Checklist for physicians may improve outcomes in cardiac ICU setting
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A checklist for cardiac ICU physicians, who often treat both cardiac and noncardiac conditions, may improve outcomes among patients admitted to a cardiac emergency care setting, according to a scientific statement published in Circulation.
“Patients admitted to cardiac intensive care often have serious, noncardiovascular conditions, such as lung, kidney or liver disease, increasing their risk for complications,” Christopher B. Fordyce, MD, MHS, MSc, assistant professor in the division of cardiology at the University of British Columbia and director of the cardiac ICU at Vancouver General Hospital, Canada, and chair of the statement writing group, said in a press release. “Cardiac patients require increasingly complex care, and it is important for cardiovascular health care professionals to be experts in treating both cardiovascular and noncardiovascular conditions, and to understand ways to prevent complications in the cardiac ICU.”
Prevention of infection
According to the statement, patients admitted to the cardiac ICU receive therapies that include invasive hemodynamic monitoring, short-term mechanical support, renal replacement therapy and targeted temperature management, which are associated with increased prevalence of catheter-associated urinary tract infection, central line-associated bloodstream infection, ventilator-associated pneumonia, multidrug-resistant pathogens and surgical site infections.
Steps to reduce the likelihood of infection include:
- Wash hands with soap and water before placement or manipulation.
- Ensure staff is adequately trained in sterile insertion using full barrier precautions.
- Use of 2% chlorhexidine solution with proper air drying before insertion.
- Avoid femoral site for catheterization.
- Promptly remove unnecessary catheters.
“A central tenet to preventing cardiac ICU complications is to anticipate the need for invasive procedures and devices to avoid emergency procedures when possible,” Fordyce said in the release. “Rates of infections and other complications are higher in urgent procedures.”
Pain management
“The clinical rationale for unit-based protocols for the timely identification and treatment of pain among critically ill patients is highlighted by the association between postdischarge memory of pain and the development of posttraumatic stress disorder and by the role of pain in the pathogenesis of ICU delirium,” the committee wrote. “We concur with the recommendations for pain assessment tools in adult critically ill patients published by the Society of Critical Care Medicine.”
The writing committee recommended all cardiac ICUs routinely assess for pain with validated instruments (numeric rating scale, behavioral pain scale or Critical-Care Pain Observation Tool) among patients with verbal or cognitive barriers.
In addition, pain should be treated before the administration of sedative-hypnotics, and treatment should be individualized based on the underlying cause of pain and patient comorbidities.
Prevention of ventilator complications
Within the cardiac ICU, some form of mechanical ventilation will be required in approximately 25% of cases. Although ventilation will be utilized when appropriate, according to the release, daily spontaneous breathing trials should be used for the early identification of patients who are ready to be taken off the ventilator.
Recommendations from the committee include:
- Routine tidal volume of 6 mL per kg to 10 mL per kg of ideal body weight in the cardiac ICU.
- Lower tidal volume suggested for patients at high risk for ventilator-associated lung injury or with established acute respiratory distress syndrome.
- Close monitoring of oxygenation and titrating supplemental oxygen to achieve oxygen saturation (SpO2) greater than 90% or partial pressure of oxygen (PaO2) greater than 60 mm Hg.
- PaO2 greater than 150 mm Hg should be avoided.
- Daily assessment of readiness for extubation on every patient undergoing mechanical ventilation.
Recommendation of early mobilization
“ICU-acquired weakness, defined as a clinically appreciable myopathic or neuropathic weakness that develops in the absence of other factors besides critical illness, occurs in as many as one-third of patients in the ICU and has been associated with decreased survival,” the committee wrote. “Bed rest is a major risk factor for ICU-acquired weakness. This has prompted many societies, including the Society of Critical Care Medicine and American College of Chest Physicians, to recommend early, progressive mobilization of patients in the ICU.”
Mobilization, defined as an intervention that facilitates movement and energy expenditure, can typically involve staged progression of passive range of motion, active range of motion, sitting, standing and ambulation, according to the statement.
Small, randomized studies suggested that early mobilization among patients in the cardiac ICU may minimize weakness, improve physical functioning, prevent delirium, decrease mechanical ventilation duration and shorten ICU length of stay, with no significant difference in mortality.
Nutrition and gastrointestinal complications
The committee estimated that approximately 38% to 78% of patients admitted to the cardiac ICU have malnutrition, which is associated with increased length of stay, readmission, infection and in-hospital mortality.
Therefore, early enteral nutrition (within 24 to 48 hours) is suggested in most patients who are unable to eat, and it may preserve gut mucosal integrity and prevent bacterial translocation, according to the committee.
“In general, parenteral nutrition should be avoided except in patients unable to meet > 60% of caloric requirements after 7 to 10 days via the enteral route,” the committee wrote. “Patients at high nutritional risk based on validated risk scores (eg, Nutritional Risk Score [Numeric Rating Scale 2002]) may be considered for earlier initiation of parenteral nutrition (within 24-72 hours) if they are unable to meet their caloric needs with enteral nutrition.”
In addition, stress ulcers or upper gastrointestinal tract ulcerations are common among patients in the ICU. Overt bleeding can occur in 2% to 4% of general ICU patients. Incidence of overt bleeding may be higher among patients in a cardiac ICU setting, where most are on antiplatelet medications or anticoagulants, according to the statement.
It recommended that stress ulcer prophylaxis may be reasonable among patients at risk for gastrointestinal bleeding, patients on dual antiplatelet therapy with high-risk features or those on triple antithrombotic therapy.
Prevention of medication complications and errors
“Medication errors (defined as an error at any point from ordering to administering medications) and adverse drug events (defined as patient harm resulting from exposure to a medication) are more common in the ICU and carry a greater likelihood of harm compared with such events in the non-ICU setting,” the committee wrote. “Cardiovascular medications and anticoagulants are the two most common medication classes associated with adverse events and medical errors in the ICU setting, highlighting the high-risk nature of medications routinely used in the cardiac ICU.”
Recent guidelines recommended the use of computerized physician order entry, bar code medication administration and smart IV infusion pumps may reduce the prevalence of adverse drug events. In addition, prior research found that the addition of pharmacists to the ICU rounding team may reduce the number of preventable adverse drug events.
Complications of device use
“The increasingly sophisticated diagnostic and therapeutic procedures that can be used in the cardiac catheterization laboratory or at the bedside have transformed cardiovascular care and potentially improved mortality,” the committee wrote. “However, with increased use come associated complications that relate both to the placement of the device and to its maintenance.”
For the prevention of device-related complications, the statement recommended that, whenever possible, procedures should be performed before they become an emergency. This includes routine ultrasound and fluoroscopic guidance.
In addition, the committee suggested prompt removal of any invasive catheter or mechanical circulatory support device when no longer needed.
Use of multidisciplinary care
“Multidisciplinary rounds, involving physicians from different specialties and other health care providers, not only improve the satisfaction of nurses and allied health professionals but also have been associated with improved outcomes,” the committee wrote.
For multidisciplinary care within the cardiac ICU setting, the statement recommended the following:
- Implement structured multidisciplinary rounds at a standard time and consider the use of daily goals-of-care checklists.
- Incorporate palliative care considerations into clinical decision-making and involve specialists in palliative care among the appropriate patients.
- Tertiary center cardiac ICUs should transition to cardiac-intensivist staffing through new hires and succession planning.
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