ICU Care Flashcards
ICU admission and death
1 in 5 Americans admitted to ICU due in or shortly after ICU stay, number anticipated to increase
Predicting survival in the ICU
APACHE II (Acute Physiology and Chronic Health Evaluation)
SAPS II (Simplified Acute Physiology Score)
SOFA (Sequential Organ Failure Assessment)
Patient death trajectory and ICU admission
- Terminal illness (e.g. advanced cancer)
- Short period of evident decline
- Steady progression of decline, followed by a clear terminal phase
- Most amenable to traditional palliative care delivery and may avoid ICU admission - Chronic illness (e.g. organ failure)
- Long term limitations, intermittent serious episodes with some recovery, overall decline, followed by sudden, seemingly unexpected death (e.g. organ failure from liver disease)
- More likely to accept ICU admission - Frailty
- Prolonged dwindling with gradual decline
- More likely to accept ICU admission
Argument for integration of palliative care into ICU care
- Death in ICU is common
- ICU providers require knowledge and skills in palliative care and symptom management
- Interprofessional palliative care improves care delivery and discussions re: future care planning
Logistics of integrating palliative care into the ICU
- ICU provider palliative care education
- Identification and support of local champions as role models and leaders/implementers
- Identification of local barriers and solutions (‘needs assessment’)
- ICU palliative care protocols
- ICU specific QI data (including surveys)
As per multidiscplinary working group in Oxford:
- Convene interdisciplinary planning/implementation team with ‘key stakeholders’
- Conduct a needs assessmets
- Define the problem (high rates of death or unfavourable outcomes, high utilization of ICU by patients not benefittig, distress or dissatisfaction by patients/providers, delayed or inconsistent use of evidence-based Palliative care, etc.)
- Evaluate resources for EOL care for ICU physicians (educational resources, protocols, etc.)
- Develop an action plan with goals, initial targets, and PDSA cycles
Role of the PC team in the ICU
- Symptom assessment and management
- Leading patient/family and interprofessional communication/collaboration
- Aligning treatment goals with plan of care
- Transition from acute to palliative care
- Emotional, social, and spiritual support
Models of palliative care in the ICU
- Integrative model
- ICU staff educated in PC principles and practices
- PC acknowledged as essential component of predictable intensive care
- Availability of PC for all patients and consultant PC service not necessary, but requires education and maintenance of competence (depends on committed culture, admin, resources, and staff) - Consultative model
- PC team provides consultation in the ICU setting
- Provision of care determined by the blend of ICU and PC team, who is ultimately referred, and available resources (e.g. hospice/PCU, care and experience of PC team)
Recommendation: Blend feasible and effective components of both models
How ICU teams determine referral to PC
- Triggers on routine assessments
- Surprise question
- Decline in function/feeding
- Unintentional weight loss
- Referral from LTC
- Previously identified hospice/PC patient
- No previous ACP
- Weak social support network
- Family/patient request for PC
- Elderly, cognitively impaired
- Out of hospital oxygen use
- out of hospital cardiac arrest
- Incurable cancer
- Difficult to control symptoms >24 or 48 hours
- Trach or GJ tube placement
- Admission > 7 days
- Recurrent ICU needs in same admission
- Lack of clear goals of care
- Limits on life extension interventions
- Physician concern re: potential poor outcome
- Potential PCU/hospice transfer - Informal identification
- PC team member in attendance at daily rounds
Domains of high quality palliative care in the ICU from the patient and SDM perspective
- Communication
- Timely, clear, and compassionate about illness, treatment, and prognosis - Patient-focussed decision making
- Identify patient preferences, goals, and values - Maintaining the patient
- Comfort, dignity, personhood, privacy - Caring for the family
- Access to the patient
- Interprofessional support
- Bereavement support
Utility of silence in conversation in the ICU
- Gives patients/families an opportunity to explain concerns
Two types:
- Invitational, interested silence enables sharing
- Compassionate silence can create a sense of empathy
ICU-related symptoms: Pain (Causes and management)
Causes
- May be related to diagnostic/treatment related pain, including airways, chest tubes, suction, turning, wound care, etc.
Management
- Consider the intention of the intervention and necessity
- Ensure pain assessment for communication and non communicative patients used (Critical-Care Pain observational tool)
- Consider analgesic needs
Assessment of pain in non-communicative patients in the ICU
Critical-Care Pain Observational Tool
ICU-related symptoms: Dyspnea (Causes and management)
Causes
- Resistance to ventilation
- Respiratory muscle weakness
- Pulm infections or ARDS
- Asthma
- Cardiac/lung disease
*May manifest as anxiety, fear, restlessness, agitation, dyssynchrony with the vent, sweating, accessory muscle weakness
Management
- Review effectiveness of ventilation and vent settings
- Opioids
- Disease-specific treatments
ICU-related symptoms: Anxiety (Causes and management)
Causes:
- May be due to new environment, invasive procedure, communication limitations, uncertain prognosis
- Symptoms (dyspnea, pain)
- Meds (use or withdrawal)
Management
- Treat underlying cause
- Psychological support
ICU-related symptoms: Restlessness and Agitation (Causes and management)
Management
- Monitor with Richmond Agitation Sedation Scale (RASS)
- Assess and treat specific causes
- Watch for alcohol withdrawal/delirium
ICU-related symptoms: Delirium (Causes and management)
Causes
- Often multifactorial, acute brain dysfunction
*Note associated with increased length of vent, LOS, mortality, and reduction in functional status and cognition in survivors
Management
- CAM-ICU to assess
- Consider and address underlying causes
- Monitor for adverse effects if neuroleptics are used
ICU-related symptoms: Sleep Disturbances (Causes and management)
Causes
- Common, but not clearly understood
- May include delayed sleep onset, fragmented sleep, change in sleep stages
- May be due to underlying illness, environment, symptoms, mechanical ventilation, or meds
Management
- Polysomnography difficult in the ICU
- Little evidence to support management
ICU-related symptoms: Thirst, dry mouth (Causes and management)
Causes
- Low body fluids
- Increased osmolarity
- Mouth breathing
- Infection
- Meds (anticholinergics, opioids, steroids, diuretics)
- N/V
- Fever
- Blood loss
Management
- Mouth care
- Oral cleansing agents
- Ice chips
- Artificial saliva, saliva substitutes
ICU-related symptoms: Acquired weakness (Critical illness polyneuropathy or myopathy) (Causes and management)
Causes
- Risk factors forCIP/CIM include sepsis, SIRS, multi organ dysfunction
Management
- Treat underlying issues
- PT and rehab
- Weakness resolves in weeks to months, but residual weakness is not uncommon
Critical Illness Polyneuropathy versus myopathy
Critical illness polyneuropathy (diminished sensation, hypoactive reflexes, EOM preserved)
- Flaccid quadriparesis, resp muscle weakness, hypoactive or absent reflexes
- Spares facial nerves
- Diminished sensation
- Axonal neuropathy and muscle denervation on biopsy
Critical illness myopathy (normal sensation, reflexes preserved)
- Flaccid quadriparesis, resp muscle weakness, reflexes normal or mildly hypoactive
- Facial muscle weakness, but extraocular movements preserved
- Normal sensation
- Myosin filament loss on biopsy (muscle necrosis if severe)
Approach to communication with ventilated patients
- Determine whether patient can respond (e.g. eye contact, one step commands)
- If possible, try to establish patient specific method for yes/no (nodding, hand squeezing, squeezing eyes shut) - Letter and picture boards
- Mouthing words slowly
- Writing
- List of common concerns for patient to point to
- Speaking valves with trach
May want to consider SLP consult for assistance
Unique ICU need for sedation or analgesia
- Use of protocols and target-based sedation
- Management of mechanically ventilated patients requires balance between sufficient medication for calm, cooperative behaviour and comfort, while also ensuring patient is awake enough to follow commands and participate in care
- Always evaluate goals of care against current med regime
Communication and Collaboration with the patient/SDM and ICU interprofessional teams
- Patient decision aids
- Measures to improve quality of care (end of life care planning, psych interventions, spiritual support)
- Printed material for patient/family
- Palliative or ethics consultations if required
- Structured ICU team communication with patient and family
How are EOL ethical issues that require decision making best approached in the ICU
- Collaborative discussion of potential healthcare options (acute and palliative), while patient/SDM report patient values, preferences, and expressed wishes
- Patient to direct decision making if possible, if unable, SDM and HCPs assist
- PC can collaborate in difficult cases
- May also consider Ethics consultation, Consent and Capacity board
Why is delivery of Palliative Care different in the ICU?
- Professional Culture
- Low threshold for medical interventions, goal is primarily life support and the primacy of saving lives - Uncertainty
- Difficult to accurately predict outcomes for individuals, particularly survival and morbidity - Time course
- Typical course of an admission is acute (hours to days), limiting patient/family ability to adjust to changes in prognosis and decide upon preferences - Environment
- Lack of privacy, noise, significant alteration to patient appearance by tubes, fluid overload, medical condition
- Limited access to bedside - Patient communication
- Patients may not be able to communicate due to illness or sedation - Scarce and expensive resource and ethics of resource allocation
Dealing with conflicts in Intensive Care
- Most commonly around withholding/withdrawing care
- Always come back to shared goal of caring for patient and family
- Acknowledge emotions
- Sometimes, time may be required for family to adjust and to observe deterioration
- Repeated discussions may be required for family’s to process information
- Bioethicists and social workers may be beneficial
- ‘Trial of therapy’ may be beneficial
Discontinuing mechanical ventilation
- Discontinue neuromuscular blockade
- May mask patient distress and confound physical assessment
- Allow the paralytic agent to wear off or reverse effects
- In rare cases, if urgent withdrawal indicated, deep sedation should be established before withdrawal - Pre-emptive sedation
- Pre-emptive dosing of opioids and sedation to prevent any sudden increase in dyspnea
- Requires individual assessment based upon baseline dosing requireents and patient’s level of distress - Discontinuing ventilation
- Gradual decrease FIO2 and PPV over 10-30 mins to allow patient to comfortably transition to spontaneous breathing through the ET
- Assess for distress at each decrease in support with additional PRNs as needed - Determine whether to extubate or not
- For highly vent dependent patients, may increase distress
- Others may prefer tube out at EOL - During process, ensure HCP available to be with family
