Bendigo Health ICU Manual
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    • Commonly used SCV Paediatric Guidelines >
      • Asthma
      • Bronchiolitis >
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        • Respiratory Distress Score for monitoring patients with bronchiolitis on HFNC and CPAP
      • Croup
      • Diabetic ketoacidosis >
        • Algorithm for the management of DKA (to be read in conjunction with SCV guideline)
        • SCV - Diabetic ketoacidosis
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    • MET calls: resources
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FAST HUGS IN BED PLEASE (courtesy of Dr Chris Nickson, LITFL, with adaptation)

Feeding/Fluids

It is the preference at Bendigo ICU to use Hartmanns' solution (CSL) as fluid for resuscitation or maintenance.

​Early feeding is preferred.  For more information, see Nutrition in ICU.  See also, PLUS study, if the patient requires fluid boluses.

Analgesia

Good pain control is vital for patient progress.  Pain needs to be differentiated from agitation.  An approach to the management of acute pain is outlined in Acute Pain Assessment and Assessment Tools (PROMPT) and Ketamine as low dose IV infusion for acute pain analgesia in adults (PROMPT).   See also, Analgesics in ICU.

Sedation

Sedation may be required for patient comfort or to control delirium/agitation.  Refer to Assessment of Pain, Delirium & Sedation of Intubated Patients in Intensive Care (PROMPT).

Thromboprophylaxis

All patients in ICU or HDU should be receiving DVT prophylaxis unless there is specific concern regarding bleeding risk, or the patient is already anticoagulated for other reasons, or the patient is well and very ambulant.  The preference is to use a LMWH, ie. enoxaparin.  UFH may be considered if there is a bleeding concern.

TED stockings are not routinely used at Bendigo Hospital ICU as there is a lack of good evidence of efficacy.  When pharmacologic DVT prophylaxis is being avoided, for example, in the presence of an intracranial hemorrhage, sequential calf compressors must be employed.

See also ​VTE prophylaxis (PROMPT) and Venous thromboembolism.

Head-up/Oral hygiene

Intubated patients should be nursed in a 30 degree head-up position to assist prevention of VAP due to microaspiration.  If the patient is under spinal precautions, the entire bed can be tilted to 10 degrees whilst the patient remains in a hard collar.

To further assist prevention of infection, particularly VAP, oral hygiene is important. 

0.12% or 0.2% Chlorhexidine solution needs to be documented on the medication chart for BD oral application for intubated patients unless anticipate a very brief period of intubation.

Please see Oral Hygiene for the Invasively Ventilated Patient in the ICU (PROMPT) for more information on oral hygiene for intubated patients.  Also, SuDDICU (Selective Decontamination of the Digestive Tract in Intensive Care Unit Patients) study currently being undertaken.

Ulcer prophylaxis

All intubated patients should have stress ulcer prophylaxis, the approach by Bendigo Hospital ICU is to use ranitidine (first-line) or pantoprazole, unless the patient is usually on a PPI then use their usual brand if possible, or has coffee-ground aspirates (without overt bleeding), or there is a contraindication to ranitidine.  Once enteral feeding is established or after extubation, the decision to continue will depend on whether the patient is usually on a H2-antagonist or PPI, and whether there is ongoing direct indication for ulcer prophylaxis.  For further information, see Stress Ulcer Prophylaxis in Critically Ill Adults (PROMPT).

Glycemic control

All patients with a blood sugar > 10 mmol for 2 or more consecutive readings should commence on an insulin infusion unless an alternative management plan for hyperglycaemia is delineated by the ICU registrar or consultant.

Be mindful of needing to cease the insulin infusion if enteral or parental feeding is ceased.

For more information, including the algorithm for titration, see Insulin IV Infusion In The Intensive Care Unit Only Drug Protocol (PROMPT).

Skin/eye care

ICU patients are particularly prone to pressure areas due to multiple reasons, eg. immobility, diaphoretic, malnutrition etc.  It is important to prevent pressure areas and to care effectively for those that have developed.  See Pressure Injury Assessment and Management Policy (PROMPT).

Indwelling catheter

Don't forget to consider removal of the IDC if the patient is able to use a bottle/commode/pan and does not require close urine output monitoring.

Nasogastric tube

If the patient is unlikely to be extubated in the next 24 hrs, consider inserting a NGT early to allow early initiation of feeding.  The preference is to insert a large-bore NGT (ie. salem sump) to allow monitoring of gastric aspirates.  Once feeding is established, a change to a fine-bore NGT should be considered for patient comfort and decrease the risk of pressure areas.

Refer to Nutrition in ICU for information regarding large NG aspirates.

Bowel care

Constipation is a contributor not just to patient discomfort, but to delirium and possibly urinary retention.  Regular or PRN aperients should be prescribed for patients on opiate analgesics.

Do not prescribe stimulant aperients, such as COLOXYL AND SENNA, to patients with a new anastomosis. If an aperient is being considered in a patient post laparotomy or bowel surgery, please discuss with the intensivist and surgical team prior to prescribing (consider lactulose if required).

A bowel management system should be considered for those patients with persistent watery diarrhoea.  This is not only to assist patient comfort in requiring multiple changes and perianal excoriation, but also nursing workload.

Environment control

This is particularly pertinent for delirious patients to maintain a quiet and calm environment.  Consider allowing visits to the ICU balcony if appropriate and the patient is stable.

De-escalation of antibiotics

Antibiotic prescribing needs to be rational and an indication must be documented for all prescriptions with a stop date written.  Refer to eTG Antibiotic Guidelines to inform prescribing practices.  For further advice, Dr Andrew Mahoney is available for advice in hours, and the Austin ID registrar can be contacted after hours.  ID rounds in ICU are conducted at 2.30pm each Monday.  
Ensure that the pink microbiology list is kept up to date.  

See also, Surgical Antibiotic Prophylaxis (PROMPT).

Psychosocial support for patient, family and staff

Social workers and Pastoral Care workers are available for family and staff who are needing further counselling.  Also, social workers are key personnel to assist sorting out legal issues, financial issues and accommodation for family/NOK.  Bendigo Health also has Aboriginal Hospital Liaison Officers to facilitate support and discussions with indigenous persons.
  • Home
  • Administration
    • Team members
    • Useful contacts
    • Orientation & Guides
    • Roster rules for ICU junior doctors (Appendix A)
    • App user tips >
      • FindMyShift
      • Kronos
      • Synapse
      • Offsite access to additional email addresses
    • VHIMS >
      • VHIMS Resources (intranet only)
      • How to enter a VHIMS (intranet only)
    • Social Media Etiquette
    • BASIC equipment loan
    • Medical Students in ICU
    • ICU Consultants Only >
      • Echuca Telehealth Consults
      • Shift swap form for consultants
      • Electronic TiL request form
      • CME Claim Process
    • ERH VITCCU
  • Clinical
    • Interface with ED & home teams >
      • ED
      • Surgical teams
      • Cardiology
      • Paediatrics
    • Admissions & Discharges >
      • Admissions & Discharges
      • Admission guidelines for surgical elective and emergency operations
    • Admission guidelines for surgical elective and emergency operations
    • Daily ICU review & care >
      • FAST HUGS IN BED PLEASE
      • Oxygen prescribing
      • Oxygen - Paediatric considerations
      • Care of the Invasively Ventilated Patient – Adult Patient (PROMPT)
      • Assessing for extubation
      • Nutrition in ICU
      • Thiamine prescribing
      • Patient Diaries
    • Drugs & Infusions >
      • Inpatient prescribing practices
      • Common ICU Drugs
      • Drug Infusions A-Z
      • Drugs by system/action >
        • Antibiotics
        • Diuretics
        • Antithrombotic therapy
        • Analgesics in ICU
        • Antipyretic
        • Anticonvulsants
        • Antiplatelets
        • Antihypertensives
        • Beta-blockers
        • Neuromuscular Blocking Agents
        • Aperients / Laxatives
        • Prokinetics
    • Care bundle >
      • Post-cardiac arrest care (TTM) (PROMPT)
      • Care of the Post-Operative Patient
      • Spinal Trauma- CPG's (includes cervical spine clearance) (PROMPT)
      • Management Of Uncontrolled, Life Threatening Bleeding (Massive Exsanguination) (PROMPT)
    • Clinical Protocols + Guidelines >
      • Approach to patient with suspected influenza
      • RAPID INFLUENZA AND RSV TESTING
      • Stroke Protocol (SCV Oct 2018)
    • NIV >
      • Domiciliary (Home) non-invasive ventilation (NIV)/CPAP patients
      • NIV (PROMPT)
    • Tracheostomy Management
    • PICCO decision making tree
    • CRRT
    • Procedures
    • The Dying Person in ICU >
      • The Dying Patient
      • Care of the Dying Patient
      • Organ & Tissue Donation
    • Patient transfers >
      • Emergency calls to the helicopter pad
      • Transferring ICU patients >
        • Intra & Interhospital transfers
        • MRI transfers - special considerations
    • Welfare & other supports for patients and family >
      • Visiting times
      • Social work, pastoral care & aboriginal hospital liaison officer support
      • Interpreter services
      • Patient relations office
  • Beyond Clinical
    • Education & Training >
      • Education & Training >
        • Learning and Training in ICU
        • Bendigo Health ICU Medical Education Principles >
          • Departmental overview
          • Medical Stream
          • Medical Weekly Schedule >
            • Wednesdays
            • Airway training (hands-on-real time) in Operating theatre
            • Radiology Conference
            • ‘Labs/lytes’ session or equipment or Journal club
            • Tracheostomy day for doctors
            • Deteriorating patient workshop
            • Ambu Bronchoscope and Cook Surgical Airway CPD workshop
            • Crucial Conversation workshop
            • Team Skills simulation day
            • ALS Simulation
            • Level 1 ECHO training
            • External Speakers
            • VICEN
            • Bendigo ICU Journal club
          • Expectations for Consultants
          • Expectations for all ICU Registrars
          • Expectations for HMOs
          • Medical Student program
          • North West Training Hub
          • ICU Simulation
        • CICM Primary Exam education
        • Curated educational videos & websites >
          • Virtual bronchoscopy
        • Mandatory training for medical staff
      • Term Assessments >
        • Registrar Assessments and In-Training Evaluation Reports (ITERs)
        • Registrar term assessments (consultant access only) >
          • Term Assessment form (consultant access only)
      • Procedures and Skills Competency Assessments >
        • Bendigo Health ICU DOPS
        • CICM CVC WCA
        • CICM Tracheostromy WCA
        • CICM Pleural Drain WCA
        • CICM Ventilation WCA
        • CICM ALS & BLS WCA
        • CICM Communication WCA
        • CICM Brain Death WCA
        • CICM OCA
        • ANZCA DOPS
        • ACEM DOPS
      • Echocardiography in ICU
      • BASIC Provider & Instructor Courses
      • Paediatric BASIC Provider & Instructor Courses
      • Other education opportunities
      • Paediatric crit care education
      • Useful learning links
    • Research & Quality >
      • Research >
        • STARRT AKI
        • SuDDICU
        • PLUS study
        • Recent Publications
    • Well-being >
      • Mentorship
      • Looking after yourself and colleagues
    • Medical Students in ICU
  • Paediatric ICU
    • Introduction
    • GO NOW Criteria
    • Admission criteria for paediatric HDU/ICU
    • Commonly used SCV Paediatric Guidelines >
      • Asthma
      • Bronchiolitis >
        • Bronchiolitis
        • Respiratory Distress Score for monitoring patients with bronchiolitis on HFNC and CPAP
      • Croup
      • Diabetic ketoacidosis >
        • Algorithm for the management of DKA (to be read in conjunction with SCV guideline)
        • SCV - Diabetic ketoacidosis
      • Seizures >
        • Febrile seizures
        • Non-febrile seizures
      • The Septic Child >
        • Assessment & Management (SCV)
        • Criteria for rapid ICU admission of children with sepsis
      • Dehydration >
        • Dehydration
        • IV fluid management
    • Paediatric Crit Care Education >
      • ED/Paeds education sessions
      • Paediatric equipment 'treasure hunt'
      • Curated paediatric educational videos
      • Other paediatric crit care education opportunities
    • Paediatric Resus Card
  • Emergency!
    • Code Blue: ALS algorithms >
      • Adult ALS algorithm
      • Paediatric ALS algorithm
      • Obstetric cardiac arrest flowchart
    • Emergency algorithms/mnemonics >
      • Airway
      • Breathing
      • Circulation
      • Disability
    • MET calls: common scenarios >
      • Staff concern
      • Hypoxic Type 1 Respiratory Failure
      • Hypercapnoeic Type 2 Respiratory Failure
      • Atrial Fibrillation
      • Hypotension and CV Shock
      • Altered consciousness
      • The Agitated Patient
      • Interface with other disciplines
      • Oliguria/Anuria
    • MET calls: resources
    • Paediatric Resus Card