1. No category

Critical care training
Severe forms of influenza infection,
including severe pneumonia, acute
respiratory distress syndrome, severe
sepsis, and septic shock
Toolkit
1
2
© World Health Organization 2012
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3
Foreword
This Toolkit is intended for clinicians working in intensive care units (ICUs) in low- and middle-income
countries and managing adult and paediatric patients with severe forms of influenza infection,
including severe pneumonia, acute respiratory distress syndrome (ARDS), severe sepsis and septic
shock.
Its main objective is to provide some of the necessary tools that can be used to care for the critically ill
patient from hospital entry to hospital discharge. It is a hands-on practical guide to be used by health
care professionals involved in critical care management during influenza epidemics.
The Toolkit is structured by topic. Each topic starts with a summary and follows with the list of the
available tools and complementary references. The tools provide a framework for users and are to be
adapted to local conditions.
An icon of a child identifies tools to be used and adapted when caring for paediatric patients.
An icon of an adult identifies tools to be used and adapted when caring for adult patients.
The tools without any icon can be used and adapted when caring for adults and paediatric patients.
4
List of abbreviations and acronyms
ABCCs Airway, breathing, circulation, consciousness/convulsing
ARDS Acute respiratory distress syndrome
ARI Acute respiratory infection
ASE Attention screening exam
AVPU Scale for assessing level of consciousness
BSI Blood stream infection
BP Blood pressure
CAM-ICU Confusion assessment method of the intensive care unit for adults
CDC Centers for Disease Control and Prevention
COPD Chronic obstructive pulmonary disease
CPAP Continuous positive airway pressure
CR Capillary refill
CVC Central venous catheter
CVP Central venous pressure
ECG Electrocardiogram
EN Enteral nutrition
ETAT Emergency triage and assessment and treatment
ETT Endotracheal tube
FiO2 Fraction of inspired oxygen
FRC Functional residual capacity
HR Heart rate
HME Heat and moisture exchanger
ICP Intracranial pressure
ICU Intensive care unit
ILI Influenza-like illness
IM Intramuscular
IMV Invasive mechanical ventilation
IV Intravenous
LMA Laryngeal mask airway
LR Lactated Ringer’s
LPV Lung protective ventilation
MAP Mean arterial pressure
MEWS Modified early warning score system
MUAC mid-upper arm circumference
NIOSH National Institute for Occupational Safety and Health
NS Normal saline
NMB Neuromuscular blockade
PALS Paediatric advanced life support
PaO2 Partial pressure pf arterial oxygen
pCAM-ICU Confusion assessment method of the intensive care unit for
children
PEEP Positive end-expiratory pressure
PEWS Paediatric early warning score system
5
PIP Peak inspiratory pressure
PPE Personal protective equipment
RASS Richmond agitation sedation scale
RR Respiratory rate
RSI Rapid sequence intubation
RT-PCR Real time polymerase chain reaction
SBP Systolic blood pressure
SSC Surviving sepsis campaign
SOFA Sequential organ failure assessment
SpO2 Oxygen saturation
ScvO2 Saturation of central venous blood
UTI Urinary tract infection
VAP Ventilator associated pneumonia
VTE Venous thromboembolism
VTM Viral transport medium
WHO World Health Organization
6
Content
Triage ......................................................................................................................... 9
Respiratory specimen collection and processing................................................... 20
Oxygen therapy ....................................................................................................... 31
Monitoring the patient ............................................................................................. 34
Antimicrobial therapy .............................................................................................. 37
Severe sepsis and septic shock .............................................................................. 41
Acute respiratory distress syndrome (ARDS) ......................................................... 52
Sedation and delirium.............................................................................................. 66
Liberation from Invasive Mechanical Ventilation ................................................... 84
Best practices to prevent complications ................................................................ 88
Quality in critical care ............................................................................................. 95
Infection prevention and control ........................................................................... 101
Ethical considerations........................................................................................... 107
7
Acknowledgements
This critical care training is the product of contributions by many individuals under the coordination of
the World Health Organization's Global Influenza Program and guidance of Dr. Nikki Shindo. Major
contributions were provided by Dr. Janet V. Diaz (WHO), Dr. Neill Adhikari (Sunnybrook Health
Sciences Centre and University of Toronto, Toronto, Canada) and Dr. Paula Lister (Great Ormond
Street Hospital, London, United Kingdom) in the overall course design and technical content. The
WHO would like to give special thanks to Cécile Duperray, Lucile Diémert and Alphonse Guyot
(Agence de Médecine Préventive - AMP) for their innovative support and creative ideas in
instructional design and multimedia development.
The WHO would like to thank the following for their preparation and contribution to original slide show
presentations under the coordination of Dr. Justin Ortiz (University of Washington, Seattle, USA) in
December 2009:
Dr. Neill Adhikari (Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada) –
Acute Hypoxaemic Failure in Adults with H1N1;Dr. Yolanda Bayugo (WHO Medical Officer, Geneva,
Switzerland) – Ethics and Culture; Dr Cheryl Cohen (National Institute for Communicable Diseases,
Johannesburg, South Africa) – Diagnostics and specimen collection, Antimicrobial Therapy; Dr
Charles David Gomersall (The Chinese University of Hong Kong, Prince of Wales Hospital, Hong
Kong, SAR) – ICU Best Practices, Weaning; Dr Carlos G. Grijalva (Vanderbilt University School of
Medicine, Nashville, USA ) - Influenza Epidemiology; Dr. Wendy Hansen (University of Kentucky,
Lexington, USA) – Pregnant Patient; Dr. Shevin Jacob (University of Washington, Seattle, WA) –
Severe Sepsis and Septic Shock Mangement; Dr. Paula Lister (Great Ormond Street Hospital,
London, United Kingdom) –Paedatric Patient; Dr. Shabir Madhi (University of the Witwatersrand,
Johannesburg, South Africa) - Diagnostics and specimen collection, Antimicrobial Therapy; Dr.
Christine Olson (Centers for Disease Control and Prevention, Atlanta, USA) – Pregnant Patient; Dr.
Daisuke Tamura (Saitama Medical Center Jichi Medical University, Saitama, Japan) – Paediatric
Patient; Dr. Eric Walter (University of Washington, Seattle, USA) - Infection Prevention and Control;
Dr. T. Eoin West (University of Washington, Seattle, USA) – Clinical management in the Hospital
Wards.
The WHO would like to thank the following globally recognized experts for reviewing the materials at
various stages of development:
Dr. Andre Amaral (Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada);
Dr. Edgar Bautista (Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico); Dr.
Satish Bhagwanjee (University of Washington, Seattle, USA); Dr. Niranjan Bhat (Johns Hopkins
University, Baltimore, USA); Dr. Hillary Cohen (Maimonides Medical Centre, Brooklyn, USA); Dr.
Shelly Dev and Dr. Gordon Rubenfeld (Sunnybrook Health Sciences Centre, University of Toronto,
Toronto, Canada; Lung Injury Knowledge Network, National Heart, Lung, and Blood Institute);Dr.
Sabine Heinrich (Berlin, Germany); Dr. Michael Ison (Northwestern University, Chicago, USA); Dr.
ArjunKarki (Patan Academy of Health Sciences, Kathmandu, Nepal); Dr. John Luce (San Francisco
General Hospital, San Francisco, California, USA); Ms. Kirsten Lunghi (San Francisco General
Hospital, California, USA); Dr. Kishore Pichamuthu (Vellore, India); Dr Kevin Rooney (Royal
Alexandra Hospital, Scotland, United Kingdom); Dr. Harry Shulman (Sunnybrook Health Sciences
Centre and University of Toronto, Toronto, Canada); Dr. Monica Thormann (Asociación
Panamericana de Infectología, Santo Domingo, Dominican Republic); Dr. Timothy Uyeki (Centers for
Disease Control and Prevention, Atlanta, USA); Dr. Khai Vu (San Francisco General Hospital,
California, USA); Dr. Steven Webb (Royal Perth Hospital, Perth, Australia; Dr. Wes Ely (Vanderbilt
University School of Medicine, Nashville, USA); Dr. Jenson Wong (San Francisco General Hospital,
San Francisco, USA). Valuable inputs were also provided by many technical staff of the WHO and
special thanks to Dr. Sergey Romualdovich Eremin; Dr. Charles Penn, Dr. Andreas Alois Reis and
their Collaborating Centres.
Finally, the WHO would like to thank PAHO for organizing a pilot of these training materials in Trinidad
and Tobago, April 2011 and the local clinician participants; and the Indonesian Ministry of Health,
st
WHO country office and PERDICI (Indonesian Intensive Care Society) for organizing the 1 Clinical
Workshop on Management of Severe ARI in Bogor Indonesia in April 2012 and the local clinician
participants that provided valuable feedback to make final course materials.
8
Triage
Summary
Principles of critical care management include
- recognize the critical condition
- intervene to fix the abnormal physiology
- treat the underlying cause
- monitor clinical parameters and respond
- deliver high quality care
Triage patients with ARI immediately upon arrival to the hospital
- recognize SARI patients
- immediately recognize and treat patients with emergency signs of ABCCs
- apply appropriate infection prevention measures
- give urgent treatments for critical conditions
Hospitalize patients when severe influenza infection is suspected
- when there is evidence of progressive, severe or complicated disease (i.e. organ
dysfunction, severe sepsis, severe pneumonia)
Adequate preparation and coordination should take place to ensure safe patient transfer to the
designated hospital unit.
Tools list
•
QUICK CHECK: Algorithm to check Airway and Breathing, Circulation and Altered Level of
Consciousness/Convulsing in adults
•
Emergency triage and assessment and treatment (ETAT): Triage of sick children
•
Memory aid: key criteria used to assess nutrition and vital signs in children
•
Decision making algorithm for the patient presenting with uncomplicated influenza-like
illness (ILI)
•
Decision making algorithm for hospitalization of a patient with suspected influenza
pneumonia
•
Checklist for admission
•
Checklist for transfer
References
•
Adhikari NK et al. Critical care and the global burden of critical illness in adults. Lancet,
2010, 376:1339 -1346.
•
Clinical management of adult patients with complications of pandemic, World Health
Organization, 2010.
•
Clinical management of human infection with pandemic influenza (H1N1) 2009: Revised
guidance, World Health Organization, 2009.
9
•
Pocket Book of Hospital Care for Children. Guidelines for the management of common
illnesses with limited resources. World Health Organization, 2005, 1:69-80.
•
Quick Check and Emergency Treatments in the District Clinician Manual. Hospital Care for
Adolescent and Adults. Guidelines for the management of illnesses with limited resources ,
World Health Organization, 2012,1:1-39.
http://www.who.int/influenza/patient_care/IMAI_DCM/en/index.html
•
Update on human cases of highly pathogenic avian influenza A (H5N1) virus infection,
World Health Organization, 2011. WER No.13, 2012
•
Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1)
2009 Influenza. New England Journal of Medicine, 2010, 362:1708-1719
•
WHO Regional Office for Europe guidance for sentinel surveillance in humans. World
Health Regional Office for Europe. Updated May 2011
10
QUICK CHECK: Algorithm to check
Airway / Brea thing, Circulation and
Altered L evel of
Consciousness/Convulsing in adults
This abbreviated tool provides a set of emergency signs that can be checked and treated quickly in
adults. It is adapted from the IMAI District Clinician Manual, World Health Organisation (WHO
(WHO), 2012
FIRST ASSESS:: Airway and breathing
Appears obstructed
or
Central cyanosis
or
Severe respiratory distress
Check for
obstruction
(noisy
breathing),
wheezing,
choking, not
able to speak.
SECOND ASSESS: Circulation
(shock or heavy bleeding)
Weak or fast pulse
or
Capillary refill longer than 3
seconds
or
Heavy bleeding from any site
or
Severe trauma
If obstructed airway:
If foreign body aspiration, treat choking
patient
If suspect anaphylaxis, give
1:1000epinephrine IM – 0.5 ml if 50 kg or
above, 0.4 ml if 40 kg, 0.3 if 30 kg
For all patients:
Manage airway
Give oxygen 5 litres/min
If inadequate breathing, assist
ventilation with bag valve mask
Help patient assume position of comfort
If wheezing, give salbutamol
Check SBP,
pulse.
Is she
pregnant?
11
Do not move neck if cervical spine injury
possible – immobilize spine.
Do not move neck if cervical spine injury
possible – immobilize spine.
If SBP <90 mmHg or pulse >110 per minute or
heavy bleeding:
Give oxygen 5 litres/min if respiratory
distress or SpO2 <90
Insert IV, give 1 litre bolus crystalloid (LR
or NS) then reassess (see give fluids
rapidly)
Keep warm (cover).
If in second half pregnancy, place on her
side (preferably on the left), not on back.
If anaphylaxis, give 1:1000 epinephrine
IM – 0.5 ml if 50 kg or above, 0.4 ml if 40
kg, 0.3 if 30 kg
THIRD ASSESS: Altered Level Consciousness and Convulsing
Do not move neck if cervical spine injury.
For all:
Protect from fall or injury
Manage airway and assist into recovery
position
Give oxygen 5 litres/min
Call for help but do not leave patient
alone
Give glucose (if blood glucose is low or
unknown)
Check (then monitor and record) level of
consciousness on AVPU scale
Altered level consciousness
or
Is she
pregnant?
Convulsing
If convulsing:
Give diazepam IV or rectally
If convulsing in second half of
pregnancy or post-partum up to one
week, give magnesium sulfate rather
than diazepam*
Then check SBP, pulse, RR, temperature.
If convulsions continue after 10 minutes:
Continue to monitor airway, breathing,
circulation
Recheck glucose
Give second dose diazepam (unless
pregnant/post-partum)
Consult district clinician to start
phenytoin
*WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. WHO, 2011. Available
at http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548335/en/index.html
12
Emergency triage and assessment and
treatment (ETAT): Triage of sick
children
This abbreviated tool provides a set of emergency signs that can be checked and treated quickly in
children. It is adapted from the WHO Pocket Book of Hospital Care for Children, 2005.
EMERGENCY SIGNS: If any sign positive: give treatments(s), call for help, draw blood for emergency
laboratory investigations (glucose, malaria smear, Hb)
ASSESS
TREAT
Airway and breathing
Obstructed breathing
Central cyanosis
Severe respiratory distress
ANY SIGN
POSITIVE
Do not move neck if cervical spine injury
possible
Check for foreign body aspiration
If foreign body aspiration
Manage airway in choking child
If no foreign body aspiration
Manage airway
Give oxygen
Make sure child is warm
Circulation
Cold hands
and
Capillary refill longer than 3
seconds
and
Weak and fast pulse
ANY SIGN
POSITIVE
Stop any bleeding
Give oxygen
Make sure child is warm
Check for severe malnutrition
If no severe malnutrition
Insert IV and begin giving fluids rapidly. If
not able to insert peripheral IV, insert an
intraosseous or external jugular line.
If severe malnutrition
- If lethargic or unconscious
Give IV glucose
Insert IV line and give fluids
- If not lethargic or unconscious
Give glucose orally or by NG tube
Proceed immediately to full assessment and
treatment
Coma/convulsing
Coma
Convulsing (now)
ANY SIGN
POSITIVE
13
Manage airway
If convulsing, give diazepam or paraldehyde
rectally
Position the unconscious child (if head or
neck trauma is suspected, stabilize the neck
first)
Give IV glucose
Severe dehydration
(only in child with diarrhoea)
Diarrhoea plusany two of these:
Lethargy
Sunken eyes
Very low skin pinch
DIARRHOEA
+ 2 SIGNS
POSITIVE
Make sure child is warm
Check for severe malnutrition
If no severe malnutrition
Insert IV line and begin giving fluids rapidly
and Diarrhoea Treatment Plan C in hospital
If severe malnutrition
Do not insert IV
Proceed immediately to full assessment and
treatment
PRIORITY SIGNS: These children need prompt assessment and treatment.
Tiny baby (<2 months)
Temperature very high
Trauma or other urgent surgical condition
Pallor (severe)
Poisoning (history of)
Pain (severe)
Respiratory distress
Note: if a child has trauma or other surgical
problems, get surgical help or follow surgical
guidelines
Restless, continuously irritable, or lethargic
Referral (urgent)
Malnutrition: visible severe wasting
Oedema of both feet
Burns (major)
NON-URGENT: Proceed with assessment and further treatment according to the child’s priority.
14
Memory aid: key criteria used to
assess nutrition and vital signs in
children
Age
Normal RR/min
RR/min in severe
distress
Normal HR/min
Normal systolic BP
(mmHg)
Lower limit systolic
BP (mmHg)
Normal urine output
< 1 month
1m – year
1-5 years
5-12 years
> 12 years
30-40
30-40
20-30
20-25
12-20
>60 or <20
>50 or <10
>40
>40
>40
120-180
120-180
100-140
90-140
90-140
60
80
90 + (2 × age)
120
50
70
70 + (2 × age)
90
1 ml/kg/hour
0.51ml/kg/hour
1–2 ml/kg/hour
KEY TIPS FOR ASSESSING A SICK CHILD
Blood pressure measurement in children:
• Cuff should cover ⅔ to ¾ of the upper arm, calf or thigh
• Cuffs that are too small give falsely high readings
• Cuffs that are too large give falsely low readings
• Child should be at rest and not distressed as this will falsely elevate the reading
To perform capillary refill (CR) assessment:
• Press the nail bed of finger or thumb (peripheral CR) or over the sternum (central CR) for 3
seconds.
• Release and count in seconds the time taken for the return of colour (perfusion).
Weight Estimates in children:
It is always best to weigh children to rather than estimate their weight.
In an emergency, weight can be estimated in visibly well-nourished children:
• Term infants: 2.5-4.5 kg
• Estimate at 6months of age: 5-7 kg
• Estimate after 1 year of age: (age in years +4) x 2 kg.
Criteria to define severe malnutrition
• Clinical signs of severe malnutrition: visible ribs and no fat on the buttocks, thighs, arms or
shoulders,
• Mid-upper arm circumference <11.5cm (MUAC)
• Bilateral pedal oedema
• Severe wasting: <70% weight –for- length or -3SD on charts pg 364-366 hospital pocket book
for children (in CD)
Signs of Respiratory Distress
• Fast respiratory rate (normal ranges in table above)
• Nasal flaring, Grunting
• Intercostal recession and tracheal tug
• In-drawing of the lower chest wall (very severe)
• Central cyanosis of the lips and tongue (very severe)
• Inability to breastfeed, drink (very severe)
• Lethargy (very severe)
15
Decision making algorithm for the
patient presenting with uncomplicated
influenza-like illness (ILI)
This is an algorithm to assist in the decision making for hospitalization and treatment of the patient
presenting with uncomplicated ILI. It takes into account the presence or absence of risk factors for
progressive, severe disease over 72 hours.
UNCOMPLICATED
Observations
ILI*
Riskfactors**
Care management
No
Any deterioration
or failure to improve
within72 hours ***
Yes
Symptomatic care at
home
Instruction on infection
prevention
Instruction on when to
return for care
Antiviral, if available
Antiviral, if available
Close observation, if
possible
Hospitalization, if
possible
Instruction on when to
return for care
*Uncomplicated ILI symptoms
•
•
•
•
•
•
•
Fever
•
NO shortness of breath
**Risk factors
Cough
Sore throat
Rhinorrhoea or nasal congestion
•
•
•
Age <2 years or ≥65 years
•
Children receiving chronic aspirin
therapy (risk of Reye's syndrome)
Headache
Muscle pain, or malaise
Gastrointestinal illness such as diarrhea or
vomiting, but NO evidence of dehydration
***
Pregnancy
Any chronic disease (pulmonary,
cardiac, metabolic, renal, hepatic,
hematologic or neurologic) or
immunosuppression (HIV, malignancy)
Signs of progression or deterioration
Decreased activity, dizziness, decreased urine
output
Increasing breathing difficulties, cyanosis,
bloody or colored sputum, chest pain
Confusion, lethargy, unconscious, severe
weakness, convulsions (seizures)
Persistent high fever and other symptoms
beyond three days without signs of resolution.
Children can also present with stridor, poor
feeding, and excessive diarrhea and vomiting
16
Decision making algorithm for
hospitalization of a patient with
pneumonia (influenza known to be
circulating)
This is an algorithm to assist in the decision making for hospitalization of the patient presenting with
pneumonia when influenza is known to be circulating. It takes into account the severity of pneumonia
and the presence or absence of risk factors for severe disease and the progression of disease.
Observations
PNEUMONIA
Non-severe
Risk factors
No
Care management
Severe*
Yes
Antimicrobials for
community acquired
pathogens
Antimicrobials for
community acquired
pathogens
Antimicrobials for
community acquired
pathogens, if suspected
Antiviral, if available
Antiviral, if available
Antiviral, if available
Close observation
Hospitalization, if possible
Instruction on when to
return for care
Instruction on when to
return for care
Hospitalization
recommended
Oxygen
*Severe Pneumonia
WHO Hospital Care for Children (2005)
• Chest indrawing
• Signs of severe respiratory distress (e.g. nasal flaring, grunting)
• Central cyanosis (very severe)
• Not able to drink (very severe)
• Lethargy (very severe)
WHO District Clinician Manual for Adolescents and Adults (2012)
• Respiratory rate > 30/min
• SpO2< 90%
• Signs of severe respiratory distress (e.g. inability to speak, use of accessory
muscles)
17
Checklist for admission
Once you have decided to admit a patient with severe influenza virus infection to the hospital,
consider using this checklist to ensure the following have been done in preparation for admission.
This is adapted from the WHO District Clinical Manual, (in press) 2012.
Emergency treatments given, patient's response checked
•
e.g. oxygen for respiratory distress, fluids for shock
Urgent treatments given for suspected condition(s)
•
e.g. appropriate antimicrobials for pneumonia, including antivirals if available
Documentation completed
Determined the level of care the patient needs
•
e.g. ICU, high dependency unit, ward
Determined infection prevention and control measures the patient needs
Verbal communication with ward staff completed to ensure continuity of care
Patient prepared for safe transfer
18
Checklist for transfer
Transport of the critically ill patient can be risky as complications during this process can be life
threatening and may be related to clinical, organizational, or equipment issues.
Consider using this checklist to ensure the safe transport of the patient to the designated unit.
This is adapted from the WHO District Clinical Manual, (in press) 2012.
Patient stabilized
Appropriate infection prevention and control measures in place: e.g. medical mask for
patients with ARI
Everything secured: airway, NG tube, IV, monitors
Enough drugs: vasopressors, sedatives
Enough oxygen: adequate SpO2
Enough IV fluids: adequate BP
Health care workers (e.g. transporters, receiving staff) and receiving unit/ward prepared
19
Respiratory specimen
collection and
processing
Summary
Influenza can be diagnosed based on clinical presentation in the context of known or suspected
influenza activity in your community and should be part of a broader differential diagnosis in patients
with severe ARI.
Collect respiratory tract specimens for influenza testing as soon as possible after onset of illness in
patients in whom treatment may be affected by making the diagnosis, such as those at risk or with
progressive or severe disease.
Also, collect appropriate samples to test for other possible pathogens and from other possible sites of
infection (i.e. blood cultures) before initiating antimicrobial therapy if the does NOT cause signficant
delay in therapy.
RT-PCR is the most sensitive diagnostic test for influenza virus infection but requires specialized
laboratory.
Rapid point-of-care tests give an indication that influenza is circulating in the community but sensitivity
is variable. Clinicians should make judgment based on all available clinical and epidemiological
information.
If your patient meets criteria for severe ARI treatment, DO NOT DELAY empiric antibiotics for
community-acquired pathogens, plus antivirals, while awaiting diagnostic tests.
Tools list
•
Influenza virus fact sheet
•
Specimen collection kit for upper respiratory tract specimens
•
Nasopharyngeal swab technique
•
Posterior pharyngeal swab or throat swab technique
•
Nasal swab technique
•
Nasopharyngeal aspirate technique
•
Guideline for specimen storage
•
Material for specimen transportation
•
Guideline for specimen transportation
References
•
Clinical management of human infection with pandemic (H1N1) 2009: revised guidance
World Health Organization, November 2009.
•
Domínguez-Cherit G et al. Critically Ill Patients with 2009 Influenza A (H1N1) in Mexico.
JAMA,2009, 302(17):1880-1887.
•
Guidance for influenza surveillance in humans, WHO Regional office for Europe, 2009.
20
•
Frequently Asked Questions Sampling and shipping of influenza clinical specimens and
virus isolates, WHO, March 2009.
•
Gill J. et al. Pulmonary Pathologic Findings of Fatal 2009 Pandemic Influenza A/H1N1
Viral Infections. Archives of Pathology & Laboratory Medicine, February 2010, 134:235243.
•
Heymann, D. et al. Control of Communicable Diseases Manual, 19 Edition, 2008
•
Instructions for storage and transport of suspected or confirmed human and animal
specimens and virus isolates of pandemic (H1N1) Global Alert Response, WHO, 2009.
•
Information for laboratory diagnosis of pandemic (H1N1) 2009 virus in humans revised,
WHO, 23 November 2009.
•
Kumar A et al. Critically Ill Patients with 2009 Influenza A (H1N1) Infection in Canada.
JAMA,2009, 302 (17):1872-1879.
•
Lister P. Swine-origin influenza virus H1N1, seasonal influenza virus, and critical illness in
children. Lancet,2009, 374:605-07.
•
Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a Novel
Swine-Origin Influenza A (H1N1) Virus in Humans. New England Journal of Medicine
2009, 360:2605-2615.
•
Recommendations on the use of rapid testing for influenza diagnosis, WHO, July 2005.
•
Safe transport of pandemic influenza A (H1N1) 2009 virus cultures, isolates and patient
specimens as Biological Substance, Category B. WHO, March 2010.
•
The ANZIC Influenza Investigators. Critical Care Services and 2009 H1N1 Influenza in
Australia and New Zealand. New England Journal of Medicine, 2009, 361:1925-1934
•
Transmission dynamics and impact of pandemic influenza A (H1N1) 2009 virus. WHO,
Weekly epidemiological record. November 2009No. 46, 2009, 84, 477–484
th
21
Influenza virus Factsheet
© WHO
Pandemic influenza
•
Unpredictable
•
Disease and death worldwide
•
Pandemic waves
•
Little or no immunity
•
No vaccine available until months
after pandemic begins
Influenza A and B cause human disease. Influenza A virus is
responsible for annual epidemics and major pandemics.
Influenza transmission
The transmission of influenza occurs via the inhalation of
respiratory droplets
•
Droplets from coughing or sneezing travel ≤1 meter
through the air
•
Close contacts of infected individuals can inhale these
droplets and become infected.
•
The incubation period is 1- 4 days (mean: 2, range: 1-7
days).
•
Infectious 1 day before symptoms appear and up to 1
day after symptoms go away.
•
Children shed virus longer than adults.
•
The estimated attack rate is 5-20% and higher in
densely populated communities and schools.
(MMWR. RR-10 2006)
Risk factors for severe disease, complications or death
Infants and young children (particular < 2 years)
•
•
Elderly, ≥65 (highest case fatality rate but lowest rate of
infection)
•
Chronic cardiovascular disease (e.g. congestive heart
failure, atherosclerotic disease, not hypertension)
•
Chronic pulmonary disease (e.g. asthma, COPD)
•
Chronic metabolic disease (e.g. diabetes)
•
Chronic kidney disease, chronic liver disease
•
Hemoglobinopathies (e.g. sickle cell anemia)
•
Immunosuppression (e.g. associated with HIV,
malignancy, organ transplant, malnutrition, recipient of
chemotherapy or corticosteroids)
•
Children receiving chronic aspirin therapy (risk of Reyes
syndrome)
•
Neurologic disorders (e.g. neuromuscular, seizures
neurocognitive)
•
Pregnancy
(WER 46 2009, NEJM 2009)
Pandemic (H1N1) Influenza hospitalization and mortality
•
Hospitalization rates averaged around 10 / 100 000 with
a range from 2.9/100 000 (Japan, summer) to 24.5/100
000 (Argentina, winter).
•
Hospitalization rates for children aged <5 years were 2–
3 times that of other age groups.
•
7-10% hospitalized cases were pregnant women in 23rd trimester
•
Proportion of hospitalized patients who required
intensive care ranged from 10% to 39%.
•
Mortality rates were highest in those aged 50–60 years.
•
Report of the 34 fatalities in New York City observed
deaths between the ages of 25-49 years (median 41.5
years)
•
Clinicopathologic features: tracheitis, bronchitis and
diffuse alveolar damage in most cases (78-100%) and
bacterial infection (55%)
(WER 46 2009, Arch Path Med 2010,134:235-243)
22
Seasonal Influenza
•
Yearly
•
Epidemics
•
Some immunity already
•
Young children and the elderly are most
often at risk
•
Vaccine available in some countries
•
•
•
Influenza-associated ICU admissions
In Australia and New Zealand winter
season 2009, influenza associated ICU
admissions were highest among infants and
young/middle-age adults.
Of these, 49% had ARDS/viral pneumonitis
and 65% required mechanical ventilation.
The median length of stay at ICU: 7 days
(interquartile range: 3-16).
N=856, (84.3% were
Influenza A (H1N1))
(ANZIC NEJM 2009)
•
•
•
•
•
•
•
•
•
Zoonotic influenza
Highly pathogenic avian influenza A(H5N1)
virus infection
1997 first human outbreak in China, Hong
Kong SAR
Since 2003, 600 cases with case fatality
proportion of 60%.
Transmission: mostly sporadic cases with
direct or indirect contact with infected
poultry.
Limited human-to-human transmission in
blood relatives.
Virus currently thought to be endemic in
animals in several countries: Bangladesh,
China, Egypt, India, Indonesia, Vietnam
Clinical features: asymptomatic infection is
rare, based on serological studies. Severe
ARI and rapid progression to ARDS and
multi-organ failure.
Prevention: disease control in animals,
avoid direct and prolonged exposure to
infected animals
Treatment: early treatment with
neuraminidase inhibitor, especially in high
risk groups
Specimen collection kit for upper
respiratory-tract specimens
It is best to compile a specimen collection kit before starting to take specimens. Here is an inventory
of all items that should be in the specimen collection kit for upper respiratory tract specimens.
The items include:
-
Personal protective equipment (gloves,
medical mask, gown)
-
Ice packs/cooler box
-
Field collection forms
-
An alcohol-resistant pen or marker
for labeling samples
-
Sterile Dacron or rayon swabs
-
1-2 ml Viral Transport Medium (VTM)
-
Specimen collection containers
©WHO/Tim Healing
Specimen collection kit contents depend on the type of specimen collected.
Swabs
It may include:
-
Swab with flexible (aluminium) shaft for
nasopharyngeal specimens
-
Swab with rigid (plastic) shaft for throat and
nasal specimens
-
Tongue depressors for throat swabs
-
Sterile saline (0.9% NS) for nasopharyngeal
aspiration
-
Sputum or mucus trap for nasopharyngeal
aspiration (also require negative pressure)
23
The type of swab used is very important. Only
sterile dacron or rayon swabs with aluminum
or plastic shafts should be used. This is
because calcium alginate or cotton swabs, or
swabs with wooden sticks may contain
substances that inactivate some viruses and
inhibit PCR testing.
Nasopharyngeal swab technique
•
Materials
-
•
Swab with flexible (aluminium) shaft
Technique
1. Apply standard and droplet precautions
2. Insert swab into one nostril and back into the
nasopharynx
3. Leave swab in place for a few seconds.
© WHO
4. Then slowly remove swab while rotating it over surface of posterior nasopharynx.
5. Withdraw swab from collection site; insert into transport tube or container with VTM.
6. Repeat procedure with another swab for the second nostril to deliver optimal
combined sample.
7. Label specimen container
8. After collection, immediately transport specimen to the laboratory for viral testing and
viral antigen detection. If transport to the laboratory is delayed, place specimen on ice
or in refrigeration.
In case of nasopharyngeal swab in infants and young children
•
Use a swab of appropriate size: measure the distance from the nose to the ear
(philtrum to the tragus).
•
Insert the swab half to full amount of that distance, stopping if you encounter
resistance.
•
Insert the swab horizontally, below the inferior turbinate, not diagonally up the
nose.
24
Posterior pharyngeal swab or throat
swab technique
•
•
Materials
-
Swab with rigid (plastic) shaft
-
Tongue depressor
© WHO
Technique
1. Apply standard precautions
2. Ask the subject to open his or her mouth and say "ah" to elevate the uvula.
3. Depress the tongue to hold out of way with tongue depressor.
4. Swab the posterior pharynx and avoid tonsils and do not touch tongue with swab.
5. Insert into transport tube or container with VTM. Break applicator tip to ensure closure
of vial.
6. Label specimen container
7. Immediately transport specimen to the laboratory for viral testing and viral antigen
detection. If transport to the laboratory is delayed, place specimen on ice or in
refrigeration.
25
Nasal swab technique
•
Materials
-Swab with rigid (plastic) shaft
•
Technique
1. Apply standard and droplet precautions
© WHO
2. Insert swab into one nostril parallel to palate.
3. Leave in place for a few seconds to absorb secretions.
4. Repeating procedure for the second nostril with the same swab.
5. Withdraw swab from collection site; insert into transport tube or container with VTM.
Can use same vial as throat swab. Break applicator tip to ensure closure of vial.
6. After collection, immediately transport specimen to the laboratory for viral testing and
viral antigen detection. If transport to the laboratory is delayed, place specimen on ice
or in refrigeration.
26
Nasopharyngeal aspirate technique
•
•
Materials
-
Suction outlet (portable:wall)
-
Sterile suction catheter
-
Specimen mucus trap (i.e.
Lucken’stube)
-
Sterile saline (0.9% NS)
© WHO
Technique
1. Attach mucus trap to catheter and suction outlet, leaving wrapper on suction catheter;
turn on suction and adjust to suggested pressure to make sure functioning. Turn off
suction.
2. Without applying suction, insert catheter into the nose, directed posteriorly and
toward the opening of the external ear.
Note: Depth of insertion necessary to reach posterior pharynx is equivalent to
distance between anterior naris and external opening of the ear.
3. Apply suction. Using a rotating movement, slowly withdraw catheter.
Note: Catheter should remain in nasopharynx for a minimal period of time, not to
exceed 10 sec.
4. Hold trap upright to prevent secretions from going into pump.
5. Repeating procedure for the second nostril using same catheter to deliver optimal
combined sample.
6. Rinse catheter if necessary with approximately 3.0 mL VTM; disconnect suction;
connect tubing to arm of mucus trap to seal
7. After collection, immediately transport specimen to the laboratory for viral testing and
viral antigen detection. If transport to the laboratory is delayed, place specimen on ice
or in refrigeration.
Catheter size and suction pressure
Patient age
Catheter size (French)
Suction pressure
Premature infant
6
80-100 mmHg
Infant
6
80-100 mmHg
Toddler/Preschooler
8
100-120 mmHg
School age
8
100-120 mmHg
Adolescent/Adult
8
100-120 mmHg
27
Guideline for specimen storage
Viral transport medium (VTM) is u
used
sed immediately after the collection of samples for viral isolation and
testing. It prevents specimen from drying out and prevents bacterial and fungal growth.
Although you should send specimens in VTM to the laboratory as soon as possible, it is important to
properly store them before you send them to a laboratory if there is a delay.
VTM with specimen
collected
Transportation within 48
hours
Transportation after 48
hours
Store at 4°C both before
and during
transportation
Store at -70°C
If impossible, keep on
ice or in a refrigerator
as long as necessary.
Do not put in a standard
freezer
DO NOT
freeze samples
freezer.
is very
important
to avoid
very important
to avoiin standard
freeze thaw
cycles.It Do
not freeze
samples
if thfreeze-thaw
will thaw cycles
and be
because
this will
destroy
the virus.
is better
keepto
a sample
on ice even
forev
a week,
to allow
frozen
again,
as this
will destroy
destro
the
heIt virus.
It istobetter
keep a sample
on ice
even
for athan
week,
than to
the sample to freeze and thaw
times.times.
and multiple
t aw multiple
VTM information
Possible suppliers: Local laboratory and commercial supplier
Description: It is usually supplied in the form of 1-3ml of VTM in
sterile container
Stock management: It is important that clinicians liaise with the
laboratory to make sure that there is sufficient stock of VTM
available at facility should patients with suspected infection be
admitted and that this is stored in an area which is accessible
accessible to
clinicians when needed
Conservation: If VTM must be stored for long periods this should be
done in a freezer at -20 ºC. For short periods of time VTM may be
stored in a fridge at 4-6 ºC.
28
Material for specimen transportation
When you are ready to pack specimens, no more than 500 ml should be in the specimen container,
for transportation from the field to the laboratory, you must use three packaging layers. This is done to
protect specimens from damaged during transportation.
•
•
Materials
-
Primary waterproof container (e.g. Falcon tube)
-
Absorbent material
-
Bubble wrap
-
Secondary recipient
-
Cooler box
-
Ice packs
-
Sample identification form
Schema of packing and labeling of infectious substances not refrigerated
29
Guideline for s pecimen transportation
1. Envelop the cryo-tube with blotting paper.
2. Place the enveloped cryo-tube in the primary
waterproof container and close in order to be
watertight.
3. Place the primary waterproof container in a
bubble wrap or shock-absorbing material.
4. Place all components in a waterproof secondary
recipient and close in order to be watertight.
5. Place ice packs in the cooler box.
6. Insert the sample identification form in a zip bag
and place the zip bag in the cooler box, next to the
secondary recipient.
Put the secondary recipient with its contain in the
cooler box. The recipient should be in a vertically
position
7. Close the cooler box in order to be watertight.
Write expeditor and addressee in the external part of the cooler box.
Put infectious substance label if necessary.
(Adapted from Influenza sentinel surveill
surveillance
ance training, Institute Pasteur of
Madagascar, CDC and WHO)
30
Oxygen therapy
Summary
Give oxygen immediately to patients with severe ARI (e.g. severe respiratory distress, shock or
hypoxaemia, SpO2<90%).
In adults, start at 5 l/min and in children at 1-2 l/min using nasal cannula and measure SpO2
immediately because clinical signs of hypoxaemia are unreliable.
Titrate oxygen to target SpO2 ≥90% (or >92-95% in pregnant females) using the appropriate delivery
device for flow rate.
Pulse oximeters should be available in all areas that emergency oxygen is delivered..
Pulse oximeters measure SpO2 quickly, easily, and reliably but have limitations.
Obtain an ABG for additional information about PaO2, pH and PaCO2 in patients who may have
severe hypoxaemia, hypercapnea, acidosis, unreliable pulse oximeter readings, are deteriorating or
are on invasive mechanical ventilation.
Wean oxygen when patient is stable.
Appropriate use of oxygen will optimize quality care, minimizes waste and save lives.
Tools list
•
Algorithm to deliver increasing oxygen
•
Checklist to troubleshoot warning signs during oxygen therapy delivery
References
•
British Thoracic Society. Emergency Oxygen Use in Adult Patients.Thorax, 2008, 63
Supplement VI: vi1–vi73.
•
Jensen LA, et al. Meta-analysis of arterial oxygen saturation monitoring by pulse
oxymetry in adults. Heart Lung, 1998, 27(6):387-408.
•
Pocket Book of Hospital Care for Children. Guidelines for the management of common
illnesses with limited resources. World Health Organization, 2005, 1:69-80
•
Potter VA. Pulse oximetry in general practice: how would a pulse oximeter influence
patient management? European Journal General Practice, 2007, 13(4):216-20.
•
Quick Check and Emergency Treatments in the District Clinician Manual. Hospital Care
for Adolescent and Adults. Guidelines for the management of illnesses with limited
resources. WHO, (in press)2010,1:1-39.
•
Rojas MX. Oxygen therapy for lower respiratory tract infections in children between 3
months and 15 years of age (Review). The Cochrane Library, 2009, Issue 3.
•
The Union Oxygen Systems Working Group publication. Oxygen is an essential medicine:
a call for international action.International Journal Tuberculosis and Lung Disease,2010,
14:1362-1368.
•
WHO Patient safety pulse oximetry project; many helpful tools available at
http://www.who.int/patientsafety/safesurgery/pulse_oximetry/en/
31
Algorithm to deliver increasing oxygen
This is reproduced from the WHO District Clinical Manual (in press 2012) intended for resource limited
settings where there is no mechanical ventilation for medical patients. This is not the case in your
hospital, so local adaption of the final step, consideration of intubation and mechanical ventilation for
respiratory failure is necessary.
Estimating FiO2 when
delivering oxygen
Adults
•
•
•
•
2-4 l/min ~ FiO20.28-0.36
5 l/min ~ FiO20.40
6-10 l/min ~ FiO20.44-0.60
10-15 l/min ~ FiO20.60-0.95
Children
•
nasal cannula 1-2 l/min (0.5
l/min, young infants) ~
FiO20.30-0.35
•
nasopharyngeal catheter 1-2
l/min ~ FiO20.45-0.60
•
10-15L/min via facemask
with reservoir –FiO20.600.95
Note: For children, headboxes
are not recommended.
Paediatric facemasks for
delivering higher flows are
available, but adult masks are
adequate in an emergency.
32
Checklist to troubleshoot warning
signs during oxygen delivery
If respiratory distress and hypoxaemia fail to improve despite increasing oxygen, use a
systematic approach to manage your patient. Consider using this checklist:
•
Repeat the Quick Check (ABCC’s)
•
Equipment
o
Is the measurement correct?
Repeat measurement (e.g. place pulse oximeter correctly; use another pulse
oximeter, get an ABG if appropriate)
o
Is there technical difficulty in delivering treatments?
Check oxygen source is working:
Is the cylinder full?
Is the concentrator on?
Check equipment (e.g. tubing and masks) are appropriate and functioning
Are the flows correct for type of mask being used?
If using a facemask with reservoir bag, is reservoir bag full?
Is the tubing kinked?
•
Is there an alternate diagnosis?
Does the patient have acute respiratory distress syndrome (ARDS)?
Does the patient have acute heart failure?
•
Is the patient getting appropriate therapy for the correct diagnosis?
Ensure underlying etiology is being appropriately managed (e.g. antimicrobials given
for pneumonia)
•
Is our treatment causing harm?
Consider complications and modify management accordingly (e.g. too much fluid
leading to pulmonary oedema? allergic reaction to medication?)
•
Does the patient have hypoxemia that is refractory to high-flow oxygen (e.g. significant shunt from
ARDS)?
Consider initiation of mechanical ventilator support for management of respiratory
failure
If the patient's mental status deteriorates despite SpO2>90%, consider the following:
Manage airway, assist ventilation if needed – do not wait for arterial blood gas results
if the patient requires assisted ventilation on clinical grounds.
Check ABG, if available, to evaluate ventilation. Patients with acute respiratory
acidosis from CO2 retention will not be diagnosed with SpO2 alone.
Consider alternate causes of altered mental status and treat appropriately (e.g. acute
CNS event? electrolyte abnormalities? low glucose? )
33
Monitoring the patient
Summary
Frequent monitoring is an essential component of critical care because it helps the clinician to detect
patient deterioration early and deliver corrective treatments.
In patients with hemodynamic instability monitor HR, cardiac rhythm, MAP, CVP, ScvO2 and function
of key end organs.
For patients with severe respiratory distress, also monitor SpO2 continuously and ABGs as needed.
Capnography is useful during intubation to confirm tube placement and may assist monitoring during
mechanical ventilation when ABG analyzer is unavailable, as long as limitations are understood.
Monitoring is just one aspect of critical care and does not substitute for history-taking and physical
examination.
When patients fail to respond to treatments or deteriorate, use a systematic approach to interpret data
and modify the treatment plan.
Tools list
•
Early Warning Scoring System for adults
•
Pediatric Early Warning score (PEWS)
References
•
Burch VC. Modified early warning score predicts the need for hospital admission and inhospital mortality. Emergency Medicine Journal, 2008, 25:674-678.
•
Ingham et al. Measurement of pO2, pCO2, pulse oximetry and capnography. Anaesthesia
and Intensive Care Medicine, 2002, 6:413-415.
•
Marino D. The ICU Book, Lippincott Williams and Wilkins 2007
•
Parshuram CS et al. Multicentre validation of the bedside paediatric early warning score: a
severity of illness score to detect evolving critical illness in hospitalized children. Critical care
2011; 15:R184
•
Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock.
New England Journal of Medicine, 2008, 345(19):1368-77.
•
Subbe CP et al. Validation of a modified Early Warning Score in medical admissions. QJM,
2001, 94(10):521-6.
•
Wiedemann HP et al. Comparison of two fluid-management strategies in acute respiratory
distress syndrome. New England Journal of Medicine, 2006, 354(24):2564-75.
34
Early Warning Scoring System for
adults
An Early Warning Scoring System can be useful to monitor patients on the ward and to identify
patients who are deteriorating and need immediate evaluation. This table shows a modified early
warning score system (MEWS). It assigns point values to abnormal vital signs based on severity.
This example is adapted with permission from the University Hospital of South Manchester, NHS
Foundation Trust. Adapt it for your hospital wards.
Patients with underlinedscores are at risk and need immediate attention.
Score
3
Heart rate
≤ 40
Respiratory
rate
≤8
2
≤ 35.0
Temperature
AVPU score
Systolic Blood
Pressure
≤ 70
SpO2
≤ 89%
71-80
93%
1
0
1
2
3
41-50
51-100
101-110
111-129
≥ 130
9-18
19-25
26-29
≥ 30
35.1-36
36.1-37.9
38-38.9
≥ 39
New
confusion
or
agitation
Alert
Voice
Pain
Unresp
81-100
101-179
≥180-199
≥200
94-96%
>96%
•
If any sign is underlined or score is ≥7 (high score), then start ABCC emergency treatments,
immediately notify charge nurse, contact physician for immediate evaluation, and consult critical
care team to consider higher level of care. Minimum observation every 30 minutes.
•
If score 3-6 (medium score), then start ABCC emergency treatments, notify charge nurse,
continue appropriate interventions, re-evaluate patient in 30 minutes.
o At 30 minutes, if MEWS score is
Less than 3, then monitor every 4 hours for next 12 hours (minimum).
Within 3-6, then contact physician to review patient within 30 minutes.
7 or more, follow actions for high score patients.
o At one hour, if MEWS score is
3 or more or increasing, then contact physician to evaluate patient within 15
minutes and get critical care consultation and consider higher level of care.
Less than 3, then monitor every 4 hours for next 12 hours (minimum)
•
If score is 1-2 (low), and causing clinical concern then follow actions for medium score patients. If
not causing concern, monitor every 4 hours (minimum).
•
If score is 0, and causing clinical concern then follow actions for medium score patients. If not
causing concern then monitor every 12 hours (minimum)
35
Pediatric Early Warning Score (PEWS)
This is an example of a paediatric early warning system that was used in Canada and the UK and
published in Critical Care in 2011 (see reference section). As in the adult scoring system, it is used to
alert staff on general paediatric wards that a child is becoming critically unwell. Each scoring system
may need calibration or adjustment if used in a different environment to that in which it was
developed.A score of 8 or more has a sensitivity of 83% of identifying an ICU emergency or
cardiopulmonary arrest.Score the seven items on the left column and add together.
A score of 8 or more indicates the child is critically ill and should be evaluated immediately by a
physician and consider higher level of care.
Item sub-score
Item
Heart rate
(bpm)
Systolic
blood
pressure
(mmHg)
Age group
0
1
2
4
0 to < 3 months
> 110 and < 150
≥ 150 or ≤ 110
≥ 180 or ≤ 90
≥ 190 or ≤ 80
3 to < 12 months
> 100 and < 150
≥ 150 or ≤ 100
≥ 170 or ≤ 80
≥ 180 or ≤ 70
1-4 years
> 90 and < 120
≥ 120 or ≤ 90
≥ 150 or ≤ 70
≥ 170 or ≤ 60
> 4-12 years
> 70 and < 110
≥ 110 or ≤ 70
≥ 130 or ≤ 60
≥ 150 or ≤ 50
> 12 years
> 60 and < 100
≥ 100 or ≤ 60
≥ 120 or ≤ 50
≥ 140 or ≤ 40
0 to < 3 months
> 60 and < 80
≥ 80 or ≤ 60
≥ 100 or ≤ 50
≥ 130 or ≤ 45
3 to < 12 months
> 80 and < 100
≥ 100 or ≤ 80
≥ 120 or ≤ 70
≥ 150 or ≤ 60
1-4 years
> 90 and < 110
≥ 110 or ≤ 90
≥ 125 or ≤ 75
≥ 160 or ≤ 65
> 4-12 years
> 90 and < 120
≥ 120 or ≤ 90
≥ 140 or ≤ 80
≥ 170 or ≤ 70
> 12 years
> 100 and < 130
≥ 130 or ≤ 100
≥ 150 or ≤ 85
≥ 190 or ≤ 75
Capillary
refill time
≥ 3 seconds
< 3 seconds
0 to < 3 months
> 29 and < 61
≥ 61 or ≤ 29
≥ 81 or ≤ 19
≥ 91 or ≤ 15
3 to < 12 months
> 24 or < 51
≥ 51 or ≤ 24
≥ 71 or ≤ 19
≥ 81 or ≤ 15
1-4 years
> 19 or < 41
≥ 41 or ≤ 19
≥ 61 or ≤ 15
≥ 71 or ≤ 12
> 4-12 years
> 19 or < 31
≥ 31 or ≤ 19
≥ 41 or ≤ 14
≥ 51 or ≤ 10
> 12 years
> 11 or < 17
≥ 17 or ≤ 11
≥ 23 or ≤ 10
≥ 30 or ≤ 9
Respiratory
effort
Normal
Mild increase
Moderate
increase
Severe
increase/any
apnoea
Oxygen
saturation
(%)
> 94
91 to 94
≤ 90
Oxygen
therapy
Room air
Respiratory
rate
(breaths/min
ute)
Parshuram et al.Critical Care 2011 15:R184
36
Any to < 4
L/minute or <
50%
≥ 4 L/minute
or≥ 50%
Antimicrobial therapy
Summary
When influenza virus is known or suspected to be circulating, treat severe ARI patients with empiric
antiviral and antibiotics for all likely community-acquired bacterial pathogens as soon as possible.
In patients also with severe sepsis, administer effective, intravenous antimicrobials within 1 hour of
recognition
If microbiologic results identify pathogen, therapy should be tailored towards this pathogen.
Oseltamivir is active against all currently circulating human influenza viruses.
The usual dose is 75 mg twice daily in adults and children ≥40 kg; for smaller children dosing is
weight-based. Consider higher doses in patients with severe disease or severe immune
compromising conditions.
If the clinical course remains severe or progressive, despite ≥5 days of antiviral treatment, treatment
should be continued without a break until virus infection is resolved or there is satisfactory clinical
improvement. Consider alternate diagnoses.
If oseltamivir is unavailable, or oseltamivir resistance suspected, treat with zanamivir.
Tools list
•
Oseltamivir notice
•
Zanamivir notice
References
•
CHMP ASSESSMENT REPORT ON Novel Influenza (H1N1) outbreak Tamiflu
(oseltamivir) Relenza (zanamivir) EMEA/H/A-5.3/1172 7 May 2009.
•
Clinical management of human infection with pandemic (H1N1) 2009: revised guidance
WHO, November 2009.
•
European Union Summary of product Characteristics, Oseltamivir Updated 2 December
2009.
•
Food and Drug Administration (FDA) Safety Relenza (Zanamivir) inhalational powder,
October 2009.
•
GlaxoSmithKline. Zanamivir Important drug warning, October 2009.
•
GlaxoSmithKline. Zanamivir Product Information Revised,March 2010.
•
Guidelines for pharmacologic management of pandemic influenza A (H1N1) 2009 and
other influenza viruses. WHO, Revised February 2010.
•
Peramivir and other Antiviral Treatment Options for Treatment of Influenzain Hospitalized
Patients for the 2009-2010 Season. Centres for Disease Control and Prevention, 26
October 2009 CDC Guidelines Antiviral Side Effects 9 September 2009.
•
Recommendations for Use of Antiviral Medications for the Management of Influenza in
Children and Adolescent for the 2009-2010 Season - Pediatric Supplement for Health
Care Providers December 11, 2009 5:00 PM ET.
37
Oseltamivir notice
•
•
WHO recommendations
o
Patients who have uncomplicated illness due to confirmed or strongly suspected virus
infection and are in a group known to be at higher risk of developing severe or
complicated illness should be treated with oseltamivir or zanamivir as soon as
possible.
o
Patients who have severe or progressive clinical illness should be treated with
oseltamivir as soon as possible.
Treatment dosing
Adults
Dosing*
Mild illness
75 mg orally, twice daily for 5 days
With severe illness or severe
immunocompromising conditions
75 mg orally, twice daily for 5 days
Children ≥1 year old
Dosing*
<15 kg
30 mg orally twice daily for 5 days
15 to<23 kg
45 mg orally twice daily for 5 days
23 to<40 kg
60 mg orally twice daily for 5 days
≥40 kg
75 mg orally twice daily for 5 days
Children <1 year old
Dosing*
14 days to 1 year
3 mg/kg orally twice daily for 5 days
Consider higher dose**, 150mg orally, twice daily
* The route of administration can be either via nasogastric or orogastric tube if the patient cannot take
medication orally (see safety profile).
Where the clinical course remains severe or progressive, despite ≥5 days of antiviral treatment,
treatment should be continued without a break until virus infection is resolved or there is satisfactory
clinical improvement.
**The rationale for higher dosing is that there is decreased enteral absorption along with high and
prolonged viral replication during severe illness. In children, consider double the daily dose.
38
•
Safety considerations and side effects
o
Safety profile
Oseltamivir has not been associated with increased adverse effects in adult outpatients. However,
oseltamivir has not evaluated in severely ill patients, pregnancy, or pediatric populations.
Oseltamivir should be used with caution:
o
-
In patients with kidney disease; reduce dose to 75 mg daily if creatinine clearance is
10-30 ml/minute.
-
In patients with liver disease the safety and efficacy has not been evaluated, so dose
reduction is not recommended at this time.
-
For pregnant or nursing mothers, oseltamivir is recommended as therapy in
pandemic influenza (H1N1) 2009 virus as there is a high risk of severe illness in
pregnant women and there is no evidence of adverse effects or birth defects.
Side effects
Side effects are generally minor and involve the gastrointestinal tract although rare
neuropsychiatric complications have been described:
•
-
Nausea (mitigated by taking with food), vomiting
-
Rare neuropsychiatric adverse events – association seen primarily in one country,
causality has not been established
Oral formulations
Formulations
Description
Capsules
30mg, 45mg, 75mg each
Preparation of oral oseltamivir
suspension
Brand names: Antiflu®, Tamiflu®, etc.
0
Store at room temperature (15-30 C)
Liquid suspension
White powder mixed with 23 mL of
drinking water
If a commercial oseltamivir powder
for oral suspension is unavailable a
suspension may be compounded in
a pharmacy:
•
The in-house suspension
should be made at 15 mg/mL
for persons >1 year and 10
mg/ml for those ≤1 year.
•
The suspension can be made
from oseltamivir phosphate
capsules using sterile water at
the bedside
Fruit flavoured
Refrigeration required
Use within 10 days
Oral dispenser included (must confirm
dosage and volume when
administering)
Oral suspension
If commercial suspension unavailable
a suspension may be prepared from
oseltamivir capsules
39
Zanamivir notice
•
WHO recommendations
o
Patients who have uncomplicated illness due to confirmed or strongly suspected virus
infection and are in a group known to be at higher risk of developing severe or
complicated illness should be treated with oseltamivir or zanamivir as soon as possible
o
In situations where oseltamivir is not available, or not possible to use, patients who have
severe or progressive clinical illness should be treated with inhaled zanamivir.
o
Patients, who have severe or progressive clinical illness with virus resistant to oseltamivir
but known or likely to be susceptible to zanamivir, should be treated with zanamivir.
Resistance to zanamivir has not been identified in pandemic influenza A (H1N1) infections. However
surveillance may be biased as screening focuses on detection of H275Y mutation by molecular
techniques and might miss other resistance mutations.
•
Treatment dosing
Children ≥5 years old and adults*:
Dosing**
Mild illness
10 mg (2 inhalations), twice daily for 5 days
Severe illness
10 mg (2 inhalations), twice daily
* Inhaled zanamivir is difficult to reliably administer to children younger than 5 years of age.
** Where the clinical course remains severe or progressive, despite 5 or more days of antiviral
treatment, treatment should be continued without a break until virus infection is resolved or there is
satisfactory clinical improvement.
The commercial formulation is not designed or intended to be used in a nebulizer or mechanical
ventilator as there is a risk that lactose drug carrier can obstruct proper functioning of the ventilator.
•
Safety considerations and side effects
o
o
•
Safety profiles
-
Pregnant or nursing females: may be used although there are few published data. In
lactating women the dose to the infant is extremely low.
-
Children <1 year: No published data
Side effects
- Bronchospasm has been reported during treatment in patients with and without
underlying airways disease.
Formulations
Formulations
Description
Inhalation
This drug is inhaled as a powder through the mouth, and requires a special
device to administer.
The commercial formulation not designed or intended to be used in
nebulizer or mechanical ventilator as there is a risk that lactose drug carrier
can obstruct proper functioning of the ventilator.
Intravenous
May be available in some jurisdictions on compassionate use grounds
40
Severe sepsis and
septic shock
Summary
The 5 management principles in septic shock are:
- Recognize the diagnosis
- Fix the abnormal physiology
- Treat the infection
- Monitor-record-respond
- Deliver quality care
Deliver early targeted resuscitation to adult patients with sepsis-induded hypoperfusion
using crystalloids, vasopressors, and in some cases blood transfusion and inotropes.
Resuscitation targets are markers of tissue perfusion, and should be used to guide resuscitation. In
children, however, low blood pressure is a late finding. In settings with limited resources, use noninvasive indicators of perfusion to guide resuscitation.
Administer fluid therapy using fluid challenge method to reduce risk of overly aggressive fluid therapy,
which may lead to respiratory impairment. This is of significant concern in settings without mechanical
ventilation.
Give empiric, effective antimicrobial therapy to target all likely pathogens, within 1 hour, of recognition
of severe sepsis or shock.
Other adjuncts to be considered in management of severe sepsis in an ICU include: Corticosteroids
when shock is refractory to fluids and vasopressor and protocolized glucose management when
glucose > 10 mmol/L or 180 mg/dL
Resuscitation strategies for children with septic shock should take into consideration availability of ICU
resources, and be modified if child has severe anemia, malnutrition, or absence of hypovolaemia or
hypotension
Tools list
•
Comprehensive approach to management of severe sepsis and septic shock
•
Details of targeted resuscitation in adults wtih sepsis-induced hypoperfusion in an ICU settings
•
Details of targeted resuscitation in childrenin an ICU setting
•
Algorithm for management of septic shock in adults in limited resource settings
•
Table to guide use of vasopressors in septic shock for adults and children
41
•
Sample central venous pressure waveform
References
•
Annane D et al. Corticosteroids for treating severe sepsis and septic shock. Cochrane
Database of Systematic Reviews, 2010
•
Annane D. Bellissant E. Cavaillon J. M. Septic shock. Lancet, 2005, 365:63-78.
•
Annane D. et al. Norepinephrine plus dobutamine versus epinephrine alone for
management of septic shock: a randomisedtrial.Lancet,2007, 370:276-684.
Brierly J et al. Clinical practice parameters for haemodynamic support of pediatric and
neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
•
•
•
•
•
•
Cribbs SK et al. Infections in Medicine, 2009; 26(5): 134-43.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international
guidelines for management of severe sepsis and septic shock: 2012. Critical care
medicine 2013;41:580-http://www.sccm.org/Documents/SSC-Guidelines.pdf.
De Oliveira CF et al ACCM/PALS haemodynamic support guidelines for paediatric shock:
an outcomes comparison with and without monitoring central venous oxygen saturation.
Intensive Care Med 2008; 34:1065-1075
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular, American
Heart Association CarePart 12: Pediatric Advanced Life , 2005
Supporthttp://circ.ahajournals.org/content/112/24_suppl/IV-167
Jones AE et al. Lactate clearance vs central venous oxygen saturation as goals of early
sepsis therapy: a randomized clinical trial. JAMA 2010 Feb 24;303(8):739-46.
•
Jones AE et al. The effect of a quantitative resuscitation strategy on mortality in patients
with sepsis: a meta-analysis. Critical Care Medicine, 2008, 36(10):2734–2739.
•
Magder S. Invasive intravascular hemodynamic monitoring: technical issues. Crit Care
Clin. 2007 Jul;23(3):401-14.
•
Maitland K et al. Mortality after fluid bolus in African children with severe infection. NEngl
J Med 2011; 364:2483-95
•
Rivers E. et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and
Septic Shock, New England Journal of Medicine, 2001, 345:368-1377.
•
Russell JA. Management of Sepsis. New England Journal of Medicine, 2006,355:16991713.
•
Siddiqui S, Razzak J. Early versus late pre-intensive care unit admission broad spectrum
antibiotics for severe sepsis in adults.Cochrane Database of Systematic Reviews 2010,
Issue 10.
•
Wills BA et al Comparison of three fluid solutions for resuscitation in dengue shock
syndrome. N Engl J med 2005; 353:877-89
42
Comprehensive approach to
management of severe sepsis and
sepsis-induced hypoperfusion
For use when influenza virus is known or suspected to be circulating.
Clinical Evaluation
Laboratory Evaluation
Management
Recognize, prioritize and
treat emergency signs
(Triage).
Check:
- Airway
- Breathing => SpO2
- Circulation =>BP
- Consciousness
Measure (if available):
- Complete blood count
- Basic metabolic panel
- Hepatic panel
- Arterial blood gas value
- Arterial lactate
Manage respiratory distress:
- Oxygen at 5 l/min
- Mechanical ventilation if
hypoxemic respiratory failure
*LYHLQLWLDOFU\VWDOORLGIOXLG
over 30 minutes or faster
- 30 ml/kg in adults
- 20 ml/kg in children
Identify SIRS:
- HR >90/min in adult or > 2 SD
above normal age for child
- RR >20/min or PaCO2 <32
mmHg in adult or > 2 SD above
normal age for child;or use of
mechanical ventilation
- Temp >38 or <36°C
Identify SIRS:
3
- White cell count >12000/mm
3
or <4000/mm or >10% bands,
Ide
Start drug therapy:
- Empiric, effective, broadspectrum antimicrobials,
including antivirals, for all likely
community-acquired pathogens
- Within 1 hour of recognition
- Do NOT wait for laboratory
confirmation
Identify source of infection:
- Community-acquired
pneumonia
- Severe influenza virus
infection
- Empyema
- Other sources of infection
(e.g. peritonitis, intra-abdominal
abscess, cholangitis, cellulitis,
fasciitis, pyelonephritis,
meningitis)
Collect appropriate specimens:
- Respiratory specimens for
influenza, bacteria, and/or fungal
based on local epidemiology
- Blood cultures (before
antimicrobial therapy, if no delay)
- From other sites that may be
infected (i.e. urine, CSF)
- For certain pathogens, if at risk
(e.g. AFB, malaria smear, PCP
testing if PLHIV)
Recognize severe sepsis:
- Renal: increased creatinine
- Hepatic: high bilirubin
- Coagulation: abnormal INR,
PTT, platelets
-Metabolic acidosis (ABG),
abnormal lactate
-Hypo/hyperglycemia
-Hypocalcemia
Control the source of infection:
Recognize severe sepsis
- CNS: AVPU
- Renal function: urinary output
- Respiratory: hypoxaemia Renal: reduced urine ouput
- GI: ileus
Recognize sepsis-induced
hypoperfusion:
-hypotension after fluid
challenge
-decreased capillary refill >2
sec, core to periphery Temp
gap > 3
Recoginze sepsis-induced
hypoperfusion:
-Lactate ≥ 4 mmol/L
-Sites of infection that may need
draingage or debridement
include: abscesses, empyema,
peritonitis, bowel infarct,
choleycystitis, cholangitis,
necrotizing gangrene
-Carry out in within 12 hours
Start EARLY quantitative,
protocolized resuscitation
- Target perfusion markers
using crystalloid fluid
challenges, vasopressors and
in some cases inotropes or
PRBC
- Reach targets within 6 hours
of recognition
Other adjuncts:
- hydrocortisone if vasopressorrefractory shock
- glucose control if > 10 mmol/L
(Adapted from Russell et al. NEJM, 2006,355:1699-1713.)
43
Details of EARLY protocolized,
quantitative resuscitation in adults
with sepsis-induced hypoperfusion
in an ICU setting:
This flowchart is adapted from Rivers et al, NEJM 2001 (see reference section for full source).
Manage targeted resuscitation
> First give LR or NS as flud challenges (i.e. 0.5-1 L)
initial challenge up to 30 mL/kg; continue until targets
are reached as long as there is a hemodynamic
response.
Oxygen therapy ±
endotracheal intubation and
mechanical ventilation
> Adult targets of fluid resusciation include: CVP 8-12
(12-15 if on IMV), MAP ≥65 mmHg, urine ouput ≥0.5
mL/kg/hr
Central venous and arterial
catheterization for monitoring
> If MAP <65 mmHg after fluid resucitation, then start
vasopressor to reach target 65 mmHg
> Once MAP at 65 mmHg and adequate fluid
resuscitation, then check ScvO2.
Sedation
(if intubated)
> If ScvO2<70%, transfuse RBC to target Hb 100 g/l or
start dobutamine. Target ScvO2 70%.
>Reach targets within 6 hours of recognition
<8 mmHg
CVP
Crystalloid
8 – 12 mmHg
MAP
< 65 mmHg
Vasopressors
≥65 mmHg
≥ 70%
ScvO2
< 70%
Transfusion of red cells until
haemoglobin>=100 g/l
≥ 70%
Dobutamine
Goals
achieved
No
Yes
Continue treatment in
hospital
44
< 70%
Details of targeted resuscitation in
children in and ICU setting
This flowchart created by the ACCM/PALS is adapted from Dellinger et al, Crit Care Med 2008 (see
References section for full source). PALS=pediatric advanced life support.
0 min
5 min
Manage airway and breathing, give oxygen and establish intravenous/
intraosseous (IV/IO) access according to PALS guidelines.
Give 20 mL/kg isotonic crystalloid every 15-20 min, up to 60 mL/kg.
Correct hypoglycemia and hypocalcemia.
Stop earlier if signs of volume overload
Fluid refractory shock**
15 min
Fluid responsive*
**Persistent hypotension,
abnormal capillary refill
or extremity coolness
Start inotropes IV/IO. Reverse cold shock with dopamine or epinephrine
Reverse warm shock with epinephrine. Use ketamine +/- atropine IV/OI/
IM to obtain central venous access and secure airway if necessary.
Fluid refractory-dopamine/dobutamine resistant shock
Observe in ICU
Monitor in ICU setting. Attain normal MAP, CVP, ScvO2 ≥70%, & Hb > 10 g/dL
For cold shock titrate epinephrine; for warm shock titrate norepinephrine.
Catecholamine-resistant shock
60 min
Begin hydrocortisone if at risk for absolute adrenal insufficiency
Normal Blood Pressure
Cold Shock
ScvO2 Sat<70%
Low Blood Pressure
Cold Shock
ScvO2 Sat<70%
Add vasodilator or type III
phosphodiesterase inhibitor
(milrinone) with volume
loading
Titrate volume and epinephrine.
If still hypotensive, consider
norepinephrine. If ScvO2 <70,
consider milrinone,
dobutamine, levosimendin
Low Blood Pressure
Warm Shock
ScvO2 Sat≥70%
Titrate volume and norepinephrine.
If still hypotensive, consider
vasopressin, terlipressin or
angiotensin. If ScvO2 <70%
consider low dose epinephrine
Persistent catecholamine-resistant shock
If possible, measure cardiac outputand direct fluid, inotrope, vasopressor,
vasodilator, and hormonal therapies to attain CI >3.3 and <6.0 L/min/m². Exclude
pneumothorax, pericardial effusion, and raised intra-abdominal pressure > 12
mmHg
* Fluid responsive is the normalization of blood pressure and clinical targets of tissue perfusion: i.e.
capillary refill 2 s, urine output >1ml/kg/hour, normal pulses with no central-peripheral differential
warm extremities, mental status, age-appropriate MAP and HR thresholds
45
Algorithm for management of adults
with septic shock in limited resource
settings
Recognize
Fix the
physiology
Septic Shock
Severe Respiratory Distress
Without Shock
Clinical diagnosis of severe sepsis
or septic shock
• SBP <90 mmHg
and 1 or more of the following
• Pulse >100 bpm
• Respiratory rate >24/min
• Abnormal temperature (<36°C or
>38°C)
• Suspected infection
Clinical diagnosis of severe
respiratory distress without
shock
• If respiratory rate >30/min or
SpO2<90, and
• SBP >90 mmHg, and
• No heart failure, and
• Suspected pneumonia or
acute respiratory distress
syndrome
Oxygen: titrate to SpO2 90%
Oxygen: Titrate to SpO2 90%
Fluids:
After initial bolus of 1000 ml, continue
rapid fluids LR or NS at 20 ml/kg/hour,
up to 60 ml/kg within the first 2 hours
Fluids:
Give fluids at 1 ml/kg/hour or
orally
First 2 hours
If wheezing, give salbutamol
Treat infection
Monitor,
Record,
Respond
Urgent empirical antimicrobials
• Antibiotics
• Antimalarials
• Influenza -specific antiviral if
suspect influenza
Identify source of infection
• Use signs or symptoms to
consider source.
• Malaria test
• Where available, molecular
testing for TB or AFB smear of
sputum, if cough
• Chest X-ray, Gram-stain sputum
• Send blood cultures.
Every 30 minutes until stable;
then every 1 hour
• SBP
• Respiratory rate
• SpO2
• Mental status (AVPU)
• JVP, auscultate for crackles (rales)
Check results of emergency
laboratory
• If haemoglobin<70 g/l, consider
transfusion.
• If glucose <3 mmol/l (54 mg/dl),
then give D50 25–50 ml
If respiratory function
SBP <90
declining(increasing RR,
falling SpO2)
• Check oxygen supply.
• If JVP elevated, increasing
crackles,
Consider fluid overload.
46
If SBP <90 mmHg,
switch to manage as septic
shock
• If wheezing, give salbutamol.
• If suspect fluid overload, slow
rate of fluid administration and
start vasopressors if still in
shock.
Recognize
Fix the
physiology
2–6 hours
Treat
infection
Monitor,
Record,
Respond
Septic Shock
Severe Respiratory Distress Without
Shock
Reconsider diagnosis if no
change in SBP following fluid
boluses.
Establish source of infection
If poor response, reconsider
pneumothorax, pleural effusion, heart
failure, poisoning, TB, and PCP
associated with HIV.
Oxygen: Titrate to SpO2 90%.
Oxygen: Titrate to SpO2 90%.
Fluids:
• If SBP >90 mmHg, continue fluids at
2 ml/kg/hour.
• If SBP <90 mmHg at 2 hours or
later, start vasopressors and
continue fluids at 5–10 ml/kg/hour.
Fluids:
• Give fluids at 1 ml/kg/hour or orally
• If wheezing, give salbutamol.
Drain surgical infection if required.
Consider source of infection.
Review results of investigations.
Every 30 minutes until stable;
then every 1 hour
• SBP
• Respiratory rate
• SpO2
• Mental status (AVPU)
• JVP, auscultate for crackles (rales)
Every 6 hours
• Temperature
• Urine output
• Repeat glucose and Hb if initial values
abnormal.
SBP <90
If respiratory function declining
(increasing RR, falling SpO2)
• Check oxygen supply
• If elevated JVP and increasing
crackles,
Consider fluid overload.
47
If SBP <90 mmHg, switch to
manage as septic shock and give
1000 ml IV.
If respiratory function declining
(increasing breathlessness,
increasing RR, or SpO2<90)
• Check oxygen supply and increase
flow rate if possible.
• If wheezing, give salbutamol.
• Check that antimicrobials have been
given. Consider broader
antimicrobial cover.
• Consider other diagnoses or
infections; see above.
• If signs of fluid overload, SBP >100
mmHg, and shock resolved, stop IV
fluids, give furosemide 20 mg IV,
and raise head of bed.
Septic Shock
Severe Respiratory Distress Without
Shock
Reconsider diagnosis if no change
in SBP following fluid boluses.
Recognize
Establish source of infection.
Consider surgical cause:
is drainage required?
Fix the
physiology
•
•
•
•
•
•
pneumothorax
pleural effusion
heart failure
poisoning
TB
PCP associated with HIV
Oxygen: Titrate to SpO290%.
Oxygen: Titrate to SpO290%.
Fluids:
Fluids:
•
•
•
•
6–24 hours
If poor response, reconsider
When SBP >90 mmHg, continue
fluids at 2 ml/kg/hour. If on
vasopressors, reduce rate.
If SBP <90 mmHg, continue or
increase vasopressors and
continue LR or NS at 2 ml/kg/hour.
Continue at 1 ml/kg/hour or orally.
If wheezing, give salbutamol.
Treat
infection
Continue empirical antimicrobials – next dose
Monitor,
Record
Every hour if SBP <90 mmHg or on
vasopressors; otherwise every
2 hours
Respond
•
•
•
•
•
•
•
•
Antibiotics
Antimalarials(if malaria tests are positive)
Antiviral if suspect influenza
SBP
Respiratory rate
SpO2
Mental status (AVPU)
JVP, auscultate for crackles (rales)
Every 6 hours
•
•
•
Temperature
Urine output
Repeat glucose and Hb if initial value
abnormal.
Respond to changes as indicated for 2–6 hours on previous page.
48
Recognize
Post-resuscitation
Fix the
physiology
Treat
infection
Nutrition
Monitor,
Record,
Respond
Septic Shock
Severe Respiratory Distress Without
Shock
Perform full reassessment.
Review available diagnostic data and
treat underlying diagnosis.
Evidence of a primary cardiac or
pulmonary process? Switch to its
specific management.
If poor response, reconsider:
• Pneumothorax
• Pleural effusion
• Heart failure
• Poisoning
• TB
• PCP associated with HIV
Oxygen: Titrate to SpO2 90% and
discontinue when 90% on room air.
Oxygen: Titrate to SpO2 90% and
discontinue when 90% on room air.
Fluids: Reduce to maintenance
maximum 2 ml/kg/hour and switch to
oral when patient is able to take.
Fluids: oral when able to take
If wheezing, give salbutamol.
Continue antimicrobials – switch to oral dose
• Antibiotics
• Antimalarials (give IV antimalarials for at least 24 hours total before switching
to oral)
• Antiviral if suspect influenza
Procedures to follow once the patient has stabilized, or after 1–2 days:
• Due to risk of aspiration, do not give food orally if patient cannot safely swallow,
(due to, e.g. altered mental status, severe shortness of breath, or severely ill with
ongoing vomiting).
• All other patients should be provided with food. Most patients lose their appetite
when ill and may find soft foods and fluids easier to tolerate. Small frequent meals
often are tolerated better.
• Consider NG feeding using pureed foods if the patient cannot swallow safely.
• In severely ill patients give a small amount initially (e.g. 20–40 ml/hour) and
monitor NG aspirates to check for absorption.
• Increase rate of feeding as tolerated.
Every 8 hours (check SBP hourly if weaning off vasopressors); then daily
• SBP
• Respiratory rate
• SpO2
• Mental status (AVPU)
Respond to changes as indicated earlier.
(Adapted from the WHO IMAI District Clinician Manual, in press 2012)
49
Table to guide use of vasoactive
agents in septic shock in adults and
children
The next step in delivering targeted resuscitation to patients with fluid-refractory septic shock is to
start vasopressors.
In adults, the Surviving Sepsis guideline recommends vasopressors to be started if MAP < 65 mmHg.
Norepinephrine is recommended as first line agent; however, epinephrine can be used as an
alternate. Administer vasopressors at a strictly controlled rate, titrate to maintain MAP 65 mmHg,
reduce as the MAP improves and discontinue promptly when no longer needed. Restrict dopamine
use to selected patients, those with low risk of tachyarrythmia or bradycardia. Administer
dobutamine, an inotrope, when hypoperfusion persists after adequate MAP and fluid status acheived,
and Hb > 100 g/L; i.e when ScvO2<70% (or clinical evidence of myocardial dysfunction)
In children, the Surviving Sepsis guidelines recommend vasopressors if clinical signs of shock persist
after fluid resuscitation and should not be delayed. The recommended first line agents are dopamine
for cold shock or epinephrine for warm shock. If shock persists on first line agents, then add
epinephrine for cold shock or norepinephrine for warm shock. These agents should be administered at
a strictly controlled rate and titrated to achieve targets of adequate tissue perfusion.
Route of
administration
Central vein
preferred
Peripheral vein if
necessary
Dopamine
/Dobutamine
Norepinephrine
Epinephrine
Initial:
0.1-0.2 µg/kg/min
Initial:
2-5 µg/kg/min
Initial:
0.1-0.2 µg/kg/min
Range:
increase by 0.1µg/kg/min
increments;
consider refractory if
>1 µg/kg/min
Range:
increase by2.5
µg/kg/min increments;
maximum20 µg/kg/min
Range:
increase by
0.1µg/kg/min
increments;
consider refractory if >1
µg/kg/min
Same dosing
Same dosing
Same dosing
Dose initiation and titration should be individualized. MAP goal can be individualized based on oher
clinical history (i.e presence of hypertension). Supplement MAP with other markers of perusion such
as capillary refill, absence of skin mottling, well felt peripheral pulses, warm dry extremeties urine
output and normal mental status. Note, children can move between various shock states and
vasopressors should be adjusted accordingly.
Side effects of vasopressors include tachyarrhythmias, ischemia to organs, and cool or cyanotic
extremities. Peripheral administration may be complicated by soft tissue necrosis if the vasopressor
is extravasated.
Side effects of inotropes, such as dobutamine, include tachyarrythmias and hypotension due to
peripheral vasodilation. Thus, in septic shock inotropes should be used in combination with
vasopressors to maintain MAP at goal in adults, and children with low SVR.
(Adapted from Marino D. The ICU book 2009; Annane D et al. Lancet, 2007, 370:276-684.)
50
Sample central venous pressure
waveform
This sample CVP waveform is from a mechanically ventilated patient. The proper site for measuring
CVP is at the base of the c wave, which can be identified from a vertical line drawn from the QRS
complex. If the c wave is not evident, the base of the a wave can be used. CVP should be measured
at end-expiration in both mechanically ventilated and spontaneously breathing patients. ART shows
the waveform from the arterial line.
The upward ‘a’ wave is due to atrial contraction and follows the peak of the electrical P wave by ~80
milliseconds. The x descent follows the ‘a’ wave and is due to atrial relaxation and the sudden
downward motion of the tricuspid valve. The upward ‘c’ wave is due to bulging of the tricuspid valve
into the right atrium at the onset of ventricular systole. The time separating the ‘a’ and ‘c’ waves
equals the electrical P-R interval. The upward ‘v’ wave is due to venous filling of the right atrium
during ventricular systole when the tricuspid valve is closed. The y descent follows the ‘v’ wave and is
due to rapid atrial emptying following opening of the tricuspid valve.
Remember, there are limitations to CVP monitoring and these should be considered when interpreting
measurements for individual patients. CVP varies with body position, intrathoracic pressure, and
structural heart disease, making interpretation challenging.
51
Acute respiratory
distress syndrome
(ARDS)
Summary
Intubation and invasive mechanical ventilation are indicated in patients with ARDS who develop
severe respiratory distress or hypoxaemic respiratory failure.
Delivering lung protective ventilation (LPV) to patents with ARDS reduces mortality.
LPV means:
- Delivering low tidal volumes (TV target 6 ml/kg or less)
- Achieving low plateau airway pressure (target Pplat≤ 30 cmH2O)
- Use of moderate-high PEEP to maintain SpO2 between 88-93%
- Allowance of permissive hypercapnea
Patients with ARDS on LPV benefit from:
- Appropriate sedation to treat patient-ventilator asynchrony and uncontrolled TV or plateau
airway pressures
- A conservative fluid strategy when not in shock or with acute kidney injury
Additional interventions for severe ARDS include:
- Neuromuscular blockade
- High PEEP alone
- Recruitment maneuvers with high PEEP
- Ventilation in the prone position
See LPV videos in complementary materials section of flash drive.
Tools list
•
Checklist for rapid sequence intubation (RSI)procedure
•
Checklist for preparing for intubation and mechanical ventilation in child
•
Memory aid: comparison of normal waveforms during volume and pressure limited ventilation
•
Memory aid: recognizing and interpreting abnormal pressure and flow waveforms during
volume control ventilation
•
Guide to distinguish between causes of high peak airway pressures: resistance vs.
compliance
•
Troubleshooting high peak airway pressures, low tidal volumes, desaturation, or
hemodynamic instability in ventilated patient
•
Memory aid: Diagnosis and classification of ARDS
•
ARDS Network protocol to deliver lung protective ventilation
•
Protocol to deliver a recruitment maneuver to adult patients with severe ARDS
•
Checklist for turning a patient with severe ARDS prone
52
References
•
Adapted from the course “Using the Ventilator to Probe Physiology: Monitoring Graphics and
Lung Mechanics During Mechanical Ventilation” by Dean Hess, PhD, RRT, Massachusetts
General Hospital Boston, MA.
•
Diaz JV et al. Therapeutic Strategies for Severe Acute respiratory distress syndrome, Critical
Care Medicine, 2010, 38:1644-1650.
•
Egan J. Acute lung injury in the child. Paediatr Resp Review 2010:11; 171-176
•
Meade M. et al. Ventilation Strategy Using Low Tidal Volumes, Recruitment Maneuvers, and
High Positive End-Expiratory Pressure for Acute Lung Injury and Acute Respiratory Distress
Syndrome A Randomized Controlled Trial. JAMA 2008, 299(6):637-645.
•
Malhotra A. Low-Tidal-Volume Ventilation in the Acute Respiratory Distress Syndrome. New
England Journal of Medicine 2007, 357:1113-1120.
•
Mercat A. et al. Positive End-Expiratory Pressure Setting in Adults with Acute Lung Injury and
Acute Respiratory Distress Syndrome. A Randomized Controlled Trial. JAMA, 2008,
299(6):646-655.
Messerole E et al. The pragmatics of prone positioning. Am J Respir Crit Care Med 2002 May
15;165(10):1359-1363.
Murray JF et al. An expanded definition of the adult respiratory distress syndrome. Am Rev
Respir Dis 1988 Sep;138(3):720-3.
Sud S et al. Prone ventilation reduces mortality in patients with acute respiratory failure and
severe hypoxemia: systematic review and meta-analysis. Intensive Care Med. 2010
Apr;36(4):585-599.
Randolph AG. Management of acute lung injury and acute respiratory distress syndrome in
Children. Crit Care Med 2009; 37: 2448-2454.
•
•
•
•
•
•
Taccone P. et al. Prone Positioning in Patients With Moderate and Severe Acute Respiratory
Distress Syndrome A Randomized Controlled Trial, JAMA, 2009, 302(18):1977-1984.
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as
compared with traditional tidal volumes for acute lung injury and the acute respiratory distress
syndrome. New England Journal of Medicine, 2000, 342:1301–1308.
•
Tobin M. Advances in mechanical ventilation. New England Journal of Medicine, 2001,
344:1986-1996.
•
Wheeler AP, Bernard GR. Acute lung injury and the acute respiratory distress syndrome: a
clinical review. Lancet,2007, 369:1553-1565.
•
Wiedemann HP et al. Comparison of Two Fluid-Management Strategies in Acute Lung Injury.
New England Journal of Medicine, 2006, 354:2564-2575.
•
Geurin et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome, New
England Journal of Medicine, 2013, May 20, 2013, at NEJM.org
•
53
Checklist for rapid sequence
intubation (RSI) procedure
This tool can be used before performing endotracheal intubation. This is adapted with
permission from the ICU and Emergency Medical Retrieval Service at the Royal Alexandria Hospital,
Paisley Scotland United Kingdom.
•
Equipment
Suction: working Yankauer under right side of pillow
Ambu-bag, 15l/min O2, PEEP valve (pre-oxygenation and post-intubation)
Endotracheal tube (ETT): correct size, cuff checked and lubricated
2 working laryngoscopes with blades
20ml syringe
Tube tie
Gum Elastic bougie on trolley top
Rapid Sequence Intubation (RSI)
Oropharyngeal airway on trolley top
Confirm laryngeal mask airway (LMA) and
surgical airway kit
Capnograph set up
Stethoscope
Target: Patients suspected of having an
increased risk of aspirating stomach contents
into the lungs.
Ventilator checks complete
Alternateoxygensource (cylinder / flowmeter)
•
Drug
IV access patent and accessible
Induction agents: hypnotic / opiate /
neuromuscular blockade (NMB)
Maintenance infusions prepared
Vasopressor and atropine drawn
•
Team role
Doctor 1: Airway and drugs
Nurse 1: Assistant
Nurse 2: Cricoid pressure
•
Definition: RSI is an advanced medical
protocol of advanced airway support
designed for the expeditious intubation of the
trachea of a patient.
Appropriate infection prevention precautions
If suspect influenza, use airborne precautions
54
Technique: Quicker form of the process
normally used to "induce" a state of general
anesthesia. It uses drugs to rapidly allow an
endotracheal tube to be placed between the
vocal cords, by blocking the patient's
involuntary reflexes and muscle tone in the
oropharynx and larynx. Once the
endotracheal tube has been passed between
the vocal cords, a cuff is inflated around the
tube in the trachea and the patient can then
be artificially ventilated. Correct ETT position
can be verified by direct visualization through
the vocal cords, capnography (persistent
CO2 return; may show CO2 transiently if in
esophagus), high SpO2, bilateral breath
sounds on chest auscultation and x-ray).
Checklist for preparing for intubation
and mechanical ventilation in child
This tool can be used before performing endotracheal intubation. Intubation and IMV can be
indicated, as in adults, in case of hypoxemia refractory to supplemental oxygen, depressed level of
consciousness (AVPU) and severe shock.
Pre-oxygenate for 3 minutes with 100% FiO2.
- Children & infants have reduced functional residual capacity (FRC), they can
desaturate quickly on induction.
Decompress the stomach to prevent diaphragmatic splinting
Use airway adjuncts to reduce stomach inflation
In Bag-Mask-Ventilation (BMV) place NG tube early & regularly aspirate with
large bore syringe to decompress stomach
Anticipate Shock
- Benzodiazepines, thiopental, inhalational agents &propofol cause myocardial
depression & vasodilation; this can unmask or worsen shock.
Anticipate and use ketamine for induction if available (with atropine).
Anticipate by pre-loading with volume (10-20 ml/kg 0.9% saline) &/or
starting/increasing inotropic support
Consider Atropine in all neonates & children to prevent bradycardia caused by vagal
stimulation during laryngoscopy
Use induction agent ± opiate & neuromuscular relaxant in all patients including neonates;
it will optimise the view and make intubation easier.
Confirm correct ETT placement. As in adults, an adequate end-tidal CO2 reading remains
the gold standard. But correct placement can be inferred from
Improving SpO2
Bilateral equal air on auscultation
Chest X-ray position of ETT tip 1-2 cm above the carina, or T3 posteriorly
Choice of an induction agent
Opiates
Induction Agent
Neuromuscular
Blockade
Notes
Atropine
Intravenous Dose
20 mcg/kg (min dose 100
mcg); >12 yr 300-600mcg
Fentanyl
2-5 mcg/kg
Can cause ↓ BP
Morphine
0.1-0.2 mg/kg
Ketamine
1-2 mg/kg
Takes long time to be
effective ~10mins
Can cause ↑ ICP
Thiopental
2-5 mg/kg
Propofol 1%
(induction only)
2.5-3.5 mg/kg
(>3 yr)
Suxamethonium
Neonate – 3 mg/kg/dose;
1-2 mg/kg all other ages
Vecuronium
0.1 mg/kg
Atracurium
Pancuronium
0.5 mg/kg
0.1mg/kg
55
Can cause ↓ BP
Antiepileptic
Can cause ↓ BP
Avoid if K+ high,
neuromuscular patients
Choice of size of endotracheal tubes
Diameter (size) of ETT
Term
infant
3-3.5
Estimate at
6months
3.5-4
Children ≥
1 yr (kg)
(Age/4) + 4
Length oral ETT at lips (confirm on X-ray)
8-9
10
Length nasal ETT at nose (confirm on Xray)
Suction Catheter size
10-11
12
(Age/2) + 12
cm
(Age/2) +15 cm
2 x ETT = 6
2 x ETT = 8
2 x ETT
Anatomical differences between children and adults
Anatomical differences between children and adults can
make ventilation more difficult.
• Lower chest wall rigidity of children implies an earlier
respiratory failure in infants in any pathology that causes
↓ compliance of lung e.g. viral pneumonitis
• Smaller airway diameter of children implies an upper
airway resistance
• Larger abdomen of children implies a ↓ FRC (functional
residual capacity) → ↑ atelectasis at end expiration &
atelectrauma
• Larger tongue, anterior larynx, narrow cricoid
ring,larger occiput require positioning of the airway (e.g.
use of neck rolls) to optimize visualisation on
laryngoscopy
o Neonates and infants in neutral position
o Older children in “sniffing morning air” position
Tips: Anticipate a difficult airway, particularly if stridor. Preoxygenate, have a range of ETT and most experienced
operator available.
56
Memory aid: comparison of normal
waveforms during volume and
pressure limited ventilation
Volume control
-
-
Pressure control
Volume limited ventilation.
Flow is fixed (shown) or descending.
Volume is set and the airway pressures are
variable.
Inspiration cycles to expiration after fixed time
or volume delivered.
To measure Pplat you need to perform an
inspiratory pause, which means to briefly stop
gas flow at the end of inspiration.
Patient can trigger a breath.
57
-
Pressure limited ventilation.
Flow is variable.
Pressure is set (see square wave form)
and the volumes are variable.
Inspiration cycles to expiration after fixed
time.
Pplat is the set inspiratory pressure
(Pinsp), equal to driving pressure + PEEP
Patient can trigger a breath.
Memory aid: recognizing and
interpreting abnormal pressure and
flow waveforms during volume control
ventilation
Pressure curves
Characteristics
Interpretation
Normal pressure
curve
Normal
Increased peak
airway pressure
Reduced
compliance
Increased Pplat
Increased peak
airway pressure
Normal Pplat
Increased
resistance
Intrinsic PEEP
Flow curves
Characteristics
Normal flow pattern
High expiratory
peak flow rate
expiratory flow is
shorter
Prolonged
expiratory flow
Intrinsic PEEP
Interpretation
Normal
Reduced
compliance
Increased
resistance
(Adapted from Hess, D. Massachusetts General Hospital.)
58
Guide to distinguish between the
causes of high peak airway pressures:
resistance vs. compliance
Abnormal airway
pressure(s)
Main physiologic
problem
Formula
High peak with high plateau
airway pressure
High peak with normal plateau
airway pressure
Reduced respiratory system
compliance (Crs)
High resistance (R)
Tidal volume
Crs = --------------------Pplat – PEEP
Normal
Problems that can
be treated quickly
Other problems that
may improve over
the time
Ppeak- Pplat
R = --------------------Flow
60-100ml/cmH2O
5-10cmH2O/l/sfor intubated adult
-
Mainstem intubation
Tension pneumothorax
Pleural effusion
Abdominal distension
Congestive heart failure
Atelectasis
Hyperinflation
Patient problem
- Patient biting, coughing, fighting
the ventilator
- Secretions
- Bronchospasm
-
ARDS
Consolidation
Fibrosis
Chest wall edema
Thoracic deformity
-
Ventilator problem
- Tube kinked
- Circuit filled with water
- Small endotracheal tube
Asthma, COPD
Factors influencing peak airway pressure
Pairway = Presistance + Pcompliance
Airflow resistance
• Size of airway
• Lower airway obstruction
• Mechanical obstruction
Respiratory system compliance
• Chest wall
• Tidal volume
• Lung elasticity
59
•
•
•
Chest wall compliance
Chest wall
Patient position
External compression of
chest from abdomen
Troubleshooting high peak airway
pressures, low tidal volumes,
desaturation, or hemodynamic
instability in ventilated patient
-
Is the endotracheal tube in the trachea?
Large cuff leak or no chest rise with inspiration suggest that ETT is dislodged: assess with
direct laryngoscopy and re-intubate
Is there a problem with the ventilator circuit or oxygen supply?
-
Take the patient off the ventilator and hand ventilate with 100% oxygen while checking
equipment
Can you pass a suction catheter through the endotracheal tube?
-
If no, ETT may be kinked: straighten or insert bite block to prevent patient from biting
-
If no, ETT may be blocked with secretions: reintubate with new ETT
-
If yes, suction ETT to remove sputum / mucus plugs
Are there breath sounds bilaterally?
-
Unilaterally absent breath sounds: evaluate for mainstem intubation/lobar collapse vs.
pneumothorax by assessing mediastinal shift and by chest X-ray if patient not in extremis
o
Suspicion of tension pneumothorax mandates immediate needle decompression
followed by chest tube placement, without a chest X-ray
o
Mainstem intubation may be suspected clinically if ETT further in patient than
previously: withdraw to previous position; can confirm with bronchoscopy if available
o
Lobar collapse or atelectasis may respond to aggressive suctioning and can be
confirmed with chest X-ray
-
Bilateral wheezing: consider bronchospasm, give bronchodilators
-
Bilateral crackles: consider pulmonary edema; give diuretic or more PEEP depending on full
clinical evaluation of volume status
Is there other problems causing low compliance?
-
Abdominal distension: drain stomach with nasogastric tube
-
Auto-PEEP: diagnose by examining ventilator waveforms. Treat with bronchodilators,
sedation; may require temporary disconnection from positive pressure
Is there hemodyamic instability?
-
Restore hemodyamic stability with fluid or vasopressors while determining and treating
primary cause
-
If severe hypotension, evaluate for tension pneumothorax or severe auto-PEEP (often in
patients with asthma or COPD)
-
Other causes includehigh airway pressures reducing venous return, vasodilation due to
sedative and analgesic medications, or a new problem (sepsis, bleeding, pulmonary
embolism, myocardial infarction)
Is the patient agitated and asynchronous with the ventilator?
-
May be secondary to any other problem, or may be primary problem and causing asynchrony
-- treat cautiously with sedation.
60
ARDS Network protocol to deliver lung
protective ventilation (LPV)
This protocol was used in the low-tidal volume trial published in NEJM in 2000 (see references for full
source). There are two PEEP-FiO2 grids; the second one can be used for more severe hypoxemia.
Principles are the same for children except that children younger than 8 years require a lower
maximum PEEP; 15cmH2O.
Ventilator set up and adjustment
1. Calculate predicted body weight (PBW)
Males = 50 + 2.3 [height (inches) - 60], Females = 45.5 + 2.3 [height (inches) -60]
Males = [(height (cm) -154) x 0.9] + 50, Females= [(height (cm) -154) x 0.9] + 45.5
2. Select any ventilator mode
3. Set ventilator settings to achieve initial TV(tidal volume) = 8 ml/kg PBW
4. Reduce TVby 1 ml/kg at intervals ≤ 2 hours until TV= 6ml/kg PBW.
5. Set initial rate to approximate baseline minute ventilation (not > 35 breaths/min).
6. Adjust TVand RR to achieve pH and plateau pressure goals below.
• Oxygenation goal: PaO255-80 mmHg or SpO288-95%
Use a minimum PEEP of 5 cmH2O. Consider incremental FiO2/PEEP combinations such as shown
below to achieve goal.PEEP levels >15 should not be used in children < 8years.
Lower PEEP/higher FiO2
FiO2
0.3
0.4 0.4 0.5 0.5 0.6 0.7 0.7
5
5
8
8
10
10
10
12
Higher PEEP/lower FiO2 for moresevere hypoxemia
0.7
14
FiO2
0.5
18
PEEP
PEEP
0.3
5
0.3
8
0.3
10
0.3
12
0.3
14
0.4
14
0.4
16
0.5
16
0.8
14
0.9
14
0.5-0.8
20
0.9
16
0.9
18
1.0
18 - 24
0.8
22
0.9
22
1.0
22
• Plateau pressure goal: ≤ 30 cmH2O
Check Pplat using 0.5 second inspiratory pause, at least q4h and after each change in PEEP or
TV.
- If Pplat > 30 cmH2O: decrease TVby 1ml/kg steps (minimum = 4 ml/kg).
- If Pplat < 25 cmH2O and TV < 6 ml/kg, increase TVby 1 ml/kg until Pplat >25 cmH2Oor TV=
6 ml/kg.
- If Pplat< 30 cmH2O and breath stacking or asynchrony occurs: may increase TVin 1ml/kg
increments to 7 or 8 ml/kg if Pplat remains ≤30 cmH2O.
• pH goal: 7.30-7.45
Acidosis Management: (pH < 7.30)
- If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2< 25 (Maximum set RR = 35).
- If pH < 7.15: Increase RR to 35.
- If pH remains < 7.15, TVmay be increased in 1 ml/kg steps until pH > 7.15 (Pplat target of 30
may be exceeded). May give sodium bicarbonate.
•
Alkalosis Management: (pH > 7.45) Decrease ventilator rate if possible.
•
I: E ratio goal: Recommend that duration of inspiration be ≤duration of expiration.
61
Memory aid: The Berlin Criteria for
the Diagnosis and classification of
ARDS
Acute Respiratory Distress Syndrome (ARDS)
Timing
Within 1 week of a known clinical insult or new or worsening respiratory
symptoms
Chest imaging*
Bilateral opacities – not fully explained by effusions, lobar/lung collapse, or
nodules
Origin of edema
Respiratory failure not fully explained by cardiac failure or fluid overload
Need objective assessment (e.g. echocardiography) to exclude hydrostatic
edema if no risk factor present.
Oxygenation**
Mild
200mm Hg < PaO2 /FiO2 ≤ 300 mm Hg with PEEP or CPAP ≥5cm H2O***
Moderate
100mm Hg < PaO2 /FiO2 ≤ 200 mm Hg with PEEP ≥5cm H2O
Severe
PaO2 /FiO2 ≤ 100 mm Hg with PEEP ≥5cm H2O
Abbreviations: CPAP, continuous positive airway pressure; FiO2, fraction of inspired oxygen; PaO2,
partial pressure arterial oxygen; PEEP, positive end-expiratory pressure.
* Chest radiograph or computed tomography scan.
** If altitude is higher than 1000 m, the correction factor should be calculated as follows:
[PaO2/FiO2 x (barometric pressure/760)].
*** This may be delivered noninvasively in the mild acute respiratory distress syndrome group.
62
Protocol to deliver a recruitment
maneuver to adults patient with severe
ARDS
This protocol is adapted from Meade et al, JAMA 2008 (see reference section for full source).
1) Increase FiO2 to 1.0
2) Adjust pressure alarm limit to 50 cmH2O, and apnoea alarm to 60 seconds
3) Change to pressure support mode, and set pressure support level to 0
4) Increase PEEP to 40 cmH2O and maintain for 40 seconds
5) Lower the PEEP to either:
• The set level prior to the recruitment maneuvre (RM) if the RM was conducted for a
circuit disconnection or derecruitment
• The level dictated by a step to the right on the higher PEEP/FiO2 chart in the LPV tool
if the RM was for persistent hypoxaemia
6) Resume Volume Control (or other selected) mode and reset alarm limits
7) Lower FiO2 to either:
• The set level prior to the RM if the RM was conducted for a circuit disconnection or
derecruitment
• The level dictated by a step to the right on the higher PEEP/FiO2 chart in the LPV tool
if the RM was for persistent hypoxaemia
*Note: modifications may be required depending on the make and model of ventilator
•
Contraindications to a RM:
• Mean arterial pressure <60 mmHg despite fluids and vasopressors
• Active air leak through a chest tube
• Pneumothorax, or subcutaneous or mediastinal emphysema, where a chest tube has not
been inserted
• Early termination of a RM
If any of the following occur during a RM, immediately return PEEP to the set level prior to the
manoeuvre (before completing the 40 second hold):
• Mean arterial pressure <60, or fall of >20 mmHg
• SpO2<85%
• Heart rate >140 or <60 per minute
• New arrhythmia, excluding isolated supraventricular extrasystoles
• New air leak through a chest tube
63
Checklist for turning a patient prone
This checklist is adapted from Messerole et al, Am J Respir Crit Care Med 2008 (see reference
section for full source). Prone ventilation should be carried out by 4-5 team members using a protocol
rehearsed in advance. It is easier to perform in children. Also see video at www. NEJM.org
• Preparation
1. Check for contraindications.
a. Facial or pelvic fractures
b. Burns or open wounds on the ventral body surface
c. Conditions associated with spinal instability (e.g., rheumatoid arthritis, trauma)
d. Conditions associated with increased intracranial pressure
e. Life-threatening arrhythmias
2. Consider possible adverse effects of prone positioning on chest tube drainage.
3. Whenever possible, explain the maneuver to the patient or their family.
4. Confirm from a recent chest X-ray that the tip of the endotracheal tube is located 2–4 cm above the
main carina.
5. Inspect and confirm that the endotracheal tube and all central and large bore peripheral catheters
are firmly secured.
6. Consider exactly how the patient’s head, neck, and shoulder girdle will be supported after they are
turned prone. Assemble all needed pillows, foam pads, or other types of supports that might be
needed.
7. Stop tube feeding, check for residual, fully evacuate the stomach, and cap or clamp the feeding
and gastric tubes.
8. Prepare endotracheal suctioning equipment, and review what the process will be if copious airway
secretions abruptly interfere with ventilation.
9. Decide whether the turn will be rightward or leftward.
10. Prepare all intravenous tubing and other catheters and tubing for connection when the patient is
prone.
a. Assure sufficient tubing length
b. Relocate all drainage bags on the opposite side of the bed
c. Move chest tube drains between the legs
d. Reposition intravenous tubing toward the patient’s head, on the opposite side of the bed
• The Turning Procedure
1. Place one (or more) people on both sides of the bed (to be responsible for the turning processes)
and another at the head of the bed (to assure the central lines and the endotracheal tube do not
become dislodged or kinked).
2. Increase the FiO2 to 1.0 and note the mode of ventilation, the tidal volume, the minute ventilation,
and the peak and plateau airway pressures.
3. Pull the patient to the edge of the bed furthest from whichever lateral decubitus position will be
used while turning.
4. Place a new draw sheet on the side of the bed that the patient will face when in this lateral
decubitus position. Leave most of the sheet hanging.
5. Turn the patient to the lateral decubitus position with the dependent arm tucked slightly under the
64
thorax. As the turning progresses the nondependent arm can be raised in a cocked position over the
patient’s head. Alternatively, the turn can progress using a log-rolling procedure.
6. Remove ECG leads and patches. Suction the airway, mouth, and nasal passages if necessary.
7. Continue turning to the prone position.
8. Reposition in the center of the bed using the new draw sheet.
9. If the patient is on a standard hospital bed, turn his/her face toward the ventilator. Assure that the
airway is not kinked and has not migrated during the turning process. Suction the airway if necessary.
10. Support the face and shoulders appropriately avoiding any contact of the supporting padding with
the orbits or the eyes.
11. Position the arms for patient comfort. If the patient cannot communicate avoid any type of arm
extension that might result in a brachial plexus injury.
12. Auscultate the chest to check for right mainstem intubation. Reassess the tidal volume and minute
ventilation.
13. Adjust all tubing and reassess connections and functions.
14. Reattach ECG patches and leads to the back.
15. Tilt the patient into reverse Trendelenberg. Slight, intermittent lateral repositioning (20–30°) s hould
also be used, changing sides at least every 2 hours.
16. Document a thorough skin assessment every shift, specifically inspecting weight bearing, ventral
surfaces.
65
Sedation and delirium
Summary
In all intubated patients on IMV, use a systematic protocol-based approach to manage pain, anxiety,
and delirium.
Evaluate the patient regularly for pain, anxiety, and delirium using standardized scales.
Set a daily target for depth of sedation:
- Use intermittent benzodiazepines or propofol (if > 16 years age) continuous infusion as first
line sedatives to reach sedation target
- Minimize the use of continuous benzodiazepine infusions
Evaluate patients on continuous sedative infusions daily for sedation interruption readiness.
If ready, then discontinue infusion and monitor closely.
- If signs of failure develop, then restart infusion at ½ the previous rate.
- If no signs of failure then perform SBT, when patient is eligible.
Regularly assess for delirium
- If present, look for and treat the underlying cause
- Use non-pharmacologic interventions preferentially
- Use antipsychotic agents when necessary
Regularly assess for pain
- Try to prevent rather than treat
- Use non-opioid and opioid medications
Tools list
•
Pain assessment scales
•
COMFORT -B scale to assess sedation in children
•
AVPU scale: a simple tool for assessing level of consciousness
•
Richmond agitation sedation scale (RASS)
•
Algorithm for RASS Assessment
•
Worksheet for the Confusion Assessment Method of the Intensive Care Unit for adults(CAMICU)
•
Flowsheet for delirium assessment
•
Worksheet for the Confusion Assessment Method of the Intensive Care Unit for children
(pCAM-ICU)
•
Procedure for assessing attention screening exam visual (ASE) for adults
•
Forms for assessing visual ASE for adults and children
•
Table for commonly used sedatives in adults
•
Table for commonly used opioid analgesics in adults
•
Table for using neuromuscular blockers in adults
•
Table for the commonly used antipsychotic, haloperidol in adults
•
Table for paediatric analgesics, sedatives, and neuromuscular blocker
66
References
•
Dellinger RP et al. Surviving Sepsis Campaign: international guidelines for management of
severe sepsis and septic shock: 2008. Critical Care Medicine,2008, 36(1):296-327.
•
Ely EW et al. Delirium in mechanically ventilated patients: validity and reliability of the
confusion assessment method for the intensive care unit (CAM-ICU). JAMA,2001, 286:27032710.
•
Ely EW et al. Monitoring sedation status over time in ICU patients: the reliability and validity of
the Richmond Agitation Sedation Scale (RASS).JAMA, 2003, 289:2983-2991.
•
Girard TD et al.Efficacy and safety of a paired sedation and ventilator weaning protocol for
mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial):
a randomised controlled trial. Lancet,2008, 371(9607):126-134.
•
Ista E et al. Assessment of sedation levels of paediatric intensive care patients can be
improved using the COMFORT “behavior”scale. Pediatr Crit Care Med 2005; 6: 58-63.
•
Jacobi Jet al.Clinical practice guidelines for the sustained use of sedatives and analgesics in
the critically ill adult.Critical Care Medicine, 2002, 30(1):119-141.
•
Johansson M, Kokinsky E. The COMFORT Behavioural Scale and the modified FLACC scale
in paediatric intensive care. Nursing in Critical Care 2009;14(3):122-130.
•
Lonergan E et al. Antipsychotics for delirium. Cochrane Database of Systematic
Reviews,2007, Issue 2.
•
Pandharipande PP et al. Effect of Sedation With DexmedetomidinevsLorazepam on Acute
Brain Dysfunctionin Mechanically Ventilated Patients: the MENDS Randomized Controlled
Trial. JAMA, 2007, 298:2644-2653.
•
Papazian L et al. Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome.New
England Journal of Medicine,2010, 363:1107-16.
•
Sessler CN et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult
intensive care patients. American Journalof Respiratoryand Critical Care Medicine,2002,
166:1338-1344.
•
Smith HAB diagnosing delirium in critically ill children: Validity and reliability of the Pediatric
Confusion Assessment method for the intensive care unit. Crit Care med 2011; 39:150-157.
•
Bar J et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium
in Adult Patients in the Intensive Care Unit Crit Care Med 2013; 41:263-306.
67
Pain assessment scales
The Visual analog scale (VAS) for pain assessment in adults and adolescents is a validated and
widely used method of monitoring the subjective level of pain experienced by patients. It is a 10 cm
scale, which ranges from zero (no pain) to 10 (the worst pain that one can imagine). It is flexible, in
that patients can make verbal or visual responses (i.e. if verbal communication is not possible, the
patient can be shown a 10 cm scale and can point to the region which corresponds to their pain).
A major limitation of the VAS is that it requires an awake patient who grasps the concept of a scale.
These conditions are frequently not satisfied in ICU patients.
The lower the VAS score, the higher the quality of the analgesia. However, a low VAS score with
excessive sedation must be avoided, if possible. The level of sedation must be also closely
monitored (see RASS scale in Toolkit).
☺
No Pain
Unbearable
Pain
The Wong-Backer faces can be used in younger children if they are asked to point to the face that
reflects their pain level.
68
COMFORT-B scale to assess sedation
in children
The sedation and pain levels of children in intensive care should be assessed at least 4 hourly in
intensive care. A number of tools are available to assess pain and sedation; we describe the use of
COMFORT- B for sedation and the Wong-Backer VAS previously for pain.
The COMFORT-B cannot be used in children who are receiving muscle relaxant drugs or children
with severe neurological impairment. The child should be observed for 2 minutes and 6 behaviours
are scored as below (Score either respiratory response or crying depending on the child’s intubation
status). Children scoring 11-22 are in the optimal range of sedation; children scoring < 10 may be
oversedated (consider weaning) and children >23 are undersedated.
Item
Alertness
Calmness/agitation
Respiratory
response
(ventilated children)
Cry
(non-ventilated
children)
Physical movement
Muscle tone
Facial tension
Description
1. Deeply asleep
2. Lightly asleep
3. Drowsy
4. Fully awake and alert
5. Hyperalert
1. Calm
2. Slightly anxious
3. Anxious
4. Very anxious
5. Panicky
1. No coughing and no spontaneous respiration
2. Spontaneous respiration with little or no response to
ventilation
3. Occasional cough or resistance to ventilator
4. Actively breathes against ventilator or coughs regularly
5. Fights ventilator, cough or choking
1. Quiet breathing, no crying
2. Sobbing or gasping
3. Moaning
4. Crying
5. Screaming
1. No movement
2. Occasional, slight movements
3. Frequent, slight movements
4. Vigorous movement limited to extremities
5. Vigorous movements including torso and head
1. Muscles totally relaxed, no muscle tone
2. Reduced muscle tone
3. Normal muscle tone
4. Increased muscle tone and flexion of fingers and toes
5. Extreme muscle rigidity and flexion of fingers and toes
1. Facial muscle totally relaxed
2. Facial muscle tone normal; no facial muscle tension
evident
3. Tension evident in some facial muscles
4. Tension evident throughout facial muscles
5. Facial muscles contorted and grimacing
Total score
Score
…
…
…
…
…
…
…
…
(Adapted from Ambuel et al. (1992)).
69
AVPU scale: a simple tool for
assessing level of consciousness
This scale is a simple way to assess a patient's mental status. Each letter corresponds to the
patients' level of consciousness:
Score
Description
A
Alert
V
Responds to verbal stimuli
P
Responds to painful stimuli
U
Unresponsive, or coma
70
Richmond agitation sedation scale
(RASS)
Assess for agitation and anxiety and sedation levels on a regular basis using a standardized scale
and set a daily sedation target based on clinical condition and management plans for the day.
Consider the use of the Richmond agitation sedation scale. This has been validated in many clinical
trials and can be easily taught to your staff.
Score
Term
+4
Combative
+3
Very agitated
+2
Agitated
Frequent non-purposeful movement, fights ventilator
+1
Restless
Anxious but movements not aggressive vigorous
0
Alert and calm
-1
Drowsy
-2
Light sedation
Briefly awakens with eye contact to voice (<10 seconds)
-3
Moderate sedation
Movement or eye opening to voice (but no eye contact)
-4
Deep sedation
No response to voice, but movement or eye opening to
physical stimulation
-5
Description
Overtly combative, violent, immediate danger to staff
Pulls or removes tube(s) or catheter(s); aggressive
Not fully alert, but has sustained awakening(eyeopening/eye contact) to voice (>10 seconds)
Unarousable
No response to voice or physical stimulation
(Adapted from Sessler AJRCCM 2002 and Wesley EW JAMA 2003)
71
Verbal
stimulation
Physical
stimulation
Algorithm for RASS Assessment
In most patients, this assessment is very quick and takes only 30 seconds. Only 10% take a few minutes. (Adapted from Sessler AJRCCM 2002 and
Wesley EW JAMA 2003.)
Observe patient
1. Patient is alert,
restless, or
agitated.
2. Patient is not
alert
State patient’s name and say to open
eyes and look at speaker
2a. Patient
awakens with
sustained eye
opening and
eye contact
2b. Patient
awakens with
eye opening
and eye
contact, but not
sustained
2c. Patient has
any movement
in response to
voice, but no
eye contact
3. Patient has
no response to
verbal
stimulation
Physically stimulate patient by shaking
shoulder and/or rubbing sternum
3a. Patient has any
movement to physical
stimulation
Score:
0 to +4
-1
-2
If RASS is -3 to +4, then proceed to the delirium assessment.
72
-3
-4
3b. Patient has no
response to any
stimulation
-5
If RASS is -4 or -5, then stop and
reassess patient at later time.
Worksheet for the Confusion
Assessment Method of the Intensive
Care Unit for adults (CAM-ICU)
Use the CAM-ICU worksheet to assess delirium in conjunction with the RASS scale.
If RASS ≠ 0, evaluate only feature 1(acute onset or fluctuating course) and feature 2 (inattention).
If RASS = 0, evaluate all features.
(© E. Wesley Ely, MD, MPH and Vanderbilt University)
73
Flowsheet for delirium assessment for
adult
This can be used as a pocket card or wall poster to easily reference the procedure to assess for the
presence of delirium.
(© E. Wesley Ely, MD, MPH and Vanderbilt University.)
74
Worksheet for the Confusion
Assessment Method of the Intensive
Care Unit for children (pCAM-ICU)
This tool is adapted from Smith, H. Diagnosing delirium in critically ill children: Validity and
reliability of the Pediatric Confusion Assessment method for the intensive care unit. Crit Care
med 2011; 39:150-157.
1. Acute Change or Fluctuating Course of Mental Status
• Is there an acute change from mental status baseline?
OR
• Has the patient’s mental status fluctuated during the past
24 hours?
NO
pCAM-ICU negative
NO DELIRIUM
YES
2. Inattention
• “Squeeze my hand when I say ‘A’.”
• Read the following sequence of letters: A B A D B A D A A Y
ERRORS: No squeeze with ‘A’ & Squeeze with letter
other than ‘A’.
• If unable to complete ASE Letters ASE Pictures
Score < 8
3. Altered Level of Consciousness
• Refer to current RASS (sedation assessment) score
Score ≥ 8
pCAM-ICU negative
NO DELIRIUM
RASS other
than zero
pCAM-ICU positive
DELIRIUM present
RASS = zero
4. Disorganized Thinking
1. Is sugar sweet? (Alternate: Is a rock hard?)
2. Is ice cream hot? (Do rabbits fly?)
3. Do birds fly? (Is ice cream cold?)
4. Is an ant bigger than an elephant? (Is a giraffe smaller than
a mouse?)
Command: “Hold up this many fingers.” (Hold up 2 fingers.)
“Now do that with the other hand.” (Do not demonstrate.)
OR “Add one more finger.” (If patient is unable to move both
arms.)
> 1 error
pCAM-ICU negative
0 – 1 error
NO DELIRIUM
(Copyright © 2008, Heidi A. B. Smith, M.D., M.S.C.I. and Monroe Carell, Jr. Children’s Hospital at
Vanderbilt, all rights reserved)
75
P rocedure for assessing attention
s creening exam visual (ASE) for adults
To be used to assess for feature 2, inattention, (a cardinal feature of delirium) when the
patient is unable to complete letters evaluation SAVEAHAART, this happens in only
about 10% of patients and can be fun to do.
•
•
•
Step 1
-
Say to the patient: “Mr. or Mrs. …, I am going to show you pictures of some
common objects. Watch carefully and try to remember each picture because I will
ask what pictures you have seen.”
-
Present 5 pictures. Each one is verbally named and shown during 3 seconds.
Step 2
-
Say to the patient: “Now I am going to show you some more pictures. Some of
these you have already sseen
een and some are new. Let me know whether or not you
saw the picture before by nodding your head yes (demonstrate) or no
(demonstrate).”
-
Present 10 pictures (5 new, 5 repeated). Each one is verbally named and shown
during 3 seconds.
Scoring
This test is scored by the number of correct “yes” or “no” answers during the step 2 (out
of a possible 10).
Important: Alternate daily between Form A and Form B (see next tool) if repeat
measures are taken. If a patient wears glasses make sure
sure he/she has them on when
attempting the Visual ASE.
(Adapted from E. Wesley Ely, MD, MPH and Vanderbilt University.)
76
Forms for assessing attention s creening (ASE) for adults
ASE Form A
(Adapted from E. Wesley Ely, MD, MPH and Vanderbilt University.)
77
ASE Form B
(Adapted from E. Wesley Ely, MD, MPH and Vanderbilt University.)
78
Table to guide the use of commonly
used sedatives in adults
There are many sedative medications available to treat agitation and anxiety. You will need to see
which medications your hospital currently has and consider which medications you may want to use in
the future. It is important to familiarize yourself with the basic pharmacokinetics and side effects of
any drug you use. The goal is to reach the lightest sedation target with lowest possible sedative
medication to minimize toxicity. The doses provided in this table are intended to use for patients who
are intubated and receiving mechanical ventilation. First line sedatives are: intermittant
benzodiazepines or continuous propofol infusion. Continous infusions fo benzodiazipines should be
avoided when at all possible to reduce risks of oversedation, prolonged days of IMV and delirium.
Benzodiazepine*
Propofol
Loading
dose
Onset
Risks
Lorazepam
Diazepam
Dexmedetomidine**
0.25-1 mg/kg
0.02-0.1
mg/kg
0.02-0.06
mg/kg
0.05-0.2 mg/kg
1 µg/kg over 10
minutes
<1 minute
1-5 minutes
5-20 minutes
2-5 minutes
1-3 minutes
25-75 µg/kg/min
0.04-0.2
mg/kg/hr
0.01-0.1
mg/kg/hr
(preferred vs.
midazolam)
Not used
0.2-0.7 µg/kg/hr
10-15 minutes
1-2 hours
2-6 hours
2-4 hours
6-10 minutes
Respiratory
depression
Respiratory
depression
Respiratory
depression
Respiratory
depression
Hypotension
Hypotension
Hypotension
Hypotension
Hypotension
Idiosyncratic
rhabdomyolysis
and acidosis
Prolonged
sedation with
infusions due
to active
metabolite
Propylene
glycol carrier
may irritate
veins and
cause
metabolic
acidosis with
prolonged
administration
Oversedation
with repeated
boluses with
accumulation
of drug and
active
metabolite
Infusion
Time to
arousal
Midazolam
↑triglycerides
Reduce dose
in renal and
liver failure
***
Bradycardia
Atrial fibrillation
More pronounced in
elderly
Safety data for up to 4
days of infusion
Dose may need to be
reduced in elderly
depending on renal
function
* Reduce dose in the elderly
**Less commonly available
*** Higher doses, up to 1.5ug/kg/hr,were used safely in a large clinical trial; see Pandharipande PP
et al. JAMA 2007, 298: 2644-2653.
Note, early in the course of severe ARDS, however, deep sedation targets may be needed to safely
achieve LPV targets and reduce asynchrony. In cases when NMB is adminstered, remember to
also give a continuous sedative for amnesia
79
Table to guide the use of commonly
used opioid analgesics in adults
There are several opioids available to treat pain. You will need to see which medications your
hospital currently has and consider which medications you may want to use in the future. Familiarize
yourself with the basic pharmacokinetics and side effects of any drug you use. Be sure to set a
therapeutic analgesia plan and communicate to all caregivers for a consistent approach.
These considerations are adapted from the 2002 “Clinical practice guidelines for the sustained use of
sedatives andanalgesics in the critically ill adult” (see reference section for details).
The doses provided in this table are suggestions and will need adjustment based on the amount of
pain and whether the patient is receiving mechanical ventilation.
Morphine
Hydromorphone
Fentanyl
Intermittent dose IV
0.01–0.15 mg/kg
every 1–2 hr
10–30 µg/kg every 1–2
hr
0.35–1.5 µg/kg every 0.5–
1 hr
Infusion
0.07–0.5 mg/kg/hr
7–15 µg/kg/hr
0.7–10 µg/kg/hr
Half-life
3-7 hr
2-3 hr
1.5–6 hr
Equianalgesic IV
dose*
10 mg
1.5 mg
200 µg
Intermittent dosing
Rapid onset in acutely
distressed patients
Situations where
drug is preferred
Intermittent dosing
Hemodynamic
instability
Renal failure
Histamine release
causing hypotension
Risks**
Prolonged effect in
renal failure due to
metabolite
Hemodynamic instability
Renal failure
Rigidity with high doses
--
Repeated dosing may
cause accumulation and
prolonged effects
*These doses produce approximately the same analgesic effects.
**Side effects common to ALL agents include respiratory depression, coma and delirium,
hypotension (especially with morphine), and ileus.
NOTE: Meperidine and codeine may be available at many hospitals. However, meperidine has an
active metabolite that causes neuroexcitation (apprehension, tremors, delirium, and seizures) and
may interact with antidepressants (contraindicated with monoamine oxidase inhibitors and best
avoided with selective serotonin-reuptake inhibitors), so it is not recommended for repetitive use.
Codeine lacks analgesic potency and is thus not useful for most patients.
80
Table for using neuromuscular
blockers in adults
Some patients with severe ARDS require neuromuscular blockade, which improved mortality in
one randomized trial when used EARLY in the course of severe ARDS and for just 48 hours.
Although cis-atracurium was used in that study, cheaper alternatives include pancuronium and
vecuronium.
Pancuronium
Intermittent: 0.08 - 0.1 mg/kg
IV dose
Common points
on dosing
Onset
Specific risks
Infusion: 0.2 - 0.6 µg/kg/min (usually 1 to 2.5
mg/h)
Vecuronium
Intermittent: 0.08 - 0.1
mg/kg
Infusion: 0.2 - 0.8 µg/kg/min
(usually 1 -4 mg/h)
Tailor intermittent dose to patient response.
Titrate infusion dose clinically or to achieve 1-2 twitches with train of four
stimulation on peripheral nerve stimulator, if available
<4 minutes
2-3 minutes
Long duration of activity: ~90-160 minutes
Intermediate duration of
activity: ~30-45 minutes
Accumulation in hepatic and renal dysfunction
Dose-dependent increased HR and BP (due to
vagolytic and weak sympathomimetic effects)
Accumulation in hepatic and
renal dysfunction
Appropriate sedation and analgesia should be administered concurrently since
these drugs have neither effect
Common risks
HR and BP should be routinely monitored; increases may indicate inadequate
sedation or analgesia
ICU-acquired weakness if used for prolonged period
81
Table to guide the use of commonly
used antipsychotic, haloperidol, in
adults
Antipsychotic agents can be used to control delirium. Haloperidol is a typical antipsychotic that has
been available for many years. Atypical antipsychotics can also be used (e.g. quetiapine,
risperidone). Dexmedetomidine is a newer agent that has both sedative and anti-delirium effects.
Haloperidol
Begin with 1-2 mg IV
Loading dose
Double dose every 15 minutes until desired effect is achieved.
st
DO NOT exceed total of 30 mg in 1 hour.
Onset
Risks
10-20 minutes
Torsade de pointes arrhythmia, do not use if the QTc interval on
ECG is prolonged to >460 msec.
Suspect neuroleptic malignant syndrome if patient develops
hyperthermia, muscle rigidity and rhabdomyolysis.
82
Table for p a ediatric analgesia,
sedation, and neuromuscular blockade
There are several agents available to for sedation, analgesia, and neuromuscular blockade. You will
need to see which medications your hospital currently has and consider which medications you may
want to use in the future. Familiarize yourself with the basic pharmacokinetics and side effects of any
drug you use. The doses provided in this table are suggestio
suggestions
ns and will need titration in individual
patients based on the amount of pain and whether the patient is receiving mechanical ventilation.
Appropriate sedation and analgesia should be administered concurrently with neuromuscular
blockade, which has no sedative or analgesic properties.
Propofol is contraindicated for sedation in children <16 years old.
Drug
Analgesia
Sedation
Enteral dose
Iv Infusion
Paracetamol
10-15mg/kg po/pr
6hrly
N/A
N/A
Codeine
0.5-1 mg/kg po 612hrly
N/A
N/A
Morphine
0.2-0.4mg/kg po 6hrly
0.1-0.2mg/kg
0-40 µg/kg/hr
Fentanyl
N/A
1-2 µg/kg
0-8 µg/kg/hr
Midazolam
N/A
0.1-0.2mg/kg
0-4 µg/kg/min
0.1-0.2mg/kg
N/A
Diazepam
Neuromuscular
Blockade
Bolus iv dose
Chloral hydrate
30-50 µg/kg pr 6hrly
N/A
N/A
Triciofos
30-50 µg/kg pr 6hrly
N/A
N/A
Allmemazine
1 mg/kg po 6hrly
N/A
N/A
Vecuronium
N/A
0.1 mg/kg as
required
0-4 µg/kg/min
83
Liberation from
Invasive Mechanical
Ventilation
Summary
Use a protocol to liberate patients from mechanical ventilation.
Coordinate daily SBT with sedation interruption evaluations.
Patients are ready for an SBT when they have:
- Clinically improved from underlying problem
- Spontaneous respiratory efforts
- Adequate oxygenation and ventilation
- No ongoing myocardial ischemia
- No significant vasopressor use
Conduct SBT by reducing ventilator support to minimum level,
-
If the patient develops signs of respiratory failure
o Stop the SBT
o Resume prior levels of mechanical ventilator support to avoid respiratory muscle
fatigue.
o Assess and treat the reason for failure and
o Determine if patient is ready to try a SBT the next day
-
If there are no signs of respiratory failure at 30 minutes or 2 hours, then assess for safety of
extubation-cough, secretions and risk of post-extuabation stridor and upper airway obstruction.
After extubation monitor the patient over the next 48 hours for signs of respiratory failure and need for
prompt reintubation.
Tools list
•
Algorithm for coordinating daily sedation interruption with daily SBT
•
Algorithm for liberating your patients from invasive mechanical ventilation
References
•
American Thoracic Society slideshow on ventilator waveforms, available at
http://www.thoracic.org/clinical/critical-care/ventilator-waveform-analysis.php (accessed 7
December 2011)
•
Blackwood B et al. Protocolized versus non-protocolized weaning for reducing the duration of
mechanical ventilation in critically ill adult patients. Cochrane Database of Systematic
Reviews, 2010, Issue 5.
•
Brochard et al. Comparison of three methods of gradual withdrawal from ventilatory support
during weaning from mechanical ventilation. American Journal Respiratory Critical Care
Medicine, 1994, 150:896-903.
•
Brooks et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical
ventilation Critical Care Medicine,1999, 27:2609-2615.
84
•
Epstein S. Decision to Extubate. Intensive Care Med, 2002, 28:535-546.
•
Esteban et al. A comparison of four methods of weaning patients from mechanical ventilation.
New England Journal of Medicine, 1995, 332:345-350.
•
Esteban et al. Extubation Outcome after spontaneous breathing. American Journal
Respiratory Critical Care Medicine, 1997, 156:459–465.
Girard et al. Who Should Receive Efficacy and safety of a paired sedation and ventilator
weaning protocol for mechanically ventilated patients in intensive care (Awakening and
Breathing Controlled trial):a randomised controlled trial. Lancet, 2008, 371:126-133.
•
•
Levine et al. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans,
New England Journal of Medicine, 2008:1327-1335.
•
Manthous et al. Liberation from Mechanical Ventilation. Chest,1998,114:886-901.
•
MacIntyre NR et al. Evidence-based guidelines for weaning and discontinuing ventilatory
support: a collective task force facilitated by the American College of Chest Physicians;
the American Association for Respiratory Care; and the American College of Critical Care
Medicine. Chest 2001 Dec;120(6 Suppl):375S-395S.
•
MacIntyre N. Discontinuing Mechanical Ventilatory Support. Chest, 2007, 132:1049-1056.
•
Newth CJL Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med
2009; 10:1-11.
•
Rothaar et al. Extubation failure. Current Opinion Critical Care, 2003, 9:59-66.
•
Wittekamp BS et al. Clinical Review: Post-extubation larygenal edema and extubation
failure in critically ill adults. Critical Care, 2009, 13:233
85
Algorithm for coordinating daily
sedation interruption with daily SBT
Consider using an algorithmic framework to systematically assess if your patient is ready to have their
sedation interrupted and be liberated from the ventilator. This is adapted from the Awakening and
Breathing Controlled trial published in Lancet 2008, 371:126-133 and can be adapted to your ICU.
q24hrs
Sedation
interruption safety
screen
Fail
Pass
Discontinue
sedation
Restart sedatives
at ½ dose
Sedation interruption Safety
screen
No active seizures
No alcohol withdrawal
No agitation
No neuromuscular blockade
No myocardial ischemia
No elevated ICP
Sedation Interruption failure
Anxiety, agitation, or pain
Respiratory rate >35/min
SpO2<90%
Respiratory distress
Hemodynamic instability
Fail
Pass
SBT readiness
screen
Fail
Pass
Perform SBT
Fail
SBT readiness screen
Spontaneous breathing efforts
Resolving/stable disease
SpO2≥ 90% on FiO2 ≤ 0.50 and
PEEP ≤ 8 cm H2O
pH> 7.3 and MV ≤ 15 l/min
No significant vasopressor
use*
No myocardial ischemia
No elevated ICP
SBT failure
Pass
Assess airway
and consider
extubation
*Dopamine ≤ 5 ug/kg/min or equivalent
ICP, intracranial pressure
86
Any sign of respiratory failure
Respiratory rate >35/min
Apnea
SpO2<90%
Hypoventilation
≥ 2 Signs of intolerance
Agitation
Diaphoresis
Accessory muscle
Hemodynamic instability
Algorithm for liberating your patient
from invasive mechanical ventilation
Consider using an algorithmic framework to systematically assess if your patient is ready to be
liberated from the ventilator. This is adapted from the review article entitled Discontinuing Mechanical
Ventilatory Support in Chest 2007.
Daily Screen for SBT readiness
- Spontaneous breathing efforts
- Resolving/stable disease
- SpO2≥ 90% on FiO2 ≤ 0.50 and PEEP ≤ 8 cmH2O
- pH> 7.3 and minute ventilation ≤ 15 l/min
- No significant vasopressor use*
-No active myocardial ischemia
-No elevated ICP
All answers « yes »
Any answer « no »
Options for SBT
Perform SBT for
30-120 minutes assessing for
- Any sign of respiratory failure
RR>35/min, apnea, SpO2< 90%,
hypoventilation
- ≥ 2 signs of intolerance
Agitation, diaphoresis, respiratory
distress, hemodynamic instability
Low level of
Pressure Support
-PS 5-7 cm H20 and
CPAP of 5 cm H20
Low level of CPAP
alone
-CPAP at 5 cm H20
T-piece alone
Pass SBT
not recommended in
children
Fail SBT
Assess for extubation
- Able to protect airway
- Risk of upper airway obstruction
Airway ok
Extubate
Resume stable, comfortable
assisted ventilation
- Search for reversible process and
treat
- Avoid muscle fatigue
- Avoid patient ventilator asynchrony
Airway not ok
Repeat «SBT screen » q 24 hrs
Treat cause,
keep airway
protected,
tracheostomy**
* Dopamine ≤ 5 ug/kg/min or equivalent
** Consider tracheostomy based on local practice
87
Best practices to
prevent complications
Summary
Complications associated with critical illness:
- nosocomial infections (e.g. catheter related BSI, VAP, UTI)
- venous thromboembolism
- gastric ulcer related bleeding
- pressure ulcers
- ICU-acquired weakness
Interventions to reduce the risk of complications:
- semi-recumbent positioning to prevent VAP
- checklist to reinforce sterile precautions to prevent BSI
- anticoagulants and compression devices to prevent VTE for adults and adolescents
- early enteral nutrition to prevent gastric ulcers and infections
- frequent turns to prevent pressure ulcers
- early mobilization to prevent weakness
Tools list
•
Procedure for providing enteral nutrition (EN) for adults
•
Procedure for providing enteral nutrition (EN) for paediatric patients
•
Checklist for central venous catheter (CVC) insertion
•
Checklist for preventing ventilator associated pneumonia (VAP)
•
Checklist for preventing urinary tract infections (UTI)
References
•
Coffin SE et al. Strategies to prevent ventilator-associated pneumonia in acute care
hospitals. Infect Control Hosp Epidemiol, 2008, 29 Suppl 1:S31-40.
•
ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital
care setting (ENDORSE study): a multinational cross-sectional study. Lancet, 2008,
371(9610):387-94. Erratum in: Lancet. 2008, 371(9628):1914.
•
Geerts WH et al. Prevention of venous thromboembolism. ACCP Evidence-Based Clinical
Practice Guidelines. Chest, 2008, 133(6, suppl):381S-453S.
•
Implement the Central Line Bundle, Resource from the institute healthcare improvement
(http://www.ihi.org/ihi)
•
Lo E et al. Strategies to prevent catheter-associated urinary tract infections in acute care
hospitals. Infect Control Hosp Epidemiol, 2008, 29:S41-S50.
•
McClave SA et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy
in the Adult Critically Ill Patient. J Parenter Enteral Nutr,2009, 3(3):277-316.
•
Muscedere J et al. Comprehensive evidence-based clinical practice guidelines for ventilatorassociated pneumonia: prevention. Journal of Critical Care, 2008, 23:125-137.
•
Pronovost P et al. An Intervention to Decrease Catheter-Related Blood stream Infections in
the ICU. New England Journal of Medicine, 2006, 355:2725-2732
88
P rocedure for providing enteral
nutrition (EN) for adults
This tool can be used to start enteral nutrition.
1. Place a feeding tube.
2. Confirm placement with radiograph (gastric or small bowel
feeding are acceptable).
3. Once the feeding tube has been confirmed, start with an
infusion of up to 30 ml/h of clear fluid or feed.
4. Aspirate the nasogastric tube every 4 hours.
5. Gradually increase the volume of feed with the aim of
building up to full feeding within 48 h.
Courtesy of Dr. Adhikari
© WHO
Feeding intolerance
Set caloric
loric target and aim to reach this within
a few days
Intolerance of feeding may result from poor gastric
emptying and lead to high residual gastric
volumes.
Estimate your patient's daily caloric needs, or basal
energy expenditure (BEE). Adjust for fever and
stress
– BEE (kcal/day) = 25 x Body weight (kg)
– Fever: BEE x 1.1 (for each degree above
the normal body temperature)
– Mild to moderate stress: BEE x 1.2-1.4
– Moderate to severe stress: BEE x 1.4-1.6
The absolute value that is too high and should
prompt cessation of tube feeds is not clear.
Stop feeding when:
- Volumes high (between 250-500 ml)
- Clinical signs of intolerance (abdominal
pain, abdominal distension and
diarrhoea)
Estimate your patient's daily protein requirements
– Normal 1.2- 2.0 g/kg
– Hypercatabolism: 2-3 g/kg
– Ratio of non-protein calories to nitrogen
(70:1-100:1)
None of the features are specific for feed
intolerance.
Possible treatments include advancing the feeding
tube into the small bowel (can be done at the
bedside) or adding prokinetic medications (e.g.
metoclopromide intravenously)
89
Procedure for providing enteral
nutrition (EN): paediatric
considerations
Enteral feeding via nasogastric (NG) tube is the preferred method of providing maintenance fluid.
© WHOhttp://whqlibdoc.who.int/publications/2005/9241546700.pdf
1. Measure the distance from the nose to the ear and then to the epigastrium.
2. Insert a nasogastric tube to the measured distance.
3. Check correct placement of tube:
- Check the pH of aspirate using pH indicator strips
- Position can be seen on chest X-ray
- If in doubt →remove & replace
4. Secure the nasogastric tube by taping to the cheek avoiding upwards pressure on the nares.
5. Once correct placement has been confirmed, flush the tube with water. It is now safe to use the
tube for administration of feed and medication.
6. Flush the NG tube with sterile water after administration of NG drugs otherwise it will block
Check the position of the nasogastric tube:
- Before each use
- Every 6h if continuous feeds
- After episodes of vomiting /retching, ↑ respiratory distress or excessive coughing
- If the tube looks dislodged (i.e. with more tubing visible)
NG tube sizes
This is only a rough guide, the bore of tube must fit easily in the child’s nostril:
Description of patient
<2 kg, preterm
2- 4 kg
Term – 1 year
Younger children
Older children & adolescents
Small adult
Large adult
90
Tubes sizes
4 fr
6 fr
8 fr
10 fr
12 fr
14 fr
16 fr
Check NG tube position.
Hourly bolus feeds–consider continuous pump for large hourly volumes.
Aspirate every 4 hours.
No Aspirate
Aspirate
Replace aspirate (max 4 hrs),
continue at same rate & reassess
after 4 hours.
Continue.
No Aspirate
Aspirate
Discard aspirate.
Abdominal distension
No abdominal
distension
Stop feeds.
Reduce Rate 50%
Medical review
& reassess at 4 hours.
91
Checklist for central venous catheter
insertion
In the literature, a research collaborative found that using a central line checklist as a
reminder for the inserter significantly reduced the incidence of central venous catheter
related blood stream infections. This checklist is adapted from the article entitled An
Intervention to Decrease Catheter-Related Blood stream Infections in the ICU. New England
Journal of Medicine, 2006, 355:2725-2732.
Hand hygiene before the procedure.
Wear maximal barrier precautions on insertion:
full sterile gown
face mask
face shields
sterile gloves
hair cover
cover the patient in a full sterile sheet from head to toe
Use Chlorhexidine 2% in 70% isopropyl alcohol for skin preparation and apply in a back and
forth friction rub motion for 30 seconds
Let dry completely before puncturing site. It should not be blotted dry.
Choose the optimal site: subclavian vein preferred, femoral vein not preferred.
Once in place in place, evaluate the central line on a daily basis for necessity
Remove line when no longer needed
92
Checklist for preventing ventilator
associated pneumonia (VAP)
In order to prevent VAP, a complication of endotracheal intubation and invasive mechanical
ventilation,consider the following procedures, when possible:
Oral intubation instead of nasal intubation.
Keep the patient in semi-recumbent position (head of bed elevated up to ≥30-45°).
Use a closed suctioning system.
Periodically drain and discard condensate in tubing.
Use a new ventilator circuit for each patient. Change if soiled or damaged but not routinely.
Change heat moisture exchanger (HME) when malfunctions, soiled, or every 5-7 days.
Perform regular antiseptic oral care.
Discontinue invasive ventilation in a safe and prompt manner:
Daily sedation interruption of continuous sedative infusions
Daily evaluation for SBT readiness
Extubation to non-invasive ventilation when appropriate (i.e. primarily for patients
ventilated because of a COPD exacerbation, and only in centres with sufficient
expertise in non-invasive ventilation).
Note: HME’s are not routinely used in infants and small children as they significantly increase
dead space. Use heated humidifiers instead.
93
Checklist for preventing urinary tract
infections (UTI)
Prevention of urinary tract infection requires an appropriate technique for catheter insertion as
well as appropriate management of indwelling catheters. Consider the following procedures when
possible:
•
Catheter insertion
Insert catheter only when necessary
Hand hygiene before procedure
Use aseptic technique and sterile equipment
Use as small a catheter as possible, consistent with proper drainage
•
Catheter management
Maintain unobstructed urine flow
Empty collection bag regularly:
Separate collecting container for each patient
Do not allow draining spigot to touch collecting container
Keep collecting bag below level of bladder at all times
Cleaning urethral meat us with antiseptic is unnecessary. Routine cleaning is adequate
Secure catheter to prevent movement and urethral traction
Sterile, continuously closed drainage system
Do not disconnect catheter & drainage tube unless catheter must be irrigated
Replace collecting system aseptically and after disinfecting catheter-tubing junction if
following occur:
-
Break in aseptic technique
-
Disconnection
-
Leakage
Remove as soon as there is no indication
94
Quality in critical care
Summary
Quality is the provision of safe, timely, effective, efficient, equitable, and patient-centred care.
Systematic quality improvement work is essential because healthcare delivery is complex and
imperfect, even with best efforts.
Quality measures are related to ICU structure, processes of care, and patient outcomes.
Use the PLAN-DO-CHECK-ACT cycle to improve quality
- focus in processes of care rather than hard to measure outcomes of care
- e.g. tidal volume targets for LPV, early antimicrobials for septic shock
Tools list
•
Checklist for daily best practices
•
Checklist: High-quality use of central venous catheters for septic shock
•
Checklist: High-quality use of IMV for ARDS
•
Process for selecting problem to focus on in the ICU and quality improvement process
•
Checklist for initiating, improving, evaluating, and sustaining a quality improvement program
References
•
Assessing and tackling patient harm: a methodological guide for data-poor hospitals.
Available at
http://www.who.int/patientsafety/news_events/news/research_apr2011/en/index.html
•
Bion JF et al. Challenges in the care of the acutely ill.Lancet, 2004, 363:970-977.
•
Brown L et al. Quality assurance of health care in developing countries. Quality Assurance
Project. Quality Assurance Methodology Refinement Series,2000.
•
Campbell et al. Global Initiatives for improving Hospital care for children. Paediatrics,
2008,121:e984-994.
•
Curtis JR et al. Intensive care unit quality improvement: a "how-to" guide for the
interdisciplinary team.Crit Care Med. 2006 Jan;34(1):211-8.
•
Hales BM, Pronovost P. The checklist—a tool for error management andperformance
improvement. Journal of Critical Care, 2006, 21:231– 235.
•
Hales BM et al. Development of medical checklists for improved quality of patient care.
International Journal for Quality in Health Care, 2007:1–9.
•
Institute for Healthcare Improvement.(http://www.ihi.org/ihi)
•
Kuzniewicz MW et al. Variation in ICU Risk-Adjusted Mortality Impact of Methods of
Assessment and Potential Confounders, Chest, 2008, 133:1319-1327.
95
Checklist for daily best practices
Consider using this checklist to assess if your patient is receiving appropriate preventative
interventions.
Patient: ………………………..
Date: ………………………..
• Daily Sedation Interruption
Yes
Not a candidate, why………………………..
• SBT
Yes
Not a candidate, why………………………..
• Head of bed elevation
Yes
Not a candidate, why………………………..
• Gastric ulcer prophylaxis
Yes
Not a candidate,
why………………………..
• Antibiotics
Yes (day…………of …………)
No
•
Today’s Sedation Target. Fill in
box with RASS score target
• Skin breakdown assessment
Yes
Not done, why …………………………….
• Enteral nutrition
Yes
No a candidate, why………………………..
• Needs Arterial Line
Yes
No
• DVT prophylaxis
Yes
Not a candidate, why………………………..
• Needs Central venous catheter
Yes
No
(Adapted with permission from San Francisco General Hospital, San Francisco USA)
96
Checklist: are you using central
venous catheters in a high-quality and
safe manner?
Consider using this tool to understand if you are using CVC to deliver quality care to your
patients with severe sepsis/septic shock.
•
Technical competence
Appropriate size and type of catheter available
Personal protective equipment for clinician inserting catheter
Skilled clinician to insert catheter
CVP monitor accurate and available
Blood gas analyzer available and working to measure ScvO2
Skilled clinician to perform targeted resuscitation
•
Safety
Insertion checklist to prevent bloodstream infections
Ultrasound guidance to prevent insertion complications
Know and plan for insertion complications (e.g. chest tube for pneumothorax, arterial
puncture)
Daily evaluation for necessity: take out the central line when no longer necessary to
minimize blood stream infections
•
Outcome measure
Complication rates (e.g. BSI, pneumothorax)
•
Process measures
CVP and ScvO2 measured and targets achieved
97
Checklist: High-quality and safe
intubation and IMV
Consider using this tool to understand if you are using IMV to deliver quality care to your
patients with ARDS
•
Technical competence
Type of mechanical ventilator available
Able to deliver PEEP
Able to measure plateau airway pressure
Able to deliver high concentrations of oxygen
Intubation equipment readily available
Infection prevention materials readily available (airborne precautions)
Skilled person to intubate available
Skilled personnel to use and troubleshoot IMV
Arterial blood gas analyzer available and working
Pulse oximeter available and working
•
Safety
Plan for difficult airway (e.g. backup personnel, equipment, and plan [e.g. cricothyrotomy])
Plan for IMV complications (e.g. chest tube for pneumothorax, sedation for agitation)
Plan for prevention while on IMV (e.g. daily SBT evaluation, daily sedation interruption, VAP
prevention)
•
Process measures
Process measures (e.g. lung protective targets met)
•
Outcome measures
Complications (e.g. VAP, pneumothorax)
98
Process for selecting problem to focus
on in the ICU and quality improvement
process
This flowchart provides a framework for selecting a problem to focus on for quality improvement
among the many that might be considered. It also shows the essential steps in the Plan-Do-Study-Act
cycle (used with permission from Dr Andre Amaral, Sunnybrook Health Sciences Centre and
University of Toronto, Toronto, Canada).
Quality walkabouts
Staff meetings
Morbidity and
mortality rounds
Safety reports
New scientific
evidence
Hospital
requirements
Pool of projects and
problems that could
be addressed
PRIORITIZE
1. Is the problem measurable? How are we currently doing?
2. Is there evidence linking this problem to quality of care/patient safety?
3. Is it a hospital requirement? What is the deadline?
4. Interferes or has synergy with other ongoing projects?
5. How easy is it to implement?
• Human resources?
• Other resources? (equipment, etc…)
• Does it require changing individual clinician behavior vs
healthcare system?
•
•
•
•
•
•
Who is the team and the lead?
What is the goal to be achieved?
When will the results be re-assessed?
Where will it be implemented as a pilot project?
How will the goal be achieved?
Resources?
•
•
•
•
Goal achieved?
Implement across the system
Goal not achieved?
Re-plan
99
Before proceeding:
. Audit
. Review literature
. Discussion with
stakeholders
•
•
Implement
Keep a log of barriers and
facilitators
•
•
Re-measure
Reflect on the knowledge gained in
this cycle (Why did it work or why
did it fail? Unexpected results?)
Checklist for initiating, improving,
evaluating, and sustaining a quality
improvement program
This checklist lists steps for initiating, improving, evaluating, and sustaining a QI program in the ICU
(adapted from Curtis JR et al. Intensive care unit quality improvement: a "how-to" guide for the
interdisciplinary team. Crit Care Med 2006 Jan;34(1):211-8.
•
Initiating or improving a quality improvement program
Do background work: Identify motivation, support team and develop strong leadership.
Prioritize potential projects and choose the projects to begin.
Prepare for the project by operationalizing the measures, building support for the project, and
developing a business plan.
Do an environmental scan to understand the current situation (structure, process, or
outcome), the potential barriers, opportunities, and resources for the project.
Create a data collection system to provide accurate baseline data and document
improvement.
Create a data reporting system that will allow clinicians and other stakeholders to see and
understand the problem and the improvement.
Introduce strategies to change clinician behavior and create the change that will produce
improvement.
•
Evaluating and sustaining a quality improvement program
Determine whether the target is changing with ongoing observation, periodic data collection,
and interpretation.
Modify behavior change strategies to improve, regain, or sustain improvements.
Focus on sustaining interdisciplinary leadership and collaboration for the quality improvement
program
Develop and sustain support from the hospital leadership
100
Infection prevention
and control
Summary
When caring for patients with ARI, use standard and droplet precautions at all times and airborne
precautions during certain high-risk procedures.
Standard precautions include:
- respiratory etiquette
- hand hygiene
- appropriate waste management and cleaning
- safe injection procedures and sharps disposal
- appropriate PPE
Droplet precautions include:
- use of a medical mask when within 1 metre of patient
- patient placement in single room, cohorted area, or separated from others by at least 1 metre
- limiting patient movement outside of hospital room
- having the patient use a medical-surgical mask, if tolerated, when outside of the hospital room
Airborne precautions include:
- gown, gloves, eye protection
- particulate respirator mask with seal check
- adequate ventilation
- minimizing unnecessary individuals in the room.
Categories of IPC strategies in health care settings include
- administrative controls
- engineering controls
- rational and consistent use of PPE and hand hygiene
PPE:
-
choose PPE based on risk assessment of potential exposure and non-intact skin
apply PPE during all potential exposure times
remove PPE correctly
PPE does not eliminate need for hand hygiene
Tools list
•
Personal Protective Equipment (PPE)
•
Hand hygiene
•
Checklist for aerosol generating procedures
References
•
Advice on the use of masks in the community setting in Influenza A (H1N1) outbreaks. WHO
Interim guidance, May 2009.
•
How To Hand Wash? WHO Poster, May 2009.
•
Infection prevention and control of epidemic and pandemic prone acute respiratory disease in
Health care. WHO Interim Guideline (WHO_CD_EPR_2007_6).
101
•
Infection prevention and control in health care for confirmed or suspected cases of pandemic
(H1N1) 2009 and influenza-like illnesses. WHO Interim guidance, June 2009.
•
Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare
Settings, Including Protection of Healthcare Personnel. CDC, July 2010.
102
Personal Protective Equipment (PPE)
Remember, PPE use should be guided by risk assessment concerning anticipated contact with blood
and other bodily fluids during patient care and presence of non-intact skin. For example, if there is a
risk of splash to the body and face then use hand hygiene, gloves, gown, medical mask, and
eyewear. Here is how to put and remove PPE appropriately.
103
104
Hand hygiene
Hand hygiene must be performed before and after any contact with patients and after contact with
contaminated items or surfaces. Use an alcohol-based product if hands are not visibly soiled. Wash
hands with soap and water when they are visibly soiled or contaminated with proteinaceous material.
Here is an example of hand washing with soap and water. The same rubbing technique can be used
with alcohol-based product. This entire procedure can take should take 40-60 seconds (20-30 for
alcohol-based hygiene.
105
Checklist for aerosol generating
procedures
Perform a particulate respirator seal check
1. Cover the front of respirator with both hands while on your face but
do not disturb position.
2. Positive check: exhale sharply. Positive pressure inside the mask
equals no leakage. If leakage, adjust position and/or tension of straps.
Retest seal. Repeat steps until secured properly
3. Negative check: Inhale deeply. If no leakage, this will make
respirator cling to your face. Leakage will result in loss of negative
pressure due to air entering through gaps in the seal.
When performing aerosol-generating procedures, such as intubation, cardiopulmonary
resuscitation, bronchoscopy, aspiration or open suctioning of respiratory tract secretions consider
using this checklist to assist you in the application of airborne precautions as follows:
Perform hand hygiene before and after patient contact, and after PPE removal
Use a facial particulate respirator (e.g. EU FFP2 or US NIOSH-certified N95)
Use eye protection (e.g. goggles or a face shield)
Use a clean, non-sterile, long-sleeved gown
Use gloves (some of these procedures require sterile gloves)
Make sure adequately ventilated room (e.g. ≥ 12 air changes per hour plus control of airflow
direction)
Avoid unnecessary individuals into the room
106
Ethical considerations
Summary
During a pandemic, the need for critical care services can exceed available resources.
decisions may need to be made on how to allocate scarce resources and prioritize patients.
Triage
Five ethical principles that can guide triage include: utility, maximum life-years saved, first-come firstserved, random selection, and life cycle.
Two triage strategies that are available as examples are from the Ontario Health Plan and the Multiple
Principle Strategy
Public engagement in pandemic preparedness is essential to develop a prioritization strategy that is
fair, transparent and builds trust.
Tools list
•
Table of the Sequential Organ Failure Assessment (SOFA) Score
•
Table of a multi-principle strategy to allocate ventilators during a public health emergency
•
Algorithm of Ontario Health Plan for an Influenza Pandemic
•
Tables of Critical Care Triage Tool
References
•
Centers for Disease Control. Ethical Considerations for Decision Making Regarding Allocation
of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health
Emergency. Prepared by the Ventilator Document Workgroup for the Ethics Subcommittee of
the Advisory Committee to the Director. Available at
http://www.cdc.gov/od/science/integrity/phethics/docs/ethical-considerations-allocationmechanical-ventilators-in-emergency-201011.pdf
•
Chapter 17A (Draft Critical Care Pandemic Triage Protocol) of Ontario Health Plan for an
Influenza Pandemic, August 2008. Available at
http://www.health.gov.on.ca/english/providers/program/emu/pan_flu/ohpip2/ch_17a.pdf
Ferreira, FL et al. Serial Evaluation of the SOFA Score to Predict Outcome in Critically Ill
Patients. JAMA, 2001, 286:1754-1758.
Swiss influenza pandemic plan. Available at
http://www.bag.admin.ch/influenza/01120/01134/03058/index.html?lang=en
•
•
•
White DB et al. Who should receive life support during a public health emergency? Using
ethical principles to improve allocation decisions. Annals of Internal Medicine, 2009, 150:132138.
•
World Health Organization. Ethical Considerations in developing a public health response to
pandemic influenza. 2007.
•
World Health Organization. Addressing ethical issues in pandemic influenza planning.
Discussion Papers. 2008
107
Table of the Sequential Organ Failure Assessment (SOFA) Score
The SOFA score is commonly used to describe and quantify organ failure and can also be used to predict outcome. The SOFA score has been used in the
subsequent triage strategies because it helps to quantify the principle of utility. To use the SOFA scoring system for triage, calculate the score by adding up
the points for each clinical characteristic at presentation and then at 48 hours. Both the initial score and change in score over 48 hours are predictive of
mortality. The maximum score is 24. In the publication by Ferriera et al (2001, see references section for full details), an initial SOFA score of >11 was
associated with 95% mortality, whereas score of ≤9 was associated with 33% mortality. Except for initial scores of more than 11, a decreasing score during
the first 48 hours was associated with a mortality rate of <6%. An unchanged or increasing score during the first 48 hours was associated with a mortality rate
of 37% when the initial score was 2 to 7and 60% when the initial score was 8 to 11. This score is used in the following triage strategies.
The Sequential Organ Failure Assessment (SOFA) Score*:
SOFA Score
Variables
0
1
2
3
4
Respiratory
PaO2/FiO2, mmHg
> 400
≤ 400
≤ 300
≤ 200†
≤ 100†
Coagulation
3
Platelets X 10 /µL╪
>150
≤ 150
≤ 100
≤ 50
≤ 20
Liver
Bilirubin, mg/dL╪
<1.2
1.2-1.9
2.0-5.9
6.0-11.9
> 12.0
No hypotension
Mean arterial pressure
< 70 mm Hg
Dop ≤ 5 or dob (any
dose)
Dop >5, epi ≤ 0.1,
or norepi ≤ 0.1§
Dop >15, epi >0.1,
or norepi > 0.1§
15
13-14
10-12
6-9
<6
<1.2
1.2-1.9
2.0-3.4
3.5-4.9 or < 500
> 5.0 or < 200
Cardiovascular
Hypotension
Central nervous system
Glasgow Coma Score Scale
Renal
Creatinine, mg/dL
Or urine output, mL/day
*Norepi indicates norepinephrine; Dob, dobutamine; Dop, dopamine; Epi, epinephrine; and FiO2, fraction of inspired oxygen.
† Values are with respiratory support.
╪To convert bilirubin from mg/dL to µmol/L, multiply by 17.1.
§ Adrenergic agents administered for at least 1 hour (doses given are in µg/kg per minute).
║To convert creatinine from mg/dL to µmol/L, multiply by 88.4.
108
Table of a multi-principle strategy to allocate ventilators during a
public health emergency
This table is adapted from White DB et al, Ann Intern Med 2009 (see references section for full source).It has been proposed as an example of how to use a
quantitative method to allocate scarce resources during a public health emergency. In this example, a scoring system is used and patients with the lowest
score would be given the highest priority to receive mechanical ventilation and critical care services during times of scarce resources. If there were two
patients with same number of points, a lottery system may be the just way to make the allocation decision.
This cannot be used in children because in general mortality rates are lower and prediction scores not useful.
Principle
Specification
Utility (Save the most
lives)
Prognosis for short-term
survival (SOFA score)
Save the most life-years
Prognosis for long-term
survival (medical
assessment of comorbid
conditions)
Life-cycle principle **
Prioritize those who have
had the least chance to live
through life’s stages (age
in years)
Point system
1
2
3
4
SOFA* score <6
SOFA score, 6-9
SOFA score, 10-12
SOFA score >12
No comorbid conditions
that limit long-term
survival
Age 12-40 y
Minor comorbid
conditions with small
impact on long-term
survival
Age 41-60 y
Major comorbid
conditions with
substantial impact on
long-term survival
Age 61-74 y
Severe comorbid
conditions; death
likely within 1 year
Age ≥75 y
* Sequential Organ Failure Assessment
** Pediatric patients may need to be considered separately, because their small size may require the use of different mechanical ventilators and personnel.
109
Algorithm of Ontario Health Plan for an
Influenza Pandemic
Any patient being assessed for possible admission/transfer to critical care will undergo the following
steps in assessment:
Step 1:
Assess to see if patient meets inclusion
criteria*
Reassess patient in future if there is
deterioration in clinical status.
No
Yes
Step 2:
Assess to see if patient meets
exclusion criteria**
“Blue tag” patient.
Do not transfer to critical care.
Continue current level of care or
palliate as indicated.
Yes
No
Step 3:
Proceed to critical care triage tool
Initial assessment
Note: This triage protocol applies to
allpatients undergoing assessment for
possible admission/transfer to critical
care.(See the following page)
*Inclusion Criteria
The patient must have 1 of criteria A or B:
A.
•
•
•
•
B.
•
Requirement for invasive ventilatory support:
Refractory Hypoxemia (Sp02< 90% on non-rebreak mask/FiO2> 0.85)
Respiratory Acidosis with pH< 7.2
Clinical evidence of impending respiratory failure
Inability to protect or maintain airway.
Hypotension:
Hypotension (SBP < 90 or relative hypotension) with clinical evidence of shock
(altered level of consciousness, decreased urine ouput, or other end organ failure)
refactory to volume resuscitation requiring vasopressor/inotrope support that cannot
be managed on the ward.
110
**Exclusion Criteria
The patient is excluded from admission/transfer to Critical Care if ANY of the following are present:
• Severe trauma (need to define further).
• Severe burns: a patient with any two of the following:
i. Age > 60 years old
ii. TBSA > 40%
iii. Inhalation injury
• Cardiac Arrest:
o Unwitnessed cardiac arrest.
o Witness cardiac arrest not responsive to electrical therapy (defibrillation, cardioversion, or pacing).
• Advanced & irreversible immunocompromise.
• Severe and irreversible neurologic event/condition.
• Endstage organ failure meeting following criteria:
o Cardiac:
i. NYHA class III or IV heart failure.
o Lung:
i. COPD with FEV1< 25% predicted, baseline PaO2< 55 mmHg, or secondary pulmonary
hypertension.
ii. Cystic fibrosis with postbrochodilator FEV1< 30% or baseline PaO2< 55 mmHg.
iii. Pulmonary fibrosis with VC or TLC < 60% predicted, baseline PaO2< 55 mmHg, or secondary
pulmonary hypertension.
iv. Primary pulmonary hypertension with NYHA class III – IV heart failure, or right atrial pressure >
10 mmHg, or mean pulmonary arteiral pressure of > 50 mmHg.
o Liver:
i. Child Pugh Score ≥ 7
• Age > 85 years old
• Requirement for transfusion of > 6 units PRBC within 24 hour period.
• Elective palliative surgery.
Appeals/Exemptions
In rare circumstances where the triage officer and/or the attending intensivist feels that, at the initial
assessment, a patient may be triaged as ‘Blue’ due to an anomaly of the protocol and in all likelihood
has a significantly lower risk of mortality, the central triage committee should be consulted. In some
circumstances, the committee may authorize a 48 hour trial of care after which the patient will be retriaged according to protocol.
111
Critical Care Triage Tool
Initial assessment
Colour Code
Criteria
Priority/Action
Blue
Exclusion Criteria* or SOFA > 11*
Medical Mgmt +/- Palliate & d/c from CC
Red
SOFA ≤7orsingle organ failure
Highest
Yellow
SOFA 8 -11
Intermediate
Green
No significant organ failure
Defer or d/c, reassess as needed
* If exclusion criteria or SOFA > 11 occurs at anytime from initial assessment to 48 hours change
triage code to Blue and palliate.
CC = critical care
d/c = discharge
48 hour assessment
Colour Code
Criteria
Priority/Action
Blue
Exclusion Criteria or SOFA > 11
or SOFA 8 – 11 with no change
Palliate & d/c from CC
Red
SOFA score < 11 and decreasing
Highest
Yellow
SOFA ≤ 7 with no change
Intermediate
Green
No longer ventilator dependant
d/c from CC
120 hour assessment
Colour Code
Criteria
Priority/Action
Blue
Exclusion Criteria** or SOFA > 11**
or SOFA < 8 no change
Palliate & d/c from CC
Red
SOFA score < 11 and decreasing
progressively
Highest
Yellow
SOFA ≤ 7 and minimal decrease
(<3 point decrease in past 72h)
Intermediate
Green
No longer ventilator dependant
d/c from CC
** If exclusion criteria or SOFA > 11 occurs at anytime from 48 - 120 hours change triage code to Blue
and palliate.
If two patients have the same score, then each should have equal chance at treatment. Use
principles of first come first served or random lottery to guide triage.
112
Index
Algorithm for coordinating daily sedation interruption with daily SBT…………………………………….86
Algorithm for improving the quality of hospital care for children in limited resource setting ................. 99
Algorithm for liberating your patient from invasive mechanical ventilation ........................................... 87
Algorithm for management of septic shock in limited resourced settings ............................................. 46
Algorithm for RASS Assessment .......................................................................................................... 72
Algorithm of Ontario Health Plan for an Influenza Pandemic ............................................................. 110
Algorithm to check Airway/ Breathing, Circulation and Altered Level of Consciousness/Convulsing in
adults ..................................................................................................................................................... 11
ARDS Network protocol to deliver lung protective ventilation .............................................................. 61
AVPU scale: a simple tool for assessing level of consciousness ......................................................... 70
Checklist are you using central venous catheters in a quality and safe manner? ................................ 97
Checklist for admission ......................................................................................................................... 18
Checklist for aerosol generating procedures ...................................................................................... 106
Checklist for central venous catheter insertion ..................................................................................... 92
Checklist for daily prevention assessment ............................................................................................ 96
Checklist for initiating, improving, evaluating, and sustaining a quality improvement program.......... 100
Checklist for preventing urinary tract infections (UTI) ........................................................................... 94
Checklist for preventing ventilator associated pneumonia (VAP) ......................................................... 93
Checklist for rapid sequence induction procedure .......................................................................... 54, 55
Checklist for transfer ............................................................................................................................. 19
Checklist for turning a patient prone ..................................................................................................... 64
Checklist to troubleshoot warning signs during oxygen therapy delivery ............................................. 33
COMFORT scale to assess sedation in children .................................................................................. 69
Comprehensive approach to management of severe sepsis and septic shock ................................... 43
Critical Care Triage Tool ..................................................................................................................... 112
Decision making algorithm for admitting a patient with pneumonia ...................................................... 17
Decision making algorithm for the patient presenting with uncomplicated influenza-like illness (ILI) .. 16
Details of targeted resuscitation in adults in an ICU setting ................................................................. 44
Details of targeted resuscitation in children in and ICU setting ............................................................ 45
Early Warning Scoring System ................................................................................................. 35, 51, 94
Emergency triage and assessment and treatment (ETAT): Triage of sick children ............................ 13
Forms for assessing attention screening (ASE)for adults..................................................................... 77
Guide to distinguish between the causes of high peak airway pressures: resistance vs. compliance . 59
Guideline for specimen storage ............................................................................................................ 28
Guideline for specimen transportation .................................................................................................. 30
Guideline to deliver increasing oxygen ................................................................................................. 32
Hand hygiene ...................................................................................................................................... 105
Material for specimen transportation..................................................................................................... 29
Memory aid comparison of normal waveforms during volume and pressure limited ventilation .......... 57
113
Memory aid: key criteria used to assess nutrition and vital signs in children ....................................... 15
Memory aid: recognizing and interpreting abnormal pressure and flow waveforms during volume
control ventilation .................................................................................................................................. 58
Nasal swab technique ........................................................................................................................... 26
Nasopharyngeal aspirate technique ..................................................................................................... 27
Nasopharyngeal swab technique .......................................................................................................... 24
Oseltamivir notice.................................................................................................................................. 38
Pain assessment scales ....................................................................................................................... 68
Pandemic influenza A (H1N1) 2009 Factsheet ..................................................................................... 22
Pediatric Early Warning Score (PEWS) ................................................................................................ 36
Personal Protective Equipment (PPE) ................................................................................................ 103
Posterior pharyngeal swab or throat swab technique ........................................................................... 25
Procedure for assessing attention screening exam visual (ASE)for adults .......................................... 76
Procedure for providing enteral nutrition (EN) paediatric considerations ............................................. 90
Procedure for providing enteral nutrition (EN) for adults ...................................................................... 89
Richmond agitation sedation scale (RASS) .......................................................................................... 71
Sample central venous pressure waveform .......................................................................................... 51
Specimen collection kit for upper respiratory-tract specimens ............................................................. 23
Stepwise approach to troubleshooting high peak airway pressures ..................................................... 60
Table for paediatric analgesia, sedation, and neuromuscular blockade............................................... 83
Table for using neuromuscular blockers in adults ................................................................................ 81
Table of a multiprinciple strategy to allocate ventilators during a public health emergency ............... 109
Table of the Sequential Organ Failure Assessment (SOFA) Score ................................................... 108
Table to guide the use of commonly used antipsychotic, haloperidol, in adults ................................... 82
Table to guide the use of commonly used opioid analgesics in adults ................................................. 80
Table to guide the use of commonly used sedativesin adults .............................................................. 79
Table to guide use of vasopressors in septic shock ....................................................................... 50, 51
Worksheet for the Confusion Assessment Method of the Intensive Care Unit for adults (CAM-ICU) .. 73
Worksheet for the Confusion Assessment Method of the Intensive Care Unit for children (pCAM-ICU)
.............................................................................................................................................................. 75
Zanamivir notice .................................................................................................................................... 40
114
Additional resources available in the USB flash drive
Title
Author, year
Introduction
Course "Epidemiology and clinical features"
Code
WHO
U00_co1.pdf
WHO
U00_co2.pdf
WHO
U00_co3.pdf
WHO, 2011
U00_doc1.pdf
WHO, 2005
U00_doc2.pdf
IMAI District Clinician Manual: Hospital Care for Adolescents
and Adults - Guidelines for the management of common
illnesses with limited resources
WHO, 2012
U01_doc1.pdf
Clinical management of adult patients with complications of
pandemic influenza A (H1N1)
Clinical management of human infection with pandemic
(H1N1) 2009: revised guidance
Update on human cases of highly pathogenic avian influenza
A (H5N1) virus infection, 2011. WER No.13, 2012
Differential diagnosis
WHO, 2010
U01_doc2.pdf
WHO, 2010
U01_doc3.pdf
WHO, 2011
U00_doc1.pdf
WHO,
updated
2010
WHO, 2010
U02_doc1.pdf
U02_doc2.pdf
WHO, 2010
U01_doc3.pdf
WHO, 2009
U02_doc3.pdf
WHO, 2009
U02_doc4.pdf
WHO, 2009
U02_doc5.pdf
WHO, 2005
U02_doc6.pdf
WHO, WER
N°46, 2009
WHO
U02_doc7.pdf
WHO, 2010
U02_doc8.pdf
WHOITUTLD,
2009
WHO, 2011
U03_doc1.pdf
Course "Special Considerations when Caring for the
Pregnant Patient"
Course "Care of the Critically Ill Infant and Child with
Pandemic Influenza A (H1N1)"
Update on human cases of highly pathogenic avian influenza
A(H5N1) virus infection
Hospital care for children : Guidelines for the management of
common illnesses with limited resources
Triage
Safe transport of pandemic (H1N1) 2009 virus cultures
isolates and patient samples
Instructions for storage and transport of suspected or
confirmed human and animal specimens and virus isolates of
pandemic (H1N1), 2010
Clinical management of human infection with pandemic
(H1N1) 2009: revised guidance
Frequently Asked Questions Sampling and shipping of
influenza clinical specimens and virus isolates
WHO information for laboratory diagnosis of pandemic
(H1N1) 2009 virus in humans
WHO Regional office from Euorpe guidance for influenza
surveillance in humans
WHO recommendations on the use of rapid testing for
influenza diagnosis July 2005
Transmission dynamics and impact of pandemic influenza A
(H1N1) 2009 virus
Guide for Shipping Infectious Substances
Use of influenza rapid diagnostic test
www.who.int/ihr/infec
tious_substances/en/
Oxygen therapy
Oxygen is an essential medicine: a call for international
action (authors copy)
The WHO pulse oximetry training manual
115
U03_doc2.pdf
Antimicrobial therapy
Guidelines for Pharmacological Management of Pandemic
Influenza A(H1N1) 2009 and other Influenza Viruses
Clinical management of adult patients with complications of
pandemic influenza A (H1N1)
Paramivir and other Antiviral Treatment Options of Influenza
in Hospitalized Patients for the 2009-2010
Novel Influenza (H1N1) outbreak Tamiflu (oseltamivir)
Relenza (zanamivir)
WHO,
revised 2010
WHO, 2010
U01_doc2.pdf
CDC, 2009
U04_doc2.pdf
U04_doc3.pdf
Zanamivir Product Information revised
European
Medecine
Agency
(EMEA),
2009
Food and
Drug
Administratio
n (FDA),
2010
GSK, 2009
Guidelines Antiviral Side Effects
CDC
http://www.cdc.gov/fl
u/protect/antiviral/sid
eeffects.htm
Clinical management of human infection with avian influenza
A (H5N1) virus
Severe sepsis and septic shock
WHO, 2007
U04_doc6.pdf
IMAI District Clinician Manual: Hospital Care for Adolescents
and Adults - Guidelines for the management of common
illnesses with limited resources
WHO, 2011
U01_doc1.pdf
WHO,2003
U06_doc1.pdf
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
Dev S.,
Rubenfeld G.
U06_vid1.mp4
Safety Relenza (Zanamivir) inhalational powder
U04_doc1.pdf
U04_doc4.pdf
U04_doc5.pdf
Acute Respiratory Distress Syndrome (ARDS)
Surgical Care at the District Hospital
Lung Injury Knowledge Network videos
Physicians' concerns
Respiratory therapists' concerns
Nurses' concerns
Setting up Lung Protective Ventilation
Troubleshooting
Clinical cases
Lung Protective Ventilation Mechanism
Lung Protective Ventilation Implementation
Lung Protective Ventilation Weaning
116
U06_vid2.mp4
U06_vid3.mp4
U06_vid4.mp4
U06_vid5.mp4
U06_vid6.mp4
U06_vid7.mp4
U06_vid8.mp4
U06_vid9.mp4
Quality in critical care
Institute for Healthcare Improvement
http://www.ihi.org/ihi
Assessing and tackling patient harm : A methodological guide
for data-poor hospitals
Infection prevention and control
WHO, 2010
U11_doc1.pdf
Infection prevention and control of epidemic - and pandemic prone acute respiratory diseases in health care
How to put on and take of PPE
WHO, 2007
U12_doc1.pdf
WHO, 2008
U12_doc2.pdf
Infection prevention and control in health care for confirmed
or suspected cases of pandemic (H1N1) 2009 and influenzalike illnesses
WHO, 2009
U12_doc3.pdf
Your 5 Moments for Hand Hygiene
WHO, 2009
U12_doc4.pdf
A Guide to the Implementation of the WHO Multimodal Hand
Hygiene Improvement Strategy
WHO Guidelines on Hand Hygiene in Health Care: a
Summary
Save lives: Clean your hands
WHO, 2009
U12_doc5.pdf
WHO, 2009
U12_doc6.pdf
WHO
U12_vid7.wmv
WHO, 2007
U13_doc1.pdf
WHO, 2008
U13_doc2.pdf
WHO, 2006
U13_doc3.pdf
Ethics and culture
Ethical considerations in developing a public health response
to pandemic influenza
Addressing ethical issues in pandemic influenza planning,
discussion papers
Global consultation on addressing ethical issues in pandemic
planning
117