What are the treatment plans for common ICU diagnoses like sepsis, ARDS, and myocardial infarction?

Common ICU Diagnoses and Treatment Plans

The three most critical ICU diagnoses requiring immediate, protocol-driven management are sepsis/septic shock, acute respiratory distress syndrome (ARDS), and acute myocardial infarction, each with specific evidence-based treatment algorithms that directly impact mortality.

1. SEPSIS AND SEPTIC SHOCK

Initial Resuscitation (First 6 Hours)

Begin aggressive fluid resuscitation immediately upon recognition with crystalloids as first-line therapy, targeting specific hemodynamic endpoints within the first 6 hours. 1

• Fluid bolus: Administer minimum 30 mL/kg of crystalloids rapidly; some patients require more aggressive volumes 1
• Hemodynamic targets:
  • Central venous pressure (CVP) 8-12 mm Hg (12-15 mm Hg if mechanically ventilated) 1
  • Mean arterial pressure (MAP) ≥65 mm Hg 1
  • Urine output ≥0.5 mL/kg/hour 1
  • Central venous oxygen saturation (ScvO2) ≥70% 1

Antimicrobial Therapy

Administer broad-spectrum antibiotics within 1 hour of recognizing septic shock. 1

• Obtain blood cultures before antibiotics, but do not delay treatment 1
• Perform imaging promptly to identify infection source 1
• Typical duration: 7-10 days guided by clinical response 2, 3

Vasopressor Support

Norepinephrine is the first-choice vasopressor to maintain MAP ≥65 mm Hg. 1, 4

• Second-line: Add epinephrine if additional agent needed 1
• Vasopressin: Can be added at 0.03 U/min to norepinephrine to raise MAP or decrease norepinephrine dose, but not as initial vasopressor 1
• Avoid dopamine except in highly selected circumstances 1
• Dobutamine: Add when myocardial dysfunction present (elevated filling pressures, low cardiac output) or ongoing hypoperfusion despite adequate volume and MAP 1

Corticosteroids

Avoid hydrocortisone if adequate fluid resuscitation and vasopressors restore hemodynamic stability. 1

• Only use in refractory shock poorly responsive to fluids and vasopressors 3
• Do not use ACTH stimulation test to guide therapy 1
• Taper when vasopressors no longer required 1

2. ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

Mechanical Ventilation Strategy

Use low tidal volume ventilation at 6 mL/kg predicted body weight (not 12 mL/kg) in all ARDS patients. 1, 5

• Plateau pressure: Maintain ≤30 cm H2O 1
• PEEP: Use higher PEEP strategies in moderate-to-severe ARDS to prevent alveolar collapse 1
• Recruitment maneuvers: Consider in severe refractory hypoxemia 1

Prone Positioning

Use prone positioning in ARDS patients with PaO2/FiO2 ratio <150 (or ≤100 mm Hg) in facilities experienced with this practice. 1

This is a strong recommendation with moderate quality evidence for severe ARDS 1

Neuromuscular Blockade

Administer neuromuscular blocking agents for ≤48 hours in early ARDS with PaO2/FiO2 <150 mm Hg. 1

• Avoid in septic patients without ARDS due to prolonged blockade risk 1
• Use train-of-four monitoring if continuous infusion required 1

Fluid Management

Use conservative fluid strategy once tissue hypoperfusion resolved in established ARDS. 1

This decreases mechanical ventilation days and ICU length of stay 3

Ventilator Liberation

Maintain head of bed elevation 30-45 degrees to prevent ventilator-associated pneumonia. 1

• Implement weaning protocols with daily spontaneous breathing trials 1
• Criteria for trials: arousable, hemodynamically stable without vasopressors, no new serious conditions, low ventilatory requirements 1

Avoid These Interventions

• High-frequency oscillatory ventilation (strong recommendation against) 1
• β-2 agonists without bronchospasm 1
• Pulmonary artery catheters routinely 1

3. ACUTE MYOCARDIAL INFARCTION

Hemodynamic Support in Cardiogenic Shock

Norepinephrine remains first-line for hypotension, even in myocardial infarction context. 4

• FDA-approved for blood pressure control in myocardial infarction 4
• Add dobutamine for low cardiac output states with adequate preload 1

Blood Product Management

Target hemoglobin 7-9 g/dL unless active myocardial ischemia, in which case higher targets appropriate. 1

This represents an exception to the restrictive transfusion strategy 1

GENERAL ICU SUPPORTIVE CARE (High Priority)

Glucose Control

Target blood glucose <180 mg/dL using protocolized insulin therapy, not tight control to <110 mg/dL. 1

• Begin insulin when two consecutive levels >180 mg/dL 1
• Monitor every 1-2 hours until stable, then every 4 hours 1

Sedation Management

Minimize continuous sedation in mechanically ventilated patients, targeting specific endpoints. 1

• Use protocols for sedation and weaning 1
• Consider daily interruptions or lightening of continuous infusions 1, 3

Thromboprophylaxis

Provide deep vein thrombosis prophylaxis in all ICU patients. 1, 3

Stress Ulcer Prophylaxis

Use H2-blockers or proton pump inhibitors in patients with bleeding risk factors. 1, 3

Transfusion Thresholds

Transfuse red blood cells only when hemoglobin <7.0 g/dL, targeting 7-9 g/dL, except in active ischemia or hemorrhage. 1

• Do not use erythropoietin for sepsis-associated anemia 1
• Prophylactic platelets when <10,000/mm³ without bleeding; <20,000/mm³ with bleeding risk; ≥50,000/mm³ for active bleeding or procedures 1

Goals of Care

Address treatment plans and end-of-life planning within 72 hours of ICU admission. 1

This should occur as early as feasible to align care with patient values 1