2. GROUP APPROACH
BUNDLE CARE
AIRWAYS
BREATHING
CIRCULATION
RADIOLOGICAL ASSESSMENT
E.T. CARE
ORAL CARE
EYE CARE
SKIN CARE
BIOCHEMICAL MONITORING
BEDSORE
NUTRITION
SUMMARY
3. Team approach include
Physician
Nursing staff
Physiotherapist
Respiratory physiotherapist(available in some
selected tertiary centre )
4. Bundle is a structured way of improving the
processes of care and patient outcomes.
A small straightforward set of evidence –based
practices-generally 3-5 that performed collectively
and reliably, have been proven to improve patients
outcomes,
5. Bundles were further described by
Berenholtz and colleagues as a means of
assessing of quality of care.
Bundle have two main strands
1. The interventions themselves.
2. The process of care of delivery.
6. WHY BUNDLE IS SO SPECIAL:
Science based.
They were well established best practices,
but they are often not performed uniformly,
making treatment unreliable.
A bundle ties the changes together into a
package of interventions that people know
must be followed for every patient, every
single time.
7. Bundle can be used to ensure the delivery of
minimum standard care.
Used as a audit tool to assess the delivery of
interventions.
Most utilized bundle is sepsis care bundle
worldwide.
8. Direct benefit to the patient
Shorter intensive care unit stay
Reduced financial cost
Improve resource utilization, and
therefore, benefit to other patients
outside the scope of the care bundle
10. 1.ELEVATION OF THE HEAD OF THE BED
2.SEDATION LEVEL ASSESMENT.
3.ORAL HYGIENE.
4.SUBGLOTTIC ASPIRATION.
5.TRACHEAL TUBE CUFF PRESSURE.
6.STRESS ULCER PROPHYLAXIS.
11. TO BE COMPLETED WITHIN 3 HRS OF
TIME OF PRESENTATION:
1.Measure the lactate level
2.Obtained blood culture prior to
administration of antibiotics
3.Administer broad spectrum
antibiotics
4.Administer 30ml/kg crystalloid for
hypotension or lactate ≥4 mmol/l
12. 5.Apply vassopressure (for hypotension that
does not respond to initial fluid resuscitation
) to maintain a mean arterial pressure(MAP
≥65 mmhg)
6. In the event of persistent hypotension
after initial fluid administration (MAP < 65
mm Hg) or if initial lactate was ≥4 mmol/L,
re-assess volume status and tissue perfusion.
7. Re-measure lactate if initial lactate
elevated
13. THE CLC MAINTENANCE BUNDLE:
1. Check the clinical indication why the
CVC is in situ – is it still required?
2. Is the CVC dressing intact and changed
within the last 7 days?
3. Has CVC hub decontamination been
performed before each hub access?
14. 4. Has hand hygiene been performed
before and after all CVC
maintenance/access procedures?
5. Has Chlorhexidine gluconate 2% in
alcohol (if compatible with CVC) been
used for cleaning the insertion site during
dressing changes?
16. POSTIONING: Maintain upright or
45˚(contraindicated in shock)
Mainly beneficial in child having
a) obesity,
b) abdominal sx,
c) ascites ,
d) taking feed(prevent aspiration)
18. PRONE POSITION :
a) Increase oxygenation in early stage of
ARDS(by increasing FRC)
b) Increase in V/Q matching
c) Enabling the drainage of secretion
d) Improve lymphatic drainage
19. PERCUSSING AND VIBRATION:
a) Manually by clamping the chest wall using
cupped hand
b) Mobilize the secretion from nondependent
area to central airway
c) From where suctioned easily
d) Vibration mainly done in neonates to avoid
to damage their fragile chest wall
20. MANUAL HYPERINFLATION:
a) Performed before and between the
suctioning
b) Prevent hypoxia while suctioning
c) Recruitment of atelectatic segment
d) Mobilize the secretions
21. CONTINUOUS ROTATIONAL THERAPY:
a) Specialized beds are used
b) Turn the patient along longitudinal axis
c) Not available in India
22. FIBEROPTIC BRONCHOSCOPY:
a) Consider in lobar atelectasis in pt not
responding to vigorous physiotherapy
b) Removal of retained secretions
c) Thick tenacious plug
23. COMPLICATION:
a) Increase incidence of hemodynamic
disturbance
b) Higher incidence of gastroesophaseal reflux
c) Increase risk of aspiration
d) Risk of fracture in neonate and children
24. Normally upper airway of a person heats and
humidifies the atmospheric air to body
temperature & 100% relative humidity
Upper airway is bypassed in intubated
patient so humidification is required
25. DECREASE IN HUMIDIFICATION LEAD TO:
a) Mucosal damage
b) Tubal occlusion
c) Atelectasis
d) FRC
e) hypoxia
26. COMPLICATION OF OVER HYDRATION:
a) Decrease nasociliary clearance
b) Hyper hydration
c) Loss of surfactant
27. 1. OBTAINED BY:
a) Heated water humidifiers
b) Heated wire circuit
c) Heat and moisture Exchange(HMEs)
(Have humidifying property, bacterial filtering
property)
28. AIRWAYS:
a) Is the tracheal tube obstructed or
displaced?
b) Is there any peritubal leak?
c) what is length of tube introduced?
d) Is it fixed properly?
e) Is the nasogastric tube in situ
29. BREATHING:
a) Check the rate of spontaneous respiration.
b) Check whether the child is breathing in
synchrony with ventilator.
c) Is there a nasal flare or accessory muscle
use?
d) Identify the cause of respiratory distress
i. Airway problem
ii. Improper ventilator setting
iii. Patient- ventilator dyssynchrony
30. CIRCULATION:
a) Assess the heart rate.
b) Peripheral perfusion.
c) BP
d) Spo2 >95% (indicate good oxygenation)
e) In ARDS aim -88-92%
32. Very small infants, a daily chest x-ray
required to verify ET position. The tip of
tracheal tube should be between T2 & T4.
Check for gastric tube or central line if
inserted.
Look for overall lung volume.
(Lung over inflation is identified by wide
intercostals space & flat diaphragms).
33. Check whether there is improvement or
deterioration of primary pathology.
Look for the atelectasis, pneumonia,
pulmonary edema & congestion.
Cardiac size.
Check for the presence of air leaks
34. ENDOTRACHEAL SUCTION:
a) To maintain gas exchange.
b) To obtained tracheal aspirate specimen.
c) To prevent the effect of retained
secretions.
35. suction carried out in three position of the
head.
Choose appropriate size catheter (lumen size
is double of the ET tube)
Pre-oxygenate patient by ventilating for 3-5
breaths with 100% oxygen
Instil 0.5-1ml of NS into trachea.
36. suction up to the tip of ET()
Don’t apply the negative pressure during
inserting the catheter
Apply intermittent suction while slowly
withdrawing catheter in rotating manner.
Duration of intermittent suction should not
exceed >5 sec. in neonate, and 10sec in
pediatric patient.
37. Reoxygenate with the manual resuscitation
bag for a minimum of 3-5 breaths at age
appropriate rate or until SaO2 returns to
baseline for 30 seconds.
Suction Pressure
100-120 mmHg in adult
80-100 mmHg in children
60-80 mmHg in infants and neonates
40. N-acetylcystene:
a) Breaks disulphide bonds in mucus.
b) Make less viscid mucus(easier to suction)
PTR- may cause bronchospasm , which can be
overcome by using beta2 agonist.
41. DNase:
a) Used in patients with cystic fibrosis
b) Expensive and not available in India
42. ORAL CARE:
a) Tooth brushing twice a day
b) Chlorhexidine rinse twice a day
Munro CL, et al.(2006) found CHX significantly
reduced VAP (24.4% vs. 52.4%, p=0.0093)
compared with tooth brushing alone
43. EYE CARE:
a) Ventilated patient is often sedated & Increase
the risk of(muscle relaxed)
1. Exposure keratitis
2. Corneal ulceration
3. Infection
TT. Passive closure of eyelid,
use lubricants,
( artificial tear. Prevention: eye packing,
lubricating ointments and artificial tears,
antibiotics eye drops)
44. SKIN CARE:
a) skin of term baby have well developed
epidermis.
b) Stratum corium similar to adult(15-20 layer
)
c) In preterm it has fewer layer & lead to
1. permeability
d) Risk of toxicity substance applied to skin
e) Evaporative heat loss.
46. BIOCHEMICAL MONITORING:
Blood gases: ABG checked 20-30 min after
initial setting, then after or twice per day or
as per need.
Need to perform frequent gases has been
reduced by pulse oximeter & ETCO2
monitoring
Other lab monitoring: S.Electrolytes,
RFT
LFT etc.
48. BACTERIOLOGICAL MONITORING are
warranted only when there is sudden change
in quantity & quality of tracheal tube
secretion, along with development of fever &
new infiltrates in the chest x-rays
BLOOD CULTURE: indicated, before changing
antibiotics appropriate culture should be
sent.
51. If cuffed ET is used, cuffs must be released
every 4 hrly for 5 min.
Confirmation of all preset alarms for gas
supply, airways pressure, apnoea, inspired O2
concentration
No change in ventilator setting should be
done without recording the reason & the
change.
52. Filling up of humidifier with sterile water
daily/continuously.
Checking the humidifier traps, condensation
&temperature.
Wash compressor filter daily or as indicated
Change of ventilator tubing periodically
53. Provision of adequate calories-with
nasogastric tube.
In few patient parenteral feeding if enteral
feeding not possible because of ileus or
abdominal pathology.
Intake & output measurement & their
calculation every 8 hrly
54. Localized injuries to the skin or underlying
tissue that usually occurs over bony
prominence as a result of pressure in a
combination with shear and friction.
Most common sites are skin overlying sacrum,
coccyx heel or the hips
Pressure ulcer occurs due to pressure applied
to soft tissue resulting in completely or
partially obstructed blood flow to the soft
tissue.
55. Lying or sitting in a
same position
Friction when a person is
dragged and not lifted or
turned in right manner.
Poor blood circulation
Poor nutrition
Constant pressure over a
particular area of body.
56. Changing in patient position frequently 2-4
hrly
A period of stretching and moving the joint
decrease bed sore as well as improve blood
circulation and prevent joint stiffness.
Support the surface by using antidecubitus
mattresses and cushions.
Controlling the heat and moisture level of
skin surface
Adequate intake of protein and calories and
vit C
58. NUTRITIONAL SUPPORT IS IMPORTANT IN CRITICALLY ALL PATIENT BECOZ:
IMPROVE THE WOUND HEALING
Decreases the catabolic response to injury
Improve the GI function and structure
Reduce the complication and length of stay
Reduce the morbidity and mortality
Enteral feeding is always superior than parenteral feeding
59.
60. Initial illness: permissive hypocaloric
nutritional support (20-30 kcal/kg/day)
Later on: improved metabolism-normocaloric
and then to hypercaloric support to promote
tissue growth and healing
Goal is BMR/REE to avoid complications of
overfeeding
61. Preferred over TPN
Reduced risk of bacteremia and pneumonia
C/In: severe GI haemorrhage, recent GI
surgery, obstruction, NEC, severe vomiting or
diarrhoea
milk
Elemental formula: carbohydrates as
oligosaccharides, maltodextrins or
hydrolysed corn starch; nitrogen as peptides
or free amino acids; lipids as oils or MCT
62. Givn via nasogastric tubes or orogastric tubes
10-15 ml/kg/day and started gradually till target
calories are achieved
Vitamins and mineral supplementation
Percutaneous endoscopic gastrostomy (PEG)
tubes in case of facial or skull trauma
Nasoduodenal or transpyloric feeding in
decreased gut motility (pts on vasoactive agents,
neuromuscular blockage, recent major insult)
For long term use: silicone tubes
63. Amino acid mixtures, lipids, glucose and
trace mineral and vitamins
Route: peripheral (osmolarity of infusate
should be <700 mOs/L) or central veins
64. Daily weight recording
Complications: catheter related infections, liver
dysfunction, hyperglycemia, hyperlipidemia,
acidosis and electrolyte imbalances
Shifted to enteral feeds as soon as gut function
improves
Growing evidences show that TPN is systemically
immunosuppressive, suppression of GALT and
disuse atrophy of gut mucosa, suppression of
immune protection at respiratory and
genitourinary surfaces
65. Glutamine, arginine, w 3 fatty acids,
nucleotides, taurine, cysteine and some complex
carbohydrates and probiotic bacteria
Reduced length of hospital stay and
decreased risk of infectious complications
66. PPN TPN
Peripheral access
<900 mOsm/L
Max D12.5%
Can go up to D15%
with non-central
PICC
Usually requires
increased fluid
allowance
Central access
No osmolarity
limitations
Typical max
dextrose usually
D25% however
can go up to
D30%
67. D – Dislodged
O – Obstructed
P- Pneumothorex
E – Equipment