From the Guidelines
ICU guidelines should prioritize a holistic approach to critical care management, focusing on pain, agitation, and delirium management, as well as end-of-life care, to improve patient outcomes and reduce morbidity, as recommended by the most recent guidelines 1. The most essential ICU protocols include:
- Early goal-directed therapy for sepsis with initial fluid resuscitation of 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L, followed by vasopressors (norepinephrine first-line at 0.05-3.3 mcg/kg/min) if fluids are insufficient
- Mechanical ventilation using lung-protective strategies with tidal volumes of 6ml/kg ideal body weight and plateau pressures <30cmH2O
- Daily sedation interruption using standardized scales like RASS (target -2 to 0) to minimize ventilator days, with propofol (5-80 mcg/kg/min) or dexmedetomidine (0.2-1.5 mcg/kg/hr) preferred for most patients
- Stress ulcer prophylaxis with pantoprazole 40mg daily and DVT prophylaxis with enoxaparin 40mg daily (adjusted for renal function) as standard
- Glycemic control targeting blood glucose between 140-180 mg/dL using insulin protocols
- Early enteral nutrition within 24-48 hours of admission to improve outcomes, starting at 25ml/hr and advancing as tolerated
- Daily multidisciplinary rounds, early mobilization protocols, and delirium prevention strategies using the CAM-ICU assessment tool to reduce complications and improve outcomes.
In terms of end-of-life care, communication within the ICU team and between the team and the patients and relatives is crucial, and structured programs for ICU HCPs aimed at improving end-of-life communication have shown promise 1. Additionally, TLTs and other means of avoiding non-beneficial care in a manner that develops a consensus between the ICU team and the patient and family may be valuable for protecting HCPs from moral distress and patients from unnecessary suffering 1.
It is also important to note that ICU guidelines should be considered in their entirety rather than as discrete or distinct recommendations, as the five sections of the guideline are interrelated 1. Furthermore, evidence-based recommendations and expert opinions should be used to guide ICU practice, taking into account the values and preferences of ICU stakeholders 1.
From the Research
ICU Guidelines Overview
- The care of critically ill patients within the intensive care unit (ICU) requires a multidisciplinary approach 2
- Achieving and maintaining effective antibiotic therapy is crucial in sepsis treatment, and therapeutic drug monitoring (TDM) is the current gold standard 3
- The use of hemoadsorption filters, such as CytoSorb®, in sepsis treatment has been studied, and results show no clinically relevant impact on antibiotic levels 4
Patient Assessment and Treatment
- A systematic approach to assessment and treatment of organ dysfunction is essential in ICU care 2
- Bedside goal-directed ultrasound is a powerful tool for rapid differential diagnosis and monitoring of cardiopulmonary disease in critically ill patients 5
- Diagnostic bedside ultrasonography can be used to evaluate patients with acute respiratory failure or distress, and protocolized approaches can be implemented for evaluation and treatment 5
Staff Education and Training
- Education, training, and workforce development are essential for ensuring that nurses can care for patients with critical care needs 6
- The role of the practice development facilitator was created to develop critical care knowledge, skills, and practice in ward areas 6
- A multi-dimensional approach to the implementation of policy is necessary to achieve comprehensive critical care 6