1 1 icu protocols memphis va medical center g. umberto meduri, m.d. w. andrew bell, pharm.d., bcps
TRANSCRIPT
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ICU Protocols Memphis VA Medical Center
G. Umberto Meduri, M.D.
W. Andrew Bell, Pharm.D., BCPS
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The ICU Team
• ICU Attending• Pulmonary and Critical Care Fellow
– Internal Medicine Resident– Medicine Interns– Medicine Students
• ICU Pharmacist– Pharmacist Resident
• Critical Care Nurse• Respiratory Therapist• Nutritionist, Physical Therapist, Palliative Care
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ICU Protocols
1. Antibiotic treatment of pneumonia
2. Antibiotic treatment for other infections
3. Fluid resuscitation and ScvO2-guided therapy
4. Vasopressors
5. Mechanical ventilation
6. Sedation and analgesia
7. Glucose control
8. Gastrointestinal and thromboembolic prophylaxis
9. Weaning from mechanical ventilation
10. Recombinant human activated protein C (rhAPC)
11. Prolonged glucocorticoid treatment in patients with shock
12. Prolonged glucocorticoid treatment in pts with severe ARDS
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Guidelines
• ATS / IDSA Pneumonia Guidelines
– 2007 Community-acquired pneumonia – 2005 Health care associated pneumonia
• Surviving Sepsis Campaign 2008
• SCCM 2002 Analgesia, Sedation, & Neuromuscular Blockade Guidelines
• ASHP 1999 Stress Ulcer Prophylaxis Guidelines
• Chest 2008 DVT Prophylaxis Guidelines
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SEPSIS PROTOCOL
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Severe Sepsis - Screening
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[continued]
ScvO2 = central venous oxygen saturation
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COVERAGE PREFERRED AGENTS OPTIONAL AGENTS
Primary Gram -Anti-Pseudomonal β-LACTAM
Piperacillin/Tazobactam 4.5g Q 6hIF β-LACTAM ALLERGY
Aztreonam 2g, Q 6h
Double Gram - Tobramycin 7 mg/kg/day*Ciprofloxacin 400mg Q 8h
Optional MRSA Vancomycin 20mg/kg Q12h**Linezolid
600mg Q 12h
*Interval adjusted from Q 24h based on renal function to a trough < 1**Interval adjusted from Q 12h based on renal function to trough of 15 to 20
NO β-LACTAM ALLERGY β-LACTAM ALLERGY
Piperacillin/tazobactam 4.5g Q 6h AND Aztreonam 2g, Q 6 hours AND
Azithromycin 500 mg/d AND Azithromycin 500 mg/d AND
Tobramycin 7 mg/kg/day* Tobramycin 7 mg/kg/day*
*Interval adjusted from Q 24h based on renal function to trough < 1
NO β-LACTAM ALLERGY β-LACTAM ALLERGY
Ceftriaxone 2 gm /d Aztreonam 2 gm q6h
AND AND
Azithromycin 500mg/d Moxifloxacin 400 mg/d
CAP with Risks factors for Pseudomonas aeruginosa
Bronchiectasis Structural
lung disease
Repeated antibiotics
Chronic glucocorticoid
use
YES
No
Health Care Associated Pneumonia
Nursing home
Hospitalized last 90 days
IV Rx
Home wound care
Hemodialysis
Within last 30 days YES
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ALI-ARDS PROTOCOL
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Gastrointestinal Prophylaxis
Gastrointestinal Prophylaxis
On PPI at home
Patient tolerates oral intake or enteral feeding
Yes - oral intake Yes - enteral feeding No
Yes Continue home treatment
Convert home regimen to Omeprazole suspension
Pantoprazole 40mg IV at same schedule (QAM, BID)
NoRanitidine Tablets 150mg BID*
Ranitidine syrup 150mg BID*
Ranitidine 50mg IV Q 8h*
PPI = proton pump inhibitors; *Adjust Ranitidine interval to Q 24h if CrCl is < 50ml/min
• All patients enrolled in the study should receive stress ulcer prophylaxis (SUP) with either a H2 antagonist or PPI
AJHP 1999; 56: 347-379
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Thromboembolic Prophylaxis
ICU DVT Prophylaxis
Unless contraindicated, ICU pts should receive Intermittent Pneumatic Compression (IPC).
Ambulatory patient admitted for < 72 hours. Immediately place IPC
OR Not ambulatory patient, recent DVT, admitted for >72 hours without IPC placed.
Obtain a duplex ultrasound LE to rule out DVT then place IPC.
AND No evidence of recent or ongoing bleeding add pharmacologic prophylaxis
No Heparin allergy or recent orthopedic surg. Heparin 5,000 units SQ Q8H
OR No Heparin allergy and recent orthopedic surg. LMWH – prophylactic dose
OR Heparin Allergy Fondaparinux 2.5mg SQ Q24H AVOID: < 50kg BW or CrCl < 30ml/min
LMWH = Low molecular weight heparin
33Albumin 5% 500ml over 30 min