the recognition and management of the seriously ill (ramsi) · the recognition and management of...

The Recognition andManagement

of the Seriously Ill

(RAMSI)

7477 RAMSI Cover:front 6/1/09 13:32

THE RECOGNITION AND MANAGEMENT OF THE SERIOUSLY ILL PAGE 1

CONTENTSIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Tracheostomies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Management of Chest Drains . . . . . . . . . . . . . . . . . . 11

Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Acute Renal Dysfunction . . . . . . . . . . . . . . . . . . . . . . 18

Bloods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Lines, IV Access and CVP . . . . . . . . . . . . . . . . . . . . . 21

Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Chest Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Microbiology: Infection Control . . . . . . . . . . . . . . . . 37

Management Plan . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Errors – Where do we go wrong? . . . . . . . . . . . . . . . 47

Appendix 1 – Pulse Oximetry . . . . . . . . . . . . . . . . . . 49

Appendix 2 – Blood Gas Analysis . . . . . . . . . . . . . . . 50

Appendix 3 – Analgesic Drugs . . . . . . . . . . . . . . . . . 52

Appendix 4 – Local Protocols . . . . . . . . . . . . . . . . . . 53

EditorAlasdair Strachan Consultant Anaesthetist

AuthorsAdam Brown Consultant MicrobiologistPaul Bedford Consultant AnaesthetistEmma Coup Senior PhysiotherapistLee Cutler Consultant Nurse, Critical Care,Matt Neal Consultant Anaesthetist and IntensivistLorraine Robinson Sister, Acute PainElaine Shaw Sister, OutreachKirsten Thomas Sister, Intensive Care Northern General, Sheffield Teaching Hospitals NHS Foundation TrustDavid Wood Consultant Anaesthetist and Intensivist

Editor and authors are based at Doncaster and Bassetlaw Hospitals NHS Foundation Trust unless otherwise stated.Unless otherwise stated photographs and diagrams by editors and authors.

7477 RAMSI Inners:Colour 2 columns 9/1/09 12:23 Page 1

THE RECOGNITION AND MANAGEMENT OF THE SERIOUSLY ILL

INTRODUCTIONWelcome to the Recognition and Management of theSeriously Ill (RAMSI) Course. Through this course youshould gain the skills required to recognise and care forthe acutely ill patient. We will help you develop asystematic approach to these patients so that you canintervene as appropriate and safely take forward thepatients care. We will not only cover the knowledgerequired but look at how anticipation, communication,teamwork and organisation are essential for themanagement of these patients. The importance ofsafety in healthcare will be highlighted and commonprecipitants of medical error will be identified.

The purpose of this handbook is to offer guidance andsupport and is not definitive. It is intended to give ahelpful overview of a patient’s general status followingthe ABCDE approach, allowing you, the healthcareprofessional, to see the global picture. If you are in anydoubt seek immediate senior advice or assistance. Thishandbook is designed to be a “living” document towhich you can add local protocols, personnel notes etc.

This one day multidisciplinary course utilising theconcept of simulation based training, has beendeveloped to assist Doctor’s, Nurses andPhysiotherapists in caring for acutely unwell wardpatients. The issues that you will meet during thecourse have been identified from a needs assessmentundertaken by the Outreach team at Doncaster &Bassetlaw Hospitals NHS Foundation Trust. It isdesigned to address the real issues facing you in ourrapidly changing Health Service.

How will Simulation be involved in yourtraining?The management of an acutely unwell patient can beincredibly stressful for all members of the healthcareteam, not least the patient and their family. The re-creation of clinical events to simulate crisissituations, gives staff permission to “manage” thatevent, identify potential errors, investigate the conceptsbehind effective leadership and teamwork, andprovides a safe environment to explore strengths andareas for improvement in our own practice.

For you to get the most out of simulation basedtraining all scenarios will be video recorded, and thenre-played to the whole group. There will be afacilitated debrief which will encourage you to reflecton how the team performs in a stressful situation, andanalyse why you do what you do, and how thisultimately affects the care that your patient receives.

The effective use of teamwork in caring for a seriouslyunwell patient can make a difference to the patientoutcome. Appropriate quick action, global assessmentand declaration of an emergency are key aspects ofgood patient management, and these principles will beincorporated into the scenarios and subsequentdebriefs.

Whilst not every delegate will be able to participate ineach scenario there is significant potential to learn fromobserving others and reflecting on and discussing theirperformance.

Confidentiality is assured and all recordings are keptsecurely at the Clinical Simulation Centre, where onlyimmediate faculty staff have access to them.

To summarise…The overall aim of this course is to prepare practitioners for any eventuality involving the seriously ill ward patient,and just in case you were thinking “It won’t happen to me”, here is an example of this mentality from history:

“When anyone asks me how I can best describe my experience of nearly forty years at sea, I merely say uneventful. I have never been in an accident of any sort worthspeaking about… I never saw a wreck and have never been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort.”

Edward J. SmithCaptain of the Titanic



AIRWAYThe aim of this chapter is to allow practitioners toassess and support a patient’s airway.

Primary Survey

Assess AirwayVerbal Response (variable if tracheostomy in-situ) Look, Listen, Feel

Support AirwayPatient positioning, chin lift, jaw thrustSuction ± saline instillationConsider Airway Adjuncts:

Nasopharyngeal AirwayGuedel Oropharyngeal Airway

Tracheostomy: Change/clean inner tubeInflation/deflation of cuffRemoval of cap/phonation valve

Supplemental Oxygensee Breathing chapter

Secondary SurveyIs senior help needed – ENT, Anaesthesia

Definitive airway management (Intubation,tracheostomy, new tracheostomy tube, decannulation)

Causes of Airway Obstruction:• Loss of muscle tone in the soft tissues of the soft

palate, epiglottis and tongue

• Secretions, vomit, blood

• Foreign bodies, dentures

• Tumours

• Direct trauma

• Oedema secondary to burns and anaphylaxis

Airway assessment:Verbal response: An appropriate, clear verbal

response reassures us that at thatpoint the airway is not in immediatedanger.

Look: Respiratory rate, patient position,use of accessory muscles, cyanosis,see-saw movement of chest andabdomen.

Listen: Noisy respiration suggests partialobstruction, absence of sound totalobstruction. Gurgling (secretions),snoring (soft tissues), stridor,wheeze.

Feel: Air movement presence or absenceat mouth or nose, chest movement.

Basic Airway Management:Simple interventions using basic equipment is often allthat is required to ensure a clear airway. First removeany obvious foreign body. Well fitting dentures may beleft in-situ as they may aid maintenance of the airwayor ventilation. Then consider some basic airwayinterventions.

Suction: A wide bore rigid sucker should beused to clear secretions (Yankauer).

Chin lift: The fingers of one hand are used to gently lift the mandible upwardsto bring the chin anterior. Thethumb may be used to depress thelower lip.

Jaw thrust: With a hand on each side the anglesof the lower jaw can be pushedforward to displace the mandibleanteriorly. This is useful if a cervicalspine injury is suspected as it is lesslikely to hyperextend the neck.

Position: Patients, if conscious, will adopt theposition most comfortable for them.If unconscious and spontaneouslybreathing then place in recoveryposition.



Airway AdjunctsThese aid the maintenance of airway patency in thespontaneously breathing or ventilated patient. Theymay occasionally make obstruction worse or causetrauma, bleeding, gagging, vomiting or impact furtheran unrecognized foreign body.

Nasopharyngeal Airway

Better tolerated by semi-conscious patient.Sizes 6mm to 8mm in adults

Oropharyngeal Airway (Guedel)

Sizes 0 (Black) to 4 (Red), Average adult size 2 (Green)

Adult Guedel Airways

Oxygen TherapyThe principle indication for oxygen therapy is correctionof hypoxaemia

Symptoms: BreathlessnessHeadacheNausea

Signs: Confusion and agitationCyanosisTachypnoeaTachycardiaLow oxygen saturation on pulse oximetry

See Breathing Chapter for detailed oxygen therapydescription.

TRACHEOSTOMIESTracheostomies can (and do) cause many problems,especially as staff are less familiar with this airway, so are covered in greater detail within this handbook. A tracheostomy is a surgical opening in the anteriorwall of the trachea to facilitate ventilation. A tracheostomy reduces upper airway anatomical dead space as air flows directly into the trachea andbypasses the nose, pharynx and larynx. Warming,humidification and filtering of air no longer occurnaturally as a result of this bypass.

Indications for tracheostomy A tracheostomy can be inserted for a number ofreasons;• To facilitate weaning from positive pressure

ventilation

• Usually expected to be a temporary tracheostomy

• To secure an airway in upper respiratory tractobstruction

• If obstruction is unrelieved then loss of thetracheostomy will result in loss of the airway

• To secure an airway in patients with surgery orinjuries to the head and neck, enablingreconstructive surgery. Again if the tracheostomybecomes dislodged then the airway may be lost ordifficult to recover.

• To facilitate removal of respiratory secretions

• Often a “mini-trach”

• To minimise aspiration risk by protecting the airway

• Patients with absent cough reflex or loss oflaryngeal function such as those with a Bulbar Palsy will need a cuffed tube to protecttheir lung against aspiration. Even if they appearto have a patent airway.

• To enable long term ventilation



Caring for a patient with a tracheostomyWhen responsible for the care or management of apatient with a tracheostomy you should always knowthe history of the patient and any future managementplans. You should always ascertain;• When and why the tracheostomy was performed • Were there any difficulties with insertion or

problems since insertion• Is there a tracheostomy tube in situ and what kind of

tube is it• Is the tube temporary or permanent• Management plan for the tracheostomy/tube• What would you do in an emergency

Techniques of tracheostomyPercutaneous tracheostomy

A tracheostomy tube is inserted between the first andsecond or second and third tracheal ring using adilation approach. This procedure is quicker than thesurgical tracheostomy and can be performed in thecritical care setting.

Surgical Tracheostomy

This procedure is used in head and neck surgery and in patients where abnormal anatomy precludes apercutaneous tracheostomy.

Cricothyroidotomy (Mini-tracheostomy or ‘mini-trach’)

A small diameter tube is inserted via a percutaneousapproach into the cricothyroid membrane. Thisprocedure is performed as an emergency for airwayobstruction or electively for sputum retention. Thepatient is still able to cough, speak and swallow. Theinternal diameter of the tube is only 4mm, the largestsuction catheter that can be passed is a size 10.

Tracheostomy tube typesSingle lumen/unlined tube

Single lumen/unlined tubes are often the initial tubesto be inserted via the percutaneous procedure. Sputumcan adhere to the inner lumen of the tracheostomytube and as a result increase the patient’s work ofbreathing and can lead to airway obstruction. Anypatient with a single lumen tube requires closemonitoring and nursing care. For this reason thepatients are generally cared for in a specialistenvironment

Double lumen/lined tube

Double lumen/lined tubes have an inner cannula thatcan be removed regularly for cleaning to avoid airwayobstruction with sputum.

Some inner cannulae are disposable and some re-usable. If re-usable, always ensure there is a spareinner cannula available to insert while cleaning thetube that has been removed. Always ensure the innercannula is the correct size.

Shiley double lumen tracheostomy tube with inner cannulae

Adjustable flange/Extended length tubes

These tubes are designed for patients with deepertracheas, for example, obese patients. The adjustableflange means the tracheostomy tube can be adjusted to the desired length.

Cuffed tubes

The cuff is towards the distal end of a tracheostomytube and acts as a balloon that can be inflated anddeflated. When the cuff is inflated air only passes inand out through the tracheostomy. When the cuff isdeflated air passes both through the tracheostomy andaround the tracheostomy and through the upperairways.

The cuff should be inflated;

• When patients are receiving positive pressureventilation

• When patients are at high risk of aspirating

• During resuscitation

An inflated cuff exerts some pressure on the trachealwall. If this pressure is too high tracheal damage canoccur. Cuff pressure should be checked daily using amanometer. It should not exceed 25mmHg. Alwaysrefer to the tube manufacturer’s recommendations.


Single lumen cuffed tracheostomy tube

Cuffless tubes

A cuffless tube does not have a cuff that can be inflatedinside the trachea. Air passes in and out through thetracheostomy as well as around the tracheostomy andthrough the upper airways. It can be inserted if thepatient does not require positive pressure ventilation orprotection from aspiration. Cuffless tubes can be usedwhen weaning patients from their tracheostomy.

Fenestrated tubes

A fenestrated tracheostomy tube has one hole, orseveral smaller holes in the posterior wall of the outerlumen. Both cuffed and cuffless tubes can havefenestrations. The fenestrations allow air to passthrough the tracheostomy and via the upper airway.Fenestrated tracheostomy tubes assist weaning andwhen used in conjunction with a phonation valve allowspeech.

Fenestrated tubes have an unfenestrated inner cannulaand a fenestrated inner cannula. Always use theunfenestrated inner cannula for suction. This avoidstracheal trauma.

In a cuffed tube always deflate the cuff whenusing the fenestrated inner cannula.

Tracheostomy WeaningIn many patients the tracheostomy is only temporary.Removal of the tracheostomy when it is still requiredwill be harmful and so a step by step process known as weaning should be followed. The patient must bebreathing spontaneously and have a linedtracheostomy with a fenestrated outer tube in position.

Ensuring Upper Airway Patency

• Cuff deflation – to allow passage of air through theupper airways

• Insertion of fenestrated inner tube

• Application of phonation valve – one way valve thatcloses on expiration so all air passes via the upperairway

N.B. The application of a phonation valve onto a cuffedtube can cause increased work of breathing due to theexpiratory resistance provided by the deflated cuff. Ifthis is the case insert a smaller, cuffless tracheostomytube.

Confirming Adequate Ventilatory Reserve

• Application of phonation valve for at least 24 hrs

Ensuring that the tube is no longer required

• If not already done then insert a smaller cufflesstracheostomy tube

• Application of decannulation cap or tube for at least24hrs

• Decannulation if no suction required in last 24hrs

• The stoma needs to be covered with an impermeabledressing to maintain an adequate seal. The stomashould close and heal without surgical intervention

Trouble shootingTube Occlusion

Assess patient to identify urgency of problem.

• Administer oxygen therapy and call for assistance

• Suction via the tracheostomy +/– saline instillation

• Remove and clean inner tube if present

• If tube still occluded and cuff inflated, deflate cuff

• Call for help as tube may need to be changed

Tube displaced/falls out

Assess patient to identify urgency of problem

• Call for help

• Oxygen therapy via stoma

• Use of tracheal dilators if tracheostomy <5 days old

• If patient not breathing consider mask to stomaventilation or occlude stoma and mask to mouthventilation.

PAGE 6 THE RECOGNITION AND MANAGEMENT OF THE SERIOUSLY ILL


Respiratory/Cardio-respiratory Arrest

• Call for help

• Administer basic life support

• Attach rebreathe bag or ambubag to tracheostomyvia catheter mount

• In a cuffed tube ensure cuff is inflated

• If ventilation via tracheostomy tube ineffectivedeflate cuff, occlude the tube and try mask to mouthventilation

PATIENTS WHO HAVE HAD A LARYNGECTOMY HAVENO CONNECTION BETWEEN THEIR TRACHEA ANDUPPER AIRWAY. RESUSCITATION SHOULD ALWAYSBE VIA THEIR STOMA

Bleeding from tracheostomy tube

In the case of profuse or heavy bleeding;

• Call for help

• Inflate the cuff

• Suction as required

References

1. Wiliam C Pruitt; Michael Jacobs. Basics of OxygenTherapy. Nursing; Oct 2003; 33,10; pg 43.

BREATHINGThis chapter summarises the general assessment andmanagement of respiratory problems and includes themanagement of a number of specific conditions.

Primary SurveyAssess breathing: look, listen, feel

pulse oximetry

Support breathing: optimal positionoxygen therapysecretion clearance

Secondary SurveyABG’s, CXR, review historyDetermine if further treatment, non-invasive or invasiveventilation is required

AssessmentThe key functions of breathing are to oxygenate theblood and to remove Carbon Dioxide. Assessment isfocused on identifying inadequacy of either of theprimary functions and looking for reversible causes ofthat inadequacy.

Look

• Position of patient

• Respiratory rate and pattern

• Use of accessory muscles, effort or clear distress

• Cyanosis

• Symmetry

Feel

• Central trachea

• Surgical emphysema

• Symmetry and adequacy of expansion

• Percussion

Listen

• Stridor

• General air entry

• Wheeze

• Crackles




Investigate

• Pulse oximetry

• Blood gases

• Chest X-ray

Review

• Current treatment

• Recent therapy changes

• Relevant historical results of investigations

Note

An acute change in respiratory rate is generally theearliest sign of a change in respiratory function.

Pulse Oximetry only assesses oxygenation which canremain good in the face of severe respiratory failurewith hypercarbia, especially if patient is receiving highconcentration oxygen. Its other weakness is that thereading can be affected by a number of factors which if unrecognised can have serious consequences. (seeAppendix 1 Pulse Oximetry).

Blood gases are the only way to assess both aspects ofrespiratory function (see Appendix 2 Blood GasAnalysis).

Systematic Respiratory SupportRespiratory support can be considered in the followingcategories:-

a. General Support

• Positioning the patient

Sitting up is best. The use of accessory muscles can befacilitated by the patient being able to rest their armson a support such as a bedside table.

• Physiotherapy to encourage clearance of sputum(see sputum retention)

• Analgesia if pain is limiting the ability to deepbreathe or cough

• Treating any respiratory disease aggressively andspecifically

• Ensuring good muscle function

• Improving the nutritional status of the patient

b. Increasing Oxygenation

It is essential that patients are treated with optimaloxygen therapy. Allowing patients to remainacutely hypoxaemic can result in significant clinicaldeterioration.

To guide appropriate delivery of oxygen therapy Trustsoften develop a Patient Group Direction for titration ofinspired oxygen in the spontaneously breathingpatient.

Oxygen Masks

At rest in normal people the rate at which air is inhaledvaries throughout the respiratory cycle up to 30 l/min.If oxygen is supplied from a wall flow meter, themaximum flow rate of which is 15 l/min. The shortfall ismade up with entrained air if an inappropriate device isused. Thus the selection of device is crucial.

• Nasal Cannulae only results in a small increase in the inspired oxygen concentration (to a maximum of24%). Nasal Cannulae are most useful for patientswho may benefit from a small increase in inspiredoxygen but have no demonstrable defect inoxygenation. Flow rate should be a maximum of4lpm to avoid nasal irritation.

• Standard Hudson Facemask – despite what it sayson the packet is only capable of delivering 35% in a slowly breathing patient at rest e.g. for a postoperative patient who requires oxygensupplementation. Tachypnoeic patients lose thepause between expiration and inspiration thusbreathing in the exhaled air still contained within the mask. When the patient pulls the mask offcomplaining that the mask is suffocating them, theyare probably right! Remember that the minimumrecommended flow rate for these masks is 5 litresper minute.

Hudson Oxygen facemask


• Fixed Performance Masks – are based on a Venturisystem that entrains air into the mask to deliver afixed concentration of oxygen into the mask. Thesemasks are probably best suited to those patientswho require fixed concentration oxygen and arebeing closely monitored. However they may help toassist interpretation of ABG’s in a small number ofpatients.

Fixed performance mask with different concentrationventuri attachments

• Masks with a Reservoir Bag (note there is a one wayvalve and so these masks are “Non-rebreathe bagmasks” and NOT “rebreather bags”). The bagincreases the reservoir of oxygen that collects duringexhalation and any expiratory pause. If the reservoirexceeds the patient’s tidal volume (500 to 700mlsfor the average adult) then the patient will receivenearly 100% oxygen. These are the best system foracutely tachypnoeic patients who are profoundlyhypoxic.

Oxygen mask with reservoir bag

• High Flow Oxygen. A high flow delivery system suchas the Whispaflow or the Vital Flow Generator willdeliver a fixed concentration of oxygen into afacemask at a rate that exceeds the maximuminspiratory flow rate, thus guaranteeing that thepatient can only breathe the predetermined gasconcentration. These systems can be potentiallydangerous because of the high flow rates andshould only be set up by competent individuals.

Wispaflow high flow delivery system (without patient breathing circuit connected)

• If the patient remains hypoxic then ContinuousPositive Airway Pressure (CPAP) will recruit alveoliand improve hypoxia. CPAP can be administered byMask or Hood.

c. Improving Removal of Carbon Dioxide

Carbon dioxide clearance is dependent on the amountof effective ventilation. If Carbon dioxide levels arehigh the patient is hypoventilating and so methods ofimproving clearance involve artificial means ofaugmenting ventilation.

• If the Patient is hypercarbic and has a respiratoryacidosis then Non Invasive Ventilation will help toincrease tidal volumes and to remove the CarbonDioxide.

• Persistent problems with hypoxia or hypercarbia atthis stage require invasive ventilation.

d. Correcting Complex defects in ventilation.

Usually requires invasive ventilation.




Sputum RetentionPatients who are having difficulty expectoratingsputum, or who are unable to expectorate at all, are at increased risk of infection, airway damage andrespiratory failure.

There are a number of causative factors that should beconsidered in any patient who won’t or can’t cough.

Dehydration

Dehydrated patients can have thick, sticky sputum thatis difficult to clear.

• Optimise systemic hydration, orally or intravenously

• Consider humidification of oxygen therapy if on>24%

• Consider saline nebulisers

Humidification system for oxygen

Position

Patients in slumped positions have a much weakercough. This has a significant effect on sputumclearance.

• Ensure they are as upright as possible in bed or satout in the chair if this is safe to do so.

Pain

Sputum clearance may be affected by patientsexperiencing pain as a result of thoracic or abdominalsurgery, rib fractures or pleuritic chest pain. Analgesiashould always be addressed first before attemptingsputum clearance techniques.

• Ensure good quality analgesia

• Spare opiates as far as possible as they are coughsuppressants

• Consider local anaesthetic blocks including epidurals

Wheeze

Patients with asthma or chronic lung disease may haveairway narrowing which is preventing sputumclearance.

• Ensure bronchodilators are optimised beforeattempting sputum clearance techniques.

• Weakness/Fatigue

Patients with neuromuscular disease, chronic lungdisease or in respiratory failure may not have themuscle power or energy to clear their sputum.

Reduced Conscious Level

Patients with altered conscious level will not clear theirsputum consistently or effectively. If sputum retention iscausing respiratory distress or worsening respiratoryparameters this patient group may require oral or nasalsuctioning.

For any patients experiencing difficultyexpectorating sputum or sputum retention refer tothe physiotherapist for further assessment, adviceand treatment.



MANAGEMENT OF CHEST DRAINSIndication for chest drainage

A chest drain is a tube inserted through the chest wallbetween the ribs and into the pleural cavity to allowdrainage of air (pneumothorax), blood (haemothorax),fluid (pleural effusion or pus (empyema), out of thechest. In any one patient it is essential to understandwhat their particular drain is trying to achieve.

Insertion of chest drains

Chest drains come in a range of sizes suitable for a variety of purposes (typically 12-36Ch) and may beinserted via an open surgical incision (thoracostomy) or using the seldinger technique incorporating a wireguide and dilator system. Simple spontaneouspneumothoraces and non-viscous effusions may bedrained with relatively small calibre drains (12Ch) buttraumatic pneumothoraces, haemothoraces andempyemas will need larger drains, typically 26Ch andabove. Older style chest drains are still supplied with a sharp trocar that was originally intended to aidinsertion. Their use for insertion of a drain in a stabbingmotion through skin, muscle and pleura is not to berecommended as it is difficult to control in all but themost experienced of hands and can easily result indamage to both intra-thoracic and intra-abdominalorgans. Open incision with blunt dissection deeptissues and forceps or introducer-guided insertion ofthe drain is the preferred technique at all times.Alternatively seldinger wire guided insertion may beappropriate in some circumstances.

The effective drainage of air, blood or fluids from thepleural space requires an adequately positioned drainand an airtight, one-way drainage system to maintainsubatmospheric intrapleural pressure. This allowsdrainage of the pleural contents and re-expansion ofthe lung. In the case of a pneumo or haemothorax thishelps restore haemodynamic and respiratory stabilityby optimising ventilation/perfusion and minimizingmediastinal shift. The commonest system is theunderwater seal (see below).

There are several different drains available which havediffering numbers of drain holes at the business end.This may range from three to seven and markings onthe drain may measure either from the end of the drainor from the most proximal drain hole.

Understanding these differences when inserting thedrain or checking its position later is very important.

All drain holes need to be in the thoracic/pleural cavityfor the drainage system to work adequately. If drainholes are situated within the subcutaneous tissues airor fluid may escape into the tissues and cause surgicalemphysema or collections of potentially infected fluid.Worsening surgical emphysema is uncomfortable,interferes with clinical examination of the patient andat its worse may track up to the neck and facepotentially causing airway embarrassment. If the drainis displaced or inadequately inserted and any drainholes appear outside the chest wall there is no effectiveseal and air may enter the drain and into the pleuralcavity allowing the lung to collapse, worsening orcreating a pneumothorax.

Surgical emphysema from chest drain site causingsignificant facial and periorbital swelling.(Harry Voesten, Netherlands, Trauma.org)

The underwater seal

The basic requirements are a suitable chest drain withminimal resistance, a fluid reservoir and a collectionchamber. The drainage tube is submerged to a depth of1-2cm in the water of the reservoir/collection chamber.This ensures minimum resistance to drainage of air andmaintains the underwater seal even in the face of alarge inspiratory effort.

The chamber should be kept below the level of thechest as significant sub-atmospheric pressures (up to -80cmH2O) may be produced during obstructedinspiration. Keeping the bottle below the level of thechest prevents fluid being sucked back up into thechest during inspiration. Drainage can be allowed tooccur under gravity or suction may be applied (seeoverleaf).


Simple underwater seal bottle showing fluid level and drainage tube

The underwater seal acts as a one-way valve throughwhich air is expelled from the pleural space andprevented from re-entering during the next inspiration.

Retrograde flow of fluid may occur if the collectionchamber is raised above the level of the patient. Thecollection chamber should be kept below the level ofthe patient at all times to prevent fluid being siphonedback into the pleural space.

If the drainage tube is allowed to slip out of the waterthen air easily passes back up the tube duringinspiration and the lung will collapse.

Absence of oscillations/swinging may indicateobstruction of the drainage system by clots or kinks,loss of sub-atmospheric pressure or complete re-expansion of the lung.

Obstructing clots may need to be removed from thedrain itself with forceps and if the drain tubing to thebottle is obstructed the bottle and tubing can bereplaced. Clots that cannot be removed from the drainitself may necessitate re-insertion of a new drain.

Persistent bubbling throughout the respiratory cycleindicates a continuing broncho-pleural air leak.

Some simple bottle systems (Portex Chest Drain Bottle500/1500ml) are supplied with a red screw fit bottlecap and a red cap to cover the suction port fordisposal. These must only be used for disposal of thebottle and contents as they effectively seal the airoutlet. You should never see a red cap on a bottle thatis in use.

What to Monitor and What to Record?

This depends on the reason for the drain’s presence. A drain inserted for a fluid collection such as aneffusion or empyema will need the volume and natureof the drain fluid recording. This should be recorded onthe fluid balance and chest drain charts unless acombined chart is being used. The frequency ofobservations depends on local policy and medicalrequest. Drains inserted just for fluid should not swingand should not bubble so the presence of thesefeatures is abnormal and should be recorded.

Drains inserted for pneumothorax or haemothorax area different matter. The presence of air bubbling out ofthe drain should be recorded, as should swinging ofthe fluid level in the drain tube. These features indicatethat the drain is still doing its job. Absence of bubblingand/or swinging indicates either the drain has done itsjob and the lung is re-inflated, or more worryingly thatthe drain has become displaced and is no longerfunctional. Bubbling and swinging are both dependanton an intact underwater seal and so can only be pickedup if the drain tube extends below the water level inthe bottle. It is worth getting down on your hands andknees to actually look at the bottle closely to confirmfunction. Bubbling and swinging should be assessedwith the patient deep breathing and if possiblecoughing. Assessment with relaxed tidal breathing willnot necessarily reveal continued air leak. Assessmenton deep breathing and coughing also has the benefit ofassessing adequacy of analgesia.

A drain inserted for drainage of a haemothorax (+/– pneumothorax) also needs blood loss recordingaccurately. With fractured ribs most bleeding is fromthe intercostal vessels, which slows down as the lungreinflates. However continued bleeding into the drainbottle is indicative of pathology that may need thoracicsurgical intervention! After thoracic trauma more than1500ml of blood into the bottle initially or continuedbleeding of greater than 200ml/hr requires discussionwith the thoracic surgeons. Blood loss should berecorded on the fluid balance chart and any suddenincreases in drain volume require medical review.

See Trust Chest Drain Chart.




Chest Drains – To Clamp or not To Clamp?

Clamping a pleural drain in the presence of acontinuing air leak (continued bubbling) may result in atension pneumothorax or possibly worsening surgicalemphysema. The authors do not recommend clampingof drains at any time if it can be avoided but recognisethat some surgeons and physicians still prefer to clampdrains for a period of time prior to removal and thenrepeat the chest x-ray. This is supposedly to pick upsmall air leaks that may otherwise be difficult toidentify. If the tube is clamped it should be under thedirect supervision of a respiratory physician or surgeonon a ward with experienced nursing staff. A patientwith a clamped tube should not leave the specialistward environment. Instructions should be left thatshould the patient become breathless or developsurgical emphysema then the drain tube must beimmediately unclamped and the medical team alerted.

Changing the drain bottle

When changing the drain bottle because it is overfull,temporary clamping of the drainage tube may benecessary to prevent ingress of air into the pleuralcavity. However it is acceptable to clamp the tubebetween thumb and forefinger. This has the advantageof removing the risk of inadvertently leaving the tubeclamped. To our knowledge nobody has ever left his orher fingers clamping a drain tube without noticing!Local policy should be followed with regard to asepsisand infection control.

Suction

A patient who is free from pain, to the degree that aneffective cough can be produced, will generate a muchhigher pleural pressure differential than can safely beproduced with suction. This combined with a functionalunderwater seal will result in re-inflation of the lung.

If a patient cannot re-inflate his own lung or persistentair leak is preventing re-inflation, high volume, low-pressure ‘thoracic’ suction in the range of 1-5kPa(approx 10-50cmH2O) can help. Prescription of suctionis a medical responsibility.

Purpose made low grade suction adaptors (max 30kPa)should be used when applying to a chest drain. DO NOT use standard high volume, high-pressuresuction adaptors, as these can be extremely dangerous.Suction that is not working properly or is turned offwithout disconnecting from the drain bottle is theequivalent of a clamped drain so when suction is no

longer needed disconnect from the drainage bottle.

Close surveillance is therefore required by nursing stafftrained to recognise faults in the drainage and suctionsystem. It is better to remove suction than to use afaulty device.

Ambulatory Chest Drain Systems

These incorporate a drainage bag with an integralflutter valve at the entry to the bag. They do notrequire an underwater seal to prevent air entering thepleural space from outside via the drain and are notdependant on being below the level of the patient toallow air to drain from the pleural space. Their namesuggests that mobility of the patient is better than withan underwater seal and they are very useful whentransferring patients between units.

Figure 2. Portex Ambulatory Chest Drain System

It is portable, does not need to be kept upright andprovides hygienic drainage of the drain effluent. Itconsists of a PVC flutter valve within a drainage bag.Originally designed for battlefield use, these Portexbags have been tested successfully following thoracicsurgery in both an inpatient and outpatient setting. Thebag is flexible, works in any position and can easily beworn under clothing. It provides a convenient, hygienicsolution, which allows early mobilisation and dischargefrom hospital.

One disadvantage is the inability to connect to suction.Therefore the lung must be adequately expanded offsuction prior to connection to the ambulatory bag. Thecapacity of the bag is approximately 1700ml, slightlyless than most bottle systems that collect 2000 to2500ml. As this volume is actually quite inconvenientto carry the bag has been designed to allow easyemptying via the vent port. Though this requiresinversion of the bag, the flutter valve remains


functional throughout the manoeuvre. Disconnection,kinking of the tubing or obstruction by lying on the bagare potential dangers.

How to connect an ambulatory drainage bag

1. Inject 20ml of air into the drainage tubing to test theflutter valve. The leaves should be seen to open asthe air passes and close spontaneously.

2. Ensure the tubing is properly fitted to the anti-kinkdevice.

3. Connect the tubing to the chest drain with a male-to-male connector.

4. Adjust the shoulder strap to length.

5. A cough will produce movement in the leaves of thevalve, completely opening if there is an air leak.

Dos and Don’ts of Chest Drains:

• Don’t raise the drain above the level of the chest.

• Don’t clamp the tubing (pinch the tubing duringbottle changes).

• Do dress the site and secure the tubing.

• Do assess the drain regularly for swinging, bubbling,and blockages.

• Check for bubbling with patient talking and alsocoughing if possible.

• Do assess the site for air leaks and surgicalemphysema and infection.

• Do assess the respiratory and cardiovascular status.

• Do monitor and document the amount and type ofdrainage.

• Use bag system when transferring patients betweensites.

CIRCULATIONThis chapter aims to review key aspects of circulatoryphysiology, assessment and clinical management. It isintended to give the reader elementary understandingof the principles that should underpin clinical practicewith regard to these topics in the acutely seriously ill.

Primary SurveyAssessment - Pulses present, character and rate

- Capillary refill time- Blood pressure- JVP/CVP

Possible sources haemorrhage - abdomen/chest/fractured pelvis

or long bones - external haemorrhage/drains

Possible sources fluid loss - vomiting/diarrhoea/stoma loss

Urine Output

IV Access - blood samples and IV fluid

Secondary SurveyBloods - U&E/FBC/clotting/group and save

/ABG/lactate/mixed venous oxygensaturation

ECG - rhythm, rate

CXR

In line with the A - B - C - D - E approach advocated inthis publication assessment of circulation shouldencompass consideration of organ perfusion includingrenal perfusion and function. For this reason the latterpart of the chapter considers aspects of renal function,assessment and immediate management in the acutelyseriously ill.

Circulatory Function and FailureThe key function of the circulatory system is to deliveroxygen (bound to haemoglobin) and energy (e.g.glucose) to the cells of the body in order that they canperform their vital and specific functions.

Shock can be described as a state of inadequate tissueperfusion. Thus there is inadequate oxygen and energydelivery to the tissues resulting in cell and organdysfunction and the increase in circulating by-products




such as lactic acid. Cellular injury resulting from poorperfusion may be reversible if recognised and treatedearly but will progress to irreversible cellular injury ifprolonged. Thus it is important to understand some keyconcepts about circulatory function, to be able torecognise poor tissue perfusion and shock, and to beable to intervene promptly.

The ideal circulatory system has an adequate pressurewithin it (BP) and it has an adequate amount of bloodbeing pumped around the body (cardiac output). Thus there is a balance to be struck in order to get anadequate pressure as well as flow. Whilst bloodpressure has to be above a certain threshold for tissueperfusion to occur, the BP alone should not be the solefocus of the clinical assessment, or indeed the factorwhich might lead to the clinical judgement that tissueperfusion is adequate.

BP is the product of cardiac output (CO) and theresistance offered by the blood vessels – known assystemic vascular resistance (SVR):

If the blood vessels offer little resistance (e.g. as inanaphylaxis or severe sepsis) the cardiac output willincrease but there will not be enough pressure in thesystem to push blood into the organs and perfusethem.

If the cardiac output falls (e.g. with the ‘pump’ failurethat occurs after Myocardial Infarction) – the SVR willrise to compensate, perhaps maintaining a normal BPbut there will be a reduced amount of blood ejectedfrom the heart and delivered to the organs.

A balance of pressure and flow is required andunderstanding this is key to interpreting assessmentfindings and making decisions about clinicalmanagement. However, before clinical management isdiscussed it is useful to review assessment techniquesand investigations as well as some of the features ofshock as they present in the clinical situation.

Circulatory Assessment In the clinical situation, when assessing a patientdivide the assessment into two phases. The first will bea primary survey as part of the A-B-C-D-E approach.

Primary Survey

The key question that should be uppermost in yourmind is:

“Is tissue perfusion adequate?”

The following parameters will be useful in helping youdecide:

Blood Pressure Low BP often results in poor tissueperfusion BUT a ‘normal’ BP can be seen in a shockedpatient.

Heart rate Often elevated in a system with a lowcirculating volume BUT beware that tachy-arrhythmiascausing reduced cardiac output may be the cause of‘shock’. ALSO those on ß-blocking drugs may fail togenerate a tachycardia even when hypovolaemic. Beaware of the other reasons for a tachycardia e.g. pain,fever, anxiety.

Capillary refill time (CRT) Is an indicator of peripheralperfusion. It should take 2-3 seconds for an area ofskin, where pressure is applied for 5 seconds, to returnto its previous colour. Ensure that the hand used iselevated to heart level to avoid capillary filling from thevenous system. In a cold environment – try the anteriorchest wall or forehead – it is more reliable. ProlongedCRT indicates poor perfusion. However, brisk filling canbe seen in the hot peripherally vasodilated septicpatient.

Other things to note:

Dry skin with poor skin turgor (tone) – indicatesdehydration.

Skin temperature – cool at the peripheries andwarming towards the trunk indicate poor perfusionhypovolaemia or poor cardiac function

Central venous pressure/Jugular venous pressure –elevation may indicate circulatory overload or cardiacfailure; reduced pressure may indicate hypovolaemia orrelative hypovolaemia in a patient with vasodilation insepsis. A target CVP should be 8-12mm Hg (11-16cmH2O) in the septic or hypovolaemic patient.

Flat hand veins – indicate hypovolaemia.

Reduced urine output (<0.5mls/kg/hr) – may indicatepoor renal perfusion.

CO SVR


Anxiety, confusion or reduced consciousness – mayindicate poor cerebral perfusion.

Rapid onset of cold clammy skin – may indicate cardiacfailure as the cause.

These parameters will enable you to begin yourjudgements about whether perfusion is adequate andwhether you need to intervene NOW!

If you suspect that hypovolaemia is present a 250mlbolus of crystalloid or colloid is indicated – stat (as fastas possible with a 50ml syringe and 3-way tap orpressure bag). The effects should be monitored and thebolus may be repeated up to 4 times whilst calling forsenior medical help. Such severe circulatory problemsrequire further investigation and a considered plan offurther action should be documented.

Secondary SurveyFollowing primary, rapid assessment and interventionin the case of suspected poor perfusion/shock thesecondary survey should include consideration of thefollowing investigations:

ECG – to rule out any acute cardiac event, to assess thecardiac rhythm (or arrhythmia) and as a baseline in thecase of further deterioration.

CXR – may be useful indicating pulmonary oedema orpulmonary infection – a common cause of sepsis in thehospitalised patient.

Bloods

U&E – May indicate renal dysfunction from poorperfusion or electrolyte disorders that requirecorrection. Abnormal levels of potassium andmagnesium may lead to cardiac arrhythmias. ElevatedUrea (+/– Sodium), may indicate dehydration.

FBC – May indicate anaemia from bleeding or elevatedWBC in sepsis.

Clotting – If you suspect bleeding.

Group and save or cross match, if you suspect bleedingor the need for surgery (e.g. an acute abdomen).

Troponin – If MI is suspected or needs to be excluded.

Blood tests of special significance if assessing forcirculatory shock:

Lactate: elevation indicates reduced tissue perfusion.> 2 is abnormal and may indicate poor perfusion. If>4 this indicates circulatory shock and requires urgentintervention with IV fluids +/– inotropic drugs orvasopressors. (Promptly refer to critical care for advice).

Oxygen Saturation of Blood taken from a Centralvenous line: This indicates mixed venous saturationand the delivery and utilisation of oxygen at the tissuelevel. Values <70% indicate inadequate oxygendelivery and/or elevated oxygen utilisation. This mayrequire urgent intervention with IV fluids +/– inotropicdrugs, vasopressors or blood transfusion (Promptlyrefer to critical care for advice).

Rivers et al (2001)

Key Aspects of Clinical ManagementDetailed guidance on a range of individual clinicaldisorders of circulation is beyond the scope of thischapter, however, it is useful to consider some keyaspects of clinical management.

Oxygen delivery

As stated above a key function of the circulatory systemis to deliver oxygen to the tissues. Markers ofinadequate oxygen delivery (e.g. elevated Lactate andreduced mixed venous oxygen saturations) areassociated with poor outcome. These should bepromptly recognised and measures taken to optimisetissue oxygenation. There are limited ways in whichthis can be achieved and they will be briefly describedhere. Whilst aspects of respiratory care have beendiscussed in another chapter – commencing andtitrating oxygen therapy and optimising gas exchangewithin the lungs should be optimised as a preliminaryand adjuvant element of managing circulatorydysfunction. Managing hypovolaemia will be of limitedphysiological benefit if the oxygen content of thecirculation is low. Part of this also involves ensuringthat Haemoglobin is adequate since 99% of oxygen iscarried bound to Haemoglobin in the circulation.




Managing Circulating Volume

There are two aspects to this. Firstly, adequateintravascular volume is required within the circulationto ensure that the heart is filled in diastole. This‘preload’ will facilitate optimum myocardial contractilityand cardiac output of blood to the tissues. (However,circulatory overload will overstretch myocardial fibresand cause acute heart failure). Secondly, the volumewithin the circulation has to ‘fill’ the intravascularcompartment. If the volume is low regional diversion ofblood will leave some areas without adequateperfusion. This is especially the case in sepsis which ischaracterised by major changes in the vascular tone ofcapillaries resulting in redistribution of blood to non-vital organs.

There is around 5-7L of intravascular circulating volume(75ml/kg). This gives little scope for intravascularvolume losses before significant physiologicalconsequences result. If there is a loss of 750-1500mlthe blood pressure may be unchanged and the urineoutput may fall slightly. Key changes will be atachycardia (>100/min) and a CRT >2 sec, the patientmay be a little anxious.

Losses greater than 1500ml will result in changes in BP– including narrowed pulse pressure and hypotension,oliguria, severely delayed CRT and further mentalstatus changes including agitation or lethargy andreduced consciousness.

If you suspect hypovolaemia at primary survey – givevolume of crystalloid or colloid. The greater the volumeloss the greater the advantage from giving colloids.You can probably afford to give anyone with signs andsymptoms of hypovolaemia 1000ml of fluid. Goodpractice would be to give 250ml stat (50ml syringe and3-way tap) and assess for effects before repeating. Inthis way you will see significant but brief changes inhaemodynamic parameters, but also avoid overloadingthe patient in cardiac failure. If there is no improvementafter a rapid 250ml bolus and the patient has atachycardia consider an ECG and CXR before furthervolume replacement.

At secondary survey begin to investigate likely causesof hypovolaemia. If this is accompanied by dehydrationensure that a plan for rehydration is made taking intoaccount previous and ongoing body water andelectrolyte losses. The following table should be usedas a general guide for which fluids to use for volumereplacement and rehydration.

Loss Comparison Replacementwith Blood Fluid

Excess urine Lower Sodium Dextrose SalineOr 0.45% Saline

Sweat Lower Sodium Dextrose SalineOr 0.45% Saline

GI tract Normal Sodium Hartman’s orand Potassium Normal Saline +

Potassium

Serous fluid Normal Sodium Hartman’s andProtein loss Consider Albumin

Blood Same Colloid initially then Blood

Vasopressors

Vasopressors (e.g. Noradrenaline) should not be usedoutside of critical care units where they are given via acentral vein and monitored minute by minute for theireffects. However, it is useful for the non-critical carepractitioner to understand when the use of vaspressorsmight be indicated and thus when referral to criticalcare is necessary.

If volume replacement is about ‘filling’ the vascularcompartment, vasopressors are about reducing the size(capacity) of the vascular compartment, and increasingthe systemic vascular resistance (SVR) thus increasingblood pressure. Volume resuscitation should always bethe first line of therapy for the hypovolaemic and/orhypotensive patient, but in some instances this is notenough. In cases where hypotension is refractory tovolume replacement, for example in severe sepsiswhere the systemic vasculature is dilated byinflammatory mediators, vasopressors may be neededto restore normal vascular tone (and systemic vascularresistance). A common example is where bloodpressure is improved by volume replacement but urineoutput remains low. In this case a higher mean bloodpressure may be needed to perfuse the kidney.

Inotropic drugs

‘Inotropy’ refers to the forceful contraction of muscle –in the case of the circulation – myocardium. Somedrugs are positive inotropes in that they act to increasethe contractility of the myocardium which is desirablein the failing heart. Digoxin is an example of a positiveinotrope, however, when ‘inotropes’ are discussed inthe context of critical care and the critically ill the drugsinclude intravenous Epinepherine (Adrenaline) and



Dobutamine. Like vasopressors these should only beused after restoring circulating volume to normal(otherwise they may precipitate cardiac arrhythmias)and within critical care units where they are given via a central vein and monitored minute by minute for their effects.

If volume replacement has failed to restore adequatecirculatory parameters, perfusion and organ function itmay be necessary to commence vasopressors orinotropes and a referral to critical care is advised.

Arrhythmia management

This is a large and complex topic area, however, it isimportant to make a few brief points here. Firstly,arrhythmias are not uncommon in the acutely ill,especially the elderly. They can be both a cause and aconsequence of serious illness and physiologicalimpairment of the circulation. Anyone who is acutely illand has a tachycardia, bradycardia, or who has chestpain or palpitations should have a 12-lead ECG. Adviceon management of arrhythmias should be soughtsooner rather than later if they are thought to becompromising circulation. There are detailed andcomplex algorithms outlining the key management ofnarrow complex tachycardias, broad complextachycardias, atrial fibrillation and bradycardias by theResuscitation Council (UK). These should be on postersin all acute clinical areas for reference – however, theyare not a substitute for expert opinion.

Monitoring and Evaluation

All therapies should be closely monitored in thecritically ill in order to evaluate their effects. A secondand very important point is that therapies should becommenced in order to achieve explicitly statedphysiological goals (e.g. Urine output >30ml/hr).When these are stated – the whole multidisciplinaryteam has something to guide their actions andjudgements. Importantly this will inform decisionsabout when to escalate treatment or that furthertreatment is futile. In both of these cases expert seniormedical opinion is required.

ACUTE RENAL DYSFUNCTIONThis section has been included here for two reasons.Firstly, this is a common clinical problem that staff inthe acute care areas will come across. Secondly, itappears here because, in many instances, the reasonthat urine output is diminished is because renalperfusion (and probably systemic tissue perfusion) isinadequate.

Renal dysfunction is a relatively common and often-preventable occurrence in the acutely ill hospitalisedadult. If undetected or untreated this can lead to acuterenal failure. Acute renal failure is the final commonpathway for a great number of very different diseasesand for this reason a comprehensive review of renalfailure is not presented here.

Renal dysfunction may present in a number of differentways. Very often this includes a decreased urine outputand/or deranged Urea and Creatinine. This may be anisolated and simple problem such as an obstructedcatheter, or it may be a manifestation of a systemicproblem such as circulatory shock. In managing thisproblem it is important to understand why urine outputis reduced. The key principles of assessment and timelyintervention are of great value in preventing thesequelae of acute renal failure.

Distinguishing the cause of acute renal dysfunction candirectly prompt intervention to address the most likelycause or range of contributory factors. This sectiondoes not consider specific renal disorders, rather itadvocates a broad approach to the patient whopresents with reduced urine output.

Primary SurveyWithin the primary survey urine output should beevaluated as part of ‘C – circulatory’ assessment orwithin the ‘E – exposure’ aspect. Look for a catheterbag hanging from the bed – and evaluate what volumeis in the bag and note its colour since dark urine mayindicate concentrated urine (however, drugs andjaundice also cause dark urine). The most useful thingis to know over what time period the urine volume hasbeen passed. Ideally hourly assessment should berecorded in the seriously ill.

Key things to do at primary survey in a patient whoappears seriously ill (especially with compromisedcirculation) are to have the patient catheterised, if notalready, and request that the urine be measured for thenext hour.



Whilst renal function is important and dysfunction cancause many system problems there is little more to doat primary survey, which should be a rapid assessment,than to initiate accurate urine measurement.

Secondary SurveyIt is at this stage of the assessment that greater depthof assessment and problem identification andevaluation can be undertaken. In a patient whoappears to have reduced urine output (<1/2ml/kg/hr or<500ml/ 24 hour – is below minimum obligatoryvolume) ensure the following:

• If not already done – catheterise.

• Accurately measure hourly urine output in order toevaluate urine output volumes.

• Assess for and manage simple outflow obstruction(e.g. blocked catheter). This often presents with a sudden drop in urine volume unrelated to otherphysiology. Palpate the bladder, confirm by bladderultrasound or by observing free flowing urinefollowing bladder washout. If in doubt always do a bladder washout and/or change the catheter.

• Optimise renal perfusion – key considerations:

• Treat hypotension (administer fluid boluses asnecessary).

• Call for expert medical help to treat cardiacarrhythmias that are compromising bloodpressure.

• Review/discontinue anti-hypertensive drugs,negative inotropes and drugs known to impairrenal perfusion (e.g. NSAIDs, ACE inhibitors).

• Consider need for inotropes/ vasopressors.

• Considering diuretics (only after optimising renalperfusion).

Following initial assessment and intervention a seniormember of medical staff should formulate acollaborative management plan including furtherinvestigations.

BLOODSBlood tests are an often painful part of hospital life –ask a patient! Blood tests are not a panacea for all,however, the information they reveal can indicatehealth or a disturbance in the daily business of living.Healthcare professionals are used to working withclinical indicators peppered with past experiences andhunches, and they know that a single test must not beviewed alone. Sometimes a single result can besufficient on its own (malaria, glandular fever, etc.) orwill make the diagnosis earlier than clinical indications(e.g. pregnancy test) but typically the bigger picturemust be taken into account. Laboratory tests are acontributing factor to more than 80% of diagnoses andare frequently used to monitor the progress oftreatment.

As with any investigation in medical practice, theultimate responsibility for chasing and acting on theresults should rest with the person who ordered thetest. If the samples are wrong or the result of a bloodtest is not checked and acted upon, then there is nopoint performing the test in the first place. Also, oneshould consider which tests are necessary for themanagement of an individual patient, rather thanperforming a blanket screen. Ask yourself if the resultof a test will alter the patients’ management, withregard to their current problem. If the answer is no,consider whether the test is actually necessary.

In a busy clinical setting, the role of obtaining a testresult may be undertaken by a variety of members ofthe multi-disciplinary team. It is imperative thateveryone takes responsibility for secure patientidentification, and ensures that results are conveyed toa member of the team who can act upon theinformation to alter the patients’ managementappropriately.

If a blood test is ordered on a patient it becomes theresponsibility of all members of the team to follow thisprocess to its conclusion. It is not intended that anymember of staff should work outside of their jobspecification, but it is expected that all healthcareprofessionals are able to offer the best of care to theirpatients. This is not an easy feat with national staffshortages across all specialities.



Top Tips to help you help your patient!1) Good communication. If a blood test has been

ordered, inform the rest of the team. Ensuring thatall members know that a blood test is requiredincreases the chance that it will be done on time andby an appropriate person.

2) Know your patient. As many as 1 in every 2000samples are labelled as someone other than thepatient from whom the sample was taken. Alwayscheck that you are dealing with the right patient andthat all labelling is correct. One of the most commoncauses is the presence of someone else’s stickers in aset of notes (or out of date ones for the correctpatient). This is why all blood transfusion relatedsamples must be written by hand and countersignedby whoever bleeds the patient.

3) Correct sample, taken at the right time, delivered tothe laboratory appropriately. Ensure that you knoweverything about the blood test before starting totake samples as some require pre-prepared sampletubes or transport on ice. If in doubt consult thelaboratory handbook, intranet or telephone thelaboratory for help.

4) Follow it up. If a blood test has been ordered thereis a reason for it, therefore follow it up. Make it apoint to review the results ASAP, most routinehaematology and chemistry results will be availablewithin 3 hours. It is a common occurrence thatpatients who deteriorate have had markers in theirblood results (often for several days) that have notbeen identified, because blood has been drawn asrequested but no-one has looked at the results.Never assume that someone else has done it.

5) Familiarise yourself with the results for frequent testsin your clinical area. Nurses are in a prime positionto intercept abnormal blood test results and informthe Doctor ASAP. Nurses and Physiotherapists are notexpected to know about every blood test on offer,but to be able to identify common tests and theirimplications for the health of their patients is goodpractice.

6) Try to erase the concepts of “it’s a Doctors job” or“it’s the nurses job” from your minds. Consideryourselves as a team working towards the bestinterest of your patient. Ordering blood tests,obtaining samples, receiving the results and actingupon them requires a multi-disciplinary approach ifthe patient is to benefit.

NHS staff may work in a variety of hospitals whereslight differences in practice will inevitably occur. It isimportant to check the normal reference ranges for thehospital that you currently work in, as individuallaboratories may have slight variations due to differingassay techniques. In addition, many ranges depend onthe gender and age of the patient.

For those who are on a rotational programme,remember that different hospitals may have differentcoloured bottles!

• Do you know which tests go to which laboratory?

• Do you know which bottles the tests go in?

Ensure that as much as possible patients have givenconsent for the procedure (this includes a patient whoholds their arm out giving implied consent).

Ensure that forms are correctly completed and that thesamples are properly labelled, as wrongly labelledsamples will be rejected and you will have to repeatthe tests. Labelling policies will again differ fromhospital to hospital but at least 3 items of identificationwill typically be required e.g. Name, unit number andDate of Birth, similarly data on the request must matchthat on every sample tube.

Some laboratory tests (e.g. Troponin and Drugs) requiresamples at a particular time relative to the onset ofsymptoms or last drug dose. Samples taken at thewrong time are at best a waste of time, at worst theycan cause mis-diagnosis and inappropriate treatment.

Ensure that the sample gets to where it’s meant to goand on time.

Remember documentation… if it’s not written downthen you didn’t do it!



Common blood testsHaematology Biochemistry Microbiology

Full Blood Urea and BloodCount (FBC) Electrolytes (U+E) Cultures (BC)

Clotting Screen Liver Function(CLS) Tests (LFT’s)

INR Cardiac Enzymes: Troponin

DDimers Amylase

Identify which blood tests are commonly used in your clinical setting. Discover why these tests areperformed, and what interventions are likely shouldthe test be abnormal. This will help your understandingand will assist you in your communication with thepatient/relatives when discussing their condition.

Common Blood Test Top TipsIf Hb is low, this is classed as anaemia either acute orchronic – remember that in an acutely bleeding patient,Hb might not have had time to drop as the patient islosing both cells and plasma.

Abnormal U+E results indicate a problem with fluidregulation either due to inappropriate intake,imbalance between circulation and tissues or change inrenal or GI function. Urea can also indicate excessivebreakdown of proteins (high) and prolonged lowprotein intake (low).

Abnormal LFT results can indicate the nature of liverdisease but are often affected by other problems suchas haemolytic anaemia (elevated Bilirubin), MI(elevated AST), increased bone turnover (elevated ALP)and renal disease (elevated ALP). Similarly the ‘Bone’group is affected by liver problems (ALP), endocrineproblems (Calcium), renal disease (ALP and Calcium)and a variety of other conditions.

Troponin is very specific to the heart (unlike CK which isalso in skeletal muscle) and is used to rule out MI inpatients with chest pain. The sample should be takenat least 12 hours after the onset of symptoms, when anundetectable result indicates a high probability that apatient has not had an MI. Taking the sample too soonwill risk missing the diagnosis of MI andinappropriately sending the patient home.

A significantly raised Amylase (at least 3 times theupper limit of normal) is consistent with acutepancreatitis. In some patients who may be in an earlystage of developing pancreatitis, a repeat sample maybe required to rule out a rising level. Especially in theabsence of abdominal pain, small increases may bedue to benign causes (e.g. Salivary gland problems).

When a patient is admitted to hospital they are relianton the multi-disciplinary team to care for them, to takeshared responsibility in reducing symptoms and ideallycure them of all ills!

Blood tests have been highlighted as a useful tool inassisting healthcare professionals to appropriately treator not treat their patients. This chapter has indicatedsome important points to consider in relation to bloodtests, their uses and their limitations, and should beused in conjunction with other available texts andresources to ensure best practice.

Appendix – add local blood test chart/guidelines



LINES AND IV ACCESSAssessment of IV Access

Common to all patients with a deteriorating clinicalcondition is the need for adequate venous access.Hence while assessing circulation you shouldinvestigate if the patient has venous access and if theaccess is appropriate to clinical need.

Venous access can be achieved by differentmethods

• Peripheral cannulation.

• Central venous catheter (CVP) – can be multi lumenenhancing ability to administer multi drug therapyand monitor central venous pressure.

• Peripheral inserted central catheter (PICC) – used forshort term central venous access with lowerpotential for complications than CVP lines but aresingle lumen only.

• Hickman line – subcutaneous tunnelled line mainlyused for long term drug therapy as can be left inplace for up to six months.

When checking IV access consider these points

• Is the line useable and will it flush easily.

• Condition – Signs of infectionIrritationTissuedSpeed of flow

• Is the dressing intact and secure. If not secure it.May be your only access and other access may beunachievable.

• Is the access appropriate for need?

• Is there a possibility of gaining more access?

Colour Size Time to infuse Common1litre crystalloid applications

Orange/ 14G 3.7 minutes Rapid blood/Brown fluid transfusion

Grey 16G 5.8 minutes Rapid blood/ fluid transfusion

Green 18G 11 minutes Surgery orreceiving largefluid volumes

Pink 20G 18 minutes Fluid therapy

Blue 22G 40 minutes Long termmedication orfluid therapy

Guidelines for MAXIMUM infusion rates based on recent company data. (Rarely achieved in

clinical practice!)

Care of IV access

In general IV access should be secured with atransparent semi permeable membrane dressing andchecked for signs of infection and or irritation at leastonce a day. Always refer to your organisational policyand procedures.

If a patient is spiking a temperature and/or raised whitecell count for no apparent reason, who also hasindwelling central access, always consider line sepsisand removal of the line sending tip for culture andblood cultures.

For further guidance and information refer toStandards for Infusion Therapy produced by RoyalCollege of Nursing October 2003 available on theirweb site.

Top Tips

If patient peripherally shut down and IV accessurgently needed try immersing hand in warm water toencourage identification of veins.

If using multiple IV drugs always considercompatibilities. A very useful book for reference is UCL Hospitals Injectable Drug Administration GuideShulman et al ISBN 0-632-05027-6

Always use dedicated line for total parenteral nutrition(TPN).



Always aspirate blood and flush with saline any line/lumen which has had a drug infusion discontinued toprevent accidental drug bolus administration orunexpected incompatibility.

Never run drug infusions with fluid boluses especiallyinotropes to prevent sudden bolus administration, asthis will give fluctuating drug dose administration andcardiovascular instability.

Central Venous Catheters

Four lumen CVP line with needle, blade, dilator, syringe and wire

A central venous catheter is designed to be insertedinto one of the central veins i.e. the superior or inferiorvena cava. These veins have the largest blood flow ofany veins in the body and return blood to the rightatrium.

Single lumen and multiple lumen catheters areavailable – the type to be chosen should depend onthe intended use e.g. fluid administration and/ormultiple drug administration. The different positionedopenings along the length of multiple lumen catheterreduce the risk of harmful drug or fluid interactions.

Distal – furthest away from patient’s externalsurface

– CVP measurements

Proximal – nearest to patient’s external surface – fluids

Medial – in the middle – Total Parenteral Nutrition

Measuring the central venous pressure

An isolated CVP reading is of little value, response to afluid bolus and several readings to identify a trend arenecessary to indicate a patient’s response to therapyand/or disease progression.

In critically ill patients treatment often aims to maintaina slightly higher than normal CVP measurement toensure sufficient blood return to the heart.

Normal values

Mid axilla point 5-10cm H20

Sternal angle 0-5cm H20

Measurement of CVP can be taken at either of thesepoints and the site chosen should be documented andthe patient’s skin marked to ensure continuity of thereadings. The reading can then be taken with thepatient positioned:

• At a 45 degree angle

• Lying flat

The position chosen should be recorded and allsubsequent measurements taken in the same positionto ensure continuity.

Causes of low CVP measurement

• Hypovolaemia – fluid losses – trauma or surgery,diabetes or diuretic therapy

• Poor venous return – cardiogenic shock

• Peripheral vasodilatation – septicaemia orvasodilatory therapy

Causes of high CVP measurements

• Hypervolaemia – excessive fluid infusion or fluidretention

• Cardiac failure – right ventricular failure, pulmonaryembolism, cardiac tamponade, mitral valve disease

• User error – wet filter

• Lumen occlusion – kinked cannula, cannula restingagainst vessel wall, thrombus



Care of the patient with a central line

• Awareness that any patient who requires a CVP line is acutely ill and that their susceptibility toinfection is increased – aseptic technique during any procedure including insertion, administeringbolus drugs, connecting infusions, blood sampling,measurements, dressing the site and removal of the line.

• Minimal handling of the central line

• Regular flushing of the line

Central lines dressings

Using an aseptic technique the dressing should bechanged when it becomes soiled, damp, loosened or a closer inspection of the site is required. The dressingused should be as per local protocol.

Central venous site inspection

The site should be inspected at least once per shift toassess for signs of infection and possible complications.The site should be assessed for swelling, redness,warmth, tenderness or discharge – if present themedical staff should be notified and the line removed.All lines, connections and hubs should be inspected forleakage and replaced as necessary. The catheter lengthshould be assessed – note the cm mark at the skin exitand compare this with the previous documentedcatheter length – if this has changed the medical staffshould be notified.

Flushing central lines

Occlusion of the lumens usually occurs as a result ofinsufficient or incorrect flushing when not in use.Precipitate formation and kinking may also affect thepatency. Sodium chloride 0.9% is most commonly usedto clean the internal diameter of the lumen of bloodand drugs, the lumen should always be flushed afterblood withdrawal or drug administration, and then atleast 8 hourly with 3-5mls sodium chloride via eachlumen not in use. It is important to use a pulsatile –push-pause method to create a turbulent flow injecting1ml at a time and completing the procedure using apositive pressure technique i.e. clamping the lumenwhile flushing before the syringe completely empties.Excessive force should never be used while flushing, ifresistance is felt due to partial occlusion and force thenapplied to the plunge – a high pressure within thelumen could result in catheter rupture.

Unblocking central line lumens

Gentle aspiration may dislodge a clot followed by a 0.9% saline flush to restore patency. Only 10mlsyringes should be used when attempting to unblock acatheter as smaller syringes appear to create a greaterpressure which may result in rupture of the catheterand/or clots being forced in to the circulation.

Removal of the central line

The patient should be given an explanation of theprocedure and reassured throughout. The patientshould be positioned lying flat and head down if thiscan be tolerated so that if an air embolus should occurit will rise to the highest point. If patients cannottolerate this position they should be asked to performthe valsalva manoeuvre during catheter removal i.e.the patient should breathe in, close their mouth andbear down to raise the intrathroracic pressure. Thecatheter should be removed rapidly and a sterile swabplaced over the site, pressure applied until bleedingceases. Caution should be taken in coagulopathy. A sterile dressing should cover the site. The catheter tip should be sent for culture and sensitivity.



Central venous catheter complications

Signs and symptoms may include

Pneumothorax/HaemothoraxChest painHypoxiaDyspnoeaTachycardiaCyanosisRestlessnessShock

Air/Pulmonary/Catheter EmbolusA clot, catheter segment or air bubbles become freefloating in the circulation and are propelled by thevenous circulation through the right heart and into thepulmonary artery. In air embolus – tenacious airbubbles then block the pulmonary capillariesDyspnoeaTachycardia, weak rapid pulseChest pain – sudden onsetHypotensionSyncopeProductive cough with reddish pink sputumTachypnoeaCyanosisLoss of consciousnessCardiac arrest

Cardiac ArrhythmiaChange in pulse rate, rhythmChange in ECG rhythm

Catheter ruptureShortness of breathAlteration in vital signs observationsArrhythmiasFluid leakage

Laceration of major vesselsRespiratory distressPain in shoulder and armTachycardiaPallorElevated blood pressureRigorsHaematoma

Action

Notify Medical Staff immediatelyAdminister oxygenRecord vital signs observationsOrder chest x-raySet up for chest drain insertion or needle cannulation

Emergency situationObtain immediate Medical AssistanceClamp catheterPlace patient head down on left side and give highflow 100% oxygenTake pulse, blood pressure, respiratory rate andsaturation levels continuouslyRecord ECG

Medical staff to reposition or remove catheterConfirm position on chest x-ray

Inform Medical Staff immediately

Inform Medical Staff immediatelyMonitor vital signs observationsApply direct pressure for 5-10 minutes



Damage to brachial or phrenic nervesAltered motor or sensory impairmentNumbing or tinglingRespiratory difficultiesHoarse voicePainful shoulder or armPainful paresthesia

Hydrothorax and vessel erosionIncreasing hypoxiaCardiac compromiseRespiratory compromiseChest painMediastinal wideningFailure to aspirate blood from catheter

SepsisPyrogens introduced into the circulation producing afebrile reaction, elevated temperature TachycardiaRespiratory distressPallorConfusionHeadacheBackachePain, swelling or inflammation at insertion siteRigorsNausea and vomiting

Occluded LumenPreventionCauses: Incorrect or insufficient flushing of the lumenwhen not in useAn administration set or infusion device being turnedoff for long periods

Deep Vein ThrombosisCan occur as a result of fibrin sheath breaking awayfrom indwelling device, thrombus from intimal damageduring insertion, infusion.Thrombus blocks flow through a vessel causingpressure to rise distal to the blockageRednessPainSwellingOedemaDifference in colour and temperature of extremitiesVein engorgement on affected side


Inform Medical StaffAdminister high flow oxygenChest x-rayEvacuation of fluid

Inform Medical StaffRemove line as instructedSwab from site/tip of catheter for C&SSend Blood Cultures

MSUsputum specimen

Use measures to cool patient

Maintain patency• Continuous infusion to keep vein open (KVO)• Intermittent flushingGentle aspiration may dislodge the clot and 0.9%saline flush may be all that is needed If not use of negative pressure technique




DISABILITYThis chapter covers the assessment and monitoring ofthe neurological system and care of the unconsciouspatient.

Primary SurveyAssess conscious level – AVPU/GCS – low level may

indicate need for intubation.Recovery position if necessaryand not contraindicated

Pupils size, reactivity, symmetryAny abnormal movements or weakness – treat seizuresBlood Glucose – treat hypoglycaemiaRash/fever suggesting meningoencephilitis – antibiotics

Secondary SurveyDetailed neurological assessment and full GCSCT scanLumbar punctureFurther investigationsRefer if necessary.

IntroductionImpairment of neurological function and consciouslevel is a potential medical emergency and mayhave many causes. The important issue is recognisingthe problem, providing appropriate resuscitation/stabilisation and identification of correctable andtreatable pathology.

Causes of impaired consciousnessAltered level of consciousness may be caused byprocesses affecting the brain stem, reticular formationor cerebral cortex. The cortex is in generally responsiblefor performance of higher functions and theinterpretation of and interaction with the environment.The brainstem is the location of structures responsiblefor vegetative and autonomic functions. The ReticularActivating System is a diffuse poorly defined area of thecentral nervous system ascending from the brainstemto the Thalami. It is responsible for maintaining thecapacity for consciousness amongst other functions.

In general acute dysfunction is caused by trauma,hypoxia, ischaemia, metabolic disturbance, toxicologyor infection.

Diffuse cortical dysfunction

• Trauma – diffuse axonal injury (DAI), shearing ortearing of cortex, cerebral contusion.

• Infection – meningitis, encephalitis or abscess,bacterial, viral and parasitic.

• Intoxication/poisoning – deliberate or accidentaleffect of drugs especially opiates and othersedatives.

• Metabolic – hepatic failure, renal failure, inbornerrors of metabolism.

• Endocrine – diabetes, hyper and hypoglycaemia.

• Hypertensive encephalopathy.

• Epilepsy – post ictal phase.

• Post cardiac arrhythmia – anoxia or hypo-perfusion.

• Intracranial haemorrhage.

• Ischaemic stroke.

• Hypoxia.

• Hypercarbia in respiratory failure – raised PaCO2 hasa direct anaesthetic effect as well as increasingcerebral blood volume and potentially increasingintracranial pressure.

• Hypothermia or hyperthermia.

Direct effect on brain stem

• Brain stem haemorrhage, infarction, neoplasm.

• Brain stem demyelination.

• Wernicke-Korsakoff syndrome – acute thiaminedeficiency associated with alcohol excess.

• Trauma.

Indirect effect on brain stem

Supra-tentorial pathology causing brainstemcompression from above such as hemisphere tumour,infarction, abscess, haematoma, encephalitis ortrauma.

Infra-tentorial pathology such as cerebellar lesions.



Clinical ApplicationPrimary Survey

As a part of the primary survey an assessment shouldbe made of conscious level and neurological disability.Initially a rapid assessment can be made using theAVPU1 system, documenting whether the patient isAlert, responding to Voice, responding to Painfulstimulus, or Unresponsive. This is a simple easilyreproducible method that is ideally suited to rapidassessment and is easier than, but not as sensitive asthe Glasgow Coma Scale and Score.

The airway and breathing should have been assessedand managed accordingly at the beginning of theprimary survey but even if the airway is clear andspontaneous breathing is maintained the airway maybe at risk due to decrease airway reflexes in the face ofdecreased conscious level. Oxygen should be given byfacemask to keep SpO2>90%. If there is absence orimpairment of the gag reflex simple measures toprotect the airway and reduce the risk of airway soilingdue to vomiting or passive regurgitation should beconsidered. Unless contraindicated the patient shouldbe placed in the recovery position with their head andlimbs positioned appropriately to avoid furtherdamage. An AVPU level of P or U should lead to urgentconsideration of formal airway and ventilatory controlby intubation of the trachea with a cuffed endotrachealtube.

Spontaneous limb movement should be documentedand any unilateral paralysis or weakness noted.

The pupils should be examined and pupillary size;symmetry and reactivity to light should be noted.

Any seizure activity should be noted and managedaccordingly in line with local policy and close attentionpaid to the ABCs.

The blood glucose should be measured to exclude hypoor hyperglycaemia.

Immediate intervention is required for:

• Hypoglycaemia, which should be corrected withintravenous (IV) 50% glucose or Glucagon IM.

• Seizure activity should be stopped with IVanticonvulsants according to local policy.

• Suspicion of meningoencephalitis should be treatedurgently with IV antibiotics and antivirals after bloodcultures have been taken.

• Wernicke's encephalopathy due to acute thiaminedeficiency in alcoholism should be treated with IVthiamine.

• Evidence of raised ICP causing lateralising signs, i.e. 3rd Cranial Nerve palsy (blown pupil) should bemanaged with IV mannitol (10%) or hypertonicsaline and urgent CT scanning considered.

1American College of Surgeons. Advanced Trauma Life Support manual 1983.

No

Give verbal stimulus orgentle shake

No

No response

Apply painful stimulus. Nail bed pressure to

uninjured limb, pressureover supra-orbital nerve,

pressure to upper border oftrapezius or sternal rub.

Eyes openspontaneously.

Oriented speech.

Obeys commands.

Yes

GCS

15

13

9

3

A

Yes V

Yes P

U

Any verbal, motor or eye response.

Any verbal, motor or eye response.

Does not respond to any stimulus.



Differential DiagnosisThe arrival at a diagnosis will depend on detailedassessment during the secondary survey. However, a list of differential diagnoses can usually be arrived at if one takes note of the context of the patient’sdeterioration. In the context of morphineadministration for postoperative analgesia thecomposition of the differential diagnosis of reducedconsciousness will have a different order to thatassociated with pyrexia and symptoms of menningism.It is worth remembering that the underlying cause of a drop in the level of consciousness may not be theobvious one and full examination and investigationshould not be limited by first impressions.

Secondary SurveyThe secondary survey is more leisurely and can becarried out once any immediately life-threateningproblems have been dealt with. Formal assessment ofconscious level using the Glasgow Coma Scale can becarried out and a full neurological examinationperformed. The art of the Neurological exam is beyondthe scope of this text but is dealt with in most books onClinical Medicine.

Detailed physiological and clinical assessment isessential. Frequent routine observations should becarried out including BP, HR, RR, SpO2 and temperatureas the patient’s condition dictates and in additionneurological observations (‘Neuro Obs’) should bedocumented. These include GCS and pupillary size andreactivity. Neuro Obs should be documented on anappropriate observation chart with the frequency asdictated by the patient’s condition and clinicalmanagement plan.

Respiratory pattern should be noted with reference torate, depth and pattern.

Eye signs – abnormalities are common in pathology ofthe Reticular Activating System or Brain stem.

Fundoscopy

The fundi should be examined with an ophthalmoscope.Signs including papilloedema, subhyaloidhaemorrhage, hypertensive retinopathy and diabeticretinopathy are of importance in the formulation of adiagnosis but the details of these are beyond the scopeof this text.

Motor Assessment

Symmetry of CNS: full assessment of tone, power,movement and reflexes. This is more a part of a formalneurological assessment and will not be covered here.

2Dolls eye movements are tested by rotating the head from side toside or irrigating the outer ear with cold fluid. With movement ofthe head the normal response is for the eyes to attempt to remainfixed on one point. Abnormal is when the eyes remain fixed intheir orbits and do not move relative to the head as the head ismoved. If using iced water irrigated into the outer ear a normalresponse is nystagmus towards the irrigated ear. An abnormalresponse is no movement with cold irrigation.

Pupillary & eye movement signs:

Normal direct and consensual reflex.

Midposition (3-5mm) non-reactive +/– irregular.

Unilateral dilated and unreactive.

Small reactive (pinpoint or pontine pupils).

Horner’s syndrome – unilateral constricted pupil withconjunctival injection.

VOR (Vestibulo-Occular Reflex)2 tested by dolls eyemovements or ice water caloric testing.

Interpretation:

Intact Brain Stem.

Midbrain lesion.

3rd nerve compression.

Pontine lesion or drugs (opiates).

Ipsilateral lateral medulla or hypothalamic lesion.

Normal indicates mostly intact brain stem between 7thnerve nucleus in the medulla to the 3rd nerve nucleusin the medulla.



The Glasgow Coma ScaleThe Beginnings.

The Glasgow Coma Scale was introduced by Teasdaleand Jennett in 1974 in their paper in the Lancet3. Therewas at the time the need for a clinical scale that couldbe used to reliably assess impaired consciousness. Itneeded to be simple, consistent and allow accuratecommunication between clinicians.

To be generally accepted it needed to be…

• Practical to use in a wide range of hospitals.

• Suitable for use by a wide range of staff withoutspecialist training.

• Not reliant on only one type of response.

• Involves identifying clearly defined responses thatcan be accurately graded according to a rank orderthat indicates the degree of dysfunction.

The Scale assesses response to stimuli in threeparameters – EMV:

• Eye opening scores 1-4

• Motor Responses score 1-6 (5 initially in the original paper)

• Verbal Responses score 1-5

• The Score calculated from these responses cantherefore range from 3-15 and be constructed from a variety of response combinations.

Eye opening 1-4.

1. No eye response

2. Eye opening in response to pain

3. Eye opening in response to speech

4. Spontaneous eye opening

Record if eyes are swollen and cannot open. Record ‘C’on chart.

The patient may move their head to attempt to locatethe examiner even if their eyes cannot open but theGCS does not allow for recording such responsesnumerically.

Motor Responses 1-6(5).

1. No response

2. Extensor posturing, decerebrate

3. Flexion – abnormal, decorticate4

4. Flexion – withdrawal response

5. Localising response

6. Obeying commands

Motor responses to painful stimuliPainful stimulus can be applied in a variety of ways butshould be assessed consistently. Pressure can beapplied to the upper border of the trapezius muscle orto the supraorbital ridges – take care with the eyes.Alternatively firm pressure to the sternum can provideadequate stimulus. However, a positive localisation topainful stimuli requires movement of the hands toabove the level of the clavicle so pressure to the nailbeds with a pencil may not provide an accurateassessment. Spinal cord injury may mean that painfulstimulus below the level of the lesion may not bedetected and therefore confound the assessment.

Note that repeated assessment can leave bruises.

Record the best response if there is a true differencebetween left and right.

3 Assessment of coma and impaired consciousness. A practical scale.Teasdale G, Jennett B.Lancet. 1974 Jul 13;2 (7872):81-4

4 Decorticate posturing not originally included in the GCS butincluded later.

Supraorbital ridge

Upper border of Trapezius

Sternal pressure



Verbal Responses 1-5.

1. No response even to painful stimuli

2. Incomprehensible speech/groaning

3. Inappropriate speech/monosyllabic

4. Disoriented, confused conversation

5. Oriented and converses

Why do we use the Glasgow Coma Scale?Before it’s introduction there were various scoringsystems around the world assessing neurologicaldysfunction with differing numerical and descriptivesystems. This could potentially lead to confusionbetween those assessing patients and in thecommunication of those assessments to the peoplemaking clinical management decisions. The GCS wasintroduced as a reliable, reproducible system based onmultiple parameters identifying clearly definedresponses that could be accurately graded according toa rank order that indicated the degree of neurologicaldysfunction. It was also simple enough to be used by a wide range of staff.

The GCS is useful in the initial assessment of patientsand as a monitor of progression, improvement ordeterioration in their condition.

As it has been widely adopted across the world it actsas a reliable communication tool in the referral of braininjured/impaired patients to specialist teams. For addedclarity it is useful to communicate the individualcomponents of the scale as well as the summated scorerecognising that the same score may be achieved by avariety of EMV combinations.

A score of 8 could therefore be communicated asGCS=8/15 (E2M4V2) with the breakdown according toindividual responses.

Prediction of outcome?The use of the score as a predictor of outcome is usefulin traumatic brain injury with the best GCS obtained inthe first 24hrs after injury after adequate resuscitationbeing predictive of overall outcome at 6 months postinjury. Its predictive usefulness in other causes ofneurological impairment is less clear. Other scoringsystems have been suggested with greater applicationto medical causes of coma but none have yet gainedthe level of usage that the GCS enjoys5,6.

The GCS is also an integral component of otherpredictive and clinical scoring systems such as RTS,TRTS, TRISS and Apache II amongst others7.

Note

The GCS is a good assessment of current state of braindysfunction.

If used in the assessment of traumatic injury the resultmay be affected by intoxication with alcohol, drugs etc.

A score of 8 or less is defined as coma andconsideration should be made of formal airwayprotection by intubation and ventilation. In addition a drop of 2 points or more points in the score shouldalso prompt consideration of intubation.

GCS and AVPU:As discussed above the AVPU score is a simpler but lesssensitive assessment tool of level of consciousness. A lack of response to verbal stimulation implies a GCSof 9 or less8.

SummaryThe Glasgow Coma Scale is a method of monitoringconscious level and indirectly an assessment of braindysfunction. It is useful as an initial assessment tooland an ongoing screen for changes in neurologicalstatus.

5Validation of a new coma scale: The FOUR score.Eelco F. M. Wijdicks, MD, William R. Bamlet, MS, Boby V.Maramattom, MD, Edward M. Manno, MD, Robyn L. McClelland,PhD. Annals of Neurology Volume 58, Issue 4 , Pages 585 – 593.

6Simple bedside assessment of level of consciousness: comparisonof two simple assessment scales with the Glasgow Coma Scale. A. F. McNarry and D. R. Goldhill, Anaesthesia, 2004, 59, pages 34–37.

7RTS (Revised Trauma Score), TRTS (Triage Revised Trauma Score),TRISS (Trauma Injury Severity Score), Apache (Acute Physiologicaland Chronic Health Evaluation).

8Association between the assessment of conscious level using theAVPU system and the Glasgow Coma Scale. Mackay C., Burke D., Burke J., Porter K., Bowden D., Gorman D. Pre-Hospital Immediate Care 2000; 4: 17-19.



Planning care and decision makingAfter initial assessment, management of lifethreatening abnormalities and specific investigations,discussion should be with appropriate specialists.

• ICU

• Neurosurgery

• Neurologists

• Radiologists

Acute airway control and protection is best provided onICU while structural brain injury, intracranialhaemorrhage, abscess or tumour needs urgentdiscussion with Neurosurgeons.

Specific care should be planned in the context ofpathology identified or suspected.

Escalation of care to an HDU or ITU environment inpatients whose neurological deterioration carries ahopeless prognosis is inappropriate and the temptationto escalate should be resisted. However, if deteriorationcan be halted and deficit potentially reversed thenintensive monitoring and support should be consideredwithout delay. Senior assessment and input is essential.

A patient with a decreased level of consciousness whois to be managed conservatively on the ward should benursed in the recovery position to minimise the chancesof airway obstruction. Basic nursing care appropriate toan unconscious patient should be continued.

EXPOSUREThe aim of this chapter is to highlight the importance ofa head to toe examination of the critically ill patientand to discuss the important information that may begathered at this time.

Primary SurveyBrief tip to toe examination including backLook, listen and feelBeware heat loss

Secondary SurveyFull detailed top to toe examination

Introduction

Once ABCD have been addressed the system comes toExposure. This is the point in time when the covers arepulled back and you take a quick look but it still followsthe key principals of Look, Listen and Feel.

Often it is at this point in the resuscitation andassessment of the patient that all the information fitstogether and a diagnosis and treatment plan is formed.

Primary SurveyAlways remember to start with a revisit to A, B, C andD to check that no deterioration has occurred beforemoving forward to Exposure.

Then while preserving the patient’s privacy and dignitypull back the covers and take a head to toeexamination using the look, listen and feel approach. It is impossible for this section to include everythingthat could be found while examining a patient but themost common aspects will be discussed.

In the primary survey a swift examination should takeplace from head to toe of the patient looking forobvious causes for the patient’s deterioration such ashaemorrhage. Any such discoveries should be treatedimmediately.

At all times remember to communicate your findings toall the members of the team and ensure each finding ifrelevant is acted upon. No matter how trivial you feelsomething may be voice your thoughts as it maybecome very important to someone else.

Again before moving on to secondary survey quicklyrevisit A,B,C and D to check no deterioration hasoccurred and take action as necessary.



Primary Survey

Skin – colourhot/coldwet/dryrashbruising

Infection –redness or inflammation of line or wound sitesColour of sputum/urineOffensive diarrhoeaSwollen red/hot areasPyrexia

Fluid losses –vomitingdiarrhoeastomanaso-gastricwound lossesburnspyrexiadrainsascites urinefluid balance?

Bleeding – wound sitespuncture sites

drain sitesstoma

PR or PVvomiting/faeces

Oedema present or not areas affected

fluid losses from puncture sites pressure limiting perfusion

Abnormal distension –abdomen

limbsdiaphragm splinting

IV access – present or not

adequate for need secured in position tissued or useable

site clean or signs of infection fluids attached or not

IV fluids what type delivered on time?

any drug infusions eg. Insulin or KCl

Secondary SurveyDuring the secondary survey the knowledge gained inthe primary survey is built upon with the additionalinformation gained from the notes, care plan andcharts together with the blood results and otherinvestigations.

The success of the secondary survey is dependant onthe quality of the history gained from the notes and thedetail documented on the charts.

If fluid balance charts have been poorly completed

dehydration or fluid overload are not as apparent.Equally poor history taking at the time when thepatient was well enough to answer questions makesdifferentiating newly developed symptoms from thepatient’s norm difficult.

Once all the information has been collated a plan ofcare needs to be formulated including organisingappropriate investigations and referral to relevantpractitioners. Where will the patient receiveappropriate care? What is the resuscitation status of the patient?



PAIN The purpose of this chapter is to gain an understandingand raise awareness of the safe and effectivemanagement of acute pain.

Primary SurveyYour first priority

Secondary SurveyIncludes the assessment, treatment and monitoring ofpain

Introduction The aim of this section is to ensure that pain isassessed and managed effectively with the appropriateanalgesic treatment for individual patients.

Pain is multi-dimensional which can make it difficult tomeasure objectively, unlike a blood pressure or a pulse.Managing pain effectively is an important aspect ofhigh quality patient care. The key to effective painmanagement is regular assessment and monitoring ofindividualised treatment. When assessing pain in theacutely ill patient the drug card should be reviewed aspart of the management plan.

Definitions• Nocioceptive pain occurs when tissue has been

damaged e.g. inflammation, post-operative pain,chest trauma. This type of pain is best treated withregular paracetamol, +/– NSAID and opiates forincident pain e.g. pain on movement.

• Neuropathic pain, which occurs as result of damageto nerve tissue e.g. ischaemic limb pain. This type ofpain is best treated with regular paracetamol, +/–NSAID adjuvants e.g. Amitriptyline, Gabapentin orPregablin and opiates.

Whether pain is nociceptive, neuropathic or acombination of both will determine the appropriatepain relief required and the frequency of painassessment and observations.

Acute pain has a protective function with a rapid onset,usually of short duration. This resolves after removal ofstimulus or tissue healing and measured in days ratherthan months. The incidence of patients experiencingchronic pain following inadequate management oftrauma/post surgery is 28%.

Chronic pain has no protective function and is presentlong after the immediate effects of an injury havesubsided and persists beyond the healing time. Paincan be described as chronic when it exists longer than3 months. In the context of acutely ill patient a historyof previous chronic pain may impact upon theirtreatment.

Why Treat Pain?Inadequate treatment of pain is distressing for patientsand can affect them physically, psychologically andemotionally. The perception of pain can be influencedby the following factors:-

• Gender

• Age

• Culture

• Individuality

• Meaning

Physiological consequences of inadequate pain controlPulmonary

• Reduced pulmonary function

• Reduced ability to deep breath and cough

• Hypoxaemia (reduced O2 in arterial blood)

• Sputum retention

• Chest infection/pneumonia – leading to possibleadmission to either High Dependency Unit orIntensive Care Unit

Cardiovascular

• Sympathetic nervous activity

• Tachycardia

• Hypertension

• Vasoconstriction

• Increased myocardial O2 consumption leading tomyocardial ischaemia/infarction

Gastrointestinal

• Reduced gut motility

• Nausea and vomiting

• Reduced nutrition – resulting in poor wound healing



Mobility

• Deep vein thrombosis

• Pulmonary embolism

• Pressure sores

Psychological effects

• Anxiety

• Insomnia

• Low mood

• Altered behaviour

• Demoralised

Initial assessment of pain• All pain needs to be assessed, by the nurse/doctor

looking after the patient, 4-6 hourly or morefrequently if necessary and documented on TPRchart or pain chart.

• Following the administration of analgesia, painshould be re-assessed to evaluate the efficacy ofanalgesia given.

• Dynamic pain assessment, i.e. at rest and onmovement and monitoring the presence of sideeffects.

Use of the Pain Assessment Tool

3 SEVERE PAIN• Free movement not possible• Pain continues at rest• Normal sleep impossible• Clinical care not tolerated

2 MODERATE PAIN• Mostly comfortable at rest• Interrupted sleep• Movement/clinical care restricted

1 MILD PAIN • Comfortable at rest• Comfortable on movement• Able to sleep/perform normal activities

0 NONE• No pain at rest or on movement• Able to perform activities of daily living

If the patient is asleep when you go to assess theirpain and they are not sedated due to opiates, thendocument ‘A’ (asleep) on the TPR chart

Analgesic Ladder To be used alongside the pain assessment tool

3 SEVERE PAIN• Regular Paracetamol +• Regular Codeine +• Regular NSAID (where not contra-indicated) +• Morphine protocol• Refer to the Acute Pain Team if pain is still not

controlled

2 MODERATE PAIN• Codeine 30-60mg PRN (use Morphine Protocol if

ineffective or post-op)• Regular Paracetamol + • Regular NSAID (Codeine 30-60mg PRN if NSAID

contra-indicated)

1 MILD PAIN• Regular Paracetamol • Regular NSAID (where not contra-indicated)

Baseline AnalgesiaBy using the concept of the analgesic ladder, if patientsare regularly given simple analgesia, e.g. Paracetamol+/– non-steroidal anti-inflammatory (Ibuprofen) if notcontraindicated, plasma levels achieved can have anopiate sparing effect therefore requiring fewer opiateshence reducing the risk of opioid side-effect (sedation,nausea, respiratory depression).

Hydration is an important factor whilst managing paineffectively. Elderly patients are often dehydrated. Inaddition they may have a degree of renal impairmentresulting in reduced blood flow, clearance andfiltration. Also consider cardiac disease in relation tothe analgesics being given and the bodies ability tometabolise and excrete the drug or in the case ofopiates the excretion of active metabolites.Dehydration is a common cause of adverse drugreactions.

• Ensuring that patients are well hydrated is essential.



Analgesic Routes• Oral

• Subcutaneous

• Intravenous

• Intra-muscular

• Rectal

• Epidural

• Intrapleural

If patients can take oral medication, this is preferredover other routes.

Naloxone Reversal of postoperative opiateinduced respiratory depression,overdose of opiates. Well tolerated ifgiven slowly. Short duration of action.

Indications Opioid induced respiratory depression(<8 per minute).

Dose By Intravenous injection, 0.4-2mgrepeated at intervals of 2-3 minutes toa maximum of 10mg. If respiratoryfunction does not improve questionthe diagnosis.

Risks Caution in cardiovascular disease,physical dependence.

CHEST TRAUMAPatients with fractured ribs, sternum or other chesttrauma are at risk of significant pulmonarycomplications. This is often related to inadequateanalgesia.

• Individual assessment of patients pain will highlighttheir respiratory support and analgesic requirements

• Baseline analgesia should be prescribed regularly

• Intrapleural blocks/epidurals can be helpful but needto be identified early

• Contact relevant expertise

Did you know?Bilateral thoracic injury is associated with a 13 foldhigher probability of prolonged ventilation thanunilateral injury.

The probability of development of a pneumothoraxand/or haemothorax is 25% with one or two ribfractures and over 80% in patients with more than twofractured ribs.

Elderly patients with rib fractures have twice themorbidity and mortality of younger patients. For eachadditional rib fracture in the elderly, mortality increasesby 19% and the risk of pneumonia by 27%.

Mortality rates as high as 36% have been reportedwith first rib fractures, which are associated with injuryto the lung, ascending aorta, subclavian artery, andbrachial plexus.

Average blood loss per fractured rib is reportedly 100-150ml.

Appendix – analgesic drugs and pain protocols



MICROBIOLOGYThis chapter aims to describe the principles ofmicrobiological practice in the critically ill.

IntroductionWhilst patients may become critically ill as a result ofan infection it must also be noted that they are allextremely vulnerable to infections. Critically ill patientsshould be regarded as being relativelyimmunocompromised and close attention to infectioncontrol is imperative.

The principles of microbiological practice in thecritically ill can be divided into infection control,microbiological diagnosis and antimicrobial prescribing.

Infection ControlInfection control measures for critically ill patientsinclude the general measures that should be applied toall patients as well as specific measures relating to theinsertion and handling of invasive lines.

General measuresDespite many clinicians still being in strong psychologicaldenial transmission of infections by staff is a major sourceof cross infection. Hand washing campaigns alone arewell documented to have substantially reduced infectionrates on intensive care units.

Universal Minimum Standard

• Bare below the elbows is the current national bestpractice guidance i.e. Short sleeves (or at least rolledup), no wristwatches, bracelets or rings.

• Wash your hands with soap and water before andafter any patient contact. At the very least usealcohol hand gel. It is important to remember,however, that alcohol hand gel is ineffective againstClostridium difficile, and is no good on visibly soiledhands.

• If you expect to come into contact with body fluidsthen wear gloves. Remember to take your gloves offbefore handling the notes, and to wash your handsbefore and after using gloves.

• Clean equipment that touches the patient betweenpatients (stethoscopes, patella hammers, otoscopes,pulse oximeter probes, sphygmomanometer cuffs toname a few). Alcohol wipes suffice on mostoccasions.

Barrier Nursed is also advisable in any patient whois critically ill. As above plus:

• Wear gloves for any patient contact

• Wear a disposable plastic apron, it will help to keep your clothes clean as well as reducingmicrobiological cross contamination betweenpatients.

• Remove the gloves and apron and wash your handsbefore leaving the patients room.

• Leave unnecessary equipment (notes, charts etc.)outside. If possible, each patient should have theirown stethoscope as opposed to each clinician.

• Minimise the number of staff entering the room.e.g. don’t take the entire team into the room duringthe ward-round.

• A side room with the door open is a bay not a room!Keep doors closed whenever possible.

Invasive proceduresInvasive procedures, by definition, breach a patient’snatural defences and provide a route of entry forinfection. Critically ill patients often undergo a numberof invasive procedures, such as insertion of venous andarterial catheters, as well as insertion of urinarycatheters The risk of introduced infection rises witheach procedure performed, and those patients withinvasive devices in situ for longer periods of time arealso at increased risk of infection. Line sepsis is notuncommon and can be fatal. Many line infections areinitiated/caused by ‘dirty’ insertion, howeverscrupulous attention must be paid to every invasivedevice to ensure there are no signs of infection, andthat devices are not left in situ for longer than isabsolutely necessary.

Basic principles for placement of central venouscatheters, etc

• Wear sterile gown, gloves, mask and hat and use an appropriately sized sterile area to work from, e.g. dressings trolley with a dressing pack openedon top.

• The most effective skin prep is 2% Chlorhexidine inalcohol (check expiry date, apply two coats allowingthe skin to dry between coats).

• Once the skin is prepped then drape an adequatelylarge area to ensure sterility. Most dressing packscontain an inadequate sterile drape but additionaldressing towels are often available, remember that



the Seldinger wires provided in some Invasive linekits can be up to 45cm long and therefore the sterilefield must extend to more than this length in alldirections from the site of puncture.

• After the procedure has finished clean the area wellbefore applying a dressing. Remember blood is theperfect culture medium. If there is ooze from thesite, a gauze dressing can be used, but aim toreplace it with a clear dressing as soon as oozinghas completely stopped. Note Kaltostat is a usefultool in this situation as it will promote clot formation– it should be removed after 24 hours and the areacleaned before a standard dressing is applied.

• Ensure that all sharps are disposed of appropriately.It is best to take a sharps bin with you wheninserting a line, rather than taking your used sharpsto the nearest sharps bin.

Central Line Specific Infection Control NotesVenous and arterial catheters are a very common causeof blood stream infection, it is essential that goodinfection control practices are followed by everyonehandling the line.

1. Surveillance

a. Daily inspection of line sites (all of them) forerythema, discharge etc. is part of the daily reviewand it is important to be aware of the length of timethe line has been in, especially if it is ≥ five days.Ask yourself every day whether a line is still required– a line left in ‘just in case’ is not acceptable. Linesthat had to be inserted in non-ideal conditions (A&E,patients deteriorating on table in theatre, etc.)should be considered for early change.

b. Daily review of markers of possible infection, e.g. pyrexia, raised white cell count, elevated CReactive Peptide, raised ESR or elevatedprocalcitonin. If any of these factors occur then apaired set of blood culture (one set from the line andone set from a venous stab).

c. At Doncaster we do not change lines routinely, but ifa line infection is suspected a change to a fresh siteis probably necessary. Avoid ‘railroading’ a line in anexisting site if possible.

2. Care

a. If you use a line (to withdraw blood or inject) thenwear gloves, clean the hub of the three-way tabwith a Chlorhexidine 2% in alcohol wipe before andafter use and keep the cap in a clean place (not the

palm of your hand, not on the bed) or, better still,replace it with a sterile one.

b. Central lines should not be used for routine venousblood sampling other than in exceptionalcircumstances (i.e. IVDU), as residual blood increasesinfection risk. Keep the use of a line to a minimum –every time the cap is removed from the line there isa potential for organisms to enter the system.

Blood Cultures

Peripheral blood cultures have to be done in a sterilefashion, otherwise the false positive rate due tocontamination will be unacceptably high. Contaminantsmay swamp true pathogens in culture bottles leadingto infections being missed, and also act as potentiallyconfusing ‘false alarms’, which may result inunnecessary antibiotic therapy or premature removal ofa line. Blood cultures do not need to be taken on everypatient regardless – only obtain blood cultures if it isthought there is a possibility of bacteraemia.

Many Trusts ensure that all sets of blood culture bottlesare supplied with the relevant equipment andinstructions to ensure that contaminants are kept to a minimum, but the basic procedure is as follows:

1. Ensure all required equipment is at hand and checkexpiry dates.

2. Wash hands.

3. Before venepuncture, remove caps from bottles andclean with 2% Chlorhexidine in 70% isopropylalcohol wipes.

4. Apply disposable tourniquet, and select vein forpuncture, clean puncture site with Chlorhexidineand alcohol swab for 30 seconds, allow to dry.

5. Wash hands again, and apply gloves.

6. If using a Vacutainer-style system, attach a butterfly needle to the adaptor cap.

7. Enter vein without palpating site again.

8. Obtain aerobic sample first, then anaerobic. If you are unable to obtain sufficient blood for bothbottles, just the aerobic bottle will suffice.

9. Discard sharps appropriately, remove gloves, andwash hands.

10. Fill in the patient details on the blood culturebottles and request forms, and record procedure inpatient’s notes.



Guidance for Antibiotic UseBasic Principles

Normally the initial prescription for an infectiveproblem is made on the basis of an educated guess.This prescription should be reviewed and refined whenthe infecting organism and its antimicrobial resistancepattern is identified. The only way the second part ofthe process can be completed is if adequate andappropriate samples have been taken and sent to thelaboratory before the administration of the initial anti-microbial and so adequate sampling prior to the firstdose of antibiotic is imperative.

Early delivery of the right/best empirical antibioticregime can reduce mortality of seriously ill patients byup to 50%. See table 1 for examples of commonly usedantibiotics and their uses.

Remember:

• Use the narrowest spectrum antibiotic

• Give an appropriate/adequate dose

• Conversion of I.V. to oral at 48hrs if the patientcondition allows.

• Limit the duration of therapy to 5 days if possible.

• For longer course of antibiotics continue to screenand take samples to identify secondary infectionwith resistant bugs.

• When causative infection has been identified, andantibiotic sensitivities obtained, it is important tonarrow the antibiotic choice down as much aspossible.

The resistance patterns of micro-organisms tend to belocation specific and local antibiotic prescribingguidelines/policies should always be followed.Microbiology consultants are an excellent source ofadvice and their guidance should be sought andfollowed.

Good Practice for Antibiotic Prescribing

Clinical Indication of Infection Requiring Antibiotics

Samples of Blood, Urine and Sputum For Culture(other samples e.g. CSF as clinically indicated)

Prescribe the Narrowest Spectrum Antibiotic appropriate to theClinical Condition or Culture results, I.V. initially and at an appropriate

dose (adjusted for renal/hepatic dysfunction if present)

Review Results of Cultures with a viewto optimising the spectrum of cover

In critically ill patients continue tomonitor for worsening of markers ofinfection e.g. Pyrexia, Rising WCC,

Increase in C-Reactive Protein or ESR orElevated Pro-calcitonin levels

Samples of Blood, Urine and SputumFor Culture (other samples

e.g. CSF as clinically indicated)



Antibiotic

Benzylpenicillin

Amoxicilllin (and ampicillin)

Co-amoxiclav(Amoxicillinand clavulanicacid, akaAugmentin)

Flucloxacillin

Piperacillin-tazobactam(Tazocin)

Clarithromycin

Clindamycin

Type

Penicillin

Broad-spectrumPenicillin

Penicillin derivativeplus ß-lactamaseinhibitor

ß-lactamase -resistant penicillin

Antipseudomonalpenicillin with - ß-lactamase inhibitorTazobactam

Macrolide

Lincosamide

Spectrum covered

Streptococcus pneumoniaeGroup A,B,C beta-haemolyticstreptococciNeisseria meningitidisAnthraxDiphtheriaClostridium

Wider spectrum than Ben-Pen, including gramnegatives such as coliforms.Most enterococci.Some Haemophilusinfluenzae.

Wider spectrum thanamoxicillin, including Staphaureus (not MRSA), somemore resistant coliforms, andmany anaerobes.Covers most amox-resistantHaemophilus influenzae.

Staphylococcus aureus

As for co-amoxiclav, plusPseudomonas aeruginosa

Similar to benzylpenicillin.Staphylococci.Chlamydia.Mycoplasma.

Gram positive organisms,especially staphylococci andstreptococci.Anaerobes.

Not covered

Some Streptococcuspneumoniae (especiallythose acquired abroad)90% staph aureusGram-negativeorganismsEnterococci

As above, also:50% coliforms.Pseudomonasaeruginosa.

Pseudomonasaeruginosa.

Gram-negativeorganisms.Streptococci (in lowdoses).Enterococci.MRSA.

MRSA

Poor activity againsthaemophilus, somestaph now alsoresistant (especiallyMRSA)

Gram-negativeorganisms.If an organism ismacrolide resistant, it isclindamycin resistant.

Comments

Narrow spectrum.Useful forsplenectomychemoprophylaxis.Susceptible to -ß-lactamase.

Susceptible to - ß-lactamase.

Antibiotic of choicewhen dealing withanimal bites.

High dose in staphendocarditis, cancause hepatitis andcholestaticjaundice.

Not first lineantibiotic, bewarepenicillin-allergywhen givingTazocin.

Less GI disturbancethan erythromycin.A good 2nd lineagent to use inpenicillin allergywhen treatingGram-positiveinfections.

Excellent tissue andbone penetration.Risk of Clostridumdifficile infection.

Table 1: Characteristics of commonly used antibiotics and their spectrum of activity



Antibiotic

Cefuroxime

Cefotaxime

Ceftazidime

Metronidazole

Ciprofloxacin

GentamicinOnce-dailydosing (seebelow or localguidelines)

Meropenem

TeicoplaninandVancomycin

Fluconazole400mg, then200-400mgper day

Type

Secondgenerationcephalosporin

Third generationcephalosporin

Third generationcephalosporin

Quinolone

Aminoglycoside

ß-lactamaseresistant Abx(Carbapenem)

Glycopeptide

Antifungal

Spectrum covered

Less susceptible to -ß-lactamase.Haemophilus influenzae.Staphylococci.Streptococci.

Better gram-negativecover than cefuroxime

Very good activityagainst pseudomonas,especially if structurallung disease present.

Anaerobes, includingClostridium difficile.Protozoa. Tetanus.

Broad gram-negativecover

Broad gram-negativecover.Some gram-positivecover (includingstaphylococci, but not a first choice to treat)

Similar to Domestos,broad gram positive andnegative cover includinganaerobes

Most gram-positivesincluding MRSA

Candida albicans

Not covered

Only moderate gram-negative cover.Pseudomonas aeruginosa.Enterococci.

Poorer gram-positivecover than cefuroxime,esp staph.Enterococci.

Enterococci.

All aerobic bacteria.

Poorer gram-positivecover, esp Streptococcuspneumoniae andenterococci.

Anaerobes, haemolyticstrep + Streptococcuspneumoniae

MRSA.VRE.

No gram negatives at all.VRE.

Some non-albicanscandida species,aspergillus, Cryptococcus.

Comments

15% of penicillin-allergic patients showcross-reactivity withcephalosporins.

First line in meningitis/meningococcal sepsis.Risk of Clostridiumdifficile infection.

Risk of Clostridiumdifficile infection.

Standard in oral/GIinfections, good forantibiotic-associatedcolitis, give orally for C. diff.

If used without staphcover quickly selectsout MRSA. May reduceseizure threshold.

Is nephro- andototoxic. Rapidlyaccumulates in renalimpairment. Poor activity incollections and in pus.

Third line antibiotic,often after tazocin.Useful in multiresistantgram-negativeinfections.

Empirical for septicshock or exclusively forMRSA.Vancomycin requirestherapeutic drug levelmonitoring.



Infections by system

RespiratoryCommunity-acquired pneumonia (CAP) is defined as a pneumonia that patients bring into the hospital withthem or develop within 48 hours of admission.

Overall, the commonest organism causing community-acquired pneumonia is Streptococcus pneumoniae,followed by Haemophilus influenzae. Other organismsimplicated include Moraxella catarrhalis, atypicals (suchas Legionella pneumophila, Mycoplasma pneumoniae,Chlamydia psittaci and Chlamydia pneumoniae), andsometimes gram-negatives such as Klebsiella. Peoplewith underlying lung disease such as COPD are atincreased risk of infection with organisms such asPseudomonas aeruginosa. Staphylococcus aureus, andMRSA in particular, can be associated with pneumoniain people who are admitted from a nursing orresidential home.

Severe haemorrhagic pneumonia due to Panton-Valentine Leucocidin (PVL) producing Staphylococcusaureus is a rare phenomenon seen mainly in the young,but the increase in the incidence of PVL-producingcommunity-acquired MRSA suggests we will see morecases in the future. All cases where this is suspectedshould be discussed with a microbiologist.

Local guidelines will dictate empirical treatment.Current Doncaster Royal Iinfirmary recommendationsfor empirical therapy to treat CAP are Benzylpenicillin1.2g QDS and Clarithromycin 500mg BD, sometimesupgraded to Co-amoxiclav 1.2g TDS (or Cefuroxime 1.5g TDS) and Clarithromycin. All patients withpneumonia severe enough to warrant admission toCritical Care should have a urine sample sent forLegionella antigen detection, along with a bloodsample for atypical serology.

However, if the patient has already received antibioticsrecently (i.e. from GP) or has only been discharged fromhospital a few days ago with the same problem, thismakes the issue more complex and the abovecombination may not be sufficient. Selection of moreresistant organisms or gram negatives such ascoliforms or Pseudomonas (see below) may have takenplace already, and these cases may need to be treatedas though they were a hospital-acquired pneumonia,as below.

Hospital-acquired pneumonia (HAP) is defined as a pneumonia developing 48 hours after hospitaladmission. The picture here is dominated by gram-negative bacteria such as coliforms and Pseudomonascolonising the oropharynx from the upper GI tract, withsubsequent silent aspiration. In addition, gram-positiveorganisms such as Staphylococcus aureus can be a cause of HAP.

Due to the different spectrum of organisms, moreextensive gram-negative cover is necessary. Other co-morbidity may give clues as to the likelihood of theinfective organisms (table 2). Piperacillin/Tazobactam(Tazocin) or Meropenem are often used. Ciprofloxacin isan option against pseudomonas, however it lowers theseizure threshold and is discouraged in head injuriesand it is hardly used as a single agent, as it quicklyselects out MRSA, and is associated with an increasedrisk of Clostridium difficile infection. Ceftazidime maybe considered where there is a strong possibility ofPseudomonas infection.

In both CAP and HAP, once the causative organism hasbeen identified, it is important to select the narrowest-spectrum antibiotic available to reduce the incidence ofsecondary infection with more resistant organisms(including MRSA and Clostridium difficile).

Table 2: Host factors associated with specificorganisms

Host factors Likely/more common organism

Epidemiological Factors

Diabetes/DKA Strep. pneum., Staph. aur.

Alcoholism Strep. pneum., Staph. aur.,Klebsiella, Anaerobes

COPD Strep. pneum., Haemophilus.,Chlamydia pneum., Legionella

Structural lung Pseudomonas, Staph. aur.disease (i.e. bronchi-ectasis, cystic fibrosis)

Intravenous drug use Staph. aur., Anaerobes, Strep.pneum, Tuberculosis

Nursing home Gram neg. bacilli, Strep. residency pneum., Haemophilus, Staph.

aur., Anaerobes, Chlamydiapneum.



GI tractThe GI tract starts at the teeth and therefore oralinfections are included here. Flora changes as you passalong the GI tract:

The mouth is heavily colonised with streptococci,anaerobes, mixed gram-negative organisms andoccasionally candida species. The stomach and smallbowel are relatively sterile environments, with bacterialload increasing as the jejunum and ileum are reached.Infections related to oesophageal, gastric and small-bowel pathology (including anastomotic leaks aftersurgery) may involve coliforms, streptococci, anaerobesand yeasts. An antifungal is often considered whengiving empirical therapy in these situations.

The distal small bowel and the large bowel are veryheavily colonised with faecal bugs such as coliforms,enterococci and anaerobes. Infections related to largebowel pathology (usually perforation of a viscus or ananastomotic leak) tend to require broad-spectrum coverto ensure the mixed faecal flora is covered. A 2ndgeneration cephalosporin such as cefuroxime, plusmetronidazole is a commonly used empirical regimen.

Hepatobiliary infection such as cholangitis orcholecystitis is usually due to faecal gut flora, and theuse of an antibiotic which achieves high concentrationsin the bile is often advocated. Piperacillin-tazobactamis one such empirical choice. Severe pancreatitis is adifficult issue, as the disease itself can mimic sepsis,even if the necrotic pancreas is actually sterile. Empiricuse of antibiotics and antifungals rapidly selects outdifficult to treat gram-negative organisms, however a partially avascular organ is obviously at risk of beinginfected. Discuss at senior level!

Patients with fistulating disease or complex abdominalpathology (e.g. after multiple laparotomies) may havedifficult to predict infective problems, and should bediscussed at senior level on a case-by-case basis.

GU tract:Remember UTI can be a significant cause of sepsis,especially in the elderly. Urosepsis needs urgentattention. The underlying treatment principle includesnot only treatment of suspected infection, but alsoensuring or establishing free flow of urine. If there isobstruction in a potentially infected kidney, anephrostomy may be necessary. Pathogens are usuallygram-negative organisms such as coliforms and socefuroxime and gentamicin have a place. Enterococci

are sometimes implicated, and often may be treatedwith amoxicillin. Use gentamicin with care in thosewith renal impairment, and always obtain levels toensure the plasma concentratration is within thetherapeutic window.

Remember abnormal findings on urine dipstick incatheterised patients are very common (i.e. leukocytes,traces of blood, candida) but this may be of very littleclinical significance. In fact, bacterial colonization of a urinary catheter becomes inevitable after just a fewdays.

Skin/soft tissues/bonesPostoperative wound infections are not uncommon(20% of nosocomial infections). Risk factors includediabetes, renal failure and use of steroids.

Most wound infections are due to Staphylococcusaureus, including MRSA, though other organisms suchas streptococci and anaerobes may be implicated.Gram negative organisms such as coliforms andPseudomonas aeruginosa tend not to cause overt softtissue infection, but can colonise a wound preventingeffective healing. On occasion (especially afterabdominal or groin surgery) mixed bacterial woundinfections can lead to a rapidly necrosing picturerequiring broad-spectrum antibiotics and promptsurgical intervention.

Burns patients are nearly always colonised (andsometimes infected) by pseudomonas and other gram-negative organisms.

Cellulitis/erysipelas is often due to Staphylococcusaureus or Group A/C/G beta-haemolytic streptococci.Empirical treatment in cases severe enough to warrantadmission to a High Dependency Area is iv flucloxacillin(2g QDS) plus benzylpenicillin (1.2g QDS); if thecellulitic area is near/over operated bone discuss withthe microbiologists (may need additional fusidic acid/rifampicin or other agents, to treat potentialosteomyelitis). Please also refer to local guidance onuse of antibiotics in orthopaedics, and discuss with themicrobiologists if the patient is allergic to penicillin.

Necrotising fasciitis is a deep, fast spreading infectioncommonly caused by Group A beta-haemolyticstreptococcus. It can lead to extensive tissue damageand severe illness with a high risk of mortality.Antibiotics alone (meropenem 1g TDS plus clindamycin600-1200mg QDS) are insufficient and prompt surgicalassessment at senior level and extensive debridement



is an integral part of the management. Survival ispossibly better when surgery is undertaken early,amputations may be unavoidable. Some patientsbenefit from intravenous human normalimmunoglobulin, but this should always be discussedwith a microbiologist before use.

Central Nervous SystemAdult meningitis is most commonly caused byStreptococcus pneumoniae and Neisseria meningitidis.Due to widespread vaccination, Haemophilusinfluenzae is now a rarer cause. The interval toadministration of the first dose of antibiotic (empiricalcefotaxime 2g) has been shown to influence outcome,so DO NOT DELAY IT. Lumbar puncture does not takeprecedent over antibiotic administration, particularly ifthere are concerns about its safety (raised intracranialpressure).

Adults over 55 years of age are also at risk of Listeriamonocytogenes meningitis, so amoxicillin 2g iv QDSshould also be given in this age group.

Corticosteroids have been shown to reduceneurological sequelae in pneumococcal meningitis if given WITH the first dose of antibiotics(Dexamethasone 0.15mg/kg qds for 4 days).

The Meningitis Research Foundation publishesexcellent guidelines and algorithms for themanagement of bacterial meningitis, which can befound on their website at: www.meningitis.org.

Children below 2 years of age may present withmeningitis due to Group B beta-haemolyticstreptococcus, E coli, Klebsiella pneumoniae or Listeriamonocytogenes, in addition to those pathogens thatcan affect adults, and therapy should be discussed witha paediatrician or microbiologist at the earliestopportunity.

Viral meningitis is usually associated with alymphocytic picture on lumbar puncture, and is mostcommonly due to enteroviruses (many of which causeminor gastrointestinal upsets), but Herpes simplex virusand Varicella zoster virus may also be implicated.Treatment is usually supportive.

Encephalitis is inflammation of the brain, commonlycaused by viral infection. The most significantpathogens are the Herpes simplex viruses type I and II,which tends to affect mostly the temporal and frontallobes. Clinical signs are focal, including seizures,altered cognition and speech alteration. Early in the

disease process CT may not be diagnostic (hypodenselesion in temporal lobe) and aciclovir (30mg/kg/d) mayhave to be started empirically.

NB: Aciclovir is not a risk-free drug, and shouldn’t bestarted unless encephalitis is suspected. MRI is moresensitive than CT early on and PCR on CSF samplesmay confirm the diagnosis.

Neutropenic patientsPatients with haematological malignancies or thoseundergoing chemotherapy often have bone marrowsuppression leading to neutropenia (White Cell Count<1). This leaves them at risk from sepsis, usually dueto gram-negative bacteria such as coliforms andPseudomonas aeruginosa. Many have tunneled venouslines (e.g. Hickman, Broviac) in situ, which can act as a portal of infection for many bugs such as coagulasenegative staphylococci (e.g. Staphylococcusepidermidis), Staphylococcus aureus, enterococci,environmental gram-negative organisms (e.g.Stenotrophomonas maltophilia and Acinetobacterbaumanii), and fungi (e.g. Candida species).

Infections in these patients can be rapid and fulminant,so require prompt intervention. Blood cultures shouldbe taken peripherally and from all lumens of anyvenous lines in situ, and then empirical broad-spectrumantibiotics commenced – DRI currently advisesPiperacillin-tazobactam 4.5g TDS along withgentamicin 7mg/kg OD (this should be reviewed afterthe 1st dose, and appropriate levels should be taken toensure the plasma concentration is within thetherapeutic window). Empirical therapy will often beamended after discussion between microbiology,haematology and the parent team consultants.

Often infections are line-related, and in some cases theideal treatment may be to remove the infected line, butthis should only be done after discussion with theconsultant intensivist/haematologist.



MANAGEMENT PLAN

1. Primary survey complete? ABCDE/monitoring/immediate management undertaken

2. Secondary survey complete? History/full exam/investigations sent

3. Definitive diagnosis? Senior help needed/furtherinvestigations/other specialists

4. Definitive treatment? Surgical/medical/radiological/location of treatment

5. Documentation? Clear, time and date of entry,full details include future care

6. Review? Who, when, what circumstances hastenthis

7. Reassess? Patient condition may deteriorate,ABCDE again, be ready to change workingdiagnosis

8. Communicate clearly your plan

1. Primary survey complete? ABCDE/monitoring/immediate management undertaken

Treatment must be prompt and appropriate. Theseshould follow the guidelines in the manual. Remembertreat simultaneously with ABCDE, not after. Despite anacceptable history and examination, initial treatmentwas often delayed, inappropriate or both. (NCEPOD2005). During treatment remember to reassess andreassess and reassess. If primary survey onlyundertaken then the lack of secondary survey must bedocumented.

2. Secondary survey complete? History/full exam/investigations sent

The secondary survey should be as thorough as timeallows. They may not occur till hours after admission. A patient with a ruptured spleen may go straight totheatre from casualty having only had ABC done.

3. Definitive diagnosis? Senior help needed/furtherinvestigations/other specialists

Is there a definitive diagnosis? If not a workingdifferential diagnosis should be outlined. Has theappropriate seniority of professional seen the patient?Should another speciality see the patient? The nationalconfidential enquiries into perioperative death and

maternal deaths always comment about the lack ofsenior clinician involved in suboptimal management ofpatients. Junior doctors must seek advice more readily.This may be from specialised teams e.g. outreachservices or from the supervising consultant. (NCEPOD2005 report). IF IN DOUBT, REFER UP. This must bedone clearly, concisely with a clear indication of theurgency. This must be documented in the notes. Furthermore specialised investigations may be needed afterthe secondary survey.

4. Definitive treatment? Surgical/medical/radiological/location of treatment

The primary and secondary survey will treat lifethreatening conditions as they are found. In somecases this will involve definitive treatment but in themajority of cases the definitive treatment will occurafter this initial plan. The definitive treatment needs tobe clearly outlined. Be careful not to be blinkered bythe specialty area you work in. Abdominal painadmitted to a surgical ward may have a medicalreason. Remember definitive treatment may bemedical, surgical, radiological etc. Is the patient in theright place for definitive treatment? This not onlycovers equipment levels, but also staffing expertise andstaffing levels. Should this patient be in a highdependency area?

5. Documentation? Clear, time and date of entry,full details include future care

The team should produce a clear management plan.This must include current assessment (history,examination, and investigation), results, possiblediagnosis and management plan at that time. Thisshould be agreed with all those involved and clearlydocumented in the notes. This must be clear, conciseand legible. Timely and appropriate. Avoidabbreviations, shorthand etc. Written notes may be allthe communication the next carer sees. Thus it shouldinclude everything, including outstanding questions,concerns and what has been done. Any communicationshould also be documented. Remember what you writein the notes may be all you have to go by in court inthree to six years time! Lawyers assume if you have notwritten it you have not done it!



6. Review? Who, when, what circumstances hasten this

It must be clear when the patient should be reviewed.This should include reviewing of tests not yetcompleted and a review of the effectiveness oftreatment. How often should the nursing team betaking observations? When should the physiotherapistsee the patient? When should the doctor review thepatient? What happens if things are not improving?Part of the treatment plan should be an explicitstatement of parameters that should prompt a requestfor review by medical staff or expert multidisciplinaryteam. (NCEPOD 2005 report).

7. Reassess? Patient condition may deteriorate,ABCDE again, be ready to change workingdiagnosis

Patients may have evolving conditions. Certainconditions e.g. haemorrhage may not reveal itself forhours. Physiology may deteriorate to reveal a problemnot in the original diagnosis. Be prepared to thinkagain and even go back to ABCDE if needed.

8. Communicate clearly your plan

As you will have gathered this is a major part of themanagement of sick patients. This is important in theinitial acute management but often fails after this stagewhich may cause significant problems. Beware ofhandovers. With most health professionals nowworking on shift patterns handovers are part of normalpractice. Multidisciplinary handovers are rare anddoctors are poor at handing over patients. There mustbe a clear ongoing management plan for the patientincluding who out of the new team should review thepatient and when.

Do not forget communication with the patient. Theywill want to know what is happening and what youare doing to care for them. The relatives will also wantto know when the appropriate time comes but this maybe best done by someone more senior if complex.

Case study – poor management of a patient

See if you can identify five problems with themanagement of this case (taken from NCEPOD 2005).The first has been identified for you.

A patient in their mid-seventies was admitted as anemergency with diarrhoea and general malaise. Theonly significant past medical history was hypertension,treated with an ACE inhibitor. On admission they werenoted to be dehydrated, with a blood pressure of

110/60mmHg and a pulse rate of 100 beats perminute. Their respiratory rate was measured at 36breaths per minute. Serum creatinine was 154 µmol/l.They were admitted by the medical SHO whoprescribed intravenous fluid (1000ml over 8 hours) andantibiotics. The impression noted in the admissionclerking was ‘? infection’. Four hours after admissionthe BP was noted to be 85/50mmHg. Maintenanceintravenous fluids (3000ml) were prescribed and givenover the next 24 hours despite the low blood pressurethat persisted. In the first 24 hours after admission thenursing staff requested medical staff review on fiveoccasions. Four of these reviews were by the PRHO andone by the SHO. Despite continuing hypotension noadditional therapy was instituted. One entry (24 hoursafter admission) by the PRHO states that the bloodpressure is 70/30mmHg but that the patient appearsstable. Analysis of blood gases at that time revealedthe following; pH 7.31, PaCO2 3.7 kPa, PaO2 13.5 kPa,base excess –11.1mmol/l, lactate 4.3mmol/l. At thattime urine output was noted to be negligible. SHOreview confirmed these findings and the differentialdiagnosis of septic shock was made. An additional500ml of colloid were infused over the next two hours.No other treatment was initiated nor advice sought.The patient remained hypotensive, tachypnoeic andconfused overnight. The patient was reviewed by theSHO on several occasions, with no changes totreatment. Indeed one nursing entry states ‘Dr. notunduly worried at present – continue with presentregime’. A deterioration in consciousness at 48 hoursafter initial hospital admission prompted referral of thepatient to the outreach service. At this point the patientwas more acidotic, tachypnoeic and shocked.Admission to the ICU was expedited but despiteinitiation of organ support the patient continued todeteriorate and died 12 hours after ICU admission.

Problems:

1. Did the medical SHO recognise how ill the patientwas?

2

3

4

5



ERRORS – WHERE DO WE GOWRONG?Let me let you into a secret – doctors are not perfect.Nurses are not perfect. Physiotherapists are not perfect.We are human and thus will make mistakes. If youcount the mistakes you make in one day (e.g. pickingup the wrong keys, making coffee when you meant tomake tea, etc) you will be surprised how often thisoccurs. Clearly making mistakes in the clinicalenvironment have greater consequences. ‘Anorganisation with a memory’ estimates that 10% ofadmissions have adverse incidents causing harmcosting the NHS approximately £2 billion per year inadditional hospitals stays alone. Some adverse eventswill be inevitable complications of treatment butaround half may be avoidable. The aim of this shortsection is to make you more aware of medical errors,the situations they more commonly occur in andhopefully how to avoid them. References at the endlead to more in depth reading of this important area.

Medical errors occur due to patient factors, carerfactors, factors concerning what we do to patients andthe organisation we do them within.

Patients

Patients may answer our questions incorrectly for manyreasons, forget important information etc. The way weask questions can increase or reduce the likelihood oferrors. Remember this possible source of error!

Carer factors

There are many situations where errors are morecommon amongst clinical staff. Unfamiliar surroundings(e.g. rotations, new jobs), unfamiliarity with drugs/procedures/equipment are some of the reasons. Whatother reasons can you think of? One pneumonicincludes many aspects and is worth remembering as a self-check before we carry out clinical work.

I’M SAFEI – Illness. Am I well enough to work?

M – Medication. Have I taken/forgotten to takemedication which will adversely effectperformance?

S – Stress (home or work) Am I too stressed to worksafely?

A – Alcohol. Am I still intoxicated or too hungover?

F – Fatigue. Am I too tired?

E – Eating.

What we do to patientsPatients undergo investigations, treatments, surgeryand other procedures all of which are error prone.Wrong diagnosis or incorrect management can be onepossibility. Poor infection control (e.g. doctors notwashing hands between patients) increases hospitalacquired infection. Fifteen percent of these may bepreventable at a cost to the NHS of £1 billion.

Medication errors are consistently reported to accountfor between 10 and 20% of all adverse events. Drugerrors are one of the most common especially amongstacutely ill patients where treatment can be complex.One common problem is giving the medication by thewrong route. Oral medications and nebuliser solutionsmay be inadvertently given by the intravenous routeetc. Key measures to reduce the risk include:

• Using devices for the administration of infusions andfeeds only for the purpose for which they aredesigned.

• Preventing oral and intravenous drugs being takento the patient’s bedside at the same time.

• Labelling the distal ends of all lines to allow positiveidentification of the site of access.

• Confirming the route of administration during thechecking process.

Clear prescriptions, appropriate checking of drugs andpharmacists questioning drug doses and pointing outpossible interactions are there to provide a safe system.

Many medication errors occur at ‘handover points’within the health care system. It is easy to understandthe critical importance of effective communicationswhen patients move from one care setting to another.



Four hundred people die or are seriously injured inadverse events involving medical devices in the NHS.Unfamiliarity with equipment, poor training andtechnical failure are the cause of most of these.

The organisation we work inIn such a large and complex organisation there areplenty of opportunities for errors to occur.Communication and teamwork are key to managingsick patients. Indeed communication, teamwork andsituational awareness can be the cause of up to 80% of errors.

When a significant adverse event occurs it is rarely dueto one single event but rather a cascade of events. Thisis illustrated by James Reasons ‘Swiss cheese model’.This shows the barriers to errors as slices of cheese. No barrier is perfect so they have holes in. When theseholes line up an ‘error trajectory’ occurs.

Successive layers of defences, barriers and safeguards.Perneger BMC Health Services Research 2005 5:71

The barriers may have holes in due to human (active)errors. The other holes may be due to latent errors.These are errors in the system waiting to catchsomeone out. There are many examples around us inhospitals. One example is the ease of which anepidural infusion bag of bupivicaine can be attached toan intravenous cannula. This is waiting to catch out a tired distracted clinician. If you add in unfamiliarequipment it would be easy to see how a patient couldreceive inadvertent intravenous bupivicaine. And it hashappened more than once!

You are part of this system. Checking a patients namebadge before giving blood, checking the consentbefore undertaking a procedure, asking about allergiesbefore giving antibiotics, washing hands betweenpatients can not only save the NHS money but alsosave lives.

Further ReadingAn organisation with a memory. Report of an expertgroup on learning from adverse events in the NHS.A government white paper worth reading. Containsmany illustrations of errors which have occurred andthe financial cost to the NHS. (www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4065083)

Building a safer NHS for patients. Improving medicationsafety. A report by the Chief Pharmaceutical Officer2004. Another government paper worth reading partsof to understand the impact of medication errors.(www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4071443)

British Medical Journal 18th March 2000. An entireissue dedicated to medical error and patient safetywritten by experts.

Somes holes due toactive failures

Losses

Other holes due tolatent conditions(resident ‘pathogens’)

Hazards



APPENDIX 1 PULSE OXIMETRY Principles

Pulse oximetry is based on the differences in theabsorption of light between oxy-haemoglobin anddeoxy-haemoglobin. Two wavelengths of light areshone through the tissue. The relative absorption ofeach wavelength is used to calculate the relativeproportions of oxygenated and deoxygenatedhaemoglobin expressed as a percentage saturation.

Figure 3. Absorption of light by oxy-and deoxy-haemoglobin

In order for the value to reflect the arterial componentit is essential to identify the arteriolar component of thetotal absorption.

Clearly light will be absorbed by tissues especially thosecontaining Myoglobin and by blood within thecapillaries and veins which can affect the calculationsand so the software specifically analyses only thepulsatile component of the total absorption. (This is whythe abbreviation for Pulse oximeter saturations is SpO2

and for directly measured arterial samples are SaO2).

Factors Affecting Accuracy

No effectFoetal haemoglobin (HbF), SulphHb, Bilirubin(absorption peaks are 460, 560 and 600nm), dark skin.

Falsely low readingA reduction in peripheral pulsatile blood flow producedby peripheral vasoconstriction results in an inadequatesignal for analysis.

Venous congestion of the limb may affect readings, ascan a badly positioned probe.

Methaemoglobin (MetHb). The presence of MetHb willprevent the oximeter from working accurately and thereadings will tend towards 85%, regardless of the truesaturation.

Use of dye (indocyine green in cardiac studies,methylene blue in surgery).

Venous congestion, which may be caused by tricuspidregurgitation, high airway pressures and the Valsalvamanoeuvre, may produce venous pulsations which canproduce low readings.

External fluorescent light in the operating theatre maycause the oximeter to be inaccurate, and the signalmay be interrupted by surgical diathermy. Shiveringmay cause difficulties in picking up an adequate signal.

Nail varnish may cause falsely low readings.

Falsely high readingCarboxyhaemoglobin (CoHb). CoHb (haemoglobincombined with carbon monoxide) is registered as 90%oxygenated haemoglobin and 10% desaturatedhaemoglobin – therefore the oximeter willoverestimate the saturation.

CalibrationOximeters are calibrated during manufacture andautomatically check their internal circuits when they areturned on. They are accurate in the range of oxygensaturations of 70% to 100% (+/–2%), but are lessaccurate under 70%. Below the saturation of 70%,readings are extrapolated. Due to the shape of theoxyhaemoglobin curve, the saturation starts to fallrapidly at 90%.

LimitationsThe oximeter averages its readings every 10-20seconds. Hence, they cannot detect acute desaturation.The finger probe has a response time of approximately60 seconds, whereas the ear probe has a response timeof 10-15 seconds.

The site of application should be checked at regularintervals, as pressure sores and burns have beenreported.

The pulse oximeter only provides information aboutoxygenation. It does not give any indication of thepatient’s carbon dioxide elimination.

10

0.1 Wavelength (mm)

HbO2

Hb

(Infrared)910nm

(Red)660nm

600 700 900 1000



APPENDIX 2 – BLOOD GASANALYSISBlood gases enable you to assess the ventilation statusof a patient i.e. their Gases pCO2 and pO2 as well astheir acid base status.

Ventilation

The pCO2 is the only indicator of the effectiveness ofventilation. Oxygenation as indicated by the pulseoximetry saturation. The pO2 can be preserved for a surprisingly long time in a patient with inadequateventilation.

Acid Base Made Easy

Changes in the concentration of Hydrogen ions [H+]affects the charge on the active moieties of enzymesand can thus have profound effects on the rate ofmetabolic reactions. As a result the body attempts tomaintain the [H+] ion concentration within verynarrow limits.

There are three values required to define an individualsacid base status.

1. pH or H+ ion concentration as a measure of acidityor alkalinity.

2. PaCO2 to identify the respiratory component.

3. HCO3- ion concentration as a measure of themetabolic component.

HCO3- is not measurable directly and so it is usually acalculated variable. A range of attempts to separate therespiratory and metabolic components have been triedresulting in the derived indices: Standard Bicarbonate,Base Excess and Buffer Base.

1. Standard Bicarbonate

Is an estimate of the bicarbonate concentration of thesample after the removal of any respiratorycomponent. It is calculated using the standardisingPaCO2 of 5.3kPa. At first glance it would seem to be aneasy way of estimating the metabolic component ofany disorder, however it makes no allowance forchronic respiratory disease associated with hypercapniaas in these disorders some metabolic compensationwill have already taken place affecting the normalvalues. Theoretically the calculation could be doneagainst the individuals known normal PaCO2 toestimate new metabolic components.

2. Base Excess

The Base Excess (in alkalosis) or Base Deficit (inacidosis) is defined as the amount of acid or baserequired to return the pH of 1 Litre of blood to normaldefined as pH 7.4 at a PaCO2 of 5.3kPa.

It is often used to calculate the dose of bicarbonaterequired to correct severe, life threatening, acidaemia.

Base Deficit x (Weight/3) = The Number of Millimolesof Sodium Bicarbonate

1 ml of 8.4% Bicarbonate = 1 millimole

3. Buffer Base

Fell out of fashion a long time ago.



Practical Acid Base Assessment

Decreased HCO3- bothactual and standard.

Usually associated witha low Pa CO2

Raised PaCO2. Likely tobe associated with a

raised HCO3- especiallyif it is a long standing

problem

Low PaCO2 with anormal standard HCO3-

Raised HCO3- bothactual and standard.

The respiratoryresponse is limited soPaCO2 will be raisedbut not greatly so

1. CNS DisorderDrug overdose

Trauma Tumour

Degeneration Infection

CVA

2. Peripheral NSPolyneuropathy

Myaesthenia GravisPoliomyelitis

BotulismTetanus

Organophosphates

3. Pulmonary Disordera. Obstruction

COADAsthmaStridor

b. Parenchyma DiseaseARDS

PneumoniaSevere Pulm oedemac. Loss of mechanicalIntegrity eg flail chest

1. SupratentorialVoluntaryHysterical

PainAnxiety

2. Specific Conditionsa. CNS

MeningitisCVA

TumourTrauma

b. Respiratory DiseasePneumonia

Pulmonary EmbolismEarly Plum oedema

Early ARDSAltitudec. Shock

HypovolaemicCardiogenic

Septic

3. MiscellaneousProgesterone

PregnancyCirrhosis

IPPV

AG 12-18Bicarbonate loss

1. RenalTubular AcidosisAcetazolamide

2. Extra RenalDiarrhoea

Billary Fistula Uretero-colic fistula

AG >18Excess acid

1. XS Formation AcidKetoacidosis

Lactic Acidosis Starvation

2. Exogenous AcidSalicylates Methanol

Ethylene Glycol

3. Poor ExcretionRenal Failure

Measure UrinaryChloride

Urine CI <20 Mmol/IChloride Responsive

1. Loss of AcidVomiting

NG suctionGastrocolic fistula

2. Chloride DepletionDiarrhoea

Diuretic abuse

3. Excess Alkalieg Antacid abuse

Urine CI >20Mmol/IChloride Resistant

1. PrimaryHyperaldosteronism

2. Cushings

3. SevereHypokalaemia

4. Carbenoxolone

Acidaemia orAlkalaemia?

pH <7.4

Metabolic orRespiratory?

Metabolic orRespiratory?

pH >7.4

METABOLIC ACIDOSIS

Calculate Anion Gap =(Na+K)-(CI+HCO3-)

RESPIRATORYACIDOSIS

RESPIRATORYALKALOSIS

METABOLIC ALKALOSIS



APPENDIX 3 – ANALGESIC DRUGSParacetamolWell tolerated. Can reduce need for stronger analgesiaif given regularly. Various routes of delivery e.g. PO, PR, IV.

Indications Mild-moderate pain/antipyretic.

Action Acts centrally and peripherally byinhibition of chemical mediators.

Dose Adults’ 1g 4-6 hourly, maximum dose4g (8 tablets) in 24 hrs.

Risks Liver impairment, toxicity

Non-steroidal anti-inflammatory drugs(NSAIDs)Indications Moderate-severe pain.

Action Anti-inflammatory analgesicInhibits the synthesis ofprostaglandins – this modifies theinflammatory process which producespainCan have an opioid sparing effect ifgiven regularly

Dose Diclofenac 50 mg TDS (oral/pr)Ibuprofen 400 mg TDS (oral)Ketorolac 10-30 mg 4-6 hourly (IV)

Risks Gastro-intestinal (GI) disturbances e.g.bleeding, ulcerationRenal – reduction in blood flow to thekidneys, fluid retention (low urineoutput) leading to toxic effects andrenal damageCardiacPlatelet/bleed – coagulation defectsHepatic impairment

TramadolIndications Moderate-severe pain

Action Weak opiate which binds to opiatereceptors

Dose 50–100mg QDS

Risks As with other opiates

Opiates

MorphineIndications Severe pain

Action Binds to opioid receptors (Mu) in thebrain, spinal cord and GI tract. Longacting opioid

Dose IV/subcut/PO/PCA (as per localprotocol)

Risks The following risks apply to allopiates

Side effects induced by opiates particularlysedation and respiratory depression must bemonitored as the drug can accumulate and maylead to a respiratory arrest. Urine output must bemonitored to ensure the patient is excreting thedrug.

FentanylIndications Severe pain

Action Binds to opioid receptors, likeMorphine, but short acting.

Dose Combined with a local anaesthetic forpost-operative epidural painmanagement

Risks Sedation, respiratory depression

Oxycodone Indications Moderate – severe pain

Action Full opioid agonist with affinity forKappa and mu opioids receptors

Dose Refer to BNF

Risks See Morphine

Breakthrough DosesIf patients are on regular opioid analgesia forbreakthrough pain should be calculated as 1/6th oftheir total regular daily dose.

e.g. MST 60mg bd = 120mg in 24 hoursBreakthrough dose = 120 divided by 6 = 20mg(as Oramorph)

Fentanyl 25mcg patch = Morphine 180mg dailyBreakthrough dose = 180 divided by 6 = 30mg(as Oramorph)



Fentanyl patch equivalences to oral morphineFentanyl 25mcg patch = Morphine 90mg daily

(i.e. MST 45mg BD)

Fentanyl 50mcg patch = Morphine 180mg daily (i.e. MST 90 BD)

Fentanyl 75mcg patch = Morphine 270mg daily (i.e. MST 135mg BD)

Fentanyl 100mcg patch = Morphine 360mg daily (i.e. MST 180mg BD)

Oxycodone equivalencesOxycodone (Oxynorm) 10mg = Morphine

(Oramorph) 20mg

Oxycodone MR (Oxycontin) 10mg = Morphine MR20mg (MST 10mgBD)

APPENDIX 4 – LOCAL PROTOCOLS (suggested to add)

Oxygen Therapy

Tracheostomy care

Pain Protocols

Antibiotic policies

Outreach/EWS


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