermis (42.24%) MMSE (26.72%), MRSE (15.5%) S.aureus (15.55%)
MRSA (12.06%), MSSA (3.2%) Total (12.06%) E. coli, P.aeruginosa CABG (ns) Agarwal
2003 1.6% (40/2558) S. aureus (57.5%) MRSA 35%, MSSA 22.5% P. aeruginosa (10%)
Neurosurgeries (1.6%) Pawar 2005 5.1% (7/136) Staphylococcus sp. (10%) - Cardiac surgery
with intraaortic balloon pulsation (5.1%) Lilani 2005 8.95% (17/190) S. aureus (35.3%)
MRSA (33%) P. aeruginosa (4/17) E.coli (2/17) Thoracotomy (44.44%) Gastrointestinal
surgeries Sharma 2009 2.5% (786/31927) Staphylococcus sp. Neurosurgeries (2.5%) Joyce
2009 12% (135/1125) S.aureus (33.3%) MRSA (14.0%) E faecalis (33.3%) VRE (1.4%) P.
Aeruginosa (24.4%), E.coli (7.4%), Klebsiellaspp(1.4%) Gastrectomy (36.4%),
Cholecystectomy (15.4%), Prostatectomy (15.2%), Hysterectomy (10.4%), Appendicectomy
(3.4%)

Profile of Surgical site infections (SSIs) in India

Patel 2011 12.72% (7/55) S. aureus (42.86%) Klebsiella sp. (ESBL) (57.14%) Colon
surgery (29.41%), Amputation (50%) Sarma 2011 21% (14/66) MRSA 67%, S. aureus
MSSA 33% E.faecalis E coli ESBL (43%), ESBL+ Amp-C hyperproducers (29%) Amp-C
hyperproducers (14%) NDM-1 producer (14%) Post-operative patients Patel S 2012 16%
(32/200) CoNS (14.3%) S. aureus (7.1%) E. coli (35.7%) Klebsiella sp. (21.4%) P.
aeruginosa (14.3%) Proteus mirabilis (7.1%) Appendicetomy (0-40%) Laparotomy (19.2-
31.6%) Amputation (10-60%) Cholecystectomy (7.1- 28.6%) Nephrectomy (13.3-40%)

Pathogenesis of SSI

Endogenous : Patient Flora ,Skin ,GI tract ,Mucous membranes ,Seeding from pre- existing
sites of infection .

Exogenous : Surgical personnel flora , Breaks in aseptic techniques , Inadequate hand

hygiene , Contaminated garments , Equipment, surgical tools, materials within operative field
, OR environment, including ventilation

Causative microorganisms of SSI:

 Acinetobacterbaumannii - 0.6%
 Klebsiellaoxytoca - 0.7%
 Candida spp - 2.0%
 Klebsiella pneumonia - 3.0%
 Enterobacterspp - 4.2%
 Pseudomonas aeruginosa - 5.6%
 Escherichia coli - 9.6%
 Enterococcus spp - 11.2%
 Coagulase-negative staphylococci - 13.7%
 Staphylococcus aureus - 30.0%

SSI Surveillance Definition Categorized based on depth infection

Superficial Incisional SSI Surveillance Definition Infection occurs within 30 days after
surgical procedure AND Involves only skin and subcutaneous tissue of the incision AND
Patient has at least 1 of the following:

 Purulent drainage from the superficial incision

 Organism isolated from an aseptically-obtained culture of fluid or tissue
  Superficial incision that is deliberately opened by a surgeon and is culture positive or
not cultured and Patient has at least one of the following signs or symptoms: pain or
tenderness, localized swelling, redness, heat
 Diagnosis of superficial SSI by surgeon or attending physician

Deep Incisional SSI Definition Infection occurs within 30 (or 90 days) after the operative
procedure AND Involves deep soft tissues of the incision, e.g., fascial& muscle layers AND
Patient has at least 1 of the following:

 Purulent drainage from deep incision

 Deep incision spontaneously dehisces or opened by surgeon and is culture positive or
not cultured and fever >38 C, localized pain or tenderness (Note: a culture negative
finding does not meet this criterion)
 Abscess or other evidence of infection found on direct exam, during invasive
procedure, by histopathologic exam or imaging test
 Diagnosis of deep SSI by surgeon or attending physician

Organ Space SSI Definition Infection occurs within 30 or 90 days after the operative
procedure AND Infection involves any part of the body, excluding the skin incision, fascia,
or muscle layers that is opened or manipulated during the operative procedure AND Patient
has at least 1 of the following:

 Purulent drainage from drain placed into the organ/space

 Organism isolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
 Abscess or other evidence of infection found on direct exam, during invasive
procedure, or by histopathologic or exam or imaging test

SSI Prevention Strategies:

 Administer antimicrobial prophylaxis in accordance with evidence based standards

and guidelines
 Administer within 1-hour prior to incision (2hr for vancomycin and fluoroquinolones)
 Select appropriate agents on basis of: Surgical procedure Most common SSI
pathogens for the procedure Published recommendations Discontinue antibiotics
within 24hrs after surgery (48 hrs for cardiac)
  Identify and treat remote infections – when possible Before elective operation •
Postpone operation until infection resolved Hair removal
 Do not remove hair at the operative site unless it will interfere with the operation
 Do not use razors If necessary, remove by clipping or by use of a depilatory agent .

Skin Preparation

 Use appropriate antiseptic agent and technique for skin preparation Operating Room
(OR) Traffic
 Keep OR doors closed during surgery except as needed for passage of equipment,
personnel, and the patient Colorectal surgery patients
 Mechanically prepare the colon (Enemas, cathartic agents)
 Administer non-absorbable oral antimicrobial agents in divided doses on the day
before the operation
 Maintain immediate postoperative normothermia Surgical Wound Dressing
 Protect primary closure incisions with sterile dressing for 24-48 hours post-op
 Control blood glucose level during the immediate post-operative period Measure
blood glucose level at 6 am on post-op day 1 and 2 (procedure day = day 0) ,Maintain
post-op blood glucose level at <200mg/dL

SSI Prevention Strategies:

 Supplemental Nasal screen for Staphylococcus aureus on patients undergoing

elective cardiac surgery, orthopedic, neurosurgery procedures with implants.
 Decolonize carriers with mupirocin prior to surgery
 Screen preoperative blood glucose levels and maintain tight glucose control post-op
day 1 and 2 in patients undergoing select elective procedures. i.e., arthroplasties,
spinal fusions, etc.
 Reduce antibiotic at 3 hr intervals in procedures with duration >3 hours . Adjust
antimicrobial prophylaxis dose for patients who are obese (body mass index >30) Use
at least 50% fraction of inspired oxygen intraoperatively and immediately
postoperatively in select procedure(s)
 Perform surveillance for SSI
 Feedback surgeon-specific infection rates

Catheter-associated Urinary Tract Infections (CAUTI)

 Major predisposing factor

 Indwelling urinary catheter average of 26% of hospitalized patients are catheterized

 Risk of CAUTI is 1-2% per procedure
 Risk ↑ for each additional day of catheterization
 Common in long-term catheterized patients Background to CAUTI surveillance Risk
Factors

Associated Risk Factors

 A history of previous catheter use

 Duration the catheter is in situ
 Length of stay in hospital prior to catheter insertion
 Location of catheter insertion

CAUTI Data Definitions

A healthcare associated UTI considered to be catheter associated if: An indwelling

catheter is in situ at time of onset of UTI (Criterion 1) OR An indwelling catheter was
removed within 3 days prior to the onset of UTI (Criterion 2) and The first positive urine
specimen is taken or the physician makes a diagnosis more than 48 hours after the
catheter was inserted

For patient’s with an indwelling catheter in situ AND ≥104 micro-organisms per ml
from a catheter specimen of urine with following symptoms

 Loin Pain , Loin or suprapubic tenderness

 Fever (≥38o C skin temp)
 Pyuria (≥104 WBC per ml)

CAUTI Criterion 2 Definition For patient’s who had catheter removal within 3 days before
the onset of CAUTI AND ≥ 105 micro-organisms from a mid stream specimen AND CAUTI
Data

Definitions CAUTI Data Definitions ONE or more of the following with no other
recognised cause:

 Urgency
 Frequency
  Dysuria
 Loin Pain , Loin or suprapubic tenderness
 Fever (≥ 38o C skin temp)
 Pyuria (≥ 104 WBC per ml) CAUTI Data DefinitionsCAUTI Data Definitions

CAUTI must meet one of the criteria 1 or 2 as described • Patients with asymptomatic
bacteriuria/bacteria in their urine are NOT considered to have a CAUTI

Ventilator associated pneumonia

CASE STUDY

A 52 year male is admitted with a severe headache and is found to have a subarachnoid
hemorrhage from a ruptured aneurysm. The neurosurgeons evacuate the hematoma and clip
his aneurysm. Post-op he remains on a ventilator. On hospital day 5 he spikes a fever to 102º
F and is noted to have copious secretions from his endotracheal tube. Increasing amounts of
inspired O2 are required. Blood and sputum cultures grow highly resistant
Enterobactercloacae.The most important are patients on ventilators in ICU.

Considerations for VAP

Recent and progressive radiological opacities of the pulmonary parenchyma, purulent

sputum and recent onsite fever. Most commonly caused by acinetobacter.

Primary risk factor is mechanical ventilation (risk 6 to 21 times the rate for non
ventilated patients Account for 27% of all MICU acquired infections Account for 15% of all
hospital associated infections Nosocomial Pneumonias

 Susceptibility to Nosocomial Pneumonias Intubation

 Altered host Defenses
 Tracheal Colonization
 Leakage of secretions containing bacteria around the ET cuff
 Micro or macro aspiration of oro pharyngeal pathogens
 Primary Route of Bacterial Entry into Lower Respiratory Tract
 Late VAP associated with antibiotic- resistant organism
 Early VAP associated with non-multi- antibioticresistant organisms
Staphlococcusaureus,Acinetobacterspp, Proteus spp,Pseudomonas aeruginosa
 Most are bacterial pathogens, with Gram negative bacilli common
Diagnosis of ventilator-associated pneumonia

 Gram staining, quantifying microorganisms in polymorphonuclear cells in

bronchoalveolar lavage samples. PCR assays
 Nuclear material extracted from BAL
 qPCR amplified up 16s DNA –i.e. quantifies bacterial load
 Quantitative assay, therefore the time to crossing the ‘threshold’ is inversely
proportional to the amount of 16s DNA present.
 Shorter time to crossing threshold (Ct) indicates higher burden of bacteria • Compared
to conventional culture as the ‘gold standard’

Hospital-acquired fevers occur in one-third of all medical inpatients , Nosocomial fevers

even more common in the ICU

Fever in the ICU

 ICU patients have several underlying medical/surgical conditions

 ICU patients undergo many invasive diagnostic and therapeutic procedures
 Therefore, fever in ICU patients must be thoroughly and promptly evaluated to
discriminate infectious from non- infectious etiologies

Causes of Fever in the ICU

 Surgical site infections

 Intravenous-line infections
 Nosocomial pneumonia
 Nosocomial sinusitis
 Intra abdominal infections
 Urinary catheter- associated bacteriuria
 Drug fever
 Post-operative fever
 Neurosurgical cause

How To Diagnose
 A positive result of semi quantitative Culture ( 15 CFU per catheter segment) or
quantitative ( 102 CFU per catheter segment) catheter culture, whereby the same
organism isolated from a catheter segment and a peripheral blood sample
 Simultaneous quantitative cultures of blood samples with a ratio of 5 : 1 (CVC vs.
peripheral)
 Differential time to positivity :positive result of culture from a CVC is obtained at
least 2 hr earlier than is a positive result of culture from peripheral blood)
 Biomarkers :Procalcitonin (PCT)-: The peptide procalcitonin is synthesized by
monocytes that are in the process of adhesion. PCT levels rise when there is local or
systemic bacterial infection but not in the presence of a virus or autoimmune disease.
Thus, PCT is more specific than CRP for detecting bacterial infection.
 C-reactive protein (CRP)-This acute phase protein is released by the liver in response
to inflammation or tissue insult and is widely used as a highly nonspecific marker of
sepsis.

Surviving Sepsis Campaign

 Step 1: Screening and Management of Infection

 Step 2: Screening for Organ Dysfunction and Management of Sepsis (formerly called
Severe Sepsis)
 Sepsis Core Measure (SEP-1) Highlights SIRS Criteria • Temp >101 • Temp < 96.8 •
HR > 90 • RR > 20 • WBC > 12,000 • WBC < 4000 • > 10% Bandemia Organ
Dysfunction Variables • SBP < 90 • MAP < 70 • SBP decrease > 40 from known
baseline • Cr > 2.0 • UOP < 0.5 ml/kg/hr for > 2 hours • Bilirubin > 2.0 • Platelets <
100,000 • INR > 1.5 or PTT > 60 secs • Altered Mental Status • Lactate > 2
 Septic shock : severe sepsis with hypoperfusion despite adequate fluid resuscitation or
a lactate > 4. •
 Within 3 hours of presentation: Measure serum lactate Obtain blood cultures prior to
antibiotics Administer antibiotics Within 6 hours of presentation: Repeat serum
lactate if initial lactate is >2 For septic shock:
 Within 3 hours of presentation: Measure serum lactate Obtain blood cultures prior to
antibiotics Administer antibiotics Resuscitation with 30mL/kg crystalloid fluids
Within 6 hours of presentation: Repeat volume status and tissue perfusion assessment
Vasopressor administration (If hypotension persists after fluid)
Recommendations:

 Initial Resuscitation and Infection Issues sepsis

 Initial Resuscitation
 Screening for Sepsis and Performance Improvement.
 Diagnosis
 Antimicrobial therapy.
 Source control
 Infection Prevention

Bundles to be followed within 3 hours:

 Measure lactate level

 Obtain blood cultures prior to administration of antibiotics
 Administer broad spectrum antibiotics
 Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L • With in 6
hours Vasopressors - to maintain a mean arterial pressure (MAP) ≥65 mm Hg • Re-
assess volume status and tissue perfusion and document findings. • Re-measure
lactate if initial lactate elevated.