Critical care

14 Critical care






Initial assessment: ABCDE


In any critically ill patient, assessment and resuscitation start with the airway, followed by breathing and circulation, the so-called ABC approach. Over time, this has been extended to include D for disability and E for exposure and examination.




Simultaneously feel for a carotid pulse and, if present, obtain a BP measurement as soon as practical. If there is no pulse, call for assistance, initiate chest compressions and follow basic and advanced life support algorithms (p. 704, 705). If there is a pulse, but no respiratory effort, call for assistance and supply rescue ventilation, ideally with a bag mask valve system connected to high-flow oxygen. Again, follow life support algorithms. If there is some respiratory effort, determine the adequacy by clinical examination, by attaching a pulse oximeter and, if practical, by obtaining an arterial blood gas (ABG) specimen. Be aware of the limitations of pulse oximetry, especially in hypotensive patients. Arterial blood needs to be sampled into an anticoagulated syringe and any air in the sample should be expelled before the sample is safely capped. The sample should be analysed immediately or transported in ice to minimize cellular metabolism in the sample from consuming oxygen and producing carbon dioxide.

The immediate management of cardiovascular and neurological abnormalities is discussed in later sections.



Guidelines for initial and daily patient assessment











General considerations for patient care in the critical care environment


Many of the items detailed below are being brought together in so-called care bundles. This approach has been shown to increase compliance.














Analgesia and sedation


Analgesia, with or without sedation, is an essential component of the holistic care of critically ill patients. With the exception of immediate life-saving interventions, patient comfort should be the priority. Ideally, patients should be calm, co-operative, and able to communicate and to sleep when undisturbed.




Guidelines










Table 14.1a Continuous infusion sedative analgesic regimens































Drug Regime Notes
Morphine Loading 5–15 mg
Maintenance 1–12 mg/hour
Slow onset. Long-acting. Active metabolites. Accumulates in renal and hepatic impairment
Fentanyl Loading 25–100 mcg
Maintenance 25–250 mcg/hour
Rapid onset. Modest duration of action. No active metabolites. Renally excreted
Alfentanil Loading 15–50 mcg/kg
Maintenance 30–85 mcg/kg/hour (1–6 mg/hour)
Rapid onset. Relatively short-acting. Accumulates in hepatic failure
Remifentanil Maintenance 6–12 mcg/kg/hour Rapid onset and offset of action, with minimal if any accumulation of the weakly active metabolite. Significant incidence of problematic bradycardia. Expensive
Clonidine Maintenance 1–4 mcg/kg/hour An α2 agonist. Has marked sedative and atypical analgesic effects
Ketamine Analgesia
Induction 0.2 mg/kg/hour
Maintenance 0.5–2.0 mg/kg 1–2 mg/kg/hour
Atypical analgesic with hypnotic effects at higher doses. Sympathomimetic; associated with emergence phenomena when given at hypnotic doses when usually co-administered with a benzodiazepine. Contraindicated in raised intracranial pressure

Table 14.1b Continuous infusion sedative regimens















Drug Regime Notes
Propofol 1% Loading 1.5–2.5 mg/kg
Maintenance 0.5–4 mg/kg/hour (0–200 mg/hour)
IV anaesthetic agent. Causes vasodilatation and hence hypotension. Extrahepatic metabolism, thus does not accumulate in hepatic failure. Has no analgesic properties
Midazolam Loading 30–300 mcg/kg
Maintenance 30–200 mcg/kg/hour (0–14 mg/hour)
Short-acting benzodiazepine. Used with morphine. Active metabolites accumulate in all patients, esp in renal failure


Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Critical care

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