To Treat Or Not To Treat In Critical Care

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Roderick Jeffery Henry
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1 To Treat Or Not To Treat In Critical Care Full Title of Guideline: Author (include and role): Division & Speciality: Version: 3 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): To Treat Or Not to Treat In Critical Care Guidelines for Practice Eleanor Douglas, Lecturer/Practitioner Physiotherapist Eleanor.douglas@nuh.nhs.uk Clinical Support, Physiotherapy Senior Physiotherapists at NUH Trust wide physiotherapists September, 2021 All patients admitted to Critical Care areas. This guideline describes how individual patients should be thoroughly assessed before each treatment and sound clinical reasoning skills employed to determine whether to treat or not to treat. The guidelines highlight most of the important aspects to consider. Each of these aspects should be taken into account before treating the patient. Treatment should only be performed if the benefit outweighs any of the risks that treatment presents. Review of research, minor changes to wording, grammar and spelling errors corrected. Well designed non-experimental descriptive studies (ie comparative / correlation and case studies). Expert committee Summary of evidence base this reports or opinions and / or clinical experiences of respected guideline has been created from: authorities. Recommended best practise based on the clinical experience of the guideline developer This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust.

2 To Treat or not to Treat on Critical Care, Guidelines for Practice 2018 Version: This replaces the to treat or Not to Treat on Critical Care Guidelines for Practice (2015) Review Date: September 2021 Contact: Eleanor Douglas Ext: 56142/56141 Disclaimer This guideline has been registered with the Nottingham University Hospitals Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in any doubt regarding this procedure, contact a senior colleague. Caution is advised when using guidelines after the review date. Please contact the named above with any comments/feedback. Introduction/indications for use There are no routine treatments on Critical Care. Each individual patient should be thoroughly assessed before each treatment and sound clinical reasoning skills should be employed to determine whether to treat or not to treat. These patients can change status from one hour to the next becoming rapidly unstable. The guidelines that follow highlight most of the important aspects to consider. Each of these aspects should be taken into account before treating the patient. Treatment should only be performed if the benefit outweighs any of the risks that treatment presents. Indications for treatment Sputum production and retention Ventilated patients will be unable to clear secretions independently. Assess for signs of sputum retention on auscultation, CXR, and palpation. Increased O 2 requirements, and increased airway pressures may indicate sputum. Decreased lung volumes associated with sputum retention, mechanical ventilation, immobility, abdominal distension and pain. Assess for signs on Chest X-Ray, auscultation, thoracic expansion, tidal volumes and O 2 requirements. Poor lung compliance e.g. in chronic chest conditions such as COPD, or in acute conditions such as ARDS and atelectasis. V/Q mismatch Associated with poor positioning, lung conditions such as pleural effusions/collapse/consolidation and mechanical ventilation. Assess for signs of poor V/Q matching with auscultation, Chest X-ray, SpO 2 and PaO 2. Mobility problems Immobility due to illness and sedation/paralysing agents can lead to joint contractures and loss of muscle mass. Bed exercises, sitting out of bed and mobilising can speed up the weaning process and shorten length of stay. Patients with neurological conditions e.g. CVA or Guillian Barre Syndrome may require specialist assessment and treatments.

3 Inotropes and Blood Results If a patient is on any inotropes e.g. noradrenaline, adrenaline or dopamine consult staff nurse prior to manual techniques or mobilisation Check patients blood chemistry prior to treatment Inotropes indicate patient is cardio vascularly unstable or compromised and physio techniques can exacerbate this. To establish is there is any indication to postpone or vary treatment If platelets are < 50 suction and IPPB should be used with caution. Any planning treatment should be discussed with medical team. Check with patient s consultant prior to insertion of NPA Suction and IPPB can cause trauma and with decreased platelets excessive bleeding If INR is > 1.5 caution with treatment is required In case of trauma clotting time is delayed and bleeding could be extensive Oesophagectomies and Thoracic Surgery Do not position flat or lie less than 30 degrees and definitely no head down tilt post oesophageal surgery Avoid oral or NP suction post oesophageal surgery if needed, discuss with the surgeon. To avoid reflux of gastric acid over anastomosis (which could lead to a leak) To avoid the catheter tip being pushed through the anastomosis if incorrectly inserted into oesophagus Consult surgical team prior to using IPPB Surgeons should be consulted prior to using positive pressure techniques Positive pressure if swallowed could distend the stomach and oesophagus and may disrupt the anastomosis/surgery and may cause vomiting To ensure they are satisfied that positive pressure will not disrupt the anastomosis

4 Chest Drains Do not clamp chest drains but temporarily kink the drain in order to pass it over the bed prior to mobilisation Drains must be kept below site of insertion at all times If a drain is on suction consult staff nurse or doctor prior to disconnection for mobilisation If increased bubbling is seen in the drain during treatment inform medical team Clamping can cause a build up of air in the thorax and cause a deterioration in the patients condition To ensure that fluid is not drained back into the chest cavity To ensure that removal of suction temporarily will not cause deterioration in patients condition This indicates that treatment may have increased air leak medical review is advised Epidurals Check epidural chart for motor function and pain score before attempting to mobilise the patient To ensure patient has adequate pain relief and motor function in order to mobilise safely Check BP prior to and during mobilisation. If BP decreases and patient is symptomatic, return patient to bed or chair. Patients with epidurals should never be placed into a head down position Ensure you are aware of epidural catheter before mobilisation or movement in the bed Epidural can lower blood pressure even when patient is cardiovascularly stable There is a risk that local anaesthetic will move proximally and affect the respiratory centre causing breathing to stop If epidural is dislodged it may need to be removed and may not necessarily be replaced

5 Bronchospasm Assess patient by auscultating chest and observing airway pressure (if mechanically ventilated) If patient is in severe bronchospasm treatment may be limited Inform nursing staff and medics if bronchospasm is detected To establish presence of bronchospasm and severity Manual respiratory techniques may exacerbate severe bronchospasm Bronchodilation therapy can only be administered via prescription Haemoptysis Assess patient by checking clotting results and platelets. If INR > 1.5 and platelets <50 treat only if indicated and agreed by doctor. Sudden and frank haemoptysis contraindicates physiotherapy treatment and manual respiratory techniques unless treatment is discussed with and agreed by a doctor Coagulopathy can lead to pulmonary haemorrhage. Manual techniques can exacerbate this and lead to further bleeding. Suction, MHI, vibrations, IPPB and excessive coughing can exacerbate bleeding and cause the patient s condition to worsen

6 Mobilisation Ensure the patient is cardiovascularly and neurologically stable. If patient is tachypnoeic reconsider treatment Assess patient s lower limb mobility and strength before attempting sitting out, e.g. Straight leg raise and static quads If patient has lower limb skin grafts check when doctors say they are happy for patients to mobilise If patient has unstable fractures or spinal cord compression mobilisation should be in accordance with orthopaedic advice If patient has an epidural assessment of motor and sensor function should be made (see epidural section) before attempting to stand patient. Assess patient s blood pressure once in chair if sitting out for first time after prolonged period in bed or post surgery If patient has External Ventricular Drain (EVD) this should be turned off by nursing staff prior to moving the patient or bed height. Once treatment is complete the nursing staff need to turn the EVD back on Sitting patients up/out of bed and/or mobilising can cause blood pressure and heart rate to fluctuate This can indicate fatigue therefore patient may not be suitable for mobilisation To ensure patient has enough strength to stand and decrease risk of injury to staff and patient If patient mobilises before grafts have taken there is a risk of displacing and losing the graft. To ensure no displacement of fractures occurs Epidurals can affect motor and sensory function of the lower limbs causing patient to lose function in one or both lower limbs therefore increasing risk of falls To ensure patient has not become hypotensive during procedure at risk of reduced blood pressure and fainting To avoid excessive drainage or backflow of cerebrospinal fluid (CSF)

7 Blood Pressure Action Assess blood pressure (BP) using arterial line (use the recent trend in BP recordings) or Non-Invasive BP reading. If BP < 90/60 or patient is hypotensive in relation to normal BP, care is required with treatment When BP is low inspiratory holds or neuromuscular facilitation may be used as an alternative to manual hyperinflation Respicare bed may be utilised as an alternative to full positioning techniques Care with suction should be taken hypotensive patients should be preoxygenated prior to suction Assess BP as above. If BP is >145/90 or patient is hypertensive in relation to normal care with treatment is required. If BP suddenly increases or decreases significantly during treatment stop and inform nursing staff if they do not settle within a few minutes and/or intervention is needed e.g. increase in inotropes. Rationale Patient may be hypovolemic, septic, sedated or have insufficient cardiac function Treatment techniques could cause BP to decrease further. Manual hyperinflation can restrict venous return - reducing cardiac output and can decrease BP further (see MHI guidelines) The Respicare bed turns are more gentle and can be graduated until the patient can tolerate a full turn or sit up or stand Suction can simulate a vaso-vagal response further reducing BP Patients may be in pain, have anxiety or have cardiac dysfunction They may not be adequately sedated e.g. if on a sedation hold Patient may require medication to control BP which requires urgent administration e.g. bolus of sedation

8 Heart Rate and Rhythm Assess heart rate and basic rhythm by looking at ECG reading or taking a pulse manually Sinus bradycardia (< 60 bpm) care should be taken. Patient should be pre-oxygenated prior to suction Sinus tachycardia (>100bpm) - care should be taken with manual techniques and exercise Full explanation of treatment and adequate analgesia should be given Patient may be sinus tachycardic bradycardic or having a variable rhythm or arrhythmias Suctioning can cause vagal stimulation and decrease HR further. Preoxygenation helps to lessen effects of sinus bradycardia and vagal stimulation Treatment can further increase HR and reduce cardiac output. Increased HR may be due to pain/anxiety or sepsis in response to decreased BP To decrease anxiety and relieve pain in order to decrease HR Slow AF is essentially stable fast AF (> 120 bpm) may contraindicate treatment If patient is in SVT or VT treatment is contraindicated Fast AF is unstable and will decrease BP further destabilising patient Patient is very unstable and at risk of a VF arrest If the patient is being externally paced, care must be taken to observe the insertion point of the wires If the patient is reliant on the external pacing, care with mobility should be taken This is in order to ensure the wires do not become dislodged. This indicates the patient is still unable to maintain their heart rhythm independently and is at risk should the pacing become disrupted.

9 Intra Cranial Pressure (ICP) Action If patients ICP is < 25mmHg patient should be considered for treatment If patients ICP is fluctuating caution is required If patient s ICP is significantly increased use of suction, manual techniques, handling, and turning should be minimal. Patients must be nursed no flatter than 30 degrees Treatment should be stopped immediately if there are any significant changes in HR, an increase in ICP or BP, an increase in pupil size or if patient starts fitting Rationale If a patient has consistent ICP levels below critical level they are stable to treat Fluctuating ICP indicates neurological instability which may worsen with physio input Treatment may increase ICP further and cause damage to brain structures These are signs of the patient becoming unstable and risk of increased ICP Fitting indicates raised ICP Haemodialysis / IABP (Intra-Aortic Balloon Pump) Action Rationale Ensure lines are secure and insertion sites are noted prior to movement A loose line may leak, patient may bleed and the therapy will be interrupted. There is also a risk of air emboli in the vessel CVVH Care required when turning to ensure lines are not kinked especially femoral CVVH line. Ensure hip flexion < 45 degrees Care should be taken to monitor BP closely If line is kinked the machine will stop and there is a risk of line blocking off BP may be compromised when patient on CVVH (see BP section) IABP Particular care should be taken when patient on IABP Hip flexion should be restricted to < 30 degrees Observe where the sensing of the IABP is occurring If IABP is blocked patients BP can be seriously compromised If line is kinked the machine will stop risk of line blocking off If ECG ensure leads are taped on before turning/moving patient. If via pacing wire ensure wires are secure before turning/moving

10 References Hough, A. (1993) Physiotherapy in Respiratory Care A problem solving approach. Chapman and Hall. MacKenzie, C. (1989) Chest Physiotherapy in the Intensive Care Unit 2 nd Ed. Williams and Wilkins. Oh, T.E. (1990) Intensive Care Manual 3 rd Edition. Butterworths. Stiller, K. (2000) Physiotherapy in Intensive Care. Chest 2000; 118: Stiller, K. (2007) Safety Issues That Should Be Considered When Mobilising Critically Ill Patients. Crit Care Clin. (2007) 23:

11 To Treat or not to Treat on Critical Care Guideline 2018

Active Cycle of Breathing Technique

Active Cycle of Breathing Technique Full Title of Guideline: Author (include email and role): Division & Speciality: Version: 3 Ratified by: Scope (Target audience, state if Trust wide): Review date (when