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 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).
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.
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.
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).
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).
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).
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.
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.
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.
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