Dx’s & Intro

ICU – Fluids – Electrolytes – Nutrition:

Last updated on 22 AUG 2013

Primary editor Andy S. Binder, MD, Pulmonologist, Critical Care.

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Most Common Reasons for ICU-CCU Admissions:

1. Respiratory failure: ARDS. Pneumonia. Exacerbation of chronic lung disease (Asthma, COPD, Bronchiectasis). Pulmonary Embolism.

2. Shock: Hypovolemic (GI Bleed and Diarrhea). Cardiogenic (Acute MI / Infarct). Distributive (Sepsis and Anaphylaxis). Obstructive (massive Pulmonary Embolism. Tamponade. Adrenal Insufficiency / Crisis |

3. Cardiac disease: Acute MI / Unstable Angina. Heart Failure (CHF). Valvular Heart Disease. Hypertension Emergency. Arrhythmia’s with hemodynamic instability (see cardiology module).

4. TRAUMA: massive, involving multiple organs. Rhabdomyolysis |

5. Burns.

6. CNS injury: Stroke. Head injury. Hemorrhage (Subdural / Epidural). Status Epilepticus. Coma. Delirium.

7. Infections: Septic shock. Toxic Shock Syndrome. Meningitis. Neutropenic fever. Endocarditis. Diarrhea

8. Metabolic derangements: Acute Renal Failure / uremia. Diabetic ketoacidosis (DKA) and HHNKS. Severe Hyponatremia or Hypernatremia. Severe Hypokalemia or Hyperkalemia. Severe Hypophosphatemia. Intentional or accidental poisoning (See Trauma-Tox module for Toxidromes).

9. GI diseases: GI Hemorrhage. Acute Liver Failure / Encephalopathy.

10. Hematologic disease: Anemias. Thrombocytopenia. TTP-HUS. DIC.

11. Psychiatric diseases: Suicide attempt. Neuroleptic Malignant Syndrome.

General Notes:

• ICU patients whose care is managed by intensivists have a higher hospital mortality rate than those managed otherwise according to an analysis of 101,832 patients from 123 ICUs across the US (Ann Int Med 2008;148:801-809).

• Factors Predicting Post-ICU Blues Intensive care patients who suffered multiple organ failure, underwent surgery, or received high doses of benzodiazepine were at significantly increased risk for depressive symptoms six months after ICU discharge (Crit Care Med 2009;DOI: 10.1097/CCM.0b013e31819fea55).

Sleep: See Deprivation & ICU Sleep issues | Delerium in Hospitalized pt’s |

• In an international study that surveyed 1953 critical care clinicians (25% physicians and 75% nurses), about 33% reported providing patient care they perceived as inappropriate (JAMA 2011;306:2694) (The most common reason for perceived inappropriate care was excessive care given the patient’s prognosis.). See: Hospital-Acquired Infection (HAI) | See Glucose Control & GIK |

Care Consideration of a patient post-ICU hospitalization: (Am Fam Physician. 2009;79:459–464).

• Often have generalized weakness or fatigue, which mandates assessment for possible anemia, nutritional deficits, sleep disturbance, muscular deconditioning, medication adverse effects, and/or neurologic impairment such as myopathy or polyneuropathy. Impaired mobility may lead to falls, difficulty with stair climbing, and/or sexual dysfunction. Possible psychological comorbidities may include posttraumatic stress disorder (PTSD), anxiety disorder, and depression. Families and caregivers may also have depression and anxiety.

• W/u: CBC, iron panel, serum chemistries, serial body weight measurement, and/or consultation with physical therapy or possibly neurology.

Specific key clinical recommendations for practice, all rated level of evidence C, are as follows:

• Post-ICU patients, especially those who are older, women, or have a history of sepsis or malignancy, should be monitored for the development of anemia.

• Risk for PTSD is higher in post-ICU patients who are younger, have received sedatives, have been on prolonged mechanical ventilation, and/or have a history of acute lung injury or traumatic brain injury.

• Patients who had delirium during their ICU stay should be evaluated for anxiety.

ICU Errors:

Parenteral administration of drugs “is a weak point in patients safety in intensive care” according to a study (BMJ 2009;338:b814)……There were 75 errors per 100 patient-days……Three quarters were errors of omission (drug given at wrong time or dosage missed)……Most mistakes occurred not during crises or unusual circumstances, but during routine situations……Roughly 1% of the population suffered permanent harm or death due to an error……Error likelihood rose in the face of higher patient/nurse ratios and dropped in the presence of a critical incident reporting system.

• Drug–drug interactions (DDIs) are frequent occurrences in the medical intensive care unit (MICU) (Int J Pharm Pract. Published online June 7, 2012)….Of 457 DDIs identified, roughly 25% (114/457) were considered to be major interactions per at least 1 of the databases used…..The rate of DDIs was 190.4/100 patients, and the most commonly involved medications were antihypertensive and anticoagulant/antiplatelet agents.

• Each year in the United States, up to 40,500 adult patients admitted to the ICU may die because of misdiagnoses according to a systematic review of autopsy studies (BMJ Qual Saf. Published online July 21, 2012)…..The most common fatal misdiagnoses were vascular events and infections (41% each). Pulmonary embolism, myocardial infarction, pneumonia, and aspergillosis were the most frequent individual class 1 misdiagnoses, cumulatively accounting for about one third of all class 1 misdiagnoses. Two thirds of discovered misdiagnoses did not directly contribute to death but may have resulted in longer hospital stays, unnecessary surgery, and reduced quality of life.

• Doctors and nurses may overestimate the quality of the care they provide hospital patients in the hours leading up to a serious complication according to a small study on 47 patients (Crit Care Med 2012;online August 10)….for more than half there were delays in recognizing that the patients’ conditions were deteriorating in advance of a crisis, such as an unplanned admission to intensive care. Meanwhile nurses, residents and specialists reported far fewer delays.

GI Ulcer Prophylaxis: There’s new concern about overuse of proton pump inhibitors (PPIs) and H2-blockers in hospitalized patients. There’s no proof acid-suppressing drugs prevent GI bleeding in hospitalized patients and they may cause harm as PPIs may increase the risk of C difficile diarrhea or hospital-acquired pneumonia (Prescriber’s Letter 2009;25(7):250701)…..PPIs and H2-blockers might increase infection risk by increasing gastric pH and allowing bacterial overgrowth in the GI tract and airways…..Stop prophylaxis when patients leave the ICU.

• Targeted use of acid-suppressive medication among non–critically ill hospitalized patients may result in fewer episodes of nosocomial GI bleeding according to data on 75,723 adult patients (J Gen Intern Med. Published online January 5, 2013)…..The researchers identified the following independent risk factors for bleeding: “age > 60 years, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulants, and coagulopathy.” A clinical risk score based on these factors was calculated, in which each risk was assigned a numerical value……The researchers identified a high-risk group in whom the NNT was fewer than 100 to prevent a single bleeding event.

Stress ulcer prophylaxis with a PPI is indicated for patients during an intensive care unit (ICU) stay who have at least one of the following:

• Coagulopathy (platelet count <50,000 mm3, INR >1.5, or aPTT >2 times control);

• Mechanical ventilation for >48 hours;

• History of GI ulceration or bleeding within one year of admission;

• Glasgow Coma score d10;

• Thermal injury to >35% of body surface area;

• Partial hepatectomy;

• Multiple trauma;

• Transplantation perioperatively in the ICU;

• Spinal cord injury;

• Hepatic failure;

• Two or more of the following risk factors: Sepsis; ICU stay of more than one week; Occult bleeding lasting at least six days; High-dose corticosteroids (>250 mg/day of hydrocortisone).

Dyspnea: A study on mechanically ventilated ICU patients found that 47% of patients reported dyspnea (most often described as respiratory effort or air hunger) and that changing ventilator settings (e.g., increasing tidal volume, inspiratory flow, or positive end-expiratory pressure for patients on assist-control ventilation; increasing pressure support or sensitivity of the inspiratory trigger for patients on pressure-support ventilation) improved dyspnea in 35% of patients (Crit Care Med 2011;39:2059)…..Reductions in dyspnea were accompanied by significant reductions in anxiety (median VAS reduction, 1.7 cm).

Cardiac: Thoracic surgeons can provide better care to critical postoperative cardiac patients in the ICU than intensivists not board-certified in thoracic surgery (Society of Thoracic Surgeons 2010 Annual Meeting; January 26, 2010)……surgeons managing the postoperative care usually had an easier time than their nonsurgeon colleagues in getting the surgeon who operated on the patient to go along with suggested changes in medication.

• “Alarm Fatigue” Hazards: Alarms on medical devices, such as infusion pumps, ventilators, and dialysis units, are designed to warn of potential dangers to patients. But alarms can contribute to adverse events. The staff may become desensitized to the frequency with which alarms are sounded and become complacent, delaying needed action. The problem is similar to that of car alarms: When they go off constantly, people tend to ignore them. “Establish protocols that ensure that each alarm will be recognized, that the appropriate caregiver will be alerted, and that the alarm will be promptly addressed.” Hospitals should determine who is responsible for responding to alarms and notify them.

Critical care E/M codes:

Code Total duration of critical care

Appropriate E/M codes Less than 30 min (less than 30 min)

99291 × 1 30–74 min (30 min to 1 h 14 min)

99291 × 1 and 99292 × 1 75–104 min (1 h 15 min to 1 h 44 min)

99291 × 1 and 99292 × 2 105–134 min (1 h 45 min to 2 h 14 min)

99291 × 1 and 99292 × 3 135–164 min (2 h 15 min to 2 h 44 min)

99291 × 1 and 99292 × 4 165–194 min (2 h 45 min to 3 h 14 min)

99291 and 99292 as appropriate

195 min or longer (3 h 15 min, etc.)

99291. Critical care: evaluation and management of the critically ill or critically injured patient; first 30–74 min

99292. Each additional 30 min (list separately in addition to code for primary service)

Critical care procedure codes for commonly performed procedures.

36620 Insertion arterial line

36556 Insertion nontunneled central line over 5 years old

93503 Placement PA catheter

33210 Insertion temporary transvenous pacemaker

37620 IVC interruption

31500 Intubation – emergency, endotracheal

31622 Bronchoscopy

31645 Bronchoscopy with therapeutic aspiration

31624 Bronchoscopy with bronchial-alveolar lavage

31600 Tracheostomy

31502 Tracheotomy tube change prior to established tract

32421 Thoracentesis

32551 Tube thoraocostomy

49080 Puncture peritoneal cavity

92950 Cardiopulmonary resuscitation

43752 Placement naso- or oro-gastric tube

43246 PEG

• When hospitals are short on beds in the intensive care unit, doctors are more likely to switch from life-saving care to end-of-life care a Canadian study shows (Arch Intern Med 2012;online March 12)…..raises the possibility that scarcity may in fact be the mother of expedited end-of-life decision-making.”…..”It’s much easier to transfer a patient to an intensive care unit whether or not they will benefit from it than it is to have a difficult discussion about the end of life.”

• Surgeons and other intensivists are often at odds regarding postoperative goals of care, according to findings of a cross-sectional study (JAMA Surg. 2013;148:29-35)…..Among 912 surgeons surveyed, 43% reported conflict with other ICU clinicians regarding postoperative goals of care, and 43% reported similar conflict with ICU nurses…..”The combination of caring for acutely ill patients, end-of-life decision making, and coordination of large multidisciplinary teams can lead to frustration, communication breakdown, and discord among members of a health care team…. This conflict has been associated with lower-quality patient care, higher rates of medical error, higher levels of staff burnout, and greater direct and indirect costs of care.” Compared with surgeons who had more than 30 years of experience, surgeons with less than 10 years of experience reported higher rates of conflict with intensivists (57% vs 32% on bivariate analysis; P = .001) and with nurses (48% vs 33%; P = .001). Surgeons practicing in closed ICUs were also more likely to report conflict than those practicing in open ICUs (mixed unit) (60% vs 41%; P = .005).

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