Category Archives: ICU

Stuff relevant to patients on ICU

All Updates, ICU, Kids, Resus

Paediatric gastric tubes

Leave a comment

A child with status epilepticus has been stabilised and intubated and is awaiting admission to the paediatric intensive care unit. You decide to insert a nasogastric tube. The nurse asks the following questions:
1. What size gastric tube would you like?

[EXPAND Answer]A general guide is twice the size of the uncuffed tracheal tube.
A four year old for example would usually need a tracheal tube size of 5.0mm internal diameter (age/4 +4), so would need a 10 Fr gastric tube.
[/EXPAND]

2. To what length are you intending to insert it?

[EXPAND Answer]A formula based on height of the child can be used, so get your tape measure or length chart out:
NGTpaed
For neonates < 2 weeks and children >8 years 4 months a method called NEMU (nose-ear-midxiphoid-umbilicus measurement) may be used.
[/EXPAND]

3. How will you confirm placement?

[EXPAND Answer]It is very likely this child will get a post-intubation chest radiograph and the gastric tube tip can be visualised on that. However non-radiological tests should be used and pH testing of the aspirate is recommended, looking for pH<6
[/EXPAND]

Further details on these measurements including positive and negative likelihood ratios of pH testing can be found in the evidence-based guideline from Cincinnati Children’s Hospital

All Updates, Guidelines, ICU

Extracorporeal Albumin Dialysis for Acute Liver Failure

Leave a comment

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

All Updates, Guidelines, ICU, Resus

Life threatening post partum haemorrhage

Leave a comment

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.

All Updates, ICU, Kids, PHARM, Resus, Trauma

Tying the tracheal tube

Leave a comment

After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy!

larks head knot
larks head knot

1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes
BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved
Anaesthesia. 2007 Jun;62(6):637

All Updates, ICU

Two new studies on ECMO

Leave a comment

Extracorporeal Membrane Oxygenation (ECMO) for severe respiratory failure features in two important papers recently.
The first, the CESAR trial, is an RCT showing a improvement in six-month disability-free survival in patients referred to an ECMO centre. The complexity of the study and the potential confounding factors led an editorialist to say: ‘This study will likely provide ammunition for both those in favour and those against the use of ECMO in the adult population‘.
Perhaps the Australasians have their own ammunition. In a paper describing the use of ECMO for patients with H1N1, they treated 68 patients with ECMO in three months, the same number of patients that actually received ECMO in the five year CESAR study!
Maybe the Aussies need to do a bigger, better RCT than CESAR?
Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial
Lancet. 2009 Oct 17;374(9698):1351-63
Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome
JAMA. 2009;302(17) (Full text)
Further information on the impact of H1N1 on Australasian critical care services, and the 722 patients admitted to ICU with the disease, is published in the New England Journal:
Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand
N Engl J Med. 2009 Oct 8. [Epub ahead of print]

Acute Med, All Updates, ICU

NIV after extubation prevented respiratory failure

Leave a comment

Spanish investigators compared NIV for 24 hours with conventional oxygen therapy in patients with chronic respiratory disorders who were extubated after a successful spontaneous breathing trial. The NIV group had signficantly lower rates of post-extubation respiratory failure.
Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial.
Lancet. 2009 Sep 26;374(9695):1082-8

All Updates, ICU

High versus low intensity renal replacement therapy

Leave a comment

What’s the optimal dose of continuous renal replacement therapy? The Australasian RENAL investigators compared 25ml/kg/hr vs 40ml/kg/hr (effluent flow) of post-dilution continuous venovenous haemodiafiltration in over 1500 intensive care patients. There was no difference in 90 day mortality or renal recovery, but the high intensity group had significantly more hypophosphataemia.
Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients
NEJM 2009;361:1627-1638

ICU, Resus, Trauma

Burns formulas and fluid resuscitation

Leave a comment

In most cases either the modified Brook formula or the Parkland formula was used for burned military casualties in Iraq and Afghanistan over the three years covered in this study.
The modified Brooke formula is 2mls x body surface areas burned (BSAB) x weight.
The Parkland formula is 4mls x body surface areas burned (BSAB) x weight.
Both formulas estimate the first 24 hour fluid requirements from the time of the burn, with half the amount given in the first 8 hours.
In this study which compared outcomes between the Brooks and Parkland groups, there were no differences in clinical outcomes. In both groups many patients were overresuscitated in terms of urine output goals. The authors’ main conclusion is that burns resuscitation can be successfully accomplished with lower initial fluid volumes. Take home message: individualise fluid resuscitation to patient’s clinical response, and avoid the ‘fluid creep’ of unphysiologic resuscitation management.
Resuscitation of severely burned military casualties: fluid begets more fluid
J Trauma. 2009 Aug;67(2):231-7

All Updates, ICU, Resus

'Shock Room' belongs to both ED & ICU

Leave a comment

Belgian authors describe a four-bedded ‘shock room’, situated between the ED and the ICU and managed jointly by ED and ICU staff, which is used to stabilise all acutely ill patients in the hospital, whether they are from outside or inside the hospital. 2514 patients were treated in their shock room in 2006, managed by either senior emergency physicians or intensivists, and nurses from both departments. 21.5% were admitted to ED shock room from other wards, and 14.5% were transfers from other hospitals.
Comment: I personally visited this unit in Brussels in 2007 and liked the concept – sick patients in the ED and patients who go off on the wards often have similar needs in terms of skills and equipment. Why not manage them all in the resus room, and have intensivists and emergency physicians working more collaboratively?
A ‘shock room’ for early management of the acutely ill
Anaesth Intensive Care. 2009 May;37(3):426-31