Category Archives: Guidelines

Guidelines relevant to the critically ill patient

Extracorporeal Albumin Dialysis for Acute Liver Failure

NICE has issued guidance on this procedure for patients with acute liver failure.

“The procedure removes toxins bound to albumin in the blood in addition to the water-soluble toxins that can be removed by haemodialysis.”

They state that current evidence on its efficacy is inadequate in quality and quantity, and recommend the procedure “should only be used with special arrangements for clinical governance, consent and audit or research.”

Guidance summary here

Life threatening post partum haemorrhage

A mother may experience life-threatening haemorrhage after delivery of her baby. What can the resuscitation doctor do?

Rosen’s Emergency Medicine describes four main differential diagnoses: uterine atony, genital tract trauma, retained placental tissue, and coagulopathies, or the “four Ts”: tone, trauma, tissue, and thrombin.

As well as resuscitation with fluid and blood products and urgent obstetric and anaesthetic referral, efforts should be made to restore uterine tone with manual and pharmacological means, and consider tamponade of the haemorrhage.

The MOET (Management of Obstetric Emergencies & Trauma) Course outlines the following interventions for major obstetric haemorrhage:

  • Empty uterus: deliver fetus if undelivered / remove placenta or retained products (this may need to be done digitally according to Rosen)
  • Oxytocin / ergometrine / prostaglandin
  • Massage & bimanual compression of uterus
  • Repair genital tract injury
  • Uterine packing or Rusch balloon
  • Compression of aorta
  • Surgical or interventional radiological options: internal iliac or uterine artery ligation, hysterectomy, arterial embolisation

A review of the different balloon tamponade devices available describes the urological Rusch balloon, the dedicated Bakri balloon, a condom sutured to a Foley catheter, multiple Foley catheters, and the Sengstaken-Blakemore tube (SBT). In order for the SBT balloon to reach the uterine fundus, either the tip of the catheter can be cut and the gastric balloon inflated, or the SBT can be folded and the oesophageal balloon inflated. Normal saline is used to inflate the balloon until tamponade is achieved. If the cervix is dilated, vaginal packing may be necessary to prevent migration of the balloon out of the uterus..

The Royal College of Obstetricians and Gynaecologists published 2009 guidelines on PPH. The full text is available here. After commencing resuscitation, summoning help, considering the ‘four T’s’, and examining the patient they recommend:

  • Bimanual uterine compression (rubbing up the fundus) to stimulate contractions.
  • Ensure bladder is empty (Foley catheter, leave in place).
  • Syntocinon 5 units by slow intravenous injection (may have repeat dose).
  • Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension).
  • Syntocinon infusion (40 units in 500 ml Hartmann’s solution at 125 ml/hour) unless fluid restriction is necessary.
  • Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma).
  • Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma), with responsibility of the administering clinician as it is not recommended for intramyometrial use.
  • Misoprostol 1000 micrograms rectally.

Balloon tamponade may then be attempted in cases of uterine atony pending surgical haemostasis if necessary.

As with all life-threatening emergencies, the resuscitation doctor should have a plan, and know his or her options regarding personnel, facilities and equipment. We recommend a closer look at the articles and guidelines referenced above in formulating your own plan as to how you might save a young mother’s life.

Spinal Cord Injury Guidelines

The Paralyzed Veterans of America produce a number of evidence-based guidelines for management of spinal cord injury and its complications that may be useful for the critical care doctor, downloadable from here.

The most relevant to frontline professionals is the Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. A summary of the major recommendations from this document can be found here.

New Guidelines for Care of Children in the Emergency Department

A joint policy statement from the American College of Emergency Physicians and the American Academy of Pediatrics lists guidelines and resources that should be in place for emergency departments to serve paediatric patients. Well worth a look through while asking yourself whether your ED ticks all the boxes.

Joint Policy Statement—Guidelines for Care of Children in the Emergency Department
Free full text access

A similar, even more comprehensive, document by these organisations’ UK counterparts was published in 2007

Services for Children in Emergency Departments
Free full text access

New Paediatric DKA guidelines

The International Society for Paediatric and Adolescent Diabetes (ISPAD) has published new comprehensive guidelines, including those for diabetic ketoacidosis.

Their summary:

• DKA is caused by either relative or absolute insulin deficiency.

• Children and adolescents with DKA should be managed in centers experienced in its treatment and where vital signs, neurological status and laboratory results can be monitored frequently

• Begin with fluid replacement before starting insulin therapy.

• Volume expansion (resuscitation) is required only if needed to restore peripheral circulation.

• Subsequent fluid administration (including oral fluids) should rehydrate evenly over 48 hours at a rate rarely in excess of 1.5 – 2 times the usual daily maintenance requirement.

• Begin with 0.1 U/kg/h. 1 – 2 hours AFTER starting fluid replacement therapy

• If the blood glucose concentration decreases too quickly or too low before DKA has resolved,
increase the amount of glucose administered. Do NOT decrease the insulin infusion

• Even with normal or high levels of serum potassium at presentation, there is always a total body deficit of potassium.

• Begin with 40 mmol potassium/L in the infusate or 20 mmol potassium/L in the patient receiving fluid at a rate >10 mL/kg/h.

• There is no evidence that bicarbonate is either necessary or safe in DKA.

• Have mannitol or hypertonic saline at the bedside and the dose to be given calculated beforehand.

• In case of profound neurological symptoms, mannitol should be given immediately.

• All cases of recurrent DKA are preventable.

Full guidelines available here
Other ISPAD guidelines available here

Detecting congenital heart disease with oximetry

Currently, critical congenital heart disease is not detected in some newborns until after their hospital discharge, but some may be detected by routine pulse oximetry performed on asymptomatic newborns after 24 hours of life. The American Academy of Pediatrics has published a statement on the topic.

Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease: A Scientific Statement from the AHA and AAP (Full Text)