Evidence based critical care guidelines

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Evidence-based Critical Care Guidelines

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Table of contents
Admission & Discharge Protocol..................................................................................................................... 1
Admission Criteria to Intensive Care Unit ................................................................................................... 1
Admission Criteria to Intermediate Care Unit............................................................................................. 3
Discharge Criteria ........................................................................................................................................ 4
Plan upon admission of patient to ICU........................................................................................................ 5
Transfer Protocol............................................................................................................................................. 7
Trauma Protocol.............................................................................................................................................. 9
Resuscitation protocol in traumatic hemorrhagic shock .............................................................................. 10
General principle: ...................................................................................................................................... 10
Fluid resuscitation...................................................................................................................................... 10
Traumatic Brain Injury................................................................................................................................... 14
General principle ....................................................................................................................................... 14
Resuscitation and basic physiologic goals ................................................................................................. 14
Intracranial Pressure (ICP) Monitoring...................................................................................................... 15
Adjunctive Medication and prevention of complication........................................................................... 17
Metabolic Monitoring................................................................................................................................ 18
Nutritional Support.................................................................................................................................... 18
NON-Emergency Surgery........................................................................................................................... 19
SURGICAL MANAGEMENT OF TBI.............................................................................................................. 19
Acute Spinal Cord Injury................................................................................................................................ 21
Hemodynamic Assessment of Patients with Circulatory failure................................................................... 23
Sepsis Management Protocol........................................................................................................................ 30
General principles...................................................................................................................................... 30
Sepsis Protocol........................................................................................................................................... 30
Vasopressors.............................................................................................................................................. 32
Sepsis screening tools................................................................................................................................ 33
Fever Assessment.......................................................................................................................................... 37
Basic principle............................................................................................................................................ 37

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Infectious causes of fever.......................................................................................................................... 37
Non-Infectious causes of fever.................................................................................................................. 37
Evaluation of new fever in ICU (See algorithm below).............................................................................. 38
Nosocomial Infection .................................................................................................................................... 42
Hospital acquired and Ventilator Associated Pneumonia......................................................................... 42
Community Acquired Pneumonia ............................................................................................................. 44
Community Acquired abdominal infection ............................................................................................... 45
Health Care Associated abdominal infection ............................................................................................ 46
Catheter related blood stream infection (CLBSI)....................................................................................... 48
Invasive candidiasis in ICU......................................................................................................................... 51
Specific Types of infections ....................................................................................................................... 55
Multi-drug resistant gram negative bacteria (MDR-GNB)......................................................................... 60
Mechanical Ventilation Protocol................................................................................................................... 64
Parameters for institution of ventilation.................................................................................................... 64
Principles in optimizing ventilation in ICU patients.................................................................................... 64
Low tidal volume Ventilation..................................................................................................................... 65
Strategies to improve severe hypoxemia.................................................................................................. 65
Weaning of Mechanical ventilation .............................................................................................................. 72
Important definitions................................................................................................................................. 72
Risk factors of extubation failure .............................................................................................................. 72
Assessment of readiness to wean ............................................................................................................. 72
Spontaneous breathing trial...................................................................................................................... 73
Extubation.................................................................................................................................................. 74
Weaning failure ......................................................................................................................................... 74
Non-invasive ventilation protocol................................................................................................................. 78
Indications of NIV....................................................................................................................................... 78
Specific indication of NIV........................................................................................................................... 78
Contraindication of NIV ............................................................................................................................. 79
Initiation and titration of therapy.............................................................................................................. 79

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Oral feeding and nutrition during NIV....................................................................................................... 79
Nutrition Protocol.......................................................................................................................................... 82
Estimation of Nutritional Requirement..................................................................................................... 83
Enteral Feeding.......................................................................................................................................... 85
Parenteral Nutrition................................................................................................................................... 86
Nutrition therapy in special population .................................................................................................... 87
Prophylaxis of Deep Venous Thrombosis...................................................................................................... 89
General Principles...................................................................................................................................... 89
Clinical risk factors for thromboembolism in critically ill patients............................................................ 89
Risk factors of bleeding.............................................................................................................................. 89
Protocol of thromboembolism prophylaxis .............................................................................................. 89
Pharmacological prophylaxis..................................................................................................................... 90
Management of Acute Pulmonary Embolism ............................................................................................... 94
Clinical classification of pulmonary embolism .......................................................................................... 94
Diagnostic strategies.................................................................................................................................. 94
Treatment in acute phase.......................................................................................................................... 94
Fluid Therapy And Electrolyte Replacement Protocol ................................................................................ 103
Electrolyte Replacement Protocol........................................................................................................... 105
Hyponatremia.......................................................................................................................................... 108
Burn Resuscitation....................................................................................................................................... 113
General Rules........................................................................................................................................... 113
Resuscitation guidelines .......................................................................................................................... 113
Stress Ulcer Prophylaxis (SUP) .................................................................................................................... 116
General Rules........................................................................................................................................... 116
Stress ulcer prophylaxis protocol ............................................................................................................ 116
Gastro-intestinal hemorrhage protocol...................................................................................................... 120
General principles.................................................................................................................................... 120
Initial Evaluation and Resuscitation......................................................................................................... 120
Find etiology and stratify risk .................................................................................................................. 120

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Send investigations.................................................................................................................................. 121
General treatment................................................................................................................................... 121
Speciﬁc treatment ................................................................................................................................... 121
Management of DKA................................................................................................................................... 125
Acid-Base protocol ...................................................................................................................................... 126
Acidosis.................................................................................................................................................... 127
Alkalosis ................................................................................................................................................... 128
Transfusion and Coagulopathy Management protocol .............................................................................. 130
Management of anemia and red cell transfusion ................................................................................... 130
Management of coagulopathy ................................................................................................................ 133
Disseminated intravascular coagulopathy .............................................................................................. 133
Cardiopulmonary resuscitation................................................................................................................... 136
Electric cardioversion.......................................................................................................................... 141
Energy level of cardioversion .................................................................................................................. 141
Post-Return of Spontaneous Circulation (ROSC) ........................................................................... 143
Procedures............................................................................................................................................... 143
Ventilation ............................................................................................................................................... 143
Hemodynamic Goals................................................................................................................................ 143
Sedation & Pain Control .......................................................................................................................... 144
Lab & Electrolyte...................................................................................................................................... 144
DVT Prophylaxis....................................................................................................................................... 144
Stress Ulcer Prophylaxis........................................................................................................................... 144
VAP Prophylaxis....................................................................................................................................... 144
Induced Hypothermia Protocol ............................................................................................................... 144
Postoperative atrial fibrillation (AF)............................................................................................................ 149
General principles:................................................................................................................................... 149
Choice of Anticoagulant in patient wit AF............................................................................................... 151
Recommendations for prevention of thromboembolism in non-valvular AF......................................... 152
Acute Coronary Syndrome .......................................................................................................................... 154

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Pediatric critical care................................................................................................................................... 157
Pediatric Sepsis & septic shock Resuscitation Management .................................................................. 157
General Principles:................................................................................................................................... 157
Definitions:............................................................................................................................................... 157
Sepsis Protocol:........................................................................................................................................ 160
Nutrition .................................................................................................................................................. 166
Nutrition screening.................................................................................................................................. 166
Determining Calorie and Protein Needs in Critically Ill Children............................................................. 166
Enteral nutrition in ICU............................................................................................................................ 167
Parenteral nutrition (PN) in ICU............................................................................................................... 170
Mechanical ventilation ............................................................................................................................ 174
Acute respiratory distress syndrome in pediatrics.................................................................................. 175
Clinical Management strategy................................................................................................................. 175
Weaning of mechanical ventilation in pediatrics .................................................................................... 178
Obstetrics critical care................................................................................................................................. 181
Respiratory distress in pregnant patient................................................................................................. 181
Hemodynamic instability......................................................................................................................... 181
Altered mental status/neurological abnormalities ................................................................................. 182
Pre-eclampsia .......................................................................................................................................... 184
Peripartum cardiomyopathy ................................................................................................................... 188
Hemorrhage during pregnancy ............................................................................................................... 191
Trauma In Pregnancy............................................................................................................................... 193
Cardiac Arrest during pregnancy............................................................................................................. 196
Pharmacotherapy........................................................................................................................................ 199
Anticoagulant........................................................................................................................................... 199
Heparin Infusion ...................................................................................................................................... 199
Warfarin Dosage...................................................................................................................................... 200

VII
Anticoagulant reversal............................................................................................................................. 203
New Oral Anticoagulants (NOACs) .......................................................................................................... 206
Antimicrobial dosing in renal insufficiency.............................................................................................. 211
Intravenous drug compatibility ............................................................................................................... 216
Pediatric drug infusion............................................................................................................................. 218

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Admission & Discharge Protocol
Admission Criteria to Intensive Care Unit
Criteria for admission to Intensive Care
1) Trauma patients
a. Injuries
i. Multisystem trauma
ii. Severe traumatic brain injuries (GCS<8)
iii. Cervical spine cord injury
iv. Severe pulmonary contusion, flail chest
v. Facial or neck trauma with threatened airway
vi. Repaired major vascular injuries
vii. Pelvic fracture with retroperitoneal hematoma
viii. Blunt cardiac trauma with hypotension or dysrhythmia
ix. Severe burn (20% TBSA, facial burns)
x. Isolated high grade solid organ injuries (grade III, IV)
b. Problems
i. Respiratory failure requiring mechanical ventilation
ii. Ongoing shock or hemodynamic instability
iii. Massive blood or fluid resuscitation
iv. Base deficit >5
v. Hypothermia
vi. Seizures
vii. Pregnancy
2) Post-operative monitoring
a. Neurosurgery
b. major vascular surgery
c. Long surgical or interventional procedures
d. massive blood loss

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e. Multiple co-morbidities with low systemic reserve)
3) Postoperative complications:
a. Acute respiratory failure requiring Invasive or non-invasive ventilation.
b. Optimization of ﬂuid balance requiring invasive procedures
c. Hemodynamic instability requiring inotropic support
d. Potential for deterioration (e.g. airway swelling, metabolic disorders,
coagulopathies, hypoxaemia, hypercarbia, hypovolaemia, intracranial events).
e. Sepsis with multi-organ dysfunction.
f. Interventions that cannot be performed in a general ward –continuous veno-
venous hemoﬁltration
4) Preoperative optimization of patients with hemodynamic instability and/or major fluid
and electrolyte disturbance
5) Severe acute pancreatitis

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Admission Criteria to Intermediate Care Unit
Criteria for admission to Intermediate care
1) Acute traumatic brain injury patients who have a Glasgow Coma Scale above 9 but
require frequent monitoring for signs of neurologic deterioration
2) Stable cervical spinal cord injured patients
3) The postoperative patient who, following major surgery, is hemodynamically stable but
may require fluid resuscitation and transfusion due to major fluid shifts
4) Appropriately treated and resolving early sepsis without evidence of shock or
secondaryorgan failure
5) Hemodynamically stable patients with evidence of compromised gas exchange and
underlying disease with the potential for worsening respiratory insufficiency who
require frequent observation
6) Diabetic ketoacidosis patients requiring constant intravenous infusion of insulin, or
frequent injections of regular insulin during the early

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Discharge Criteria
Criteria for discharge from Intensive care unit to ward
1) Patient not on any support or intervention (or unlikely to need them in the next 24
hours) that cannot be provided in the ward. This includes equipment and nurse staffing
issues.
2) Low likelihood of deterioration in the next 24 hours. For long-stay patients and those
with low systemic reserve, the duration should be extended to 48 hours or more.
3) Supplemental inspired oxygen concentration <50%
4) Hemodynamically stable; any fluid losses should be at a rate manageable in the ward
environment
5) Cardiac dysrhythmias are controlled
6) The admission etiological factor is under control or not significant any more
7) Patients in whom treatment has been withdrawn and only need basic nursing care and
drugs for comfort

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Plan upon admission of patient to ICU
Discharge
Planning
 Stable medical condition
 Inform in charge nurse
 Communicate with
receiving team
 Inform patient and family
 Hemodynamic
parameter
 Ventilatory parameter
 Weaning Potential
 Sedation regimen
 Need for radiological
procedure
 Electrolyte
 Fluid Balance
 Nutrition
 Renal Function
 Lines
 Adverse drug reaction
 Communication
Daily ReviewCall assistant lecture
for any change in
patient condition
Admission Order
General
 DVT prophylaxis
 GI prophylaxis
 Sedation/paralysis
 Nutrition
 Fluid replacement
 Skin Care
Specific Care
Plan
Define Reason for
admission
Define goal for ICU care
Assess needs for ventilator support
Hemodynamic monitoring
Urgent Consultation
Data Collection
History and Physical Exam
Review old charts
Laboratory data
Radiological data
Follow ACLS protocolArrival To ICU
ABC
Communication:
The most overlooked
aspect of patient care
 Critical care staff
 Family
 Nurse
 Pharmacy

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References
1. Department of Health Working Group. Guidelines on Admission to and Discharge from Intensive Care
and High Dependency Care Units. London:Department of Health. (1996)
2. Daly K, Beale R, Chang S Reduction in mortality after inappropriate early discharge from intensive
care unit: logistic regression triage model. Br. Med. J. 2001, 322:1274

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Transfer Protocol
Airway
Patients with (or at risk from) airway
compromise should be intubated prior to
transfer
The tracheal tube should be secured and
conﬁrmed in correct position
Circulation
 Adequate intravenous access
 Circulating volume optimized
 Hemodynamically stable
 All lines are patent and secured
 Any active bleeding controlled
 Long bone/pelvic fractures stabilized
 ECG and blood pressure monitored
C. Spine
Adequate spinal immobilization (if indicated)
Disability
 No active seizures
 Initial treatments for raised intracranial
pressure (if indicated)
 Life-threatening electrolyte disturbances
corrected
Blood glucose >70 mg/dl
Breathing
Patient adequately sedated if ventilated
Ventilation established (and stable) on
transport ventilator
Adequate gas exchange on transport
ventilator conﬁrmed by arterial blood gas
analysis
Adequate oxygen supply on transfer vehicle
Exposure
Patient adequately covered to prevent heat
loss

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References
1. Intensive Care Society Guidelines for the Transport of the Critically Ill Adult, 2nd edn.
London:Intensive Care Society (UK). 2002

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Trauma Protocol
Figure 1: Initial Trauma management

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Resuscitation protocol in traumatic hemorrhagic shock
General principle:
 Traumatic death is the main cause of life years lost worldwide. Hemorrhage is responsible for
almost 50% of deaths in the first 24 h after trauma.
 The optimal resuscitative strategy is controversial: choice of fluid for resuscitation, the target of
hemodynamic goals for hemorrhage control, and the optimal prevention of traumatic
coagulopathy are questions that remain.
Fluid resuscitation
I. Type of fluid
 Lactated Ringer’s solution is recommended as first-line resuscitation fluid in trauma patients
 Albumin should be avoided in patients with TBI
 In patients with TBI, isotonic saline should be preferred over hypotonic fluids because it can
reduce the risk of cerebral edema.
II. Endpoints of resuscitation
 Three different target systolic blood pressure values can be considered for three different
traumatic conditions before controlling source of hemorrhage:
o 60–70 mmHg for penetrating trauma
o 80–90 mmHg for blunt trauma without TBI
o 100–110 mmHg for blunt trauma with TBI
 Lactate ≥ 2 mmol/L and base deficits ≥ -5 mEq/L have been demonstrated useful to stratify
patients who need a larger amount of fluid after the initial resuscitation.
III. Vasopressor
 Early use of norepinephrine could limit fluid resuscitation and hemodilution.
 The dose of norepinephrine should be titrated until we reach the target systolic blood pressure
as indicated above
IV. Transfusion and prevention of acute coagulopathy of trauma
The correction and prevention of traumatic coagulopathy have become central goals of early
resuscitative management of hemorrhagic shock.
a) Red blood cells
 In patients without TBI: Target haemoglobin level (7-9 g/dL)
 In patients with severe TBI (GCS ≤ 8): Target haemoglobin level ≥ 10 g/dL
a) Fresh Frozen Plasma (FFP)
 In all patients FFP should be considered when PT or PTT ≥ 1.5 times normal value

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 The initial recommended dose of FFP is 10 to 15 ml/kg
b) Platelet
 In patients without TBI: Platelet transfusion is recommended when platelet count ≤ 50.000/L
 In patients with TBI: Platelet transfusion is recommended when platelet count ≤ 100.000/L
c) Fibrinogen
 In all patients, fibrinogen level should be maintained ≥ 150-200 mg/dL
 The use of FFP failed to rapidly correct the hypofibrinogenemia
o Resuscitation with 10 to 15 mL/kg of FFP only increased the fibrinogen plasma level to 40
mg/dL
o More than 30 mL.kg of FPP should be necessary to increase the fibrinogen plasma level to
100 mg/dL
 10 single bags of cryoprecipitate derived from whole blood are needed to raise the plasma
ﬁbrinogen level by 100 mg/dL
d) Adjuvant Therapy
I. Tranxemic acid: routine administration of tranexamic acid (loading dose of 1 g over 10 min,
then infusion of 1g over 8 hr) in patients with hemorrhagic shock was associated with a
decreased mortality rate.
II. Factor VIIa: No clear recommendation to use activate factor VII and the use of this factor
should be discussed on a case-by-case basis.
III. Ionized calcium level should be maintained between 1.1-1.3 mmol/L

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Figure 2: initial management of traumatic hemorrhagic shock (1)

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References
1. Bouglé A, Harrois A, Duranteau J. Resuscitative strategies in traumatic hemorrhagic shock. Ann
Intensive Care. 2013; 12:1

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Traumatic Brain Injury
General principle
 Traumatic brain injury (TBI) is a serious public health problem in Egypt, contributing to over 50%
of trauma deaths
 Protocolized management of severe TBI [defined as a post-resuscitation Glasgow Coma Score
(GCS) < 8] has been demonstrated to improve patient outcome
 Protocol for management of TBI is based on management guidelines proposed by PROTECT III trial
Resuscitation and basic physiologic goals
A. Airway management
 Patients with a GCS ≤ 8 should be intubated for airway protection
 Sedative and analgesic choices should include short acting agents through the initial resuscitation,
as temporal assessment of neurological status is critical
o Propofol is strongly recommended as the choice for sedation,
o Succinylcholine, Rocuronium bromide – paralytic for induction
B. Oxygenation/Ventilation
 The Target Oxygen status is PaO2 ≥ 100 mmHg and O2 Sat ≥ 90%
 Avoidance of hypoxia
o Patients with moderate TBI who do not require intubation should have pulse oximetry
maintained to at least 90%.
o Intubated patients PaO2 should be maintained at ≥ 100 mmHg, except during weaning.
Pulse oximetry > 90 % remains goal during ventilation wean
 Ventilation
o Hyperventilation should be intensively avoided during the initial resuscitation
o The Target PaCO2 is (35-45 mmHg)
o Prophylactic hyperventilation (PaCO2 < 35 mmHg) is prohibited.
o Therapeutic hyperventilation may be necessary for brief periods when there is acute
neurological deterioration that coincides with a cerebral herniation syndrome or for
refractory elevations in ICP
C. Blood Pressure, Volume Resuscitation, Anemia, and Coagulopathy
 Blood Pressure
o A systolic blood pressure (SBP) should be kept between 100 mmHg and 180 mmHg.
Recognize that lower blood pressures can represent a “relative” hypotensive state in TBI
patients (especially with elevated ICP)

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o Normal Saline Fluid should be used as the initial method of maintaining euvolemia to
achieve the target blood pressure.
o Assessment for transfusion and/or implementation of vasoactive drugs should be
considered for treatment of hypotension. Such Vasopressors or Inotrops include
Phenylephrine (Neosynephrine), Levophed, Epinephrine, Dobutamine, and Vasopressin.
 Euvolemia – The primary target is euvolemia.
o In many cases a central venous pressure (CVP) monitor will be placed. A CVP goal of 5-7
mmHg correlates with euvolemia, but should be assessed in the context of the individual
patient’s clinical picture. CVP or other types of invasive monitoring are recommended in
patients with severe TBI requiring ventriculostomy or intubation.
o Brain-injured patients should be maintained in a euvolemic state with volume replacement
of blood products and crystalloid.
o The initial resuscitation fluid should be normal saline. Hypertonic saline should only be
used as a secondary osmotic agent in ICP control.
o Volume resuscitation to achieve euvolemia should NOT be withheld to prevent concerns
with cerebral edema.
o Conversely, hypervolemia should be avoided as it is associated with increased incidence of
ARDS in TBI patients.
 Anemia - The target is to keep hemoglobin concentration at 8 g/dl or above.
o The hemoglobin concentration (Hgb) of the patient should be maintained at ≥ 8 g/dL
o Blood should be transfused for Hg < 8 g/dL.
 Coagulation – Coagulation panels should be followed closely.
o The Target INR is less than or equal to 1.4
o FFP, Vitamin K, Factor VII, should be administered, as clinically indicated, in order to
correct coagulopathy.
o INR and platelet count should be corrected in anticipation of placement of
ventriculostomy, or other intracranial surgery.
o Platelets should be transfused for a platelet count < 75 x 103
/ mm3
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Intracranial Pressure (ICP) Monitoring
 All patients with signs and symptoms of increased intracranial pressure (ICP) and/or GCS ≤ 8
should receive a ventriculostomy for ICP monitoring (unless there is a direct contraindication to
invasive monitoring, such as INR >1.4 or platelet count of <75 x 103
Indications
o Salvageable patients with severe TBI (GCS 3-8 after resuscitation) and an abnormal CT scan
(hemorrhage, contusions, swelling, herniation or compressed basal cisterns)
o Patients with severe TBI and normal CT scan if two of the following are noted at admission:
age > 40 yrs, unilateral or bilateral posturing, systolic BP < 90 mmHg

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Management of increased ICP
o General recommendation
 Ventilation – Keep O2 Sat >90, and PaO2>100, and PCO2 = 35-45.
 Monitor Systolic BP and MAP - avoid hypotension, Systolic >100 mmHg.
 Normothermia goal <38.3°C: treat fever with acetaminophen and/or cooling
blankets.
 Adjust cervical collar placement if applicable.
 Consider repeat CT: a repeat CT scan of the brain should be considered to rule out
the development of a surgical mass or unexpected intracranial lesion
o TIER 1
 Head of patient’s bed to be placed at ≥ 30 degrees.
 Sedation and analgesia using recommended agents (propofol, fentanyl, and versed)
in intubated patients. Pain relief and sedation are appropriate initial modalities for
treatment of intracranial hypertension.
 Ventriculostomy - extraventricular drain; drain to 10 cmH2O for ICP ≥ 20 mmHg
sustained for ≥ 5min
 Mannitol – 0.25-1.0g/kg; IV bolus x 1 dose
Tier 1 completed within 120 minutes, if ICP ≥ 20 mmHg/27.2 cm H20 mmHg proceed to Tier
2
o TIER 2
 Hyperosmolar therapy
 Mannitol: intermittent boluses of mannitol (0.25 - 1 gm/kg body weight)
should be administered.
 Hypertonic saline: boluses of 3% sodium chloride solution (250 cc over ½
hour)
 Measure serum osmolality and electrolytes q 12 hrs
 Hold hypertonic saline therapy for serum Na > 160 mEq/L
 Hold mannitol therapy for serum osmolality > 320 mOsm
 Protect the Brain
 Initiate continuous EEG monitoring to rule non-convulsive status
epilepticus
 Provide judicious analgesia and sedation to control pain and agitation
 Fentanyl 25-150 mcg/hr IV infusion
 Propofol 10-50 mcg/kg/hr IV infusion for Richmond Agitation
Sedation Score (RASS) > -2
Tier II completed within 120 minutes, if ICP ≥ 20 cmH20/mmHg proceed to Tier 3.

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 TIER 3
 Decompressive hemi-craniectomy or bilateral craniectomy should only be
performed if Tiers 1 and 2 are not sufficient.
 Barbiturate
 Pentobarbital 10 mg/kg IV over 10 minutes, then 5 mg/kg IV q 1 hr x 3, then
1 mg/kg/hr IV infusion
 Titrate pentobarbital to the minimal dose required to achieve EEG burst
suppression
 Discontinue all other sedative agents and paralytics
Adjunctive Medication and prevention of complication
A. Antiseizure Prophylaxis
 Post traumatic seizures are a recognised complication of closed head injuries with incidence
depending largely on severity of injury.
 Post traumatic seizures are classified as either
o Immediate, early (0-7 days) or
o Late/delayed (>7 days)
 Anti-convulsants are therefore only indicated in the first week following closed head injury to
reduce the risk of complications from early post traumatic seizures. They should not be
routinely continued long term.
 The following CT scan findings may indicate the need for late PTS prophylaxis (anticonvulsant
therapy for longer than 7 days post injury) (1):
o Biparietal contusions.
o Dural penetration with bone and metal fragments.
o Multiple intracranial operations.
o Multiple subcortical contusions.
o Subdural hematoma with evacuation.
o Midline shift greater than 5mm.
o Multiple or bilateral cortical contusions.
 Anticonvulsant drugs
o Phenytoin is effective in decreasing the risk of early PTS in patients with severe TBI.
 Dose: phenytoin is administered intravenously with a loading dose of 17 mg/kg
intravenous infusion over 30-60 minutes, followed by a maintenance dose of 100
mg given three times daily, either intravenously or orally for a total of seven days.
 Valproate should NOT be used for early PTS prophylaxis.
 Levetiracetam is an effective and safe alternative to phenytoin for early PTS
prophylaxis.

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 Dose: A loading dose of 20 mg/kg IV (rounded to the nearest 250 mg and
administered over 60 min) followed by a maintenance dose of 1000 mg IV
every 12 hrs (given over 15 min)
B. Glucocorticoids
 The use of glucocorticoids is not effective at improving outcome or reducing intracranial
hypertension, and should NOT be administered
C. Stress Ulcer Prophylaxis
 Patients with significant traumatic brain injury requiring mechanical ventilation as well as those
with coagulopathies or a history of gastric or duodenal ulcers should receive stress ulcer
prophylaxis
D. Deep Venous Thrombosis (DVT) Prophylaxis
 All patients with significant traumatic brain injury requiring mechanical ventilation and sedation
should receive DVT prophylaxis in the form of sequential compression stockings upon admission
 Subcutaneous low-dose heparin may also be initiated within 72 hours of admission, unless
contraindicated due to evidence of bleeding, need for surgery, or indwelling intracranial monitor.
E. Early Tracheostomy
 Tracheostomy is recommended in ventilator dependent patients to reduce total days of ET
intubation.
Metabolic Monitoring
A. Serum Electrolyte
 The baseline goal for electrolytes (such as, sodium) will be to maintain within normal range (Na
135-145 mmol/L)
 In the treatment of elevated ICP with HTS, Na goal increases to a target of 145 mmol/L (lower
threshold) and 160 mmol/L (upper threshold).
B. Glucose Monitoring
 The glucose level should be maintained between 80 and 180 mg/dl.
 Serum glucose should be monitored frequently following the initiation of nutritional support,
particularly in patients with known or suspected diabetes mellitus.
 In the ICU, initial treatment with regular insulin for hyperglycemia is recommended, with
subsequent transition to other patient specific regimens per team.
Nutritional Support
 Nutritional support should be initiated via gastric or enteral route within 72 hours post injury

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 Frequent assessment of residual volumes of gastric nutrition should be performed, as patients
with TBI frequently do not tolerate intragastric feeding, and are at risk for emesis and aspiration.
 TPN should be utilized cautiously in patients with TBI due to the high glucose concentrations of
hyperalimentation solutions
NON-Emergency Surgery
 Non-Emergent surgeries that require general anesthesia, such as orthopedic procedures and
plastic surgery, should be avoided in BOTH moderate and severe TBI patients until it is clear that
the brain injury has stabilized or resolved.
 In the case of Emergency surgeries, priority should be given to maintaining target physiological
parameters such as systolic blood pressure > 100 mmHg (or higher if ICP is elevated), and
oxygenation (PaO2 ≥ 100 mmHg and Pulse Ox ≥ 90%) in all patients suspected of having a TBI.
SURGICAL MANAGEMENT OF TBI
A. Epidural Hematomas
 Epidural hematoma should be surgically evacuated if
o epidural hematoma (EDH) of greater than 30 cm3
o acute EDH, GCS <9, and anisocoria
 EDH of less than 5 mm midline shift in patients with GCS >8 and no focal neurological deficit can
be closely monitored in an ICU with serial CT scans
B. Acute Subdural Hematomas
 Acute subdural hematomas (SDH) should be evacuated emergently if
o (SDH) with a thickness of greater than 10 mm or 5 mm of midline shift on CT scan
regardless of the GCS
o SDH less than 10 mm thickness and less than 5 mm midline shift should be evacuated
emergently if the patient has: GCS decrease by 2 points, asymmetric pupils or fixed pupils,
or ICP > 20 mmHg
C. Subarachnoid Hemorrhage
 All patients with GCS <9 and SAH should have a ventriculostomy inserted.
D. Parenchymal Lesions
 Intraparenchymal hemorrhage (IPH) should be evacuated if
o medically refractory ICP elevations, or significant mass effect
o Frontal or temporal contusions with IPH >20 cm3 and >5 mm shift or cistern compression
in patients with GCS 6-8
o IPH >50 cm3

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E. Diffuse Medically-Refractory Cerebral Edema and Elevated ICP
 Decompressive craniectomy for refractory elevated ICP (unilateral or bilateral) within 48 hours of
injury is an option in TIER 3
F. Posterior Fossa Mass Lesions
 Patients with posterior fossa (PF) lesions that show distortion, dislocation, or obliteration of the
4th ventricle, or compression or loss of visualization of the basal cisterns, or obstructive
hydrocephalus on CT should be evacuated
G. Depressed Skull Fractures
 Open skull fractures depressed greater than the thickness of the inner and outer table should
undergo operative management.
 Open depressed fractures that are less than 1cm depressed and have no dural penetration, no
significant intracranial hematomas, no frontal sinus involvement, no gross cosmetic deformity, no
pneumocephalus, and/or no gross wound contamination may be managed non-operatively
 All open skull fractures should be treated with prophylactic IV antibiotics, such as Vancomycin and
Ceftriaxone.
References
1. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological
Surgeons, Joint Section on Neurotrauma and Critical Care. Guidelines for the Management of Severe
Traumatic Brain Injury J Neurotrauma 2007;24:1-106.
2. Stevens RD, Huff JS, Duckworth J, Papangelou A, Weingart SD, Smith WS. Emergency
neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2012; 17:S60-
S65.
3. Debenham S, Sabit B, Saluja RS, Lamoureux J, Bajsarowicz P, Maleki M, Marcoux J. A critical look at
phenytoin use for early post-traumatic seizure prophylaxis. Can J Neurol Sci. 2011; 38:896-901

21
Acute Spinal Cord Injury
A. Initial assessment
 Airway
 Breathing
 Circulation
 Disability
 Exposure
B. Radiographic assessment
 Radiographic evaluation of the cervical spine is not recommended in
o Awake, asymptomatic patient who is without neck pain or tenderness.
o Who has normal neurological examination, is without an injury detracting from an accurate
evaluation,
 High-quality computed tomography (CT) imaging of the cervical spine is recommended in.
o The awake, symptomatic patient
o The obtunded or unevaluable patient
 If high-quality CT imaging is not available, a 3-view cervical spine series (anteroposterior, lateral,
and odontoid views) is recommended
C. Cardiopulmonary management
 Correction of hypotension in spinal cord injury (systolic blood pressure, 90 mmHg) when possible
and as soon as possible is recommended.
 Correction of hypotension can be done by
o NS 2L IV – only for trauma bay resuscitation
o Norepinephrine 0.05mcg/kg/min – titrate to keep MAP >70
o Consider Midodrine 5mg po TID
D. Gastrointestinal management
 Stress Ulcer Prophylaxis: PPI 20mg IV/ Q12H VTE prophylaxis
 Obtain feeding access and initiate enteral support within 48 hours
 Maintain normoglycemia (Blood Glucose < 180)
E. Pharmacologic treatment
 Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) IS
NOT recommended.

22
References
1. Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE, Harrigan MR, Rozelle CJ, Ryken TC,
Theodore N; American Association of Neurological Surgeons; Congress of Neurological Surgeons
Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update.
Neurosurgery. 2013;60 Suppl 1:82-91.

23
Hemodynamic Assessment of Patients with Circulatory failure
Hemodynamic monitoring can only improve outcomes if three conditions are met:
1. The data obtained from the monitoring device must be sufficiently accurate to be able to
influence therapeutic decision making
2. The data obtained from the monitoring system must be relevant to the patient being monitored
3. The changes in management made as a result of the data obtained need to be able to improve
outcomes.
The approach asks three sequential questions before giving any treatment.
1. Is the patient hemodynamically unstable? Is there sign of tissue hypoperfusion?
a. MAP <65 mm Hg, a decrease in MAP of > 20 mm Hg in a previously hypertensive patient
and one of the two (b and c below)
b. Evidence of end-organ hypoperfusion: a decrease in urine output to <20 ml/hr, confusion,
new onset tachycardia, lactic acidosis, ileus
c. Symptoms of increased sympathetic tone: agitation, confusion, restlessness
2. Is the patient preload-responsive?
a. For initial evaluation of the critically ill patient, an invasive approach is still often needed,
which includes insertion of an arterial catheter and a central venous catheter
b. Inferior Vena Cava (IVC) can be used to provides an indication of intravascular volume and
has been used to estimate the central venous pressure (CVP) (IVC collapsibility index)
i. IVC diameter <2.1 cm that collapses >50% with sniﬀ correlates to a CVP pressure of
3 mm Hg (range 0–5 mm Hg)
ii. A larger IVC >2.1 cm that collapses <50% suggests a high CVP pressure of 15 mm
Hg.
iii. IVC collapsibility index (max-min)/ max value). This index is used only for
spontaneously breathing non ventilated patients
c. In patients with normal to high CVP or larger IVC diameter and or IVC <2.1 with low
collapsibility, dynamic tests should be used to detect fluid responsiveness.
i. In mechanically ventilated patients with tidal volume of 6-8 ml/kg with no
significant arrhythmia.
1. Pulse pressure variation (PPV) refers to the difference between the
maximum (PPmax) and minimum (PPmin) pulse pressure over a single
mechanical breath. A PPV of ≥13% has been shown to be a specific and
sensitive indicator of preload responsiveness. (Fig. 1)
PPV% = 100 x {(PPmax – PPmin )/ (PPmax + PPmin)/2}

24
2. IVC distensibility index (max-min)/min value) > 18%
Figure 3: Pulse pressure variation and stroke volume variation

25
Figure 4: Measuring the maximum and minimum diameters in a M-mode tracing of the IVC
ii. In spontaneously breathing patient, or the presence of significant arrhythmia
1. Passive leg raising test (PLR) together with measuring SV by Doppler or VTI
by transthoracic echo TTE. Increase these indices by 15% or more indicate
fluid responsiveness. (Fig 2)

26
Figure 5: Leg raising test
3. What is the status of cardiac function? (Figure 3)
a. Evaluation for the presence of pericardial effusion and cardiac tamponade.
i. The first step is to visualize pericardial sac to determine if the patient has a
pericardial effusion.
ii. If a pericardial effusion is identified, the next step is to evaluate the heart for signs
of tamponade. Evaluation for cardiac tamponade specifically focuses on the
movement of the right atrium and ventricle during diastolic filling.
b. Evaluation of Left Ventricular Contractility
i. The left ventricle can be analyzed for global contractility in left parasternal long axis
and short axis view
ii. Based on these assessments, a patient’s contractility can be broadly categorized as
being normal, mild-moderately decreased, or severely decreased.
c. Evaluation of Right Ventricular Size
i. Evaluation of right ventricular size in left parasternal long axis view, apical 4
chamber view, and/or subxiphoid view
ii. Signs of higher pressures within the right side of the heart and the pulmonary
artery include:
1. Dilation of the right ventricle, especially to a size equal to or greater than
the left ventricle
2. Deflection of the inter-ventricular septum toward the left ventricle

27
Figure 6: Four basic echocardiographic views:
( a ) left parasternal long axis, ( b ) left parasternal short axis, ( c ) apical four chambers, and ( d ) subcostal

28
Figure 7: Stepwise approach of assessment of hemodynamically unstable patient

29
References
1. Monnet X, Teboul JL. Assessment of volume responsiveness during mechanical ventilation: recent
advances. Crit Care. 2013;17:217
2. Seif D, Perera P, Mailhot T. Bedside ultrasound in resuscitation and therapid ultrasound in shock
protocol. Crit Care Res Pract.2012;2012:503254.
3. Vincent JL, Rhodes A, Perel A. et al. Clinical review: Update on hemodynamic monitoring--a
consensus of 16. Crit Care. 2011;15:229

30
Sepsis Management Protocol
General principles
 Treatment guidelines follow those recommended by the Surviving Sepsis Campaign
 Definitions:
o SIRS (Systemic inflammatory response syndrome): The clinical syndrome that results from
a deregulated inflammatory response or to a noninfectious insult.
o Sepsis: SIRS that is secondary to infection that has been diagnosed clinically. Positive
cultures add to the validity but are not required for the diagnosis.
o Severe Sepsis: Sepsis plus at least one sign of hypoperfusion or organ dysfunction (see
below), that is new, and not explained by other known etiology of organ dysfunction.
o Septic Shock: Severe sepsis associated with refractory hypotension (BP<90/60) despite
adequate fluid resuscitation and/or a serum lactate level >=4.0 mmol/L.
Sepsis Protocol
I. Recognition
 Sepsis is defined as at least two of the following signs and symptoms (SIRS) that are both present
and new to the patient and suspicion of new infection
o Hyperthermia >38.3°C or Hypothermia
<36°C
o Acutely Altered Mental Status
o Tachycardia >90 bpm o Tachypnea >20 bpm
o Leukocytosis (>12,000 μL-1) or
Leukopenia (<4,000 μL-1) or >10% bands
 Severe sepsis includes SIRS and at least one of the following signs of hypoperfusion or organ
dysfunction that is new and not explained by other known etiology of organ dysfunction
o Hypotension (<90/60 or MAP <65) o Lactate > 2 mMol/L
o Areas of mottled skin or capillary refill o Creatinine > 2 mg/dl

31
>3 seconds
o Disseminated intravascular coagulation (DIC)
o Acute renal failure or urine output<0.5
ml/kg/hr for at least 2 hours
o Cardiac dysfunction
o Platelet count <100,000
o Hepatic dysfunction as evidenced
by Bilirubin >2 or INR >1.5
o Acute lung injury or ARDS
 New septic shock is defined as severe sepsis associated with refractory hypotension (BP<90/60)
despite adequate fluid resuscitation and/or a serum lactate level ≥ 4.0 mmol/L
 Screening: Patients are screened for severe sepsis upon admission and daily thereafter using paper
screening sheet (see below)
II. Resuscitation
Septic Shock Resuscitation Bundle
A. To be completed within 3-Hours
1. Measure Lactate level
2. Obtain blood culture prior to administration of antibiotic
3. Early and appropriate broad-spectrum antibiotic administration Timely re-evaluation of antibiotic
therapy based on causative agent and susceptibilities is recommended
4. Administer 30 mL/kg crystalloid for hypotensive or lactate ≥ 4 mmol/L
B. To be completed within 6 hours
1. Apply vasopressors for hypotensive that does not respond to initial fluid resuscitation to maintain
mean arterial pressure ≥ 65 mmHg
2. In the event of persistent arterial hypotension despite volume resuscitation or initial lactate ≥ 4
mmol/L (36 mg/dL)
a. Maintain adequate central venous pressure (Target > 8 mmHg)
b. Maintain adequate central venous saturation (Target > 70%)
Fluid responsiveness can be measured by dynamic parameters
 In patients who require large volume of resuscitation, dynamic hemodynamic monitor can be used

32
 Dynamic parameters are pulse pressure variation (PPV), stroke volume variation (SVV), and
inferior vena cava (IVC) distensibility index.
o Mechanically ventilated patients:
 PPV (PPmax-PPmin)/(PPmean)>13% indicates fluid responsiveness and more fluid
can be given
 To measure PPV the Tidal volume should be ≥ 8 mL/Kg and no significant
dysrhythmias exist
 IVC distensibility index (max-min)/min value) > 18%.
o Spontaneous breathing patients
 Utilize passive leg raising test (PLR) together with measuring SV by Doppler or VTI
by transthoracic echo TTE. Increase these indices by 15% or more indicate fluid
responsiveness. See figure 2
Vasopressors
 The vasopressor of choice is noradrenaline
o Dose 0.02-0.7 µg/kg/min
 IV dopamine or adrenaline can be added if blood pressure is poorly responsive to noradrenaline
o Dopamine dose 10-20 µg/kg/min
o Adrenaline dose 0.01-0.2 µg/kg/min
o Caution: Adrenaline may worsen acidosis and increase the lactate
Dopamine may cause serious cardiac dysrhythmia and should be used in patient
with low risk of dysrhythmia
 Consider adding IV hydrocortisone 50 mg every 6 hours in refractory shock (norepinephrine dose
exceeding 0.2 µg/kg/min)

33
Sepsis screening tools
Evaluation for severe sepsis screening tool
1. Is the patient’s history suggestive of a New infection?
o Pneumonia, Empyema
o Urinary tract infection
o Acute abdominal infection
o Meningitis
o Soft tissue infection
o Bone, joint infection
o Wound infection
o Blood stream catheter
infection
o Endocarditis
o Implantable device
infection
o Others
o Yes o No
2. Are any two of the following signs and symptoms of infections both present and new to the
patients?
o Hyperthermia > 38 o
C
o Hypothermia < 36 o
C
o Tachycardia > 90 bpm
o Tachypnea > 20 bpm
o Acute altered mental status
o Leukocytosis (WBC > 12.000)
o Leukopenia (WBC < 4.000)
o Hyperglycemia (Blood glucose
>120 mg/dl) in absence of
diabetes
o Yes o No
If the answer is yes to both questions 1 and 2 suspicious of infection is present
 Obtain: Blood lactate, Blood culture, CBC with differential, and basic chemistry lab including
bilirubin
 At the physician discretion obtain: chest x-ray, CRP, CT scan, amylase, lipase
3. Are any of the following organ dysfunction criteria present at the site remote from the site of
infection that are not considered to be chronic condition?
o SBP < 90 mmHg or MAP < 65 mmHg
o SBP decrease > 40 mmHg from baseline
o Bilateral pulmonary infiltrate with a new oxygen requirement to maintain SPO2 > 90%
o Creatinine > 2 mg/dl or urine output < 0.5 ml/kg/hour for > 2 hours
o Bilirubin > 2 mg/dl
o Platelet count < 100.000
o Coagulopathy (INR> 1.5)
o Lactate > 2 mmol/L (18 mg/dl)

34
If the suspicion of infection is present AND organ dysfunction is present, the patient meets the
criteria for SEVERE SEPSIS and should be entered into severe sepsis protocol.

35
Figure 8: Severe sepsis and septic shock Resuscitation Algorithm (3)

36
References
2. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL,
Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM,
Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL,
Moreno R; Surviving Sepsis Campaign Guidelines Committee including the Pediatric
Subgroup. Surviving sepsis campaign: international guidelines for management of severe
sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
3. Seif D, Perera P, Mailhot T. Bedside ultrasound in resuscitation and therapid ultrasound in
shock protocol. Crit Care Res Pract.2012;2012:503254.
4. Marik PE. Early management of severe sepsis: concepts and controversies. Chest.
2014;145:1407-18.

37
Fever Assessment
Basic principle
 The Society of Critical Care Medicine and the Infectious Disease Society of America
considers a temperature of 38.3◦C or greater as a fever in an ICU patient which warrants
further evaluation.
 This does not necessarily imply that a temperature below 38.3◦C does
 The onset of fever in the intensive care unit patient must be approached systematically
and guided by clinical findings.
Infectious causes of fever
 Ventilator associated pneumonia
 Catheter-related bloodstream infection (CRBI)
 Primary septicemia
 Sinusitis
 Surgical site/wound infection
 Clostridium difﬁcile colitis
 Cellulitis/infected decubitus ulcer
 Urinary tract infection (urosepsis)
 Suppurative thrombophlebitis
 Endocarditis
 Diverticulitis
 Septic arthritis
 Abscess/empyema
Non-Infectious causes of fever
 Drug fever
o b -Lactam, antiepileptics, sulfonamides
o Antipsychotics (neuroleptic malignant syndrome, serotonin syndrome)
 Blood products, IV contrast, immunoglobulins, albumin
 CNS causes: blood in cerebrospinal ﬂ uid, pontine bleed
 Pulmonary/cardiac causes: acute respiratory distress syndrome, pulmonary emboli, fat
emboli, pericarditis
 Abdominal causes: ischemic gut, pancreatitis, acalculous cholecystitis
 Metabolic: adrenal insufficiency, thyroid storm, gout
 Postoperative fever (48 h), postprocedure (bronchoscopy)
 Thrombophlebitis, decubitus ulcer, hematoma, deep venous thrombosis (DVT)

38
Evaluation of new fever in ICU (See algorithm below)
 Blood cultures are recommenced in all ICU patients who develop a fever.
 If catheter-related sepsis is suspected, two peripheral blood cultures should be obtained
with an additional culture from each indwelling catheter.
 Expressed purulence from an intravascular catheter insertion site should be cultured.
 Do not routinely culture removed intravascular catheters. Culture only those
suspected of being the source of infection.
 If a lower respiratory tract infection is suspected, obtain a portable AP chest radiograph.
 Quantitative cultures obtained by either bronchoscopy or catheter lavage should be
obtained if pneumonia is suspected.
 Pleural fluid should be cultured if an adjacent infiltrate is noted or infection is
suspected.
 In patients whose clinical picture is consistent with infection and in whom no clinically
obvious source has been documented
o Removal of all central lines greater than 48 h old
o Evaluation for C. difficile infection should begin with a C. difficile toxin EIA.
o CT scan of the sinuses with removal of all nasal tubes
 Send stool cultures for enteric pathogens or ova and parasite only if diarrhea was
present prior to ICU admission, the patient is immunocompromised or it is
epidemiologically indicated.
 Obtain urine for microscopic exam, Gram stain and culture in all high risk patients
showing signs or symptoms of UTI.
 If the patient is at risk of abdominal sepsis or has any abdominal signs (tenderness,
distension, unable to tolerate enteral feeds), CT scan of abdomen is indicated. Patients
with right upper quadrant tenderness require an abdominal ultrasound or CT
examination.
 Surgical wounds with suspected infection should be opened to obtain samples for Gram
stain and culture. Cultures of the skin overlying a wound should not be performed.
 If CNS infection is suspected, send CSF for Gram stain and culture, glucose, protein, and
cell count with differential.
 Chest radiographs, urinalysis, or urine cultures are NOT indicated in the first 72
hours post-operatively unless history and clinical findings suggest a high probability of
infection.
 Noninfectious causes of fever should be investigated, including new medications
and administration of blood products.
 If fever is accompanied by altered consciousness or focal neurologic deficits, lumbar
puncture or evaluation of CSF from an indwelling ventriculostomy should be considered.

39
 All neutropenic patients with fever and patients with severe or progressive signs of
sepsis should be started on broad-spectrum anti-microbial therapy immediately after
obtaining appropriate cultures.

40
Figure 9: Fever Management Protocol (2)

41
References
1. O'Grady NP et al. Guidelines for evaluation of new fever in critically ill adult
patients: 2008 update from the American College of Critical Care Medicine and the
Infectious Diseases Society of America. Crit Care Med 2008; 36:1330-1349.
2. Claridge JA et al. The "fever workup" and respiratory culture practice in critically ill trauma
patients. J Crit Care 2010; 25:493-500.

42
Nosocomial Infection
Hospital acquired and Ventilator Associated Pneumonia
 Diagnosis
o Bacteria in endotracheal suction may represent tracheal colonization and NOT infection.
o Tracheal colonization of Gram-negatives and S. aureus is not eradicated even though
lower airways are sterilized. Thus, post-treatment cultures in the absence of clinical
deterioration (fever, rising WBC, new infiltrates, worsening ventilatory status) are not
recommended.
 Definitive therapy
o De-escalate antimicrobial based on sensitivities
o Consider Linezolid for documented MRSA pneumonia
o Consider combination therapy for Pseudomonas for the first 5 days of therapy.
o Inhaled Colistin can be used as adjunctive therapy in pseudomonas and acinetobacter
 Duration of therapy
o Three days if CPIS remains ≤ 6 in patients with initial CPIS ≤ 6; VAP is unlikely
o Eight days if the patient has clinical improvement except for Pseudomonas in which 15
days is recommended
o Consider extended therapy (15 days) if CPIS > 6 at Day 8
Figure 10: Ventilator Associated Pneumonia

43
Table 1: Modified Clinical pulmonary infection score

44
Community Acquired Pneumonia
Figure 11: Management of community acquired pneumonia

45
Community Acquired abdominal infection
Figure 12: Management of Community Acquired abdominal infection

46
Health Care Associated abdominal infection
Figure 13: Management of Health Care Associated abdominal infection

47
Table: Initial Intravenous Adult Dosages of Antibiotics for Empiric Treatment of Complicated
Intraabdominal Infection
Antibiotic Adult Dose
B lactam/b-lactamase inhibitor combination
 Piperacillin tazobactam 4.5 g every 6 h
Carbapenems
 Ertapenem
 Imipenem/cilistatin
 Meropenem
1 g every 24 h
500 mg every 6 h or 1 g every 8 h
1 g every 8 h
Cephalosporins
 Cefazolin
 Cefepime
 Cefotaxime
 Cefoxitin
 Ceftazidime
 Ceftriaxone
 Cefuroxime
1–2 g every 8 h
2 g every 8–12 h
1–2 g every 6–8 h
2 g every 6 h
2 g every 8 h
1–2 g every 12–24 h
1.5 g every 8 h
Tigecycline 100 mg initial dose, then 50 mg every 12 h
Fluoroquinolones
 Ciproﬂoxacin
 Levoﬂoxacin
400 mg every 12 h
750 mg every 24 h
Metronidazole 500 mg every 8–12 h or 1500 mg every 24 h
Aminoglycosides
 Gentamicin or tobramycin
 Amikacin
5–7 mg/kg every 24 h
15–20mg/kg every 24 h
(initial dose should be based on adjusted body
weight)
Aztreonam 1–2g every 6–8h
Vancomycin 15–20 mg/kg every 8–12 h (initial dose should
be based on total body weight)

48
Catheter related blood stream infection (CLBSI)
Bloodstream infection related to a short-term central venous catheter (CVC) is defined as
bacteremia or fungemia in a patient with the CVC in place
 Prevention of CLBSI
o Use aseptic technique including the use of a cap, mask, sterile gown, sterile
gloves, and a large sterile sheet, for the insertion of CVCs
o Wear clean or sterile gloves when changing the dressing on intravascular
catheters.
o Disinfect clean skin with an appropriate antiseptic before catheter insertion and
during dressing changes. 70% alcohol can be used
o Do not use topical antibiotic ointment or creams on insertion sites
o Do not routinely replace central venous solely for the purposes of reducing the
incidence of infection
o When adherence to aseptic technique cannot be ensured (i.e., when catheters
are inserted during a medical emergency), replace all catheters as soon as
possible and after no longer than 48 hours
o Replace any short-term CVC if purulence is observed at the insertion site, which
indicates Infection
o Replace catheter-site dressing if the dressing becomes damp, loosened, or visibly
soiled
o Replace dressings used on short-term CVC sites every 2 days for gauze dressings
and at least every 7 days for transparent dressings,
o Clean injection ports with 70% alcohol or an iodophor before accessing the
system
o Cap all stopcocks when not in use
o Minimize contamination risk by wiping the access port with an appropriate
antiseptic and accessing the port only with sterile devices
o Complete the infusion of lipid-containing solutions (e.g., 3-in-1 solutions) within
24 hours
o Complete infusions of blood or other blood products within 4 hours of hanging
the blood
o Do not use hemodialysis catheters for blood drawing or applications other than
hemodialysis except during dialysis or under emergency circumstances.
 Diagnosis of CLBSI: at least one of the following diagnostic criteria should be met:
o Cultures of the catheter tip and of the peripheral blood grow the same organism.
 Catheter tip culture should be quantitative, with more than 102
colony-
forming units (cfu) per catheter segment, or semiquantitative, with more
than 15 cfu per catheter segment.
o Blood drawn from the catheter lumen grows the same organism as blood drawn
from a peripheral vein.

49
 Initial management of suspected blood-stream infection related to short-term central
venous catheters
Figure 14: Management of clinically suspected blood stream infection related to short term
CVL

50
Figure 15: Management of CLBSI

51
Invasive candidiasis in ICU
 Prevention of C/IC in intensive care unit patients
o Routine antifungal prophylaxis of all intensive care unit (ICU) patients is not
recommended.
o High-risk subgroups of patients who may be candidates for prophylaxis include
the following:
 ICU patients with recurrent gastrointestinal perforation or anastomotic
leakage. In this selected high-risk group, IV fluconazole 400 once daily
may be administered.
 There are insufficient data to support specific recommendations for
antifungal prophylaxis in severe acute pancreatitis
 Yeast in a blood culture SHOULD NOT BE considered a contaminant
 Treatment
o Immunocompromised (transplant, neutropenic, AIDS)
 Start amphotericin B and wait for identification
o Non-Immunocompromised
 Patients who are clinically stable and have not received prior long-term
azole therapy Fluconazole 800 mg IV/PO X 1 dose, then 400 mg IV/PO
once daily
 Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy Echinocandins (See algorithm
below)
 Non-pharmacologic management
o Removal of all existing central venous catheters is highly recommended.
o Patients should have blood cultures daily or every other day until candidemia is
cleared.
o Patients should have an ophthalmologic examination to exclude candidal
endophthalmitis prior to discharge, preferably once the candidemia is controlled.
o Echocardiography can be considered if the patient has persistent candidemia on
appropriate therapy.
 Endophthalmitis
o Management in conjunction with Ophthalmology
o Due to poor CNS and vitreal penetration, treatment with echinocandins is NOT
recommended.
o Preferred therapy

52
 Amphotericin B 1 mg/kg IV once daily OR AmBisome (liposomal
amphotericin) 5 mg/kg IV once daily

53
Figure 16: Management of fungemia

54
Table 2: IDSA guidelines of treating invasive fungal infectionle 1:.....

55
Specific Types of infections
Deep tissue infection (Necrotizing fasciitis)
 These are SURGICAL EMERGENCIES! antibiotics are only an adjunct to prompt
debridement EMPIRIC TREATMENT (adjunct to surgery)
o Vancomycin (see dosing section, p. 145) PLUS [Piperacillin/tazobactam 3.375 g
IV Q6H OR Cefepime 1 g IV Q8H] PLUS Clindamycin 600-900 mg IV Q8H
o In penicillin allergy: Vancomycin (see dosing section, p. 145) PLUS [Ciprofloxacin
400 mg IV Q8H PLUS Clindamycin 600-900 mg IV Q8H
Meningitis – Empiric treatment
 Antibiotics should be started as soon as the possibility of bacterial meningitis becomes
evident, ideally within 30 minutes.
 Do not wait for CT scan or lumbar puncture results. If lumbar puncture must be delayed,
get blood culture and start therapy.
Host Preferred antibiotics Alternative therapy
Immuno competent*
age < 50
Vancomycin PLUS
Ceftriaxone
Chloramphenicol
PLUS Vancomycin
Immunocompetent*
age > 50
Vancomycin PLUS
Ceftriaxone PLUS
Ampicillin
Chloramphenicol
PLUS Vancomycin
PLUS TMP/SMX
Immuno -compromised Vancomycin PLUS
Ceftriaxone PLUS
Ampicillin
Vancomycin PLUS
TMP/SMX PLUS
Ciprofloxacin
Post neurosurgery or
penetrating head
trauma
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprofloxacin
Infected shunt Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprofloxacin
 Immunocompromised is defined as HIV infection or AIDS, receiving
immunosuppressive therapy, or after transplantation.
 Addition of dexamethasone is recommended in all adult patients with suspected
pneumococcal meningitis.
o Dose: 0.15 mg/kg IV Q6H for 2–4 days
o The first dose must be administered 10–20 minutes before or concomitant
with the first dose of antibiotics.
o Dexamethasone should not be given to patients who have already started
antibiotics.

56
o Continue dexamethasone only if the CSF Gram stain shows Gram-positive
diplococci or if blood or CSF grows S. pneumoniae
CNS shunt infection
 Diagnosis:
o Culture of cerebrospinal fluid remains the mainstay of diagnosis.
o Clinical symptoms may be mild and/or non-specific, and CSF chemistries and
leukocyte counts may be normal.
 Empiric Therapy:
o Vancomycin: (see dosing section, p. 145) PLUS Cefepime 2 g IV Q8H OR
o Penicillin Allergy: Vancomycin PLUS Ciprofloxacin 400 mg IV Q8H
 Removal of all components of the infected shunt with external ventricular drainage or
intermittent ventricular taps in combination with the appropriate intravenous antibiotic
therapy leads to the highest effective cure rates
 The role of intraventricular antibiotics is controversial, and generally limited to
refractory cases or cases in which shunt removal is not possible.
 Intraventricular antibiotics
o Amikacin: 30 mg Q24H
o Gentamicin: 5 mg Q24H
o Tobramycin: 5 mg Q24H
o Vancomycin: 20 mg Q24H
Diabetic foot infections
Treatment depends on clinical severity
 Moderate severity: > 2 cm of cellulitis, spread beneath the superficial fascia, deep tissue
abscess, gangrene, involvement of muscle, tendon, joint, or bone
o Ertapenem 1 g Q24H OR
o Ciprofloxacin* 400 mg IV Q12H PLUS ONE of the following
o [Clindamycin 600 mg IV Q8H/300 mg PO TID OR Metronidazole 500 mg IV/PO
TID] BUT avoid fluoroquinolones in patients who were on them as outpatients
o If patient at risk for MRSA, add Vancomycin to regimens that do not include
Clindamycin.
o Risk factors for MRSA
 History of colonization or infection with MRSA
 Recent (within 3 months) or current prolonged hospitalization > 2 weeks
 Severe infection: As moderate severity PLUS systemic toxicity or metabolic instability
o Pipercillin/tazobactam 4.5 g IV Q6H OR
o Carpabenems OR

57
o Ciprofloxacin* 400 mg IV Q8H PLUS Clindamycin 600 mg IV Q8H
o Avoid fluoroquinolones in patients who were on them as outpatients.
o If patient at risk for MRSA
 Carpabenems OR Piperacillin/tazobactam 4.5 g IV Q6H PLUS Vancomycin
OR
 Ciprofloxacin* 400 mg IV Q8H PLUS Metronidazole 500 mg IV Q8H PLUS
Vancomycin
Infective Endocarditis
Duke criteria for infective endocarditis
 Definite endocarditis
o Presence of 2 major criteria OR 1 major AND 3 minor OR 5 minor Possible
endocarditis
 Possible endocarditits
o Presence of 1 major AND 1 minor OR 3 minor criteria
 Major criteria
o Microbiologic
 Two separate blood cultures positive for a typical organism: viridans
streptococci, S. bovis, HACEK, S. aureus, Enterococcus spp.
 Persistent bacteremia with any organism as evidenced by: 2 positive
blood cultures drawn at least 12 hours apart OR 3/3 positive blood
cultures with at least 1 hour between the first and last OR the majority of
more than 4 cultures positive from any time period.
 Positive Coxiella burnetti (Q fever) culture or serology.
o Echocardiographic (TEE strongly recommended for prosthetic valve)
 Vegetation (on valve or supporting structure OR in path of regurgitant
jet)
 Abscess
 New dehiscence of prosthetic valve
o Physical exam
 regurgitant murmur (worsening of old murmur is NOT sufficient)
 Minor criteria
o Predisposing condition: previous endocarditis, injection drug use, prosthetic valve,
ventricular septal defect, coarctation of the aorta, calcified valve, patent ductus,
mitral valve prolapse with regurgitation, IHSS or other valvular heart disease
o Fever ≥ 38.0°C (100.4°F)
o Embolic events: arterial or pulmonary emboli, conjunctival hemorrhage, retinal
hemorrhage, splinter hemorrhage, intracranial hemorrhage, mycotic aneurysm

58
o Immunologic phenomenon: Osler nodes, glomerulonephritis, positive rheumatoid
factor
o Positive blood cultures that don’t meet criteria above OR serologic evidence of
active infection with an organism known to cause endocarditis BUT single positive
cultures for coagulase-negative staphylococci are NOT considered even a minor
criterion
Management
A. Native valve endocarditis
o Vancomycin PLUS Gentamicin 1 mg/kg IV Q8H
B. Prosthetic valve endocarditis
o Vancomycin PLUS Gentamicin 1 mg/kg IV Q8H
AND
o Rifampin 300 mg PO Q8H after blood cultures have cleared

59
Table 3: Vancomycin dosing and monitoring

60
Multi-drug resistant gram negative bacteria (MDR-GNB)
General principles
 Multidrug resistance gram negative bacteria (MDR-GNB): is defined as is an isolate that
is non-susceptible to at least one agent in at least three antimicrobial categories, which
are potentially active against the respective GNB.
 Extensively drug resistance (XDR): is defined as isolate that is non-susceptible to at least
one agent in all but two or fewer antimicrobial categories, which are potentially active
against the respective GNB.
 Pandrug-resistance (PDR): is defined as isolate that is non-susceptible to all agents in all
antimicrobial categories for this isolate
Management
 Combination therapy is the mainstay of treatment of XDR and PDR gram negative
bacteria through
o Maximizing bacterial killing
o Minimizing emergence of resistance
o Enable shorter therapy duration
o Improve clinical and microbiological outcome
 An algorithm based on minimum inhibitory concentration (MIC) of commonly used
antimicrobial agents is suggested to optimize the use of combination therapy (8)

61
Figure 17: Flowchart for selecting mainstream and adjuvant therapy against Gram-
negative bacteria (8)

62
a) Colistin methanesulfonate sodium (CMS) –
 Loading dose: 150,000 IU (corresponding to ~5 mg colistin base activity) weight in kg;
caution should be taken in using any dose above the current maximum approved daily
dose of 10 million IU (~300 mg of colistin base activity).
 Maintenance dose: started 12 or 24 h later: 9–12 million IU/day split into 2 or 3 doses
(every 8 or 12 h) for patients with creatinine clearance ≥ 60 ml/min.
 Adjust for renal dysfunction
b) If the pathogen is suspected to be a metallo-b-lactamase-producing GNB, the aztreonam
MIC may be evaluated at the same time as the MIC of the carbapenems.
c) Carbapenems
 Some authors suggest that if the MIC ≤ 4 mg/l for carbapenems, a carbapenem should
be the cornerstone drug in the combination
d) Meropenem: 2 g every 8 h over 3–4 h. Imipenem may be used 1 g every 6 h, but there is
few data concerning its stability in extended infusion and it poses a higher risk of
convulsion at higher doses.
e) 9–12 g/day of the sulbactam component every 6–8 h infused over 3–4 h. High-dose
extended infusion sulbactam may also be considered against organisms with MIC = 16
mg/l
f) If the organism is pseudomonas, we go directly to step 4
g) Tigecycline
 200 mg as loading dose followed by 100 mg every 12 h for MIC = 0.5 or 1 mg/l, or 100
mg as loading dose followed by 50 mg every 12 h may be appropriate for MIC ≤ 0.25 mg.
 Higher doses may be considered for severe urinary tract infections
 If tigecycline is the cornerstone drug, high doses should always be considered regardless
of the MIC.
h) Fosomycin
 high doses (20–24 g/day divided in 3 or 4 doses) are recommended for fosfomycin MIC =
16–32 mg/l. Lower doses (12–16 g/day) may be appropriate for MIC<16 mg/l.
i) Aminoglycosides
 Gentamicin and tobramycin should be chosen on the basis of the lower MIC; MIC ≤
0.5: 5 mg/kg once daily. MIC 1 or 2 mg/l: 7 mg/kg once daily (for MIC = 4 mg/l even
higher doses may be more appropriate); a loading dose must be administered in
critically ill patients.
 Amikacin: 15 mg/kg once daily is more likely appropriate for MIC ≤4; for MIC = 8 or
16 mg/l higher doses may be necessary; a loading dose ‡25 mg/kg must be
administered in critically ill patients.

63
References
1. ATS/IDSA Guidelines for HAP/HAV: AJRCCM 2005;171:388.
2. IDSA/ATS Consensus Guidelines for CAP: Clin Infect Dis 2007;44:S27
3. IDSA Guidelines for Bacterial Meningitis: Clin Infect Dis 2004;39:1267.
4. IDSA Guidelines for Intra-abdominal Infections: Clin Infect Dis 2010;50:133–164.
5. IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related
Infections: Clin Infect Dis 2009;49:1-45
6. IDSA Guidelines for diabetic foot infection. Clin Infect Dis 2012;54:132-173
7. AHA Scientific Statement on Infective Endocardits: Circulation 2005; 111:e394-434
8. Zavascki AP, Bulitta JB, Landersdorfer CB. Combination therapy for carbapenem-resistant
Gram-negative bacteria. Expert Rev Anti Infect Ther. 2013 ;11:1333-53

64
Mechanical Ventilation Protocol
Parameters for institution of ventilation
i) Clinical assessment is the most sensitive assessment of respiratory failure.
ii) Do not delay the initiation of ventilatory support pending results, blood gases or
mechanical measurements where clinically indicated, e.g.
o Threatened airway
o Fatigue / exhaustion
o Failure of secretion clearance
o Overt respiratory failure
o Speech impairment due to dyspnoea
o Reduced GCS in the absence of other causes
Objective measurements are adjuncts to clinical assessment and must be used in the clinical
context, e.g.
 PaO2/FIO2 ratio remains the most convenient and widely used bedside index of gas
exchange.
 In ventilated patient, oxygenation index (OI) incorporates the severity of oxygenation
impairment (PaO2/F IO2 ratio) and mean airway pressure into a single variable:
o OI = (FIO 2 X mPaw X 100)/PaO2
o OI > 30 is used to represent failure of conventional ventilation
Principles in optimizing ventilation in ICU patients
1. There is no evidence that a particular mode of mechanical ventilation is associated with
survival benefit
2. Appropriate goal is far more important than chosing a particular mode of mechanicak
ventilation
3. Low tidal volume ventilation should be instituted in all patients on mechanical ventilation.
Target tidal volume of 6 mL/kg ideal body weight and plateau pressure of < 30 cmH2O
4. The optimal time to initiate ventilator rescue therapies is within 96 hours of onset of
Acute Respiratory Distress Syndrome (ARDS)
5. The choice of rescue therapy should be based on equipment availability and clinician
expertise. If the therapy does not result in improved oxygenation, it should be
abandoned.

65
Low tidal volume Ventilation
 Calculate the ideal body weight of the patient
o Male=50 + 0.91[height(cm)-152.4]kg
o Female=45.5 + 0.91 [height(cm)-152.4]kg
 Mode: Pressure controlled ventilation (PCV) or volume controlled ventilation (VCV)
 Aim for tidal volume of 6 mL/kg IBW while not exceeding Pplat of 30 cmH2O. In PCV
Pplat is equivalent to peak airway pressure. If VCV is used, Pplat needs to be measured
regularly every 2-4 hr
 If Pplat > 30 cmH2O, decrease tidal volume by 1 mL/kg up to 4 mL/kg. If Pplat < 25
cmH2O tidal volume may be increased by 1mL/kg up to 8 mL/Kg if Pplat remains ≤ 25
cmH2O
 Adjust FIO2 and PEEP (cm H2O) to maintain PaO2 55–80 mm Hg.
o Use PEEP 8-12 cmH2O if PaO2/FIO2 ≥ 250
o Use PEEP > 12 cmH2O if PaO2/FIO2 < 250
 Keep the arterial PH > 7.1
o pH <7.30, increase rate to maximum 35 breaths/min
o pH <7.30 and rate = 35, consider bicarbonate administration
o pH <7.15, consider increase in tidal volume by 1mL/kg even if Pplat > 30 cmH2O
o Contraindication to permissive hypercapnia include intracranial hypertension,
acute coronary syndrome, and right-sided failure with concomitant pulmonary
hypertension
Strategies to improve severe hypoxemia
Definition of severe hypoxemia
 Oxygenation index > 30
 PaO2/F IO2 ratio ≤ 120
Ventilatory strategies
 The potential for lung recruitment can be identified by the use of a 30 minute trial of
increase PEEP at 15 cmH2O. High potential are those at the end of the trial demonstrate
all of the following
o Increase SPO2 by 5%

66
o Increase PaO2/F IO2 ratio
o Increase in compliance
 Subsequent ventilator strategies is based on distinction between patients who are low
potential recruiters (Non-recruiters) and high potential recruiters (recruiters)
 In non-recruiters no further recruitment manoeuvre should be used. Consider non-
ventilatory strategies
 Steps of recruitment manoeuvre
o Consider sedation and paralysis during manoeuvre.
o Monitor for hypotension and desaturation.
o Different types of recruitment manoeuvres can be performed
 Sustained high inflation pressure
 CPAP 30-50 cmH2O for 20-40 seconds
 PCV with driving pressure 20-25 cmH2O with PEEP 20-25 cmH2O, RR
10/min, I:E 1:1, FIO2 for 2 min.
 PCV with stepwise increase in PEEP every 2 min, keeping the driving
pressure constant up to PIP of 40-50 cmH2O (See the algorithm below)
o At the end of recruitment manoeuvre perform ABG at FIO2 1.0
 PaO2 +PaCO2 ≥ 400 mmHg suggests that there is less than 5% of alveolar
collapse.
 PaO2 +PaCO2 < 400 consider repeating recruitment manoeuvre
o Determine the optimal PEEP using the decremental PEEP technique.
 Set PEEP at 20 cmH2O and reduce the PEEP in a stepwise fashion (1
cmH2O every 5 min) until decrement occurs as demonstrated by a
decrease in PaO2 ( a reduction of more than 10% from the previous
indicates the collapse pressure).
 The optimal PEEP is set at 2 cmH2O above the collapse pressure.
 Re-recruit the lung at the optimal PEEP level
Non-Ventilatory strategies
Prone positioning
 Indication of prone position in ARDS
o Indicated in moderate to severe ARDS defined as PaO2/FIO2 < 150 on at least 5
cmH2O PEEP
 Steps of prone position
o It should be instituted early in the course of disease within 24-48 hours of the
onset of ARDS

67
o Patients should be placed in a completely prone position for at least 16
consecutive hours.
o The criteria for stopping prone treatment will be any of the following:
o improvement in oxygenation (defined as a Pao2:Fio2 ratio of ≥150 mm Hg, with
a PEEP of ≤10 cm of water and an Fio2 of ≤0.6
o These criteria had to be met in the supine position at least 4 hours after the end
of the last prone session).
 Contraindication to prone positioning
o Absolute contraindications
 spinal instability and unmonitored increased intracranial pressure.
o Relative contraindications
 open abdominal wounds,
 multiple trauma with unstabilized fractures,
 pregnancy,
 severe hemodynamic instability
 high dependency on airway and vascular access
Neuromuscular Blockers
 Indicated in moderate to severe ARDS defined as PaO2/FIO2 < 150
 It should be instituted early in the course of disease within 24-48 hours of the onset of
ARDS
 Cisatracurium/ atracurium are the agents of choice
Moderate dose glucocorticoids
 Should be considered in patients with early ARDS (within 72 hours of diagnosis) with
PaO2/FIO2 < 200
 The role of steroid in less severe cases PaO2/FIO2 > 200 is less clear
 The following regimen is as follow
o 1 mg/kg/day D1 to D14
o 0.5 mg/kg/day D15 to D21
 If extubated between D 1 –D14 proceed to D15 therapy
 Change to single oral dose when enteral feeding is restored
Other non-ventilatory strategies
 Conservative fluid management with or without frusemide may decrease days of
mechanical ventilation. Hypovolemia should be avoided

68
 Avoid drug that inhibit pulmonary vasoconstriction such as nitrates, calcium channel
blocker, dopamine
 Albumin 20% with Frusemide may be considered in patients who are hypoproteinemic
o 25 g albumin IV over 1.5-2 hr q 8 hrs with continuous infusion of frusemide for 5
days.

69
Figure 18: Algorithm of ARDS management protocol (1)

70
Figure 19: Stepwise approach of lung recruitment (4)

71
References
1. Esan A, Hess DR, Raoof S, George L, Sessler CN. Severe hypoxemic respiratory failure: part
1--ventilatory strategies. Chest. 2010 May;137:1203-16.
2. Silversides JA, Ferguson ND. Clinical review: Acute respiratory distress syndrome - clinical
ventilator management and adjunct therapy. Crit Care. 2012;17:225
3. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress
syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188:1286-93.
4. Hodgson CL, Tuxen DV, Davies AR, Bailey MJ, Higgins AM, Holland AE, Keating JL, Pilcher
DV, Westbrook AJ, Cooper DJ, Nichol AD. A randomised controlled trial of an open lung
strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in
patients with acute respiratory distress syndrome. Crit Care. 2011;15:R133.

72
Weaning of Mechanical ventilation
 Most patients require a period of rest after intubation, but consideration of weaning
process should begin very soon after intubation.
 The cause of the patients' initial respiratory failure must be significantly improved or
resolved before consideration of readiness to wean.
 Evaluation of readiness to wean should be started early and repeated and repeated at
least on a daily basis.
 The patient must be awake, cooperative hemodyamically stable and able to cough and
protect airway before extubation.
Important definitions
 Simple weaning: refers to patients who can be successfully extubated after the first
weaning test
 Difficult weaning: patients who require up to three Spontaneous breathing trial SBTs (or
as long as 7 days) to be successfully extubated.
 Prolonged weaning: applies to patients who exceed the limits of difficult weaning.
Risk factors of extubation failure
 Impaired neurological status
 Poor cough
 Increased secretion
 High APACHE score at the time of weaning
 Positive fluid balance
 High Risk for failure population
o Age > 65 ys
o Chronic respiratory disease
o Chronic cardiac disease
Assessment of readiness to wean
 Clinical assessment
o Resolution of acute phase of disease for which patient was intubated.
o Adequate cough
o Absence of excessive tracheobronchial secretion
 Objective criteria
o Adequate oxygenation: PaO2>60 mmHg with PEEP ≤ 8 cmH2O, SaO2≥90%,
FIO2≤0.5, PaO2/FIO2 > 200
o Respiratory rate < 30 /min

73
o PH and PaCO2 appropriate for patients’ baseline respiratory status.
o Hemodynamically stable: minimal or no vasopressor /inotropes, no evidence of
myocardial ischemia
o HR< 140 beats/min
o Patient is arousable or Glasgow Coma Scale (GCS) ≥ 13
Spontaneous breathing trial
 The SBT can be conducted through
o Ventilator
Use pressure support (PS) ventilation of 5-7 cmH2O + low PEEP level (5 cmH2O)
The advantage is patient safety as patient is not disconnected from ventilator
with monitoring of tidal volume and respiratory rate
o T-Piece
 Deliver oxygen enriched gas at high flow rate through a horizontal arm of the T-
shaped circuit
 Protocol for SBT
o Allow 30 to 120 minutes of initial trial of spontaneous breathing
o Increase the FIO2 by 10% for the period of spontaneous breathing
o For case of short-term ventilator support (post surgery), a successful one-hour of
spontaneous breathing is enough to discontinue ventilation
o SBT is considered failure when patients develop respiratory, cardiovascular, or
neurological disability.
 Criteria of successful SBT
o Gas exchange acceptable (SPO2≥90%; PaO2≥60 mmHg; PH ≥ 7.32; increase in
PaCO2 ≤ 10 mmHg from the start of the trial
o Stable respiratory rate (RR ≤ 30-35 breaths /min, change in RR < 50%)
o Hemodynamically stable (HR < 120-140, HR increase by less than 20%, SBP > 90
mmHg and < 180 mmHg, change in SBP < 20%
o No significant change in mental status, anxiety, or agitation
o No diaphoresis or sign of increased work of breathing (use of accessory muscle,
dyspnea, paradoxical breathing)
 Failure of SBT
o Increase ventilator setting to previously tolerated level or higher if necessary until
patient stable again and wait 24 hours before trying again
o Search for potential reversible etiology
o Use pressure support ventilation as weaning tool by gradually reducing pressure
support by 2 cmH2O once or twice a day as tolerated

74
o Once pressure support is reduced to 10 cmH2O, repeat SBT daily until the patient
can be successfully extubated
Extubation
Before extubation assess patient’s ability to protect and maintain airway
 Level of consciousness
 Cough strength
 Quantity of secretion and frequency of suction. Probability of failed extubation
increases with increase secretion and frequent suction interval
 Airway patency- cuff leak test. (Patients with prolonged intubation, or
difficult/traumatic intubation are at risk of post-extubation upper airway
obstruction.
o Cuff leak test:
 Change to volume-cycled ventilation then deflate cuff and
measure the difference between inspired and expired tidal
volumes.
 Average the lowest three tidal volumes over 6 breaths and
substract that from inspired tidal volume give you the cuff leak
volume
 Cuff leak volume < 110 ml or <12-24% of delivered tidal volume is
the threshold of determination of decrease airway patency
Weaning failure
 In difficult weaning, do thorough diagnostic test to exclude respiratory pump failure
versus cardiac pump failure versus muscle weakness.
 In prolonged weaning, Consider tracheostomy for increased patient comfort
 In High Risk for failure population, a specialized algorithm is suggested to minimize the
risk of extubation failure (figure 17).

75
Figure 20: Weaning Algorithm

76
Figure 21: Weaning strategy for high risk for failure population (3)

77
References
1. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, Pearl R, Silverman H,
Stanchina M, Vieillard-Baron A, Welte T. Weaning from mechanical ventilation. Eur
Respir J. 2007;29:1033-56.
2. Perren A, Brochard L. Managing the apparent and hidden difficulties of weaning from
mechanical ventilation. Intensive Care Med. 2013;39:1885-95
3. Jeganathan N, Kaplan CA, Balk RA . Ventilator Liberation for High-Risk-for-Failure
Patients: Improving Value of the Spontaneous Breathing Trial. Respir Care.2014 Oct 21
[Epub ahead of print]

78
Non-invasive ventilation protocol
Indications of NIV
 Bedside observation
o Increase dyspnoea moderate to severe
o Tachypnoea (>24 bpm in obstructive, >30/ min in restrictive)
o Signs of increased work of breathing, accessory muscle use, and abdominal paradox
 Gas exchange
o Acute or acute on chronic ventilatory failure (best indication), PaCO2 > 50 mmHg,
PH < 7.35
o Hypoxaemia (use with caution), PaO2/FIO2 < 200
Specific indication of NIV
 Chronic obstructive pulmonary disease
o it is now considered the first-line therapy in COPD and there is growing evidence
that its use may be applicable in patients with severe acidaemia (pH<7.25) and
hypercarbic coma
 Cardiogenic pulmonary oedema
o There is good evidence to support the use of both CPAP and NPPV in acute
pulmonary oedema
 Pneumonia
o NOT recommended to be used in patient with pneumonia except in COPD patient
 Lung contusion/chest trauma
o Respond well to NIV and may improve mortality
 Neuromuscular disorder
o NOT recommended in acute neuromuscular disorders such as Guillain–Barré
syndrome and acute myasthenia because of high incidence of aspiration.
o May be used in Chronic neuromuscular disorders, notably motor neurone disease
(MND) as it improves quality of life
 Post extubation in intensive care
o NOT recommended to treat post extubation respiratory failure
o It could be used as a tool to help wean patients deemed not suitable for extubation
from MV
o The use of CPAP both prophylactically and as a treatment for hypoxic respiratory
has been demonstrated to reduce reintubation rates and mortality in after open
abdominal visceral surgery

79
Contraindication of NIV
 Agitation
 Glasgow<12 (the exception being suitable "do not intubate" unconscious patients
with hypercapnic COPD)
 Ineffective cough
 Airway obstruction
 Distended abdomen
 Vomiting
 Upper GI bleeding
 Hemodynamic instability
 Complex arrhythmia
 Facial trauma
 Esophageal surgery
 Undrained barotrauma
Initiation and titration of therapy
 Initial settings for Bilevel Positive Airway Pressure (BPAP) : Inspiratory Positive
Airway Pressure (IPAP) of 10cmH2O and Expiratory Positive Airway Pressure (EPAP) of
4-5cmH2O= Pressure Support (PS) level of 5-6cm H2O
 Initial settings for Continuous Positive Airway Pressure (CPAP)
 Increases to IPAP of 2-5cmH2O can be undertaken every 10 minutes or as clinically
indicated, until therapeutic response is achieved. The maximum IPAP should not exceed
20 – 23 cmH2O.
 Optimal Non-invasive Positive Pressure Ventilation (NIV) is the lowest pressure and
lowest Fi02 that achieve Sa02 of 90% or Pa02 of 60mmHg without further clinical
deterioration
 If the patient does not clinically improve within four hours of starting NIV, the decision
to intubate and ventilate is to be made
Oral feeding and nutrition during NIV
 Oral feeding is to be initiated if the patient is able to tolerate small periods off NIV.
 No oral intake is to be implemented if the patient has a decreased LOC or in respiratory
distress with an increased work of breathing (i.e. R.R > 30/min). Intravenous fluids are to
be commenced.
 Patients receiving NIV are to have a strict fluid balance and stool chart implemented for
the duration of their NIV therapy, to assess for elimination and fluid status

80
Figure 22: Non-Invasive ventilation Algorithm
Re-evaluate in 2 hoursWorsenin
g
COPD Exacerbation Cardio-pulmonary edema Hypoxemia Postoperative
PS/PEEP CPAP=10 cmH2O PS/PEEP CPAP≤ 7,5 cmH2O
PS=Vt 6-8 mL/kg or PS=Vt 6-8 mL/kg PS < 15 cmH2O
PEEP 5-7 cmH2O PS/PEEP PEEP ≥ 8 cmH2O
PS=Vt 6-8 mL/kg
PEEP 10 cmH2O
NO
RR>25/min
Respiratory
workload
7.25>PH<7.35
SPO2<90%
FIO2>30%
NIV contraindicated
Agitation
Glasgow<12
Ineffective cough
Airway obstruction
Distended abdomen
Vomiting
Upper GI bleeding
Hemodynamic
instability
Complex arrhythmia
Facial trauma
Esophageal surgery
Undrained barotrauma
YES
Consider
Intubation

81
References
1. GBS McNeill, AJ Glossop. Clinical applications of non-invasive ventilation in critical care
Contin Educ Anaesth. Crit Care Pain. 2012; 12: 33-37.
2. Keenan, S.P., et al., Clinical practice guidelines for the use of noninvasive positive-
pressure ventilation and noninvasive continuous positive airway pressure in the acute
care setting. Cmaj. 2011;183: p. 14.
3. Plant, P., J. Owen, and M. Elliott, Early use of non-invasive ventilation for acute
exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a
multicentre randomised controlled trial. The Lancet. 2000; 355:1931-1935.

82
Nutrition Protocol
Figure 23: Stepwise Enteral Nutritional Algorithm

83
Estimation of Nutritional Requirement
Figure 24: Estimation of nutritional requirement

84
Table 4: Daily requirement of micronutrients
Table: Daily requirement of micronutrients
Sodium 1.0 mmol/kg/day
Potassium 1.0 mmol/kg/day Dependent on renal function
Phosphate 0.2 mmol/kg/day Dependent on renal function
Magnesium 0.3 mmol/kg/day Dependent on renal function
Calcium 0.1 mmol/kg/day
Vitamins
B groups daily
B12, Folate, A, D, E, K
weekly
Trace elements as required.
Replacement
solutions
1. Urine
2. Nasogastric/ileostomy
3. Pancreatic/biliary
fistulae
1.½ Normal saline ± KCl 10 ml/L
2. ½ Normal saline ± KCl 10 ml/L
3. Ringer Lactate or Acetate

85
Enteral Feeding
1. Start enteral feeding within 24-48 hours of ICU admission if the GIT is functioning and
the patients have been adequately resuscitated.
2. For patients who have undergone recent bowel anastomosis, discussion between
surgeon and intensivist may be required before starting enteral feeding
3. Enteral feedin will be carried out using nasogastric or orogastric tube. Use 12-14 F in
adult and confirm the correct position by any two of the following methods
a. Gastric content aspiration
b. Auscultation of epigastric area after injecting 10-20 mL of air down the tube
c. X-ray
4. Use any of the following methods to administer enteral feeding
a. Continuous feeding
b. Intermittent bolus feeding
5. Withhold enteral feeding in the following conditions
a. Any procedure involving the airway or gastrointestinal tract
b. Planned extubation specially for high risk if reintubation or anticipated difficult
airways
c. In the setting of hemodynamic compromise (patients requiring signiﬁcant
hemodynamic support, including high-dose catecholamine agents, alone or in
combination with large volume ﬂuid or blood product resuscitation to maintain
cellular perfusion), EN should be withheld until the patient is fully resuscitated and/or
stable
6. Enteral formula preparation and hanging time
a. Sterile water should be used for formula reconstitution, medication dilution, and
tube flush
b. Duration for hanging time
i. For ready to hang formula the duration of hang time ranging from 24-48
hr according to manufacturer recommendation
ii. For sterile decanted formula the duration of hang time is 8 hr
iii. For powdered reconstituted formula the duration of hang time is 4 hr
c. For open system change the administration sets every 24 hr
d. Opened unused formula must be refrigerated and discarded within 24 hr
7. Calories and protein requirement
a. Non-protein calorie should be provided at 20-25 kcal/kg/day
b. Protein should be supplied at least 1-1.5 g/kg/day
8. Enteral feeding intolerance
a. Monitor patient’s GIT tolerance to feeding every 4 hours look for

86
i. Diarrhea
ii. Abdominal distension
iii. High gastric residue aspirate
iv. Multiple emetic episodes
b. Consider nasojejunal feeding in patients with feeding intolerance or pancreatitis
c. IV metochlopramide 10-20 mg/8 he and Erythromycin 250 mg/12 enhance
motility
Parenteral Nutrition
Indication
1. PN should not be initiated in the immediate postoperative period, but should be
delayed for 5-7 days
2. If there is evidence of protein calorie malnutrition (recent weight loss > 10-15% or
actual body weight < 90% of IBW) on admission and EN is not feasible, initiate PN as
soon as possible
3. If a patient is malnourished and is expected to undergo major upper GI surgery and EN is
not feasible, initiate PN 5-7 days preoperatively and continue it into the postoperative
period
4. In high output enterocutaneous fistulae, initiate PN early if more than 60% of energy
needs are not met with EN after 2 days
Administration
a. High osmolarity PN through central line
b. Low osmolarity (<850 mOsmol/L) PN can be administrated through dedicated peripheral
venous line
Components
a. Non-protein calorie should be provided at 20-25 kcal/kg/day
b. Protein should be supplied at least 1-1.5 g/kg/day
c. Lipids are provided at 0.7-1.5 g/kg/day
d. Glucose : fat calorie ratio are around 60:40 or 70:30 of non-protein calories in order to
avoid hyperlipidemia
e. Daily dose of multivitamins and trace element should be included
f. Electrolyte is added according to serum levels
Monitoring
a. Blood glucose level every 4 hours
b. Daily renal profile

87
c. Biweekly liver function tests, phosphate, magnesium, and serum calcium level
d. Catheter related blood stream infection
Nutrition therapy in special population
Obese patients
a. For all classes of obesity where BMI is >30, the goal of the energy goal should not
exceed 60% to 70% of target energy requirements or 11–14 kcal/kg actual body
weight/day (or 22–25 kcal/kg ideal body weight/day)
b. Proteins are provided at ≥ 2 g/kg IBW/day for BMI 30-40 and at ≥ 2.5 g/kg IBW/day for
BMI ≥ 40
Burns
a. Glucose is provided at 5-7 mg/kg/min which represents 50% of total caloric intake
b. Protein are provided at 1.5-2 g/day
Liver failure
a. Provide energy requirement at 1.3 normal requirement
b. Protein should be provided at1.5 – 1.8 g/kg/d utilizing IBW for all patients
b. Severe Hepatic Encephalopathy: protein restrict to 0.6 g/kg /d
Respiratory failure
a. Specially high-lipid low-carbohydrate formulations designed to manipulate the
respiratory quotient and reduce CO2 production ARE NOT RECOMMENDED for
routine use in ICU patients with acute respiratory failure.
b. Provide formulation characterized by an antiinflammatory lipid profile (i.e., omega-3 fish
oils, borage oil) and antioxidants
Acute Kidney injury
a. Patients receiving hemodialysis or continuous renal replacement therapy should
receive increased protein, up to a maximum of 2.5 g/kg/day
b. Protein should not be restricted in patients with renal insufficiency as a means to
avoid or delay initiation of dialysis therapy.

88
References
1. Martindale RG, McClave SA, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB,
Napolitano L, Cresci G; American College of Critical Care Medicine; A.S.P.E.N. Board of
Directors. Guidelines for the provision and assessment of nutrition support therapy in
the adult critically ill patient: Society of Critical Care Medicine and American Society for
Parenteral and Enteral Nutrition: Executive Summary. Crit Care Med. 2009;37:1757-61.
2. Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van
Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L,
Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G. Early versus late
parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506-17

89
Prophylaxis of Deep Venous Thrombosis
General Principles
 Pharmacologic methods are the most effective methods against DVT prophylaxis
 Mechanical methods of prophylaxis should be used routinely in whom pharmacological
prophylaxis is contraindicated
 Elastic stockings are considered the least effective methods of DVT prophylaxis and
should never be used alone in moderate to high risk of DVT
 Intermittent pneumatic compression is more effective than elastic stockings and can be
used alone as a replacement for pharmacological prophylaxis in patients who are
bleedings or who have high risk of bleeding.
Clinical risk factors for thromboembolism in critically ill patients
 Recent surgery
 Trauma
 Burn
 Malignancy
 Sepsis
 Stroke, spinal cord injury
 Age > 40 years
 Obesity
 Mechanical ventilation
Risk factors of bleeding
 Active bleeding
 Acquired bleeding disorder (acute liver failure)
 Use of anticoagulants
 Acute stroke
 Thrombocytopenia (platelets < 50.000)
 Uncontrolled systolic hypertension (> 230/120 mmHg)
 Inherited bleeding disorder (e.g. Hemophilia)
Protocol of thromboembolism prophylaxis
 Assess all patients on ICU admission for risk of thrombosis and risk of bleeding and
subsequently daily.
 Provide thromboembolism prophylaxis to all patients admitted to ICU according to
reason of admission, taking in account
o Any planned interventions

90
o The use of other therapies that may increase risk of bleeding
 For neurosurgical patients, mechanical methods of prophylaxis are favoured. However
the use of heparin products is considered safe after 48 to 72 hrs.
 It is recommended to withhold pharmacological prophylaxis for 2 weeks after
thrombotic stroke and 1 week after embolic stroke.
 Withhold pharmacological prophylaxis with significant decrease in platelet count (30-
50% initial count), thrombocytopenia (<50000/mm3
) or INR > 1.5
 The insertion and removal of epidural catheter should follow guidelines (see table)
Pharmacological prophylaxis
 Low dose unfractionated heparin (LDUH)
o Recommended dose: 5000 units SC /8-12 hr.
o Stop LDUH 4 to 6 hr prior to elective surgery.
o Table .... use of LDUH in neuroaxial blockade.
 Low molecular weight heparin (LMWH) (Enoxaparin)
o Recommended dose
 Prophylaxis: CrCl ≥ 30ml/min  40 mg SC /24 hrs
CrCl < 30ml/min  30 mg SC /24 hrs
 Therapeutics: CrCl ≥ 30ml/min  1 mg/kg SC Q12H
CrCl < 30ml/min  1 mg/kg SC once daily
o Stop LMWH 24 hrs before elective surgery
o In obese patients with BMI > 40
 Prophylaxis: 1 mg/kg ideal + 25% (actual body weight- ideal body weight)
 Therapeutic: 1 mg/kg/12 based on actual body weight
o Table... describe the use of LMWH in neuroaxial blockade
 Fondaparinux
o Recommended dose
 Prophylaxis: 2.5 mg SC /24 hrs
 Therapeutics: 7.5 mg SC/ 24
o Contraindicated Cr Cl < 30 ml/min
o Stop fondaparinux 2 to 4 days prior to elective surgery in patients with normal
renal function

91
Table 5: perioperative anticoagulation for epidural anesthesia
LDUH Enoxaparine Fondaparinux
Insertion of
catheter
4 hrs after last
dose
Single-daily dose
12 hrs after last
dose
Twice-daily dose
No
recommendation
Delay block for
24 hrs
No
recommendation
Removal of
catheter
4 hrs after last
dose
12 hrs after last
dose
NA 36 hrs after last
dose
Subsequent
dose after
removal
1 hr 4 hrs 4 hrs 12 hrs
Traumatic
puncture
Initiate
prophylaxis
after 6 hr
Consider
initiating
prophylaxis after
24 hrs
NA Single shot spinal
is safe but avoid
epidural
analgesia
Contraindications to the use of graded compression
 Arterial insufficiency
 Absent peripheral pulse
 Deep vein thrombosis
 Lower extremity ischemia/gangrene

92
Figure 25:VTE prophylaxis protocol

93
References
1. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; American College of
Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive
summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012
;14:7S-47S

94
Management of Acute Pulmonary Embolism
Clinical classification of pulmonary embolism
The stratification of severity of pulmonary embolism (PE) is based on the patient’s clinical status
at presentation
1. High risk pulmonary embolism: Defined as systolic blood pressure < 90 mmHg, or a
systolic pressure drop by > 40 mmHg, for > 15 minutes
2. Not-high risk pulmonary embolism
Diagnostic strategies
The diagnostic algorithms for suspected PE—with and without shock or hypotension is
demonstrated in figures 1 and 2
Treatment in acute phase
Pulmonary embolism with shock or hypotension (high-risk pulmonary embolism)
I. Hemodynamic and respiratory support
1. Correct systemic hypotension using norepinephrine or epinephrine
2. Fluid challenge 500 mL (avoid aggressive fluid resuscitation).
3. Start O2 therapy to correct hypoxemia , if mechanical ventilation is required keep end –
inspiratory plateau pressure <30 cmH2O & PEEP should be applied cautiously
II. Antocoagulation
1. Intravenous unfractionated heparin (UFH) should be administered.
2. LMWH or fondaparinux have not been tested in the setting of hypotension and shock
III. Primary reperfusion therapy
1. Systemic thrombolysis.
2. Surgical embolectomy is recommended when thrombolysis is contraindicated.
Pulmonary embolism without shock or hypotension (intermediate- or low-risk
pulmonary embolism)
I. Anticoagulation
1. Low molecular weight heparin (LMWH) or fondaparinux, given subcutaneously at
weight-adjusted doses without monitoring, is the treatment of choice unless there is
severe renal dysfunction
II. Risk stratification
1. In patients without shock, risk assessment should begin with a validated clinical score,
preferably the simplified pulmonary embolism severity index sPESI.
a. Patients with sPESI=0 are considered low-risk patients and early discharge with
outpatient treatment should be considered

95
b. Patients with sPESI ≥ 1 are considerd intermediate risk. These patients are
further classified into
i. Intermediate-high risk group:
 Patients with acute PE, an echocardiogram or CT scan indicating RV
dysfunction, and a positive cardiac troponin test.
 Systemic thrombolysis is not routinely recommended as primary
treatment for patients with intermediate-high-risk PE, but should be
considered if clinical signs of hemodynamic decompensation appear.
ii. Intermediate-low risk group: Patients in whom the echocardiogram (or
CT angiogram) or the cardiac troponin test—or both—are normal.
Anticoagulation is indicated
 Anticoaulation is indicated
 Primary reperfusion treatment IS NOT indicated.
IV. Thrombolytic therapy
1. Indicated in high risk pulmonary embolism (shock or hypotension)
2. The approved regimens for thrombolytic therapy are shown in table 1
3. Contraindications to thrombolytic therapy are
a. Absolute contraindication
 Any prior intracranial hemorrhage
 known structural intracranial cerebrovascular disease (eg, arteriovenous
malformation)
 Known malignant intracranial neoplasm
 Ischemic stroke within 3 months
 Suspected aortic dissection
 Bleeding or bleeding diathesis
 Recent surgery encroaching on the spinal canal or brain, and recent significant
closed-head or facial trauma with radiographic evidence of bony fracture or
brain injury
b. Relative contraindications
 age > 75 years
 Current use of anticoagulation
 Pregnancy;
 Noncompressible vascular punctures;
 Prolonged cardiopulmonary resuscitation (10 minutes)

96
 Recent internal bleeding (within 2 to 4 weeks)
 History of chronic, severe, and poorly controlled hypertension; severe
uncontrolled hypertension on presentation (systolic blood pressure > 180 mm
Hg or diastolic > blood pressure 110 mm Hg)
 Remote (>3 months) ischemic stroke
 Major surgery within 3 weeks.
4. Unfractionated heparin infusion should be stopped during administration of
streptokinase or urokinase; it can be continued during rtPA infusion
5. In patients receiving LMWH or fondaparinux at the time that thrombolysis is initiated,
infusion of UFH should be delayed until 12 hours after the last LMWH injection
Table 6: approved regimens for thrombolytic therapy in acute PE
Agent Dosage Precautions
Streptokinase 250000 IU over 30 min
Then 100000 IU/hour X 24 hours
 Unfractionated heparin (UFH)
should not be given concomitantly
with fibrinolytic therapy in acute
massive PE.
 After fibrinolytic therapy,
anticoagulation treatment is
recommended to prevent
recurrent thrombosis.
 Do not begin heparin until the
activated partial thromboplastin
time (aPTT) has decreased to less
than twice the normal control
value
Urokinase 4400 U/kg/10 min
4400 U/kg X 12-24 hours
Altepase (tPA) Patient weight < 67 kg
 15 mg I.V. bolus followed by 0.75
mg/kg over the next 30 minutes
(Max 50 mg) and then 0.5 mg/kg
over the next 60 minutes (Max 35
mg).
Patients weight >67 kg
 15 mg I.V. bolus followed by 50 mg
over the next 30 minutes and then
35 mg over the next 60 minutes
V. Anticoagulation
1. The standard duration of anticoagulation should cover at least 3 months.
2. Acute-phase treatment consists of administering parenteral anticoagulation
[unfractionated heparin (UFH), LMWH or fondaparinux] over the first 5–10 days.
3. Parenteral heparin should overlap with the initiation of a vitamin K antagonist (VKA);
alternatively, it can be followed by administration of one of the new oral anticoagulants
4. LMWH and fondaparinux are preferred over UFH for initial anticoagulation in PE
5. UFH is recommended for patients in whom primary reperfusion is considered, aswell as
for those with serious renal impairment (creatinine clearance ,30 mL/min), or severe
obesity.
6. The LMWHs approved for the treatment of acute PE are listed in Table......
7. Oral anticoagulants should be initiated as soon as possible, and preferably on the
same day as the parenteral anticoagulant.

97
8. Anticoagulation with UFH, LMWH, or fondaparinux should be continued for at least 5
days and until the international normalized ratio (INR) has been 2.0–3.0 for two
consecutive days
9. Warfarin can be started at a dose of 10 mg in younger (e.g. ,60 years of age), otherwise
healthy outpatients, and at a dose of 5 mg in older patients and in those who are
hospitalized.
10. Patients with PE should receive at least 3 months of anticoagulant treatment
Table 7: Low-molecular-weight heparins and pentasaccharide (fondaparinux) approved
for the treatment of pulmonary embolism
Dosage Interval
Enoxaparin 1.0 mg/kg
or
1.5 mg/kga
Every 12 hours
Once dailya
Dalteparin 100 IU/kg
Or
200 IU/kg
Every 12 hours
Once daily
Fondaparinux 5 mg (body weight <50 kg);
7.5 mg (body weight 50–100 kg);
10 mg (body weight >100 kg)
Once daily
a
Once-daily injection of enoxaparin at the dosage of 1.5 mg/kg is approved for
inpatient (hospital) treatment of PE in the United States and in some, but not all,
European countries
VI. Inferior vena cava filter
1. Adult patients with any confirmed acute PE (or proximal DVT) with
contraindications to anticoagulation or with active bleeding complication should
receive an IVC filter
2. For patients with recurrent acute PE despite therapeutic anticoagulation
3. IVC filter may be considered for patients with acute PE and very poor cardiopulmonary
reserve, including those with massive PE
4. An IVC filter should not be used routinely as an adjuvant to anticoagulation and
systemic fibrinolysis in the treatment of acute PE
5. Anticoagulation should be resumed in patients with an IVC filter once contraindications
to anticoagulation or active bleeding complications have resolved

98
Figure 26: Proposed diagnostic algorithm for patients with suspected high-risk PE

99
Figure 27: Proposed diagnostic algorithm for patients with suspected non-high-risk PE

100
Table 8: simplified revised Geneva score for prediction of PE
Items Clinical decision rule points
Simplified Revised Geneva score
Previous PE or DVT I
Heart rate
75–94 b.p.m.
≥95 b.p.m
I
2
Surgery or fracture within the past month I
Haemoptysis I
Active cancer I
Unilateral lower limb pain I
Pain on lower limb deep venous palpation and
unilateral oedema
I
Clinical probability
Three-level score
Low 0–1
Intermediate 2–4
High ≥5
Two-level score
PE unlikely 0–2
PE likely ≥3
Table 9: Simplified pulmonary injury severity index
Items Clinical decision rule points
Simplified pulmonary embolism severity index
Age in years I point (if age > 80 years)
Cancer I point
Chronic heart failure
I point
Chronic pulmonary disease
Hear rate > 110 bpm I point
Systolic blood pressure < 100 mmHg I point
Arterial oxygen saturation < 90% I point
Risk Strata
0 point 30 day mortality 1%
≥ 1 point 30 day mortality 10%

101
Figure 28: Risk-adjusted management strategies in acute PE

102
References
1. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JS,
Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E,
Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk
Noordegraaf A, Zamorano JL, Zompatori M; Task Force for the Diagnosis and
Management of Acute Pulmonary Embolism of the European Society of Cardiology.
2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism.
Eur Heart J.2014; 35:3033-69

103
Fluid Therapy And Electrolyte Replacement Protocol
a) Maintenance fluids
I. Usually crystalloids:
 5% dextrose + 1/2 N. Saline
 5% dextrose / N. Saline
 1/2 N. Saline
 Ringer Lactate
 Ringer Acetate
II. Usual volumes: 25-30 ml/kg/day → 80-120 ml/hr
III. TPN (refer to guidelines)
b) Replacement / resuscitation fluids
I. N.saline should be used for most fluid resuscitation.
 Equivalent to 5% albumin for resuscitation
 Better for patients with head trauma.
II. Colloid (5% albumin, gelatins, and Hydroxyethyl starch 6% 130/0.4) may be
considered for fluid resuscitation in selected patients.
III. Blood and blood component therapy as indicated and according to Transfusion
guidelines. (See transfusion therapy protocol)
IV. Crystalloid replacement is usually used for excessive renal, enteric and burns
losses.

104
Table: Fluids for intravenous replacement of extracellular volume or water deficit.
[Na+] (meq/L) [Cl–
] (meq/L) [osm] (mosm/L) Other
Crystalloids
0.9% NaCl
(normal saline)
145 145 380
5% dextrose in
0.9% NaCl
145 145 468 Glucose, 50 g/L
Ringer’s lactate 138 181 373 K+, Ca2+, lactate1
5% dextrose in
water
8 8 343 Glucose, 50 g/L
0.45% NaCl 77 77 145
5% dextrose in
0.45% NaCl
77 77 586 Glucose, 50 g/L
Colloids
6% hetastarch in
0.9% NaCl
145 145 380
5% albumin 138-168 138-168 338
Table: Guidelines for replacement of fluid losses from the gastrointestinal tract.
Replace mL
Per mL with
Add
Gastric (vomiting or
nasogastric aspiration)
0.45% NaCl KCl, 10 meq/L
Small bowel 0.45% NaCl KCl, 10 meq/L
Biliary Ringer Lactate
or acetate
Large bowel (diarrhea) 0.45 NaCl KCl, 20 meq/L
Urine 0.45% NaCl KCl, 10 meq/L

105
Electrolyte Replacement Protocol
Patients must meet the following criteria prior to initiation of the Potassium,
Magnesium, or Phosphorus protocols:
 SCr < 2 mg/dL
 Weight > 40 kg
POTASSIUM REPLACEMENT PROTOCOL – INTRAVENOUS
 Recommended rate of infusion is 10 mEq/h
Maximum rate of intravenous replacement is 20 mEq/h with continuous ECG monitoring
(the maximum rate may be increased to 40 mEq/h in emergency situations
Maximum Concentration for Central IV administration = 20 mEq/50 mL
Maximum Concentration for Peripheral IV administration = 10 mEq/50 mL
Current Serum
Potassium Level
Central IV
administration
Peripheral IV Administration Monitoring
3.6 – 3.9 mEq/L 20 mEq IV over 2 HR x 1 10 mEq IV over 1 HR x 2 No additional action
3.4 – 3.5 mEq/L
20 mEq IV over 2 HR x 1
AND
10 mEq IV over 1 HR x 3 No additional action
3.1 – 3.3 mEq/L 20 mEq IV over 2 HR x 2 10 mEq IV over 1 HR x 4
Recheck serum potassium
level 2 hours after infusion
complete
2.6 – 3 mEq/L
AND
complete
2.3 – 2.5 mEq/L 20 mEq IV over 2 HR x 3 10 mEq IV over 1 HR x 6
complete
< 2.3 mEq/L
Call Physician AND
Call Physician AND
complete
• If both potassium and phosphorus replacementrequired, subtract the mEq of potassium given as potassium phosphate from total
amount of potassium required. (Conversion: 3 mmols KPO = 4.4 mEq K+
)4
POTASSIUM REPLACEMENT PROTOCOL – ORAL or ENTERAL (PT)
• Standard dosage forms: KCl 20mEQ tablet or KCl 10% solution (20 mEq/15 mL)
Current Serum
Potassium Level
Total Potassium Replacement Monitoring
3.7 – 3.9 mEq/L 20 mEq KCl PO/Per feeding tube x 1 dose No additional action
3.5 – 3.6 mEq/L 20 mEq KCl PO/Per feeding tube Q2H x 2 doses No additional action
3.3 – 3.4 mEq/L 20 mEq KCl PO/Per feeding tube Q2H x 3 doses Recheck serum potassium level 4 hours
after last oral dose
3.1 – 3.2 mEq/L 20 mEq KCl PO/Per feeding tube Q2H x 4 doses Recheck serum potassium level 4 hours
< 3.1 mEq/L
20 mEq KCl PO/Per feeding tube Q2H x 4 doses Recheck serum potassium level 4 hours

106
MAGNESIUM REPLACEMENT PROTOCOL
• Infusions should be no faster than 1gm of magnesium sulfate every 30 minutes.
• Standard Concentrations: 1 gm/100 mL and 2 gm/50 mL
Current Serum Magnesium Level Total Magnesium Replacement Monitoring
Serum magnesium >2.1 mg/dl No Replacement Required No additional action
1.8 – 2.1 mg/dl 2 grams Magnesium Sulfate IV over 2 HR No additional action
1.3 – 1.7 mg/dl 4 grams Magnesium Sulfate IV over 4 HR Recheck serum magnesium level 4 hours
after infusion omplete
< 1.2 mg/d 6 grams Magnesium Sulfate IV over 6 HR Recheck serum magnesium level 4 hours
after infusion complete
PHOSPHORUS REPLACEMENT PROTOCOL
• Replacement must be ordered in mmol of phosphorus.
• Recommended rate = 3mmol/hr (= 4.4 mEq/h of K)
• Maximum rate = 10 mmol/hr (= 15 mEq/h of K)
Current Serum
Phosphorus Level
Total Phosphorus Replacement Monitoring
2 – 2.5 mg/dL 15 mmol Potassium Phosphate IV over 4 HR No additional action
1 – 1.9 mg/dL 21 mmol Potassium Phosphate IV over 4 HR
Recheck serum phosphorus level 4 hours
< 1 mg/dL
30 mmol Potassium Phosphate IV over 4 HR
(Administered as: 15 mmol Potassium Phosphate
IV Q2H x 2 doses)
Recheck serum phosphorus level 4 hours
• If both potassium and phosphorus replacementrequired, subtract the mEq of potassium given as potassium phosphate from total
amount of potassium required. (Conversion: 3 mmols KPO = 4.4 mEq K+
)4
Calcium Replacement Protocol
 For every 1 g/dL decrease of serum albumin less than 4.0 g/dL, add 0.8 mg/dL to
total serum calcium level to correct value (normal serum calcium level at VUMC
8.5 - 10.5 mg/dL)
 IV replacement should be with calcium chloride (272 mg elemental calcium/1 gm

107
CaCI2) if a central access is present; if not, use calcium gluconate (94 mg elemental
calcium/1 gm calcium gluconate)
Ionized Calcium
Total Calcium Replacement Monitoring
0.85-0.95 mmol/L 2 g CaCl2 With next AM lab
0.75 – 0.85 mmol/L 3 g CaCl2
Recheck serum Calcium level 4 hours after
infusion complete
0.65-0.75 mmol/dL
4 g Ca Cl2 Recheck serum Calcium level 4 hours after
infusion complete
<0.65 mmol/L
5 g CaCl2
Recheck serum Calcium level 4 hours after infusion
complete

108
Hyponatremia
General principles:
 Hyponatremia can be defined according to biochemical severity into
o Mild hyponatremia: serum sodium concentration between 130 and 135 mmol/l.
o Moderate’ hyponatremia: serum sodium concentration between 125 and 129
mmol/l.
o Profound hyponatremia: serum sodium concentration <125 mmol/l.
 Definition of hyponatremia based on time of development
o Acute hyponatraemia: hyponatremia that is documented to exist <48 h.
o Chronic hyponatraemia: hyponatremia that is documented to exist for at least 48
h.
o If hyponatraemia cannot be classified, we consider it being chronic, unless there
is clinical or anamnestic evidence of the contrary
 Definition of hyponatremia based on symptoms
o Moderately symptomatic’ hyponatremia: any biochemical degree of
hyponatraemia in the presence of moderately severe symptoms of hypo-
natraemia (Table 5).
o Severely symptomatic hyponatremia: any biochemical degree of hyponatremia
in the presence of severe symptoms of hyponatremia
Table 10: Classiﬁcation of symptoms of hyponatraemia

109
Diagnosis of hyponatremia
Figure 29: Diagnosis of hyponatremia

110
Figure 30: Management of hypotonic hyponatraemia 1

111
Calculate total body water in liters
Step 1 wt in kg
Men<65
yr Men>65 or Woman<65 yr Woman>65 yr
40 24 20 18
45 27 23 20
50 30 25 23
55 33 28 25
60 36 30 27
65 39 33 29
70 42 35 32
75 45 38 34
80 48 40 36
85 51 43 38
90 54 45 41
95 57 48 43
100 60 50 45
105 63 53 47
110 66 55 50
115 69 58 52
120 72 60 54
125 75 63 56
130 78 65 59
135 81 68 61
140 84 70 63
145 87 73 65
150 90 75 68
155 93 78 70
160 96 80 72
165 99 83 74
Step 2 Calculate Infusion Rate of Selected IV Fluids
Maximum rate of IV infusioin
(ml/hr) Maximum rate of IV infusioin (ml/hr)
for increase in Na of 0.5 mEq/L/hr for increase in Na of 1 mEq/L/hr
TBW (Liters) 0.9% Normal Saline 3% Saline TBW (Liters) 0.9% Normal Saline 3% Saline
20 65 19 20 130 39
25 81 24 25 162 49
30 97 29 30 195 58
35 114 34 35 227 68
40 130 39 40 260 78
45 146 44 45 292 88
50 162 49 50 325 97
55 179 54 55 107
60 195 58 60 117
65 211 63 65 127
70 227 68 70 136
75 244 73 75 147
*Note: The infusion rates above are the maximum recommended rates to achieve the desired rate of
Na increase. Initially, cap infusion rate of 3% saline at 75 mL/hour for a Na increase of 0.5 mEq/L/hour
and at 150 mL/hr for an increase of 1 mEq/L/hour
TBW * (goal serum Na conc – current serum Na conc) / (IV fluid Na concentration/L) * 1000
(number of hours needed to correct Na)
Table 11: Treatment of Hyponatremia Dose Calculator

112
References
1. Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and
treatment of hyponatraemia. Eur J Endocrinol. 2014 25;170:G1-47

113
Burn Resuscitation
General Rules
 Acute major burns are serious life threatening conditions.
 The patient’s optimal chance for survival and a meaningful recovery depends upon
appropriate fluid resuscitation, airway management, and appropriate, timely burn care.
Resuscitation guidelines
 Estimate initial fluid requirements with the Parkland formula (4 mL/kg/% TBSA burned).
o Give ½ of the fluid volume calculated over the first 8 hours from the time of the
burn
o Give the remaining half of the fluid volume over the next 16 hours.
 For ≥ 30% TBSA burns, Vitamin C infusion should be considered.
o Ascorbic acid should be infused at 66 mg/kg/hr for the initial 24 hours of burn
resuscitation.
o The appropriate solution may be prepared by mixing 25 grams of ascorbic acid in
1000 mL of Lactated Ringer’s solution (resulting in a 25 mg/mL concentration).
o The solution bag should be covered with a black bag to prevent light-induced
auto-oxidation.
o Infusion should be begun within six hours of burn injury.
o The fluid volume associated with the ascorbic acid infusion should be included in
the total volume of fluid resuscitation calculated according to the Parkland
formula.
o Once ascorbic acid infusion is begun, point of care (POC) glucose testing results
should be considered inaccurate for at least 36 hours after completing the
infusion.
o Blood glucose should be monitored using serum glucose levels whenever
ascorbic acid infusions are in use.
 Avoid the use of hypertonic saline
 In patients with burns ≥ 20% TBSA:
o Insert a central venous catheter
o Insert a urinary (Foley) catheter
o Monitor intra-abdominal (bladder) pressure q 4 hours during the initial
resuscitation.
o Consider invasive hemodynamic monitoring to guide resuscitation
 Resuscitation endpoints in the first 24 hours post-burn injury:
o Monitor arterial lactate q 4 hours until < 2 mMol/L
o Maintain urine output at 30-50 ml/hr (50-100 ml/hr if receiving Vitamin C)

114
o In electrical injury or rhabdomyolysis patients, serial creatinine kinase levels
should be checked daily until < 2500 mcg/L
o Monitor hemoglobin to ensure that it is not trending upward
 If the patient requires ≥ 1.5 times the calculated Parkland formula volume (6
ml/kg/TBSA), consider colloid rescue:
o 5% albumin at 1/3 Parkland rate + 2/3 Parkland rate of Lactated Ringers OR
o 25% albumin at 1/15th the Parkland rate + 2/3 Parkland rate of Lactated
Ringers.
 If the patient has received > 250 mL/kg of fluid resuscitation, intraocular pressure
should be measured.

115
References
1. Aboelatta Y, Abdelsalam A. Volume overload of fluid resuscitation in acutely burned
patients using transpulmonary thermodilution technique. J Burn Care Res. 2013;34:349-54
2. Al-Benna S. Fluid resuscitation protocols for burn patients at intensive care units of the
United Kingdom and Ireland. Ger Med Sci. 2011;9:
3. Pham TN, Cancio LC, Gibran NS; American Burn Association. American Burn Association
practice guidelines burn shock resuscitation. J Burn Care Res. 2008;29:257-66
4. Kahn SA, Beers RJ, Lentz CW. Resuscitation after severe burn injury using high-dose
ascorbic acid: a retrospective review. J Burn Care Res. 2011;32:110-7

116
Stress Ulcer Prophylaxis (SUP)
General Rules
1. The goal of SUP is to prevent bleeding from gastric erosions
2. Routine prophylaxis for all patents is NOT recommended as the risk differs between
patients
3. There is increasing body of evidence about the protective role of enteral feeding on
gastric mucosa
Stress ulcer prophylaxis protocol
1. Start prophylaxis on patients with any of the acute risk factors below
a. Mechanical ventilation
b. Coagulopathy
c. Hypoperfusion state and organ dysfunction (septic, hemorrhagic, cardiogenic
shock)
d. Severe head injury or spinal cord injury
e. Severe burn (>35%)
f. High dose corticosteroids (>250 hydrocortisone /day or its equivalent)
2. Consider prophylaxis for patients who are not fed and have two potential risk factor
below
a. Concomitant use of non-steroidal anti-inflammatory (NSAID) drugs
b. Concomitant use of corticosteroids
c. History of peptic ulcers, upper GIT disease
d. Mild/moderate brain or spinal cord injury
3. Prophylaxis therapy of stress ulcers
a. Use IV ranitidine 50 mg q 8 hrs. Change to oral ranitidine 150 mg q12 hrs in
patients who are enterally fed.
i. In renal failure, reduce IV dose to 50 mg q 12 hrs or oral 150 mg q 24 hrs
ii. Proton pump inhibitors (PPIs) are indicated in patients with proven ulcers
and are already on PPI treatment. PPIs are not eliminated via the renal
route and dose adjustment in renal impairment is not necessary.
4. Treating active upper GI bleed in ICU
a. PPIs remain the main stay of treatment in patients that develop active upper GI
bleeding
b. Give PPI as an infusion 8 mg/hrs over 48-72 hrs, following a loading dose of 80
mg as an adjunct to endoscopic or surgical management.
c. For those who develop clinically significant bleed in ICU, continue PPIs for at
least 2 weeks

117
5. Discontinuation of SUP
a. Prophylactic therapy may be discontinued once patient is tolerating full feeds
and has no more risk factors.

118
Figure 31: Stress ulcer prophylaxis protocol

119
References
1. Marik PE, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the new
millennium: a systematic review and meta-analysis. Crit Care Med. 2010 ;38:2222-8.

120
Gastro-intestinal hemorrhage protocol
General principles
 Gastrointestinal (GI) bleeding encompasses a wide range of diagnoses with multiple
types of lesions and bleeding that can occur virtually anywhere in the GI tract
 Management and the outcome of GI bleeding depend on both the severity of the
bleeding and any comorbid conditions present at the time of the bleeding
 Acute GI bleeding often requires close monitoring and management in an intensive care
unit
Initial Evaluation and Resuscitation
 The first step in clinical evaluation is to assess the severity of the bleeding.
 Patients who present with hemodynamic instability and signiﬁcant hematemesis will
have resting tachycardia (pulse ≥ 100 per min), hypotension (systolic blood pressure
<100 mmHg), or postural changes (increase in the pulse of ≥20 beats/min or a drop in
systolic blood pressure of ≥ 20 mmHg on standing)
 In patients with exsanguinating bleeding or the patient who is delirious, airway should
be protected by elective intubation. In conscious patients, give oxygen by nasal cannula.
 Two large-bore intravenous channels should be placed at the earliest.
 Fluid resuscitation should be started with Ringer’s lactate or normal saline. Crystalloid or
colloid solutions may be used for treating hypotension aiming a systolic blood pressure
of more than 100 mmHg.
 Do typing and crossmatching of blood. Target hemoglobin usually around 7–8 g% for
otherwise healthy individuals without active bleeding. A target hemoglobin
concentration of about 9 g% would be appropriate in patients older than 65 years or
those with cardiovascular disease.
 The patient should be kept nil orally. This is necessary because an urgent endoscopy or
even intubation may be needed in the event of a repeat bleeding.
 Stop factors that enhance bleeding—anticoagulants (warfarin, heparin) and antiplatelet
agents (aspirin, clopidogrel).
Find etiology and stratify risk
 The severity of presenting symptoms, current medications, and history are instrumental
in establishing the etiology of UGI bleeding.
 The history of use of aspirin and nonsteroidal anti-in ﬂ ammatory drugs (NSAIDs)
suggests a bleeding ulcer. The history of prolonged alcohol intake and the stigmata of
chronic liver disease including jaundice and ascites would indicate a possible variceal
hemorrhage.

121
Send investigations
 Hemoglobin levels are required in all patients. It must, however, be noted that initial
levels may be falsely high and underestimate true blood loss due to hemoconcentration.
 Blood should be sent urgently for cross matching and availability.
 Send blood parameters including prothrombin time, partial thromboplastin time, and
platelet count.
 Blood urea, creatinine, and liver function tests may assist in diagnosing the cause and
severity of bleeding.
General treatment
 Any coagulopathy found needs to be corrected by appropriate blood products. If
prothrombin time/international normalized ratio is prolonged, give fresh frozen plasma
or vitamin K injection.
 Proton-pump inhibitors: 80 mg IV bolus should be administered followed by
intravenous infusion of 8 mg/h or 40 mg 12 hourly
 If there is known or suspected variceal bleeding (or known or suspected chronic liver
disease), empiric treatment with terlipressin 2 mg IV stat followed by 2 mg IV QDS and a
dose of broad-spectrum antibiotics should be given.
 If there is history of active alcohol abuse, thiamine replacement should be
started.
 Insert the nasogastric tube
o The nasogastric tube insertion is helpful in many ways. The type of aspirate such
as fresh blood, bilious, or altered blood helps in determining whether bleeding is
ongoing or has stopped.
o Gastric lavage before endoscopy also helps in giving a clear view for endoscopy.
 Carry out endoscopy
o Endoscopy is a mainstay for all cases of UGI bleeding. It enables Identiﬁcation of
the source of bleeding.
Timing of endoscopy: After resuscitation, an endoscopy is arranged. Patients
with profuse hemorrhage may need emergency endoscopy; the endoscopy
should take place within 24 h of presentation, both to guide management
and to facilitate the early discharge of patients with a low risk of recurrent
bleeding.
Speciﬁc treatment
A. For nonvariceal bleeding

122
 Intravenous proton-pump inhibitor bolus is followed by infusion for 72 h after
endoscopic hemostasis; oral proton-pump inhibitors can be started after completion of
intravenous therapy.
 Stop NSAIDs and substitute with less toxic drugs. There is no role for H2 blocker,
somatostatin, or octreotide. Oral intake of clear liquids can be initiated 6 h after
endoscopy in patients with hemodynamic stability.
 Surgical or interventional radiologic consultation should be taken for angiography
for selected patients with failure of endoscopic hemostasis or massive rebleeding.
B. For variceal bleeding
 Vasoactive drug treatment should be continued (terlipressin for 48 h, octreotide,
or somatostatin each for 3 days).
 Antibiotic therapy should be commenced/continued.
 Balloon tamponade should be considered as a temporary salvage treatment for
uncontrolled bleeding.
 Transjugular intrahepatic portosystemic stent shunting is recommended as the
treatment of choice for uncontrolled variceal hemorrhage.

123
Figure 32: Approach to managing upper gastrointestinal bleeding in critical care patients.

124
References
1. Barkun AN, Bardou M, Kuipers EJ: International consensus recommendations on the
management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med.
152:101-113 2010
2. Sheikh RA, Prindiville TP, Trudeau W: Gastrointestinal bleeding in portal hypertension.
DiMarino AJ Benjamin S Gastrointestinal Disease: An Endoscopic Approach. 2nd ed 2002
Slack Thorofare, NJ 605-644
3. Hashizume M, Akahoshi T, Tomikawa M: Management of gastric varices. J Gastroenterol
Hepatol. 26:102-108 2011
4. Laine L, McQuaid KR: Endoscopic therapy for bleeding ulcers: An evidence-based approach
based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol. 7:33-
47 2009
5. Ioannu GN, Doust J, Rockey D: Systematic review: Terlipressin in acute oesophageal
variceal hemorrhage. Aliment Pharmacol Ther. 17:53-64 2003
6. Corley DA, Cello JP, Adkisson W, et al.: Octreotide for acute esophageal variceal bleeding:
Meta-analysis. Gastroenterology. 120:946-954 2001

125
Management of DKA
Figure 33: Management of DKA

129
References
Kellum JA (2005) Disturbances of acid–base balance. Textbook of Critical Care, 5th edn, eds.
Fink MP Abraham B, Vincent JL, Kochanek PM. Philadelphia, PA: Elservier.

130
Transfusion and Coagulopathy Management protocol
Management of anemia and red cell transfusion
General Principle:
 Anemia is highly prevalent among the critically ill; 60% of patients admitted to intensive
care units (ICU) are anaemic and 20–30% have a first haemoglobin concentration (Hb)
<9.0 g/dL
 After 7 d, 80% of ICU patients have an Hb <9.0 g/dL and 30–50% of ICU patients receive
red cell (RBC) transfusions.
Protocol of red blood cell transfusion
 A transfusion threshold of 7.0 g/dL or below, with a target Hb range of 7.0–9.0 g/dL,
should be the default for all critically ill patients, unless specific co-morbidities or acute
illness-related factors modify clinical decision-making.
 Transfusion triggers should not exceed 9.0 g/dL in most critically ill patients.
 Erythropoietin should NOT be used to treat anemia in critically ill patients.
 In the absence of clear evidence of iron deficiency, routine iron supplementation is NOT
recommended during critical illness.
 Red cell transfusion transfusion should NOT be used as a strategy to assist weaning
from mechanical ventilation when the Hb is >7.0 g/dL
Transfusion in patient with sepsis
 In the early resuscitation of patients with severe sepsis, if there is clear evidence of
inadequate DO2, transfusion of RBCs to a target Hb of 9.0–10.0 g/dL should be
considered.
 During the later stages of severe sepsis, a restrictive approach to transfusion should be
followed with a target Hb of 7.0–9.0 g/dL
Transfusion in neurocritical care
 In patients with severe TBI (GCS ≤ 8): Target haemoglobin level ≥ 10 g/dL
 In patients with subaracnoid hemorrhage, the target Hb should be 8.0–10.0 g/dL

131
 In patients presenting to the ICU with an acute ischemic stroke the Hb should be
maintained above 9.0 g/dL
Transfusion in patient with ischemic heart disease
 In patients suffering from ACS the Hb should be maintained at >8.0 g/dL
Transfusion related acute lung injury (TRALI) & Transfusion associated circulatory
overload (TACO)
 Patients developing acute dyspnoea with hypoxia and bilateral pulmonary inﬁltrates
during or within 6 h of transfusion should be carefully assessed for the probability of
TRALI and patients should be admitted to a critical care area for supportive treatment
and monitoring
Figure 34: A suggested approach to transfusion in critical care

132
References
1. Retter A, Wyncoll D, Pearse R, Carson D, McKechnie S, Stanworth S, Allard S, Thomas D,
Walsh T; British Committee for Standards in Haematology.Guidelines on the
management of anaemia and red cell transfusion in adult critically ill patients. Br J
Haematol. 2013 ;160:445-64.

133
Management of coagulopathy
Protocol of Fresh frozen plasma (FFP)transfusion
 Reversal of warfarin effect: FFP should only be used for the reversal of warfarin
anticoagulation in the presence of major bleeding.
 Perioperative transfusion in the presence of major bleeding
 Disseminated intravascular coagulopathy: consider FFP if there clinical evidence of
bleeding
Protocol of Platelet transfusion
Indication Transfusion trigger
 Prophylactic use pre-procedure
o Surgery involving critical sites (brain-eye)
o Non critical site surgery (laparotomy)
o Neuraxial blockade
100.000
50.000
75.000
 Routine prophylactic use to reduce bleeding 10.000
 Prophylactic use in patients with additional
risk factors e.g. sepsis
10.000-20.000
Disseminated intravascular coagulopathy
General principle:
 Bleeding manifestation due to disseminated intravascular coagulation (DIC) occurs in 1%
of hospital admission.
Management:
I. Establish diagnosis
1. Take history of known systemic conditions associated with DIC and coagulation
disorders
2. Laboratory investigations:
a. Complete blood count
b. Prothrombin time (PT), partial thromboplastin time (PTT), INR
c. Fibrinogen level, ﬁbrin degradation product (FDP), D-dimer.
d. Renal and liver function tests.
The commonest abnormality is thrombocytopenia followed by elevated FDPs,
prolonged PT, prolonged PTT, and a low ﬁbrinogen.
3. Calculate DIC score of International Society of Thrombosis and Hemostasis (ISTH).
a. More than 5 overt DIC: repeat score daily.
b. Less than 5 suggestive for nonovert DIC: repeat for the next 1–2 days.

134
Table: ISTH diagnostic score of DIC
Platelet count
>100.000 0
50000-100000 1
>100000 2
Fibrin marker
No increase 0
Moderate increase 2
Strong increase 3
Prolonged PT
< 3 s 0
> 3 but < 6 s 1
>6 s 2
Fibrinogen level
≥1 g/dL 0
< 1 g/dL 1
II. Management
 Treatment of underlying cause.
 Transfusion of platelets or plasma (components) in patients with DIC should not
primarily be based on laboratory results and should in general be reserved for patients
that present with bleeding.
 In patients with DIC and bleeding or at high risk of bleeding (e.g. postoperative
patients or patients due to undergo an invasive procedure) a platelet count should be
maintained more than 50,000
 In non-bleeding patients with DIC, prophylactic platelet transfusion is not given unless
it is less than 10,000.
 In bleeding patients with DIC and prolonged PT and PTT FFP should be administered at
dose 15-30 ml/kg
 Severe hypofibrinogenemia (<100 mg/dL) may be treated with fibrinogen concentrate
or cryoprecipitate.
 In cases of DIC where thrombosis predominates, weight adjusted doses (e.g. 10
µ/kg/h) may be used.
 Do not use antifibrinolytic agents as they may aggravate thrombosis.

135
References
1. Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of
disseminated intravascular coagulation. British Committee for Standards in
Haematology. Br J Haematol. 2009;145:24-33
2. Stroncek DF, Rebulla P. Platelet transfusions. Lancet. 2007;370:427–38

136
Cardiopulmonary resuscitation

137
ACLS guideline of Tachy-arrhythmia

138
ACLS guideline of Narrow-Complex Tachycardias

139
ACLS guideline of stable Ventricular Tachycaridas

140
ACLS guideline of Bradycardia

141
Electric cardioversion
Energy level of cardioversion

142
References
Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, Samson RA,
Kattwinkel J, Berg RA, Bhanji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA,
Perlman JM, Sinz E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Link M,
Morrison LJ, O'Connor RE, Shuster M, Callaway CW, Cucchiara B, Ferguson JD, Rea TD, Vanden
Hoek TL. Part 1: executive summary: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov
2;122:S640-56

143
Post-Return of Spontaneous Circulation (ROSC)
Procedures
Ventilation
 Place patient on AC Mode
 Set Vt to 8 ml/kg Ideal Body Weight
 Set IFR to 60 lpm
 Set Initial rate to 18 bpm
 Set Initial O2 to 50%
 Titrate FiO2/PEEP to achieve ABG Saturation 94-96%.
 Often pulse ox will not read well due to peripheral vasoconstriction
Hemodynamic Goals
Ensure Adequate Preload
 Assess by passive leg raise, pulse pressure variation. CVP may provide some indication if
very low.
 Use normal saline, or lactated ringers. Use room temperature fluid if patient at goal
temperature.
 Replace patient’s urine losses 1:1
MAP > 65
 at all times, MAP > 80 is preferred to augment cerebral perfusion
 Preferred initial pressor is norepinephrine, may add epinephrine if necessary
 If MAP is < 80 and CVP > 10 perform passive straight leg raise to assess fluid
responsiveness.
 If MAP > 100, start nitroglycerin infusion
Corrected ScvO2 > 70
 If ScvO2 < 70 and HB < 7.0 g/dL (some would advocate <10 as trigger), transfuse patient
 If HB ≥ 7.0 g/dL, evaluate echocardiogram and consider inotropes vs. balloon
pump/revascularization
Lactate
 Hypothermia will raise lactate levels and post-arrest patients will have high lactate.
 Send a baseline level after the patient achieves goal temperature.
 From this point on, the lactate should stay the same or drop.
 If lactate is increasing, the patient is under-resuscitated or seizing

144
Sedation & Pain Control
 To gain the full benefits of hypothermia, it is imperative that the patient is adequately
sedated
 Optimize fentanyl infusion rate first
 Add on propofol or midazolam if necessary
 Titrate to Ramsay Score of 4/5
Lab & Electrolyte
 Send ABG with Electrolytes and Lactate Q 2 hour for first 4 hours, then Q 4 hours.
 On arrival, send CMP, CBC, Lytes, PT/PTT, Lipase, Cardiac Enzymes, Type and Hold, & Pan-
Cultures.
 Send CMP (complete metabolic panel) and CBC Q 12 hours.
 Send Cardiac Enzymes Q 12 hours.
 Keep Magnesium at high-normal at all times with aggressive IV repletion
 Replete Potassium if < 3.8 with IV KCl
 Keep iCal at high normal at all times
 Keep Sodium at least 140 at all times, 150 is preferable
 Keep Glucose < 150 with Insulin Drip (preferred) or Subcutaneous Regular Insulin
DVT Prophylaxis
 If no contraindication, Heparin 5000 units subcutaneous Q 8 hours
Stress Ulcer Prophylaxis
 PPI 40 mg IV x 1
VAP Prophylaxis
 VAP bundle
Induced Hypothermia Protocol
Inclusion Criteria (Must have All)
 Post Cardiac Arrest (Any rhythm as cause of arrest is eligible)
 ROSC < 30 min from EMS/Code Team Arrival
 Time now <6 hrs from ROSC
 Comatose (Does not follow commands)
 MAP > 65 on no more than one vasopressor
Exclusion Criteria
 Patient has poor baseline status, or terminal disease
 Active or Intracranial Bleeding

145
 Traumatic etiology for arrest
 Pregnancy (Relative-Consider OB/Gyn consult)
 Recent Major Surgery (Relative)
 Severe Sepsis/Septic Shock as cause of Arrest (Relative)
Protocol
 Send blood for: CMP, LFTs, Superstat I, Lactate, CBC, PT/PTT, CK/MB/Troponin,
Lipase/Amylase
 Completely expose patient and place cooling blanket above and below with nothing
between blanket & skin.
 Place temp probe in mid-esophagus (~4 cm above xiphoid via oral/nasal); if unable to place
in esophagus, probe can be placed rectally (5 cm)
 List time Now (Starting Protocol): List Initial Patient Temperature: ° C
 If initial temperature is < 33º C, allow patient to warm to 33º C.
 Begin opioids & sedation protocol. Titrate to Ramsay Score 4/5
 Infuse refrigerated crystalloid, preferably through large bore, peripheral IV Administer at
~100 ml per minute using pressure bag (evacuate air first). Maximum initial infusion is 30
cc/kg; if patient not < 34º C after this amount, wait 15 minutes before giving further 250 cc
boluses Q 10 minutes.
 Administer IV perfalgan 1 gm / 6 hours or paracetamol GI 500 mg Q6
 If during induction, pt has shivering unrelieved by the above meds, Vecuronium 0.1 mg/kg
x1 can be used
 If patient’s temperature rises above 34º C, infuse 250 cc boluses of cold crystalloid Q 10
min until <34º C
 Maintain temperature 32-34º C for 24 hours (ideal temperature is 33º C).
 Significant bleeding or severe hemodynamic instability, consider rewarming
 Maintain MAP>80: Multiple Pressors and/or Dobutamine may be used during protocol, if
fluid loading ineffective.

146
Figure 35: Post-cardiac arrest algorithm

147
Figure 36: Protocol of induced hypothermia

148
References
1. Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for
cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Peberdy MA,
Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers
SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL; American Heart Association.
Circulation. 2010;122:S768-86.
2. Scirica BM. Therapeutic hypothermia after cardiac arrest. Circulation. 2013 ;127:244-50

149
Postoperative atrial fibrillation (AF)
General principles:
 Beta-blockade should be the first line of therapy for postoperative atrial fibrillation to
achieve rapid ventricular rate control and conversion to sinus rhythm
 Amiodarone should be considered as an alternative therapy to beta-blockade for
postoperative atrial fibrillation when the patient is hemodynamically unstable or has a
known ejection fraction of < 40%. Amiodarone should be dosed as a repeatable 150mg IV
bolus followed by 20mg/kg IV for 24 hours. Patients should then be converted to 200mg
PO every 8 hours for the first week followed by 200mg PO every twelve hours for three
weeks.
 Digoxin, due to its delayed onset of action and ineffectiveness, should not be used for
acute rate control in atrial fibrillation, but may have a role for chronic rate control
 During the 48 h after onset of AF, the need for anticoagulation before and after
cardioversion may be based on the recommendation of European society of cardiology
guidelines of management of AF. (See below)
 AV nodal blocking agents (beta-blockers, calcium-channel blockers, and digoxin) should be
avoided in Wolf-Parkinson-White and other pre-excitation syndromes
 Immediate cardioversion with heparinization followed by 4 weeks of anticoagulation may
be performed if no atrial thrombus is visualized using transesophageal echocardiography
(TEE)
 Electrical cardioversion is indicated in patients with paroxysmal atrial fibrillation and rapid
ventricular response who have ECG evidence of acute myocardial infarction or
symptomatic hypotension, angina, or heart failure not responsive to pharmacological
measures
 Pharmacologic cardioversion by Propafenone: 450-600mg, immediate oral dose (Pill-in-the
pocket) approach. Use in conjunction with βblockers or nondihydropyridine calcium
blockers.

150
Figure 37: Management of postoperative AF

151
Choice of Anticoagulant in patient wit AF
Figure 38: Choice of anticoagulant in patient with AF

152
Recommendations for prevention of thromboembolism in non-valvular AF

153
References
1. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P;
ESC Committee for Practice Guidelines-CPG; Document Reviewers. 2012 focused update of
the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC
Guidelines for the management of atrial fibrillation--developed with the special
contribution of the European Heart Rhythm Association. Europace. 2012;14:1385-413
2. Takeshi Omae and Yuichi Kanmura. Management of postoperative atrial fibrillation. J
Anesth. 2012; 26: 429–37.

154
Acute Coronary Syndrome
Figure 39: Acute coronary syndrome (1)

155
Table: Contraindications for ﬁbrinolysis
Absolute contraindications
Haemorrhagic stroke or stroke of unknown origin at any time
Ischaemic stroke in the preceding 6 months
Central nervous system damage or neoplasms
Recent major trauma/surgery/head injury (within the preceding 3 weeks)
Gastro-intestinal bleeding within the last month
Known bleeding disorder
Aortic dissection
Relative contraindications
Transient ischaemic attack in preceding 6 months
Oral anticoagulant therapy
Pregnancy within 1-week post-partum
Non-compressible punctures
Traumatic resuscitation
Refractory hypertension (systole. blood pressure >180 mm Hg
Advanced liver disease
Infective endocarditis
Active peptic ulcer

156
References
1. O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O'Neil
BJ, Travers AH, Yannopoulos D. Part 10: acute coronary syndromes: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation. 2010 ;122:S787-817

157
Pediatric critical care
Pediatric Sepsis & septic shock Resuscitation Management
General Principles:
 Treatment guidelines follow those recommended by the Surviving Sepsis Campaign.
Definitions:
 SIRS is a response to a stimulus, which results in two or more of the following:
Pediatric age SIRS criteria
Age group Heart rate Respiratory
rate
Leukocytic
count X
103
/mm
Systolic blood
pressure
mmHg
0 days to 1
Wk
>180 <100 >60 >34 <59
1 wk to 1
Mo
>180 <100 >50 >19.5 or <5 <75
1 mo to < 2 y >180 <90 >35 >17.5 or <5 <75
2-5 yrs >140 Not
applicable
>30 >15.5 or <6 <75
6-12 yrs >130 Not
applicable
>20 >13.5 or <4.5 <83
>12 yrs >110 Not
applicable
>20 >11.5 or <4.5 <90
 Sepsis: is SIRS with a suspected or confirmed bacterial, viral, or fungal cause.
 Severe sepsis: Includes SIRS and at least one of the following signs of hypoperfusion or
organ dysfunction that is new and not explained by other known etiology of organ
dysfunction:
o Hypotension < 5 th percentile for age or systolic BP < 2 SD below normal age for
age.

158
o Need for vasoactive drug to maintain BP in normal range (dopamine >5
µg/kg/min or dobutamine, epinephrine at any dose)
o Two of the following:
 Unexplained metabolic acidosis: base deficit > 5.0 mEg/L
 Increased arterial lactate > times upper limit of normal
 Oliguric: urine output <0.5 mL/kghr
 Prolonged capillary refill: > 5 secs
 Core to peripheral temperature gap > 3°C
o PAO2/FIO2 <300 in absence of cyanotic heart disease or preexisting lung disease
o PaCO2 >65 mmHg or 20 mmHg over baseline PaCO2
o Proven need for >50% FiO2 to maintain saturation ≥ 92%
o Need for nonelective invasive or noninvasive mechanical ventilation
o Glasgow Coma Score ≤11
o Acute change in mental status with a decrease in Glasgow Coma Score ≥3 points
from abnormal baseline
o Platelet count < 80,000/mm3
or a decline of 50% in platelet count from highest
value recorded over the past 3 days (for chronic hematology/oncology patients)
o International normalized ratio >2
o Serum creatinine ≥ 2 times upper limit of normal for age or 2-fold increase in
baseline creatinine
o Total bilirubin ≥4 mg/dL (not applicable for newborn)
o ALT 2 times upper limit of normal for age

159
 Septic shock: is sepsis with fluid refractory hypotension and signs of hypoperfusion.
o Cold shock: capillary refill >2 sec, decrease peripheral pulse, or mottled cool
extremities
o Warm shock: flash capillary refill, increase peripheral pulse
o Fluid refractory shock: persistent shock after 60 mL/kg fluid resuscitation
o Catecholamine resistant shock: Persistent shock after use of direct-acting
catecholamines: epinephrine and norepinephrine

160
Sepsis Protocol:
I. Recognition:
 According to the above criteria, the patient can be categorized as having sepsis, severe
sepsis or septic shock.
 Screening: Patients are screened for severe sepsis upon admission and daily thereafter
using paper screening sheet (Appendix 1)
II. Septic Shock Resuscitation Bundle
Step 1: Initial resuscitation
 Zero minutes:
o Recognize decreased mental status and perfusion.
o Maintain & establish vascular access—use intraosseous if IV fails in 90 s.
 5–15 min :
o Push 20 mL/kg normal saline/colloid × 3 up to 60 mL/kg.
o Assess between each push (Rapid expansion of the liver span, rales and increased
work of breathing, enlargement of the cardiac silhouette on chest X-ray, drop in
SPO2.
o Correct hypoglycemia and hypocalcemia.
Step 2: Manage 15-min fluid-refractory shock
 15-60 min:

161
 Establish central venous access.
 Start dopamine 10 mcg/kg/min.
 Establish arterial access.
 Continue maintenance fluids 4 mL/kg/h and boluses of 0.9% normal saline/colloid as
needed.
 60 minutes have passed—fluid-refractory, dopamine-resistant shock.
o When normotensive with a low cardiac output (CO) and high systemic vascular
resistance (SVR), initial treatment of fluid-refractory patients consists of the use of
an inotropic agent such as dobutamine. Dopamine at a dose of 10–15 m /kg/min
should be administered at this time.
o When hypotensive with a low CO and high SVR (cold shock), EPI (epinephrine) is
started at a dose of 0.1 m g/kg and titrated to effect.
o When BP improves, an inodilator (dobutamine, milrinone, and nitroglycerine) is
added to improve tissue perfusion.
o When hypotensive with a high CO and low SVR (warm shock), then norepinephrine
is the vasopressor of choice.
Step 3: Early goal-directed therapy
All four goals to be met for success:
o Normal MAP (>60 mmHg).
o Mixed venous saturation >70%.
o Urine output >1 mL/kg/h.

162
o CVP >8–12 cm H2O.
Step 4: Give antibiotics within the first hour and control the source
 Every attempt should be made to get appropriate cultures earlier, but this should not
hold up the administration of the drug.
 The choice should be on the basis of the site of infection and local patterns.
 A broad-spectrum antibiotic like a third-generation cephalosporin should be used.
 De-escalate antibiotics once the culture results are available.
Step 5: Mechanical ventilation and sedation
 This step should be considered in any patient who is not rapidly stabilized with fluid
resuscitation and peripherally administered inotropes.
Step 6: Give steroids
 If at risk of absolute adrenal insufficiency (e.g., purpura fulminans, congenital adrenal
hyperplasia, prior recent steroid exposure as in asthma, or nephrotic syndrome) and
remains in shock despite epinephrine or norepinephrine infusion, fluids and inotropes
are optimized for an hour (catecholamine resistant shock).
 Hydrocortisone as an intermittent or continuous infusion at 2 mg/kg 6-hourly till
hemodynamic stability is achieved.
Step 7: Glucose control
 D5 or D10 for maintenance along with insulin and insulin is titrated to keep blood
glucose between 100 and 150 mg/dL. Hyperglycemia should not be treated by reducing
fluid concentrations to glucose-free fluids and removing insulin as there is poor glucose
utilization and insulin is needed.

163
Table: Initial Intravenous Pediatric Dosages of Antibiotics for Empiric Treatment of Complicated
Intraabdominal Infection
Antibiotic pediatric Dose Frequency of
Admonistration
B lactam/b-lactamase inhibitor combination
 Piperacillin tazobactam 200–300 mg/kg/day of
piperacillin component
Every 6–8 h
Carbapenems
 Ertapenem
 Imipenem/cilistatin
 Meropenem
15 mg/kg twice daily
60–100mg/kg/day
60mg/kg/day
Every12 h
Every 6 h
Every 8 h
Cephalosporins
 Cefepime
 Cefotaxime
 Cefoxitin
 Ceftazidime
 Ceftriaxone
 Cefuroxime
100 mg/kg/d
150-200 mg/kg/d
160 mg/kg/d
150 mg/kg/d
50-75 mg/kg/d
150mg /kg/d
Every 12 h
Every 12 h
Every 6–8 h
Every 4–6 h
Every 8 h
Every 12-24 h
Every 6–8 h
Tigecycline 100 mg initial dose, then 50
mg every 12 h
Fluoroquinolones
 Ciproﬂoxacin 20-30 mg/kg/d Every 12 h
Metronidazole 6 mg/kg/d Every 8 h
Clindamycin 20-40 mg/kg/d Every 6–8 h
Aminoglycosides
 Gentamicin or tobramycin
 Amikacin
3–7.5 mg/kg/d
15–22.5mg/kg/d
Every 2-4 h
Every 8–24 h
Aztreonam 90-120 mg/kg/d Every 6–8 h
Vancomycin 40 mg/kg Every 6–8 h

164
Figure 40: Algorithm for time-sensitive, goal-directed management in children with severe
sepsis

165
References
1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL,
Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM,
Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL,
Moreno R; Surviving Sepsis Campaign Guidelines Committee including the Pediatric
Subgroup. Surviving sepsis campaign: international guidelines for management of severe
sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
2. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis.
International pediatric sepsis consensus conference: definitions for sepsis and organ
dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6:2-8.

166
Nutrition
Energy requirement according to the status of patient
Nutrition screening
 Nutritional assessment of critically ill children should be conducted within the first 24 to
48 hours and then at least weekly.
 It should include
o Weight for age and height/length for age for infants <2 years of age. (see length for
age and weight for age chart)
o Body mass index for children >2 years of age (see BMI chart)
 Risk of malnutrition include
o Infant < 2 years
 Weight for age <3rd percentile
 Height/length for age <3rd percentile
o Children ≥ 2 years
 Underweight children with body mass index (BMI) <5th
percentile for age
 Overweight children with BMI >95th
percentile for age
 Children with a >10% weight loss during their ICU stay
 Children unable to consistently meet their recommended energy and protein
requirements during PICU stay
o Infant and children on the ventilator for > 7 days
o Children requiring significant inotropic support or those on muscle relaxants for
greater than 7 days
Determining Calorie and Protein Needs in Critically Ill Children
3. Estimate basal energy needs (BEE)
Age 1 wk to 10 mo Age 11 to 36 mo Age 3 to 16 yr
Metabolic Rate Metabolic Rate Metabolic Rate
Weight (kcal/day) Weight (kcal/day) Weight (kcal/day)
(kg) Male or Female Male Female (kg) Male Female
3.5 202 9.0 528 509 15 859 799
4.0 228 9.5 547 528 20 953 898
4.5 252 10.0 566 547 25 1046 996
5.0 278 10.5 586 566 30 1139 1092
5.5 305 11.0 605 586 35 1231 1190
6.0 331 11.5 624 605 40 1325 1289
6.5 358 12.0 643 624 45 1418 1387
7.0 384 12.5 662 646 50 1512 1486
7.5 410 13.0 682 665 55 1606 1584
8.0 437 13.5 701 684 60 1699 1680

167
8.5 463 14.0 720 703 65 1793 1776
9.0 490 14.5 739 722 70 1886 1874
9.5 514 15.0 758 741 75 1980 1973
10.0 540 15.5 778 760
10.5 566 16.0 797 782
11.0 593 16.5 816 802
4. Determine Stress Factor: Total Calories = BEE X Stress Factor
Clinical Condition Stress Factor
Maintenance without Stress
Fever
Routine/elective surgery, minor sepsis
Cardiac failure
Major surgery
Sepsis
Catch-up Growth
Trauma or head injury
1.0 - 1.2
12% per degree > 37 C
1.1 - 1.3
1.25 - 1.5
1.2 - 1.4
1.4 - 1.5
1.5 - 2.0
1.5 - 1.7
5. Estimate patient's protein requirements
Age g/kg/day
0-6 months 2-3
7-12 months 2-3
13-23 years 2-3
24 months-3 years 1.5-2
4-13 years 1.5-2
14-18 years 1.5
Enteral nutrition in ICU
Timing
 Infants and malnourished children: initiate nutrition, preferably from the enteral route,
within 48 hours of admission.
 For older children and those identified to have had good nutritional status prior to
admission: initiate nutrition, within 48 - 96 hours of admission.
 Critically ill children who are unable to achieve full enteral feeds in a timely manner and
require parenteral nutrition (PN) for the majority of their nutritional support will benefit
from the initiation of trophic feedings

168
o Trophic feedings are typically defined as minimal EN provided at less than 25% of
energy needs for the purpose of stimulating the GI tract.
 Contraindication to EN
o Escalating vasoactive or inotropic support
o Hemodynamic instability with ongoing volume resuscitation
o Suspected or confirmed necrotizing enterocolitis or intestinal ischemia
o Mechanical bowel obstruction
o Significant gastrointestinal bleeding
Routes
 Nasogastric, orogastric, and transpyloric or nasoduodenal feedings. No preference of
one method over another.
 EN may be administered via either continuous or intermittent delivery methods in
pediatric who have normal gastric emptying with no gastric distension
 Feeds are switched over to continuous feedings only for those children who do not
tolerate the intermittent or bolus schedule
Methods
 Continuous feeding: initiate at 0.5-1 mL/kg/hr or 25/hr maximum
 After 4 hours measure gastric residual volume (GRV) and assess sign of intolerance
 If GRV > 3ml/kg o evidence of intolerance, hold for 1 hour and reassess and if still there
is sign of intolerance hold for 4 hours
 If GRV < 3ml/kg, advance by 0.5-1.0 mL/kg/4-6 hrs and assess sign of intolerance
 Signs and symptoms of intolerance
o Vomiting: 2 or more episodes/24 hours
o Abdominal discomfort
o Abdominal distension - 2 consecutive increases of AG in 24 hrs; or AG increase >
2 cm in very low birth weight (VLBW) infants.
o Diarrhea: 3 or more episodes of loose stool in 24 hours
Risk Factors of aspiration
 Previous history of aspiration
 Altered intestinal motility
 Delayed gastric emptying
 Witnessed regurgitation or aspiration of gastric contents
 Severe gastro-esophageal reflux disease
 Altered mental status with depressed gag and cough reflexes
 Persistent vomiting (2 or more episodes in a 24-hour period)
 Severe bronchospasm
 Noninvasive ventilation (escalating or high settings)

169
Age/Weight Initial Infusion Rate Daily Increases Goal Rate
2.0 - 15 kg 2 - 15 cc/hr
(1 cc/kg/hr)
2 - 15 cc/hr q 4 - 8 hr
(1 cc/kg)
15 - 55 cc/hr
16 - 30 kg 8 - 25 cc/hr
(0.5 - 1 cc/kg/hr)
8 - 16 cc/hr q 4 - 8 hr
(0.5 cc/kg)
45 - 90 cc/hr
30 - 50 kg 15 - 25 cc/hr
(0.5 cc/kg/hr)
15 - 25 cc/hr q 4 - 8 hr
(0.5 cc/kg)
70 - 130 cc/hr
> 50 kg 25 cc/hr 25 cc/hr q 4 - 8 hr 90 - 150 cc/hr
Intermittent Tube Feeding Progression
Age/Weight Initial Volumes Daily Increases Goal Volume
2.0 - 15 kg 5 - 30 cc q 3 - 4 hr 5 - 30 cc q 6 - 8 hr 50 - 200 q 4 hr
12 - 30 kg 20 - 60 cc q 4 hr 20 - 60 cc q 6 - 8 hr 150 - 350 cc q 4 hr
30 kg 30 - 60 cc q 4 h 30 - 60 cc q 6 - 8 hr 240 - 400 cc q 4 hr

170
Parenteral nutrition (PN) in ICU
Timing of PN
 If enteral feeds cannot be started, PN should be started by Hospital Day 3 in infants or
previously malnourished patients and by Hospital Day 5 in previously well nourished
children.
Initiation and advancement
 Parenteral dextrose
o Begin PN at 10 - 15% dextrose depending on whether the line is peripheral or
central and the clinical status and age of the child.
o Advance by 2.5 - 5% in older infants and children and by 5 - 10% per day in
adolescents until an endpoint of D12.5% dextrose for PPN or generally between
20 - 25% dextrose for CPN, as needed to meet nutritional needs (see table
below).
o Glucose infusion rate (GIR)
(
% 𝑑𝑒𝑥𝑡𝑟𝑜𝑠𝑒 𝑋 𝑉𝑜𝑙𝑢𝑚𝑒
𝑊𝑒𝑖𝑔ℎ𝑡
)/1.44
 Example: 10% dextrose with rate 30ml/H (720ml total volume) for 10 kg patient:
(
(0.1 𝑋 720
10
)/1.44 = 5
 GIR should not exceed 12.5 mg/kg/min in term infant
Age Initiate Advance Maximum
< 1 yr 6-9 mg/kg/min 1-2 mg/kg/min Goal: 10-12mg/kg/min
Max: 12.5mg/kg/min
1-10yr 1-2mg/kg/min 1-2mg/kg/min Max: 8-10mg/kg/min
>10 yrs (adolescence) Max: 8-10mg/kg/min Max: 8-10mg/kg/min Max: 5-6mg/kg/min
 Parenteral Amino acid
o Initiation and advancement as shown in table below
< 1 yr 1-2 g/kg/day 1 g/kg/day 4 g/kg/day
1-10 yr 1-2 g/kg/day 1 g/kg/day 1.5-3 g/kg/day
>10 yrs (adolescence) 1g/kg/day 1g/kg/day 0.8-2.5g/kg/day

171
 Parenteral lipid
o Initiation and advancement as shown in table below
o Goal is dependent on total kcal goal
o We should not exceed 60% of total caloric intake via lipid
o Maximum lipid clearance 0.15 g/kg/hr
< 1 yr 1 g/kg/day 1 g/kg/day 3 g/kg/day
1-10 yr 1 g/kg/day 1 g/kg/day 2-3 g/kg/day
>10 yrs (adolescence) 1g/kg/day 1g/kg/day 1-2.5g/kg/day
 Parenteral electrolytes
Electrolyte Preterm/Neonates Infant/Children Adolescence/Children
>50 kg
Sodium (mEq) 2-5meq/kg 2-5meq/kg 1-2meq/kg
Potassium (mEq) 2-4meq/kg 2-4meq/kg 1-2meq/kg
Calcium (mEq) 2-4meq/kg 0.5-4meq/kg 10-20meq/day
Phosphate (mEq) 1-2mmol/kg 0.5-2mmol/kg 10-40mmol/day
Magnesium (mEq) 0.3-0.5meq/kg 0.3-0.5meq/kg 10-30meq/day
Chloride (mEq) As needed to maintain acid-base balance
Selenium (mcg) 1 - 2 mcg/kg/day

172
Figure 41: Stepwise algorithm for initiating and advancing enteral nutrition in critically ill
pediatric patients.

173
References
1. Mehta, N., Compher, C., & ASPEN board of directors. (2009). A.S.P.E.N. clinical
guidelines: nutrition support of the critically ill child. Journal of Parenteral and Enteral
Nutrition, 33(3), 260-76.
2. Mehta, N., & Duggan, C. (2009). Nutritional deficiencies during critical illness. Pediatric
Clinics of North America, 56, 1143-1160.
3. Rogers, E.J., Gilbertson, H.R., Heine, R.G., Henning, R. (2003). Barriers to adequate
nutrition in critically ill children. Nutrition, 19:865-8.
4. Sy, J., Gourishankar, A., Gordon, W.E., Griffin, D., Zurakowski, D., Roth, R.M., Coss-Bu, J.,
Jefferson, L., Heird, W., Castillo, L. (2008). Bicarbonate kinetics and predicted energy
expenditure in critically ill children. American Journal of Clinical Nutrition, 88:340-7
5. Hamilton S, McAleer DM, Ariagno K, Barrett M, Stenquist N, Duggan CP, Mehta NMA
stepwise enteral nutrition algorithm for critically ill children helps achieve nutrient
delivery goals. Pediatr Crit Care Med. 2014 Sep;15(7):583-9

174
Mechanical ventilation
Figure 42: Indication and initial setting of mechanical ventilation

175
Acute respiratory distress syndrome in pediatrics
General principles
 Although the overall incidence of pediatric ALI is low, the mortality in this population
remains high, ranging from 22% to 35%
 The definition of ARDS for infants (older than one month of life), children, and
adolescents are essentially identical to those for adults.
 There are intrinsic differences between pediatric patients and adults, which often can
affect management strategies which could be summarized as follow:
o More compliant chest wall
o Higher sedation requirement
o Higher baseline airway resistance
o Low functional residual capacity
 Although the definitive management of ARDS is protective lung strategy, the data for
infant and children are lacking
Clinical Management strategy
Initial setting
Tidal volume
 6-8 mL/kg predicted body weight.
Pressure
 Because many pediatric patients are still ventilated with uncuffed endotracheal tubes,
measuring the plateau pressure is not always possible.
 Maintain peak airway pressure < 30 cmH2O
 Minimum PEEP was set at 8-10 cmH2O
Initial inspiratory time
 For infant: 0.4-0.65 s
 For children: 0.5-0.75 s
 For adolescence: 0.7-1:0 s
Initial inspiratory rate:
 For infant: 25-30 breath/min
 For children: 20-25 breaths/min
 For adolescence: 15-20 breaths/min
Subsequent strategies
 Assess oxygenation and ventilation

176
o PIP, mean airway pressure, and oxygenation index
 If adequate, continue the previous setting
o PIP< 30 cmH2O
o Mean airway pressure < 17 cmH2O
o Oxygenation index < 15
 If not adequate, consider
o Recruitment manoeuver
o Prone position
o Airway pressure release ventilation
o Extracorporeal lung oxygenation (ECMO)
Figure 43: Algorithm of ARDS management in pediatrics

177
Figure 44: Recruitment manoeuver in critically ill pediatric patients

178
Weaning of mechanical ventilation in pediatrics
General principles
 Weaning should start when
o The underlying disease process is improving
o Gas exchange is adequate
o No conditions exist that impose an undue burden on the respiratory muscles, such
as cardiac insufficiency, severe hyperinflation, severe malnutrition, and multiple
organ system failure;
o The patient is capable of sustaining spontaneous ventilation as ventilator support is
decreased without expending an excessive amount of energy.
Assessment of readiness to wean
 Alert mental status
 Good cough and gag reflexes
 Core temperature below 38.5° C
 Spontaneous respiratory effort
 pH 7.32–7.47
 PaO2 >60 mm Hg or pulse oximetry reading >95%
 Fio2 ≤ 0.50
 PEEP ≤7 cm H2O
 PaCO2 <50 mm Hg
 No further need for vasoactive agents
 No clinical need for increased ventilator support in the past 24 hours
 No planned operative procedures requiring heavy sedation in the next 12 hours
Spontaneous breathing trial
 The SBT can be conducted through
o Ventilator
Use pressure support (PS) ventilation. The minimal PS is adjusted according to
size of endotracheal tube
 PS 10 cmH2O for ET 3-3.5 mm
 PS 8 cmH2O for ET 4-4.5 mm
 PS 6 cmH2O for ET ≥ 5 mm
The advantage is patient safety as patient is not disconnected from ventilator
with monitoring of tidal volume and respiratory rate
o T-Piece

179
 Deliver oxygen enriched gas at high flow rate through a horizontal arm of the T-
shaped circuit
 Protocol for SBT
o Allow 30 to 120 minutes of initial trial of spontaneous breathing
o SBT is considered failure when patients develop respiratory, cardiovascular, or
neurological disability.
 Criteria of failure of SBT
o Inability to maintain gas exchange
 Pulse oximeter saturation < 95% with 40% inspired oxygen
 Needing > 50% inspired oxygen to maintain oxygen saturation > 95%
o Inability to maintain effective ventilation
 Measure exhaled tidal volume < 5 mL/kg
 An increase in PaCO2 > 5 mmHg or an increase of >10 mmHg
 Respiratory acidosis with PH < 7.3
o Increased work of breathing
 Respiratory rate outside of acceptable range for age
 <6 months: 20–60 breaths/min
 6 months to 2 years: 15–45 breaths/min
 2–5 years: 15–40 breaths/min
 >5 years: 10–35 breaths/min
 Use of accessory respiratory muscle
o Other signs of respiratory distress
 Diaphoresis
 Anxiety
 Heart rate > 90th
percentile for a given age
 Change in mental status
 Failure of SBT
o Increase ventilator setting to previously tolerated level or higher if necessary until
patient stable again and wait 24 hours before trying again
o Search for potential reversible etiology

180
References
1. Ira M Cheifetz. Pediatric Acute Respiratory Distress Syndrome. [Respir Care
2011;56(10):1589–1599.
2. Pablo Cruces, MD Alejandro Donoso, MD, Jorge Valenzuela, FrancoDı´az. Respiratory
and Hemodynamic Effects of a Stepwise Lung Recruitment Maneuver in Pediatric ARDS:
A Feasibility Study. Pediatric Pulmonology 48:1135–1143 (2013)

181
Obstetrics critical care
General principles
 Initial evaluation and resuscitation of the obstetric patient should focus on airway,
breathing and circulation.
 Immediate assessment of gestational age is necessary because of potential aorto-caval
compression from the pregnant uterus if >20 weeks gestation.
Respiratory distress in pregnant patient
Causes:
I. Pulmonary causes:
a. Pulmonary oedema
i. Pre-eclampsia/Eclampsia
ii. Tocolytic-induced
iii. Acute respiratory distress syndrome
b. Aspiration (Mendelson’s syndrome)
c. Exacerbation of an underlying pulmonary disorder (e.g. asthma)
d. Pneumomediastinum/pneumothorax
e. Pneumonia
II. Cardiovascular
a. Peripartum cardiomyopathy
b. Pre-existing myopathic or valvular disease
c. Embolic disorder
i. Venous thromboembolism
ii. Amniotic fluid embolism
iii. Venous air embolism
d. Anaemia
i. Dilutional
ii. Haemorrhage
Hemodynamic instability
Causes
I. Obstetric haemorrhage (particularly post-partum) MOST IMPORTANT
II. Sepsis
III. Peripartum cardiomyopathy
IV. Amniotic fluid embolism
V. Pulmonary embolism

182
VI. Uterine rupture
VII. Epidural/spinal anaesthetic
Resuscitation of the hemodynamically compromized patient
 Establish large bore intravenous access and send blood for
o Complete blood count
o Urea, creatinine & electrolytes
o Liver function tests
o Acid-base analysis
o Coagulation screen
o Group/Type and crossmatch
 Interpretation of laboratory results in hemodynamic compromise requires a knowledge
of expected values in a normal pregnancy at a particular gestation
 Basic indicators of tissue perfusion include
o Level of consciousness (Glasgow coma score)
o Vital signs
o Urine output
o Acid-base status and lactate concentration
Altered mental status/neurological abnormalities
Causes:
 Complication of a pregnancy-specific illness:
o Eclampsia
o Acute fatty liver of pregnancy
o Amniotic fluid embolism
 Pre-existing medical condition that deteriorates during pregnancy:
o Hypertension (encephalopathy)
o Intracranial neoplasm
o Epilepsy
 Obstetric predisposition to particular medical conditions:
o Cerebral venous sinus thrombosis
o Hepatitis E infection
o Subarachnoid haemorrhage

183
Table 12: Expected values in a normal pregnancy
Parameter Non-
pregnant
Term pregnancy Impact on resuscitative care
PaO2 (mmHg) 100 103 A rightward shift of the maternal
oxyhemoglobin dissociation curve is a
compensatory mechanism to improve
fetal oxygenation
PaCO2 (mmHg) 40 30 Maintenance of materno-fetal CO2
gradient is important for ongoing fetal
CO2 excretion
HCO3 (mmol/L) 24 20 Decrease Buffering capacity, acidosis
more likely
White cell
count
4-11 6-16 Interpretation of trends in infection more
difficult
Creatinine 0.7-1.1 0.6-0.8 Seemingly normal renal indices may
indicate renal dysfunction in the
parturient
6.4-8.6 g/dL 4.8-6.4 g/dL Reduction in albumin:globulin
ratio, ↑free fraction of albumin-bound
medications ↓ Colloid oncotic pressure
Transaminase
levels -
unchanged.
Alkaline
phosphatase
markedly
elevated

184
Pre-eclampsia
Diagnosis
 Pre-eclampsia is a multisystem disease process. Two cardinal features must exist in
order to make the diagnosis:
o Presence of sustained hypertension
 Systolic blood pressure >140 mmHg
 Diastolic blood pressure >90 mmHg
o Proteinuria
 >300 mg protein in a 24-hour urine collection
 Severe pre-eclampsia is diagnosed by the presence of
o Systolic blood pressure >160 mmHg or diastolic blood pressure >110 mmHg on
two occasions at least 2 hours apart
o Proteinuria: >5 g in a 24hr collection
o Oliguria: <500 mL in 24hr
o Elevated serum creatinine
o Pulmonary oedema or cyanosis
o Persistent headaches
o Visual disturbances
o Seizures
Laboratory investigations are necessary to assess the severity of pre-eclampsia
 Complete blood count (to include platelet count)
 Blood urea nitrogen/serum creatinine/serum urate
 Liver function tests (bilirubin/transaminases)
 Coagulation profile
 Blood type (group) and antibody screen
 24 hour urine collection for protein if time permits
 Chest X-ray if respiratory compromise is present, may identify pulmonary edema
 Non-contrast CT brain or MRI brain if seizures occur, rule out intracranial
 Pathology
Management
 Fluid Balance
o Increased risk of fluid overload and pulmonary oedema that exists secondary to
reduced colloid oncotic pressure
o No evidence that colloid replacement in pre-eclampsia is superior to crystalloid
except perhaps in cases where there is renal or cardiopulmonary compromise
 Blood pressure control

185
o The goal of antihypertensive treatment is prevention of potential complications
such as stroke (intracerebral haemorrhage), cardiac failure and placental
abruption
o The threshold for treatment is a diastolic blood pressure (DBP) >110 mmHg
and/or systolic blood pressure (SBP) >160 mmHg.
o Slow but steady reduction of SBP to 140-160 mmHg and DBP to 80-110 mmHg
with constant fetal monitoring (fetal heart rate) is required
o Drugs commonly used in the acute setting for blood pressure control include
 labetalol may be administered in bolus form (20-40 mg) I.V. to a
maximum of 220 mg with or without a continuous infusion (1-2 mg/min)
 Hydralazine can be given in 5mg aliquots every 20 minutes to a maximum
of 40 mg.
 Angiotensin-converting enzyme (ACE) inhibitors and angiotensin -2
receptor blockers are both CONTRAINDICATED in the acute management
of pre-eclampsia secondary to their potential to cause neonatal renal
failure and also secondary to their relatively delayed onset of action (1–4
hours)
 Seizure prophylaxis
o A standard prophylactic and therapeutic MgSO4 regime includes:
o Loading dose of 4-6 g over 15 min intravenously
o Maintenance infusion of 1-2 g/hr
o Target serum concentration of magnesium: 2-3.5 mmol/L (4.8–8.4 mg/dL)
o Monitoring of magnesium levels
 HELP syndrome
o Laboratory investigations and results consistent with HELLP include:
 Peripheral blood smear
 Presence of burr cells and/or schistocytes indicates
microangiopathic haemolytic anaemia
 Reduced serum haptoglobin levels, elevated serum bilirubin and LDH
>600 IU/L are consistent with haemolysis
 Presence of thrombocytopaenia (Platelet count L)
 Elevated liver function tests
 Aspartate aminotransferase (AST) and alanine aminotransferase
(ALT) > 70 IU/L
o A differential diagnosis for HELLP syndrome should include:
 Acute fatty liver of pregnancy
 Acute hepatitis
 Autoimmune thrombocytopenic purpura

186
 Thrombotic thrombocytopenic purpura
 Haemolytic-uremic syndrome
o Management
 Delivery of the baby
 Supportive management

187
References
1. Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet 2010; 376:
631-644
2. Engelhardt T, MacLennan FM. Fluid management in pre-eclampsia. Int J Obstet Anesth
1999; 8: 253-259
3. Fujitani S, Baldisseri MR. Hemodynamic assessment in a pregnant and peripartum patient.
Crit Care Med 2005; 33: S354-361.
4. Vidaeff AC, Carroll MA, Ramin SM. Acute hypertensive emergencies in pregnancy. Crit Care
Med 2005; 33: S307-312
5. Altman D, Carroli G, Duley L, Farrell B, Moodley J, Neilson J, et al; Magpie Trial
Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from
magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet
2002; 359

188
Peripartum cardiomyopathy
 The diagnosis of peripartum cardiomyopathy requires the presence of the following four
criteria:
o Development of cardiac failure in the last month of pregnancy or within 5
months of delivery (~78% of cases)
o Absence of any other identifiable cause for the cardiac failure
o Absence of heart disease prior to last month of pregnancy
o Echocardiographic evidence of reduced left ventricular function
 Ejection fraction <45% and/or
 Fractional shortening <30%
 End-diastolic dimension >2.7 cm/m2
 Laboratory investigations include:
o Electrocardiogram
o Chest X-ray
o Laboratory Investigations:
 Full blood count
 Renal profile
 Liver function tests
 Coagulation profile
 Cardiac enzymes/troponin
 Arterial blood gas
 B-type natriuretic peptide
o Transthoracic echocardiogram
 Management
o Optimisation of preload
 Salt and fluid restriction +/- diuretics
 Continuous venovenous haemofiltration may be required in cases
refractory to more conservative measures.
o Reduction in afterload
 Vasodilators such as nitroglycerine and/or hydralazine
o ACE inhibitors are contraindicated antepartum due to potential teratogenic
effects but are safe in post-partum and in breast feeding mothers.
o Hemodynamic support
 Determined by severity of presentation and response to initial
interventions. Inotropic and/or vasopressor support may occasionally be
required.
o Antiarrhythmic therapy should follow normal protocols..

189
o Anticoagulation should be considered in all patients with peripartum
cardiomyopathy because of increased risk of venous thrombo-embolism.
o Immunosuppressive (if myocarditis proven on biopsy) or immunomodulatory
therapy may be beneficial in patients when standard treatment has not yielded
an adequate response.

190
References
1. Sliwa K, Blauwet L, Tibazarwa K, Libhaber E, Smedema JP, Becker A, et al. Evaluation of
bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-
concept pilot study. Circulation 2010; 121: 1465-1473.
2. Habedank D, Kühnle Y, Elgeti T, Dudenhausen JW, Haverkamp W, Dietz R. Recovery from
peripartum cardiomyopathy after treatment with bromocriptine. Eur J Heart Fail 2008; 10:
1149-1151.
3. Jahns BG, Stein W, Hilfiker-Kleiner D, Pieske B, Emons G. Peripartum cardiomyopathy–a
new treatment option by inhibition of prolactin secretion. Am J Obstet Gynecol 2008; 199:
e5-6

191
Hemorrhage during pregnancy
 Obstetric blood loss is defined as significant if greater than 1000 mL and major if greater
than 2500 mL and/or the transfusion of five or more units of blood and/or requiring
treatment for coagulopathy.
Management
 Initial patient evaluation and management should follow the ‘ABCDE’ approach with
early establishment of large bore intravenous access and immediate commencement of
fluid resuscitation
 Appropriate monitoring of patients requiring massive transfusion includes:
o Invasive blood pressure
o Central venous pressure
o Urinary output
o Body temperature
o Periodic arterial blood gas analysis
o Periodic coagulation assessment
o Electrolyte and lactate analysis
 Oxytocin is administered in bolus form, up to 10 IU and also as an infusion usually at a
rate of 10 IU/hour.
 Parenteral administration of ergometrine (0.2 mg) results in alpha-adrenergic
stimulated contraction of uterine smooth muscle
 Tranexamic acid 1 gm IV to be repeated after 4 hours.
 Recombinant factor VIIa is not recommended by the World Health Organization as a
validated therapeutic strategy for PPH

192
References
1. Snegovskikh D, Clebone A, Norwitz E. Anesthetic management of patients with placenta
accreta and resuscitation strategies for associated massive hemorrhage. Curr Opin
Anaesthesiol 2011; 24: 274-281.
2. Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet
Gynaecol 2010; 24: 353–365.
3. Wise A, Clark V. Strategies to manage major obstetric haemorrhage. Curr Opin
Anaesthesiol 2008; 21(3): 281-287

193
Trauma In Pregnancy
Airway and breathing
 All pregnant trauma patients should receive supplemental oxygen, because the fetus is
extremely sensitive to hypoxia.
 In general, pregnancy does not affect the decision to intubate. The use of medications for
rapid-sequence intubation in pregnancy is not well studied; however, no absolute
contraindications exist.
 If a chest tube is placed, enter the chest 1 or 2 interspaces higher than usual, because the
diaphragm is elevated during pregnancy.
Circulation
 Resuscitate the patient with warmed crystalloid administered through large-bore
catheters placed for intravenous lines, because as the relative hypervolemia of pregnancy
allows for a 30-35% loss of blood volume before hypotension develops.
 Rule out occult sources of bleeding, because maternal blood flow is maintained at the
expense of fetal blood flow.
 If blood is needed on an emergency basis, use Rh-negative blood unless the patient’s Rh
status is known.
 Avoid supine hypotension syndrome, which occurs when the gravid uterus compresses
the inferior vena cava by placing rolled towels beneath the spinal board and tilting the
patient to the left by 15°.
 If warranted, fetal heart tones may be auscultated as part of the initial fetal assessment
and to reassure the mother.
Lab Studies
 Determination of CBC: Pregnancy-induced leukocytosis peaks to levels of 12,000-18,000
per cubic millimeter during the third trimester. During labor, levels as high as 25,000 per
cubic millimeter may occur.
 Determination of electrolyte and glucose levels.
 Blood typing and cross matching.
 Rhesus (Rh) blood group determination (administer RhoGAM if the mother is Rh
negative).
 Urine pregnancy testing, if the status is unknown in female of reproductive age with
trauma
 Urinalysis
 Assessment of coagulation profile
 Toxicology screening
 D-dimer testing helps in determining the course of action for placental abruption.

194
Imaging Studies:
 Radiologic examinations should not be deferred because of the presence of the fetus.
 The risk of teratogenesis is greatest from week 1-15 of gestation.
 Exposure to ionising radiation is expressed in terms of the rad and fetal exposure to <5
rad is considered safe (see below)
 Ultrasonography
o Assess fetal viability.
o Assess for multiple gestations.
o Assess the size, gestational age, and position of the fetus.
o Ultrasonography can depict free intraperitoneal fluid or hemorrhage in the
mother.
 MRI: No report of adverse effects.
Blunt Abdominal Trauma
 Placental Abruption: Over 50% of fetal losses are due to placental abruption (usually
occurs within 6 hours of the event). Classic triad of frequent contractions, bleeding and
abdominal pain occurs in fewer than half of cases. Ultrasound will identify placental clot
only 50% of the time. If mother is hypotensive without a source, consider abruption.
 Uterine Rupture: Not common. Classic presentation is searing pain, abnormalfetal heart
rate, and transabdominal palpation of fetal parts
 Fetal-Maternal Hemorrhage: Defined by fetal blood cells in the maternal circulation.
 All pregnant trauma patients with Rh (-) blood type should receive a vial of RhoGam
within 72hrs.
Table 13: Fetal exposure during radiological examination of pregnant patient
Procedures Fetal dose (millirad)
Chest X-ray <1
Cervical spine plain film < 1
CT Thorax 30-1300 (mean 600)
CT Abdomen 250
CT Head < 1000
Helical CT pulmonary angiogram (CTPA < 50
V/Q scan < 100
Barium enema 700 -1600

195
Reference
1. Cheng HT, Wang YC, Lo HC, Su LT, Lin CH, Sung FC, Hsieh CH. Trauma during pregnancy: a
population-based analysis of maternal outcome. World J Surg 2012; 36: 2767-2775
2. Raja AS, Zabbo CP. Trauma in pregnancy. Emerg Med Clin North Am 2012; 30: 937-948.
3. Brown HL. Trauma in pregnancy. Obstet Gynecol 2009; 114:147-160

196
Cardiac Arrest during pregnancy
Figure 45: Maternal Cardiac Arrest Algorithm (1)

197
Figure 46:Left uterine displacement technique (one-handed and two-handed)
Figure 47: Manual leftward uterine displacement-with resuscitation (2)

198
References
1. T. L. Vanden Hoek, L. J. Morrison, M. Shuster et al., “Part 12: cardiac arrest in special
situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care,” Circulation 2010; 122: S829–S861.
2. F. M. Jeejeebhoy, C. M. Zelop, R. Windrim, J. C. A. Carvalho, P. Dorian, and L. J. Morrison,
“Management of cardiac arrest in pregnancy: a systematic review,” Resuscitation 2011; 82.
801–809

199
Pharmacotherapy
Anticoagulant
Table: Anticoagulants
Warfarin
 Variable dose ∝ INR
 See age-adjusted Warfarin loading protocol below
 Daily INR
Heparin
(infusion)
 25000u/50ml = 500u/ml
 See below: titrate against APTT:
 Cease 4-6 hours prior to surgical procedures
Heparin (sub cut)
 5000 u sub cut bd <70 kg
 5000 u subcut 8 hrly >70 kg or high risk DVT
Enoxaparin
(Clexane®)
 Prophylaxis:
40mg subcut daily
20mg subcut daily if Creat clearance < 30ml/min
 Treatment:
1mg/kg subcut bd - lean body mass
1mg/kg subcut once daily if Creat clearance
<30ml/min
Fondaparinux
(Arixtra)
 Prophylaxis:
2.5 mg subcut daily
 Treatment
< 50 kg 5 mg sc
50-100 7.5 mg sc
> 100 kg 10 mg sc
Heparin Infusion
Table: Heparin infusion protocol
Weight (kg) 45-55 56-65 66-75 76-85 86-95 >95
Bolus (U) 3,500 4,200 4,900 5,600 6,300 7,000
Infusion (U/hr) 900 1,100 1,250 1,400 1,600 1,800
Infusion adjustment
APTT IV bolus Stop Infusion Rate Change Repeat APTT
< 37 5,000 units ↑ 400u/hr 6 hrs
38-64 ↑ 200u/hr 6 hrs
65-110 No change Daily
111-130 ↓ 50u/hr 6 hrs
131-140 30 min ↓ 100u/hr 6 hrs
141-150 60 min ↓ 150u/hr 6 hrs
>150
120 min or
APTT < 150
↓ 200u/hr 2 hrs
Note: Infusion: 25,000 units in 50ml syringe = 500U/ml
Check first APTT 6 hrs afcter bolus
dose

200
Warfarin Dosage
General principle
 Warfarin doses should be adjusted to achieve the target INR based on indication
as indicated below
 Loading doses of warfarin (i.e. 10 mg) should not be used
 Newly initiated warfarin (or re-initiation) should have daily PT/INR checks, beginning 2-3
days into therapy, until stable
 Patients with significant drug interactions or risk factors should be initiated on a
lower dose of warfarin
Thromboembolic risk factors
 Atrial fibrillation  Age < 70
 Left atrium enlargement  Prior thromboembolism
 Low left-ventricular ejection fraction  Hypercoagulable state

201
Goal and therapeutic INR range
Indication Target
INR
Range Duration of therapy
Treatment of VTE 2.5 2-3 3 months – lifetime
Atrial Fibrillation 2.5 2-3 Variable
Myocardial infarction
Antiphospholipid Syndrome 2.5 2-3 Lifetime
Aortic Valve Replacement (AVR) and/or Mitral Valve Replacement (MVR)
Bioprosthetic (tissue) Valve
• Aortic Valve (AVR)
• Mitral Valve (MVR)
2.5 2-3 3 months
Mechanical Prosthetic Valve
• Mitral Valve (MVR) – all
mitral valves with or
without risk factors for
thromboembolism1
• Aortic Valve (AVR)
o First generation aortic valve
(i.e. caged ball or caged disk)
o Modern aortic valve in a
patient with normal left
atrium and in sinus rhythm
o Modern aortic valve with
atrial fibrillation or other
risk factor(s) for
thromboembolism1
ƒ St. Jude medical bileaflet
ƒ Carbomedics bileaflet
ƒ Medtronic Hall tilting disk
3
3
2.5
3
2.5-3.5
2.5-3.5
2-3
2.5-3.5
Lifetime

202
Initiation and maintenance
Initiation of warfarin
Day INR Dosage
1 5 mg
2 or 3 < 1.5
1.5-1.9
2-2.5
> 2.5
5 mg
2.5 mg
1-2.5 mg
0 mg
4 < 1.5
1.5-1.9
2-2.5
2.5-3
> 3
5-10 mg
2.5-5 mg
0-2.5 mg
0-2.5 mg
0 mg
5 < 1.5
1.5-1.9
2-3
> 3
10 mg
5-7.5 mg
0-5 mg
0 mg
6 < 1.5
1.5-1.9
2-3
> 3
7.5-12.5 mg
5-10 mg
0-7.5 mg
0 mg
Maintenance of warfarin
INR Weekly dose change Dosage
< 1.1 Consider re-initiation
1.1-2.0 Consider increasing weekly
dose by 10-20%
2-3 Maintain same dose
3-3.9 Consider decreasing weekly
dose by 10-20%
>4 Consider holding a dose and
decreasing weekly dose by
20%
Points to remember in initiation therapy
 Check INR at least 4 times during the first
week of therapy
 User lower initial dose (2.5-5 mg) if
o Age > 75,
o Weight < 60 kg,
o Interacting medication known to
potentiate warfarin,
o Hepatic dysfunction,
o Severe heart failure,
o Renal dysfunction,
o Hypoproteinemia,
o Impaired nutritional intake, and
o Increase in baseline INR (INR > 1.4)
 Use higher initial dose (5-10mg) if: younger
patients, interacting medications known to
diminish warfarin effects, enteral nutrition,
and a diet rich in Vitamin K.
Points to remember in maintenance therapy
 If patient is on outpatient warfarin therapy,
use the home dosage as a guide when
continuing warfarin therapy in the hospital
 Monitor INR for medication administration
changes in interacting drugs, liver function
changes, cardiac function changes, and
changes in diet
 Once on therapy for > 1 week, dose
modifications between 5 to 20% are
recommended. Larger change overcorrect
abnormally high or low INR
 Recheck an INR within 4-6 days after
adjustment for abnormal INR.

203
Anticoagulant reversal
General Principles
 Management of anticoagulant associated bleeding should follow HASHTI
o Hold further doses of anticoagulant
o Consider Antidote
o Supportive treatment: volume resuscitation, inotropes as needed
o Local or surgical Hemostatic measures: topical agents (aminocaproic acid,
tranexamic acid)
o Transfusion (red cells, platelets, FFP as indicated)
o Investigate for bleeding source
 Reversal of anticoagulant can be classified into two main classes
o Reversal of Elevated INRs or bleeding patients on anticoagulant/platelet therapy
o Preoperative management of elevated INRs in patients on warfarin
Reversal of Warfarin
Reversal of Elevated INRs or bleeding patients on Warfarin
Condition Intervention
INR > goal but < 5
No significant bleeding
or risk of bleeding
Lower dose or omit next dose
INR ≥ 5 or < 9
AND
or risk of bleeding
 Preferred: Omit next 1-2 doses
 Alternatively, omit 1-2 doses and give Vitamin K (1-2.5 mg po)
 Alternatively for patients at high risk of thrombosis (i.e. valves), omit
1-2 doses and use FFP 2 units IV – DO NOT use Vitamin K
INR ≥ 9
AND/OR
Low-moderate risk of
Bleeding
 Hold warfarin therapy
 Give FFP 2 units IV
 Give Vitamin K (2.5-5 mg po)
 In patients with prosthetic heart valves, give FFP 2 units IV and
lower dose of Vitamin K (1-2.5mg po)
Serious bleeding at any
elevation of INR
AND/OR
High risk of bleeding
 HASHTI
 Give FFP 4 units IV
 Vitamin K 10mg by slow IV infusion
 May repeat FFP and Vitamin K as needed
 In patients with prosthetic heart valves, FFP is preferred over
Vitamin K; use only very low doses of Vitamin K (1mg by slow IV
infusion)

204
Preoperative management of elevated INRs in patients on warfarin
 Four doses should be omitted to reduce the INR to ≤ 1.5 in patients taking
warfarin with a target INR of 2.5
 Bridging protocol started with therapeutic doses of low molecular weight heparin
either 2 or 3 days in advance, and the last dose should be given 24 h before
 INR should be checked on the day before the procedure, enabling vitamin K to be
given if the INR is ≥ 1.5
 Postoperative bridging with therapeutic doses should not be restarted within 48–72 h
after high bleeding-risk procedures
 Reduced doses, or no bridging at all, should be considered until the bleeding risk has
subsided.
INR value Urgent Surgery or Procedure Elective Surgery or Procedure
(check algorithm below)
INR ≥ 1.5 but ≤ 1.9 Treatment with FFP  Stop 5 days prior to
procedure
 Check INR 1-2 days prior
o If INR >1.5 administer
vitamin K 1-2 mg PO
INR > 1.9 but ≤ 5 who require
reversal for a procedure
For rapid (< 12 hours) reversal:
FFP + Vitamin K 1-3 mg slow IV
INR > but < 9 who require
surgery
For rapid (< 12 hours) reversal:
FFP + Vitamin K 2-5mg slow IV
Figure 48: High-risk bridging guidance (3)

205
Reversal of low molecular weight heparin
Non urgent Urgent (not bleeding) Urgent (bleeding)
Hold day of procedure Wait 12-24 hr if possible HASHTI
Once daily regimen
Half dose day prior
Consider protamine sulfate
if delay not possible for high
bleeding risk procedure
Protamine sulphate
Twice daily regimen
Holding evening dose day prior
Consider recombinant factor VII
Protamine Dose for Reversal of Heparin and LMWH
Agent Half life Protamine sulphate dosing for reversal
Heparin 1-2 hr 1 mg per 90-100 units heparin given in previous
2-3 hours
• e.g., 25-35 mg if 1000-1250 units/hour heparin
Infusion
Enoxaparin 4.5 hours 1 mg per 1 mg Enoxaparin in previous 8 hours
Dalteparin 2.2 hours 1 mg per 100 units Dalteparin in previous 8 hours

206
New Oral Anticoagulants (NOACs)
General Principles
 The NOACs fall into two classes: the oral direct thrombin inhibitors (e.g. dabigatran) and
oral direct factor Xa inhibitors (e.g. rivaroxaban, apixaban, etc.)
 The pharmacokinetics and recommended dosages are explained in table below
Selection of patient groups for warfarin or the new anticoagulants
 For Warfarin
o Good level of control: patients already taking warfarin with excellent INR control
may have little to gain by switching to new oral anticoagulants
o Renal impairment: warfarin remains the treatment of choice for patients with a
calculated creatinine clearance close to or less than 30 mL/min
o Mechanical heart valve replacement
o Gastrointestinal diseases: patients with intestinal angiodysplasia, inﬂammatory
bowel disease, or diverticulosis, or those with a history of other forms of
gastrointestinal bleeding may experience a deterioration on treatment with new
oral anticoagulants
o Poor compliance: Patients with documented poor adherence to the treatment
with warfarin are particularly problematic when switched to new oral
anticoagulants.
o Drug cost
 For the new oral anticoagulants
o Unexplained poor warfarin control:
o Poor level of control because of unavoidable drug-drug interactions.
o New patients on anticoagulant therapy for atrial ﬁbrillation.

207
Drug interactions with at least 50% change in the exposure to dabigatran or rivaroxaban
Dabigatran Rivaroxaban
Mechanism Interacting drug ∆ exposure, % Interacting drug ∆ exposure, %
P-glycoprotein
inhibition
Ketoconazole 150 Ketoconazole 160
Quinidine 53
Amiodarone 60
Verapamil 50
P-glycoprotein
induction
Rifampicin -67 Rifampicin -50
CYP3A4 inhibition Ketoconazole 160
clarithromycin 50
Ritonavir 50
CYP3A4 induction Rifampicin -50
Conversion from warfarin to dabigatran or rivaroxaban
 Starting medication with dabigatran or rivaroxaban when warfarin has been
discontinued and the INR has decreased to less than 2.3
Conversion from dabigatran or rivaroxaban to warfarin
Calculated creatinine
clearance, mL/mi
Dabigatran: start day
with warfarin
Rivaroxaban: start
day with warfarin
>50 Day-3 Day-4
31-50 Day-2 Day-3
15-30 Day-1 Day-2
Dabigatran/rivaroxaban is stopped on day 0. The longer overlap with rivaroxaban is justiﬁed by its half-
life being shorter than that of dabigatran and by the concern about thromboembolic events shortly after
transitioning from rivaroxaban to warfarin

208
Periprocedural management of dabigatran or rivaroxaban
Preoperative management
Timing of interruption of dabigatran or rivaroxaban before surgery or invasive procedures (2)
Calculated creatinine
clearance, mL/min
Half-life, hours Standard risk of
bleeding*
High risk of bleeding†
Dabigatran
>80 13 (11-22) 24 h 2 d
>50-≤80 15 (12-34) 24 h 2 d
>30-≤50 18 (13-23) 2 d 4 d
≤30 27 (22-35) 4 d 6 d
Rivaroxaban
>30 12 (11-13) 24 h 2 d
≤30 Unknown 2 d 4 d
*Examples are cardiac catheterization, ablation therapy, colonoscopy without removal of large polyps,
and lab cholecystectomy
†Examples are major cardiac surgery, insertion of pacemakers or defibrillators (resulting from the risk
for pocket hematoma), neurosurgery, large hernia surgery, and major cancer/urologic/vascular surgery.
Postoperative management
 The time point for resumption of dabigatran or rivaroxaban depends almost exclusively
on the postoperative risk of bleeding.
o For major abdominal surgery or urologic surgery with incomplete hemostasis,
resumption should be delayed until there is no drainage or other evidence of
active bleeding.
o For procedures with good hemostasis shortly after the end of the procedure,
same evening a minimum of 4 to 6 hours after surgery.
 The dosage for dabigatran, should be started with a half dose (75 mg) for the first dose
 A similar strategy dose, for rivaroxaban where a 10-mg dose could be used as the first
dose.
 Patients with bowel paralysis may require bridging with a parenteral anticoagulants given
their inability to take their oral anticoagulant

209
Reversal of NOACs
Figure 49: Management of bleeding in patient taking NOACs (4)

210
References:
1. Bonow RO, Carabello BA, Chatterjee K, et.al. 2008 Focused update incorporated into the
ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a
report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management
of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular
Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. Circulation. 2008;118:e523-661.
2. Schulman S, Crowther MA. How I treat with anticoagulants in 2012: new and old
anticoagulants, and when and how to switch. Blood. 2012;119:3016-23
3. Van Veen JJ, Makris M. Management of peri-operative anti-thrombotic therapy.
Anaesthesia. 2015 ;70:58-e23
4. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P;
ESC Committee for Practice Guidelines-CPG; Document Reviewers. 2012 focused update of
the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC
Guidelines for the management of atrial fibrillation--developed with the special
contribution of the European Heart Rhythm Association. Europace. 2012;14:1385-413

211
Antimicrobial dosing in renal insufficiency
 Dosing recommendations can vary according to indication and patient-specific
parameters.
 All dosage adjustments are based on creatinine clearance calculated by Cockcroft-Gault
equation
𝐶𝑟 𝐶𝑙 =
(140 − 𝑎𝑔𝑒)(𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔)
72(𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒)
𝑋 0.85 (𝑖𝑓 𝑓𝑒𝑚𝑙𝑒)

216
Intravenous drug compatibility

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