1 1 icu protocols memphis va medical center g. umberto meduri, m.d. w. andrew bell, pharm.d., bcps

1

ICU Protocols Memphis VA Medical Center

G. Umberto Meduri, M.D.

W. Andrew Bell, Pharm.D., BCPS

2

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

3

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

4

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

5

6

SEPSIS PROTOCOL

7

Severe Sepsis - Screening

8

9

10

11

12

13

14

[continued]

ScvO2 = central venous oxygen saturation

15

16

17

18

19

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

20

21

22

ALI-ARDS PROTOCOL

23

24

25

26

27

28

29

30

31

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

32

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