What is the recommended prescription for a patient in the Intensive Care Unit (ICU) without a specific diagnosis?

ICU Prescription Template

For a patient in the ICU without a specific diagnosis, you should implement a standardized approach addressing pain management, sedation, delirium prevention, infection surveillance, and supportive care, with specific medications and monitoring protocols tailored to the clinical presentation.

Pain Management

Initiate IV opioids as first-line therapy for non-neuropathic pain, titrated to patient comfort. 1

• Morphine or fentanyl: Start with bolus dosing (morphine 2-4 mg IV q2-4h PRN or fentanyl 25-50 mcg IV q1-2h PRN), then consider continuous infusion if frequent dosing required 1
• For neuropathic pain: Add gabapentin 300 mg PO/NG TID or carbamazepine 200 mg PO/NG BID in addition to opioids 1
• Nonopioid adjuncts: Consider IV acetaminophen 1000 mg q6h to reduce opioid requirements and side effects 1
• Pain assessment: Use validated tools (BPS for intubated, CPOT for non-intubated) every 4 hours and PRN 1

Sedation Protocol

Maintain light sedation (RASS -1 to 0) unless clinically contraindicated, as this improves outcomes. 1

• Preferred agent: Propofol 5-50 mcg/kg/min IV continuous infusion for short-term sedation (<48 hours) 1
• Alternative: Dexmedetomidine 0.2-0.7 mcg/kg/hr IV (no bolus) for longer-term sedation or to facilitate extubation 1
• Avoid: Benzodiazepines (midazolam, lorazepam) as first-line due to increased delirium risk 1
• Monitoring: Assess sedation level with RASS or SAS every 4 hours 1
• Daily sedation interruption: Implement unless contraindicated (active seizures, alcohol withdrawal, neuromuscular blockade) 1

Delirium Prevention and Management

Screen for delirium twice daily using CAM-ICU and implement non-pharmacologic prevention strategies. 1

• Non-pharmacologic measures: 1
  • Reorient patient frequently (clocks, calendars, family presence)
  • Minimize sleep disruption (reduce nighttime noise/light)
  • Early mobilization when feasible
  • Ensure hearing aids/glasses are available
• Avoid routine antipsychotics for delirium prevention 1
• If delirium present with agitation: Haloperidol 2-5 mg IV q6-8h PRN or quetiapine 25-50 mg PO/NG BID (use lowest effective dose) 1

Infection Surveillance and Empiric Therapy

For New Fever (Temperature >38.3°C)

Obtain central and peripheral blood cultures simultaneously, chest X-ray, and urinalysis before starting empiric antibiotics. 1

• Blood cultures: Draw at least 2 sets (60 mL total) from different sites without time interval 1
• If central line present: Sample at least 2 lumens for differential time to positivity 1
• Imaging: Chest X-ray mandatory; consider CT abdomen/pelvis if recent surgery or unclear source 1

Empiric Antibiotic Coverage (if infection suspected)

Do NOT routinely prescribe antibiotics without clinical signs of infection. 1

• For suspected bacterial pneumonia (CAP): 1
  • Non-ICU: Ceftriaxone 1-2 g IV q24h PLUS azithromycin 500 mg IV/PO q24h
  • ICU/critically ill: ADD vancomycin 15-20 mg/kg IV q8-12h (target trough 15-20 mcg/mL) for MRSA coverage
• Duration: 7 days if afebrile for 48 hours and clinically stable 1

Empiric Antifungal Therapy (if high risk for invasive candidiasis)

Consider echinocandin empiric therapy only in critically ill patients with risk factors for invasive candidiasis and septic shock. 1, 2, 3

Risk factors requiring consideration: 1, 2

• Candida colonization at multiple sites
• Broad-spectrum antibiotics >4 days
• Central venous catheter present
• Total parenteral nutrition
• Recent major surgery (especially abdominal)
• Necrotizing pancreatitis
• Dialysis requirement

Preferred empiric antifungal regimen: 1, 2, 3

• Anidulafungin: 200 mg IV loading dose, then 100 mg IV q24h, OR
• Micafungin: 100 mg IV q24h, OR
• Caspofungin: 70 mg IV loading dose, then 50 mg IV q24h

Alternative (if no recent azole exposure and not colonized with azole-resistant species): 1, 2

• Fluconazole: 800 mg (12 mg/kg) IV loading dose, then 400 mg (6 mg/kg) IV q24h

Duration: 2 weeks after clinical improvement or documented clearance if started empirically 1, 2

Discontinue empiric antifungals if no clinical response at 4-5 days and no evidence of invasive candidiasis 1

Stress Ulcer Prophylaxis

• Proton pump inhibitor: Pantoprazole 40 mg IV/PO q24h OR omeprazole 40 mg PO/NG q24h (if mechanical ventilation >48 hours or coagulopathy present) 4

Venous Thromboembolism Prophylaxis

• Enoxaparin: 40 mg SC q24h (if CrCl >30 mL/min) OR
• Heparin: 5000 units SC q8-12h
• Mechanical prophylaxis: Sequential compression devices if anticoagulation contraindicated 4

Glycemic Control

• Target glucose: 140-180 mg/dL 4
• Insulin infusion protocol: If glucose persistently >180 mg/dL despite subcutaneous insulin
• Avoid hypoglycemia (<70 mg/dL) which worsens outcomes 4

Sleep Hygiene Protocol

Implement multicomponent sleep-promoting protocol to reduce delirium and improve recovery. 1

• Reduce nighttime noise: Close doors, reduce alarm volumes, cluster care activities 1
• Reduce nighttime light: Dim lights 10 PM-6 AM, use eye masks if tolerated 1
• Avoid: Routine melatonin or propofol specifically for sleep (insufficient evidence) 1

Daily Monitoring Requirements

• Vital signs: Every 4 hours minimum (temperature, HR, BP, RR, SpO2)
• Neurologic assessment: RASS, CAM-ICU, pain scale every 4 hours 1
• Labs: Daily CBC, BMP, consider procalcitonin if infection suspected 1
• Central line assessment: Daily necessity evaluation, remove if no longer needed 1, 2

Chlorhexidine Bathing

Implement daily chlorhexidine bathing to reduce bloodstream infections including candidemia. 1, 2

• 2% chlorhexidine gluconate cloths: Daily bathing of all ICU patients

Critical Pitfalls to Avoid

• Do not use benzodiazepines as first-line sedation due to increased delirium and worse outcomes 1
• Do not maintain deep sedation (RASS -3 to -5) routinely, as this prolongs mechanical ventilation 1
• Do not start empiric antifungals based solely on Candida colonization without clinical signs of invasive infection 1, 2
• Do not continue empiric antibiotics beyond 7 days without documented infection 1
• Do not use antipyretics routinely for fever reduction alone; fever may aid immune response 1