1 1 ICU Protocols Memphis VA Medical Center G. Umberto Meduri, M.D. W. Andrew Bell, Pharm.D., BCPS

2 2 The ICU Team ICU Attending Pulmonary and Critical Care Fellow –Internal Medicine Resident –Medicine Interns –Medicine Students ICU Pharmacist –Pharmacist Resident Critical Care Nurse Respiratory Therapist Nutritionist, Physical Therapist, Palliative Care

3 3 ICU Protocols 1.Antibiotic treatment of pneumonia 2.Antibiotic treatment for other infections 3.Fluid resuscitation and ScvO 2 -guided therapy 4.Vasopressors 5.Mechanical ventilation 6.Sedation and analgesia 7.Glucose control 8.Gastrointestinal and thromboembolic prophylaxis 9.Weaning from mechanical ventilation 10.Recombinant human activated protein C (rhAPC) 11.Prolonged glucocorticoid treatment in patients with shock 12.Prolonged glucocorticoid treatment in pts with severe ARDS

4 4 Guidelines ATS / IDSA Pneumonia Guidelines –2007 Community-acquired pneumonia –2005 Health care associated pneumonia Surviving Sepsis Campaign 2008 SCCM 2002 Analgesia, Sedation, & Neuromuscular Blockade Guidelines ASHP 1999 Stress Ulcer Prophylaxis Guidelines Chest 2008 DVT Prophylaxis Guidelines

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6 6 SEPSIS PROTOCOL

7 7 Severe Sepsis - Screening

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14 [continued] ScvO2 = central venous oxygen saturation

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19 C OVERAGE P REFERRED A GENTS O PTIONAL A GENTS Primary Gram - Anti-Pseudomonal β-L ACTAM Piperacillin/Tazobactam 4.5g Q 6h I F β-L ACTAM ALLERGY Aztreonam 2g, Q 6h Double Gram -Tobramycin 7 mg/kg/day* Ciprofloxacin 400mg Q 8h Optional MRSAVancomycin 20mg/kg Q12h** Linezolid 600mg Q 12h *Interval adjusted from Q 24h based on renal function to a trough < 1 **Interval adjusted from Q 12h based on renal function to trough of 15 to 20 N O β-L ACTAM ALLERGY β-L ACTAM ALLERGY Piperacillin/tazobactam 4.5g Q 6h ANDAztreonam 2g, Q 6 hours AND Azithromycin 500 mg/d AND Tobramycin 7 mg/kg/day* *Interval adjusted from Q 24h based on renal function to trough < 1 N O β-L ACTAM ALLERGY β-L ACTAM ALLERGY Ceftriaxone 2 gm /dAztreonam 2 gm q6h AND Azithromycin 500mg/dMoxifloxacin 400 mg/d CAP with Risks factors for Pseudomonas aeruginosa CAP with Risks factors for Pseudomonas aeruginosa Bronchiectasis Structural lung disease Repeated antibiotics Chronicglucocorticoiduse YES No Health Care Associated Pneumonia Nursing home Hospitalized last 90 days IV Rx Home wound care Hemo dialysis Within last 30 days YES

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22 ALI-ARDS PROTOCOL

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31 Gastrointestinal Prophylaxis On PPI at home Patient tolerates oral intake or enteral feeding Yes - oral intakeYes - enteral feedingNo Yes Continue home treatment Convert home regimen to Omeprazole suspension Pantoprazole 40mg IV at same schedule (QAM, BID) No Ranitidine Tablets 150mg BID* Ranitidine syrup 150mg BID* Ranitidine 50mg IV Q 8h* PPI = proton pump inhibitors; *Adjust Ranitidine interval to Q 24h if CrCl is < 50ml/min All patients enrolled in the study should receive stress ulcer prophylaxis (SUP) with either a H2 antagonist or PPI AJHP 1999; 56:

32 Thromboembolic Prophylaxis ICU DVT Prophylaxis Unless contraindicated, ICU pts should receive Intermittent Pneumatic Compression (IPC). Ambulatory patient admitted for < 72 hours.Immediately place IPC OR Not ambulatory patient, recent DVT, admitted for >72 hours without IPC placed. Obtain a duplex ultrasound LE to rule out DVT then place IPC. ANDNo evidence of recent or ongoing bleeding  add pharmacologic prophylaxis No Heparin allergy or recent orthopedic surg.Heparin 5,000 units SQ Q8H ORNo Heparin allergy and recent orthopedic surg.LMWH – prophylactic dose ORHeparin Allergy Fondaparinux 2.5mg SQ Q24H AVOID: < 50kg BW or CrCl < 30ml/min LMWH = Low molecular weight heparin

33 Albumin 5% 500ml over 30 min