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Caring for the ICU Boarder in YOUR
EDMichael Winters, MD, MBA, FACEP
Professor of Emergency Medicine and MedicineVice Chair for Clinical and Administrative Affairs
University of Maryland School of MedicineTwitter: @critcareguys
“People come into your life for a reason, a season, or a
lifetime…”- Unknown
CaseText
Caring for the ICU Boarder in YOUR
EDMichael Winters, MD, MBA, FACEP
Professor of Emergency Medicine and MedicineVice Chair for Clinical and Administrative Affairs
University of Maryland School of MedicineTwitter: @critcareguys
• Analysis of National Hospital Ambulatory Medical Care Survey
✓ Total annual hrs of critical care increased by 217%
✓ Average daily amount of critical care provided tripled to 5.6 hours
Herring AA, et al. Crit Care Med 2013
• Retrospective cohort
• Single center in Taiwan
• Effect of delayed ICU admission on mortality
Hung SC, et al. Crit Care 2014
• 1,242 Patients
✓ Increased mortality after 4 hours
✓ Increased hospital LOS
Hung SC, et al. Crit Care 2014
• Retrospective cohort of critically ill ED patients for ICU admission
• Single center
• Effect of ED crowding and ICU occupancy on ICU admission decisions
Mathews KS, et al. Crit Care Med. 2018
• 854 requests for ICU Admission from ED
✓ Significant effect of MICU bed availability on ICU admission decisions
✓ Longer ED boarding times have independent negative effect on inpatient morbidity and mortality
Mathews KS, et al. Crit Care Med. 2018
ICU Boarder
✓ Analgesia & Sedation
✓ Mechanical Ventilation
Pain & Anxiety• Critically ill patients experience pain
✓ Mechanical ventilation (ETT, LPV, etc)
✓ Invasive procedures
✓ Surgical procedures
✓ Nursing care (suctioning, repositioning)
Pain & Anxiety• Critically ill patients unable to report pain
✓ Altered mental status
✓ Mechanical ventilation
✓ Sedative and NMBA medications
Pain & Anxiety• Rotondi, et al. Crit Care Med 2002
✓ 82% remembered pain with ETT
• Gelinas, et al. Intensive Crit Care Nurse 2007
✓ 77% remembered pain during ICU stay
• Chanques, et al. Anesthesiology 2007
✓ Over 50% of MICU and SICU pts had pain
• 247 Ventilated Patients
✓ 90% suffered pain during procedures
✓ 33% had significant pain at rest
Ayasrah SM. J Crit Care. 2019
Pain & Anxiety• Short-term consequences
✓ Increase catecholamines
✓ Arteriolar vasoconstriction
✓ Impair tissue perfusion
✓ Increase myocardial oxygen consumption
Pain & Anxiety• Long-term consequences
✓ PTSD
✓ Post-ICU Syndrome
✓ Depression
✓ Family / Caregivers
Pain & Anxiety✓ Providers consistently under rate and
under treat pain in the critically ill
Devlin, et al. Crit Care Med. 2018
• “Suggest an assessment-driven, protocol-based, stepwise approach for pain management”
• Use validated protocols
• Analgosedation or analgesia-based sedation
Devlin, et al. Crit Care Med. 2018
• “Suggest an assessment-driven, protocol-based, stepwise approach for pain management”
• Use validated protocols
• Analgosedation or analgesia-based sedation
Devlin, et al. Crit Care Med. 2018
Pain Assessment
Vital signs are inadequate!
Pain Assessment• Validated Protocols
✓ Shorter duration of mechanical ventilation
✓ Reduced ICU LOS
✓ Reduced sedative requirements
✓ Reduced medication side effects
Pain Assessment✓ Numeric Rating Scale
✓ Behavior Pain Scale
✓ Critical Care Pain Observation Tool
✓ Visual Analog Scale
Pain Assessment✓ Numeric Rating Scale
✓ Behavior Pain Scale
✓ Critical Care Pain Observation Tool
✓ Visual Analog Scale
• “Suggest an assessment-driven, protocol-based, stepwise approach for pain management”
• Use validated protocols
• Analgosedation or analgesia-based sedation
Devlin, et al. Crit Care Med. 2018
• Retrospective cohort
• Single center MICU
• Evaluate impact of an analgosedation protocol
Faust, et al. Anesth Analg 2016
• Control Group
✓ Sedative: propofol
✓ Analgesics administered second (morphine)
Faust, et al. Anesth Analg 2016
• Intervention Group
✓ Revised protocol
✓ Analgesics first (fentanyl)
✓ Sedative: propofol or dexmedetomidine as needed
Faust, et al. Anesth Analg 2016
• Results - Intervention Group
✓ Improved pain control
✓ Reduced sedative infusion by 54%
✓ Decreased duration of mechanical ventilation
Faust, et al. Anesth Analg 2016
Pain Treatment• Opioids are first-line analgesics
✓ Fentanyl
✓ Morphine
✓ Hydromorphone
✓ Remifentanil
Pain Treatment• Adjuvants to Opioids
✓ Ketamine
✓ Acetaminophen
✓ Neuropathic pain meds
• Lidocaine
• NSAIDS
Pain Treatment• Adjuvants to Opioids
✓ Ketamine
✓ Acetaminophen
✓ Neuropathic pain meds
• Lidocaine
• NSAIDS
Analgesia✓ Vital signs alone are inadequate
✓ Implement protocols (BPS, CPOT)
✓ Start with analgesics (opioids)
✓ Consider adjuvants to opioids
Agitation• Associated with adverse outcomes
• Consequences of prolonged, deep sedation
✓ Increased duration of mechanical ventilation
✓ Increased ICU LOS
• Secondary analysis of prospective cohort
• Single, tertiary, academic center
• Assess relationship b/w ED sedation depth and outcome
Stephens RJ, et al. Chest 2017
• Results - 414 patients
✓ 14.3% received no analgesic
✓ 15.2% received no sedation
Stephens RJ, et al. Chest 2017
• Results - Outcome
✓ Median RASS (-3)
✓ Deep sedation occurred in 64%
✓ Deeper ED RASS associated with increased hospital mortality (aOR 0.77)
Stephens RJ, et al. Chest 2017
• Results - Outcome
✓ Median RASS (-3)
✓ Deep sedation occurred in 64%
✓ Deeper ED RASS associated with increased hospital mortality (aOR 0.77)
Stephens RJ, et al. Chest 2017
• Multicenter, prospective cohort study
• EDs and ICUs of 15 medical centers
• Characterize ED sedation practices and test hypothesis that deep sedation is associated with worse outcomes
Fuller, et al. Crit Care Med. 2019
• Results - 324 Patients
✓ Deep ED sedation: 171 (53%)
✓ Light ED sedation: 153
Fuller, et al. Crit Care Med. 2019
• Results - 324 Patients
✓ 28.4% given no analgesia
✓ 21.3% given no sedation
✓ 10.8% given no ED analgesics or sedatives
Fuller, et al. Crit Care Med. 2019
• Results - Depth of Sedation
✓ Patients exposed to deep sedation had higher frequency of deep sedation on ICU day 1 and day 2
✓ Median RASS during first 24 hrs in ICU: -3
Fuller, et al. Crit Care Med. 2019
• Systematic review and meta-analysis
• Impact of deep sedation within 48 hours of initiation of mechanical ventilation
Stephens, et al. Crit Care Med. 2018
• 4,521 Patients (9 Studies)
✓ Early, light sedation associated with lower mortality vs. deep sedation (9.2% vs. 27.6%)
✓ Early, light sedation associated with fewer mechanical ventilation days (-2.1 days)
Stephens, et al. Crit Care Med. 2018
• “Suggest using light sedation in critically ill mechanically ventilated adults”
• No universally accepted definition of light sedation
• Most use RASS -2 to +1
Devlin, et al. Crit Care Med. 2018
• “Suggest using light sedation in critically ill mechanically ventilated adults”
• No universally accepted definition of light sedation
• Most use RASS -2 to +1
Devlin, et al. Crit Care Med. 2018
• “Suggest using light sedation in critically ill mechanically ventilated adults”
• No universally accepted definition of light sedation
• Most use RASS -2 to +1
Devlin, et al. Crit Care Med. 2018
Agitation Assessment• Richmond Agitation-Sedation Scale
• Sedation-Agitation Scale
• Ramsay Sedation Scale
• Sedation Intensive Care Score
• New Sheffield Sedation Scale
Agitation Assessment• Richmond Agitation-Sedation Scale
• Sedation-Agitation Scale
• Ramsay Sedation Scale
• Sedation Intensive Care Score
• New Sheffield Sedation Scale
• “Suggest using either propofol or dexmedetomidine over benzodiazepines”
• Most studies benzodiazepines given as continuous infusion
Devlin, et al. Crit Care Med. 2018
Analgesia✓ Vital signs alone are inadequate
✓ Implement protocols (BPS, CPOT)
✓ Start with analgesics (opioids)
✓ Consider adjuvants to opioids
Sedation✓ Early sedation depth may be associated
with increased mortality
✓ Target lighter levels of sedation
✓ RASS -2 to +1
✓ Propofol or dexmedetomidine
✓ Minimize benzodiazepine use
• Survey of academic EM attendings
• 7 academic hospitals in the Northeast
• Most receive ≤ 3 hrs of MV education a year
Wilcox SR, et al. West J Emerg Med 2016
• Prospective, observational study
• 4 academic EDs
• Further characterize ED mechanical ventilation practices
Fuller, et al. Chest 2015
• 219 patients
✓ LPV used in only 56%
✓ 11% ventilated with Vt > 10 ml/kg PBW
Fuller, et al. Chest 2015
• 219 patients
✓ LPV used in only 56%
✓ 11% ventilated with Vt > 10 ml/kg PBW
Fuller, et al. Chest 2015
• Prospective observational cohort 525 pts
• 3 academic EDs
• Is longer duration of ED MV associated with in-hospital mortality, duration of mechanical ventilation, LOS?
Angotti LB, et al. West J Emerg Med 2017
• 64 Patients Ventilated > 7 hours
✓ Higher in-hospital mortality (45.9% vs. 29.4%)
✓ Longer duration of MV (4.8 days vs. 2.5 days)
✓ Less likely to have changes in ventilator settings during ED time
Angotti LB, et al. West J Emerg Med 2017
LPV✓ Tidal volume: 6-8 ml/kg IBW
✓ Permissive hypercapnia
✓ Reduce FiO2 as soon as possible
✓ Pplat: < 30 cm H2O
• Quasi-experimental study
• ED / ICU of academic, tertiary care center
• Evaluate the effectiveness of an ED-based lung-protective mechanical ventilation protocol on pulmonary complications
Fuller, et al. Ann Emerg Med 2017
• Intervention
✓ Tape measure for accurate height
✓ Tidal volume: 6 ml/kg PBW
✓ Limit plateau pressure < 30 cm H2O
✓ Titrate FiO2 (SpO2 90-95%)
✓ Elevate HOB
Fuller, et al. Ann Emerg Med 2017
• Results - ED
✓ LPV increased by 48.4%
✓ Tidal volume decreased by 1.8 ml/kg PBW
Fuller, et al. Ann Emerg Med 2017
• Results - ICU
✓ LPV increased by 30.7%
✓ Tidal volume decreased by 1.1 ml/kg PBW
Fuller, et al. Ann Emerg Med 2017
• Results
✓ Decreased ICU and hospital LOS
✓ Mortality: 14.5% absolute risk reduction
Fuller, et al. Ann Emerg Med 2017
Mechanical Ventilation• ED Ventilator Settings Matter!
✓ Tape measure for accurate height
✓ Tidal volume: 6 ml/kg PBW
✓ Decrease FiO2 (SpO2 90-95%)
✓ Elevate HOB
✓ Measure plateau pressure
Ventilator Pressures• Peak Pressure
✓ Reflects pressure from airflow resistance and respiratory system compliance
✓ Measure during inspiratory flow
Ventilator Pressures• Plateau Pressure
✓ Reflects static respiratory system compliance
✓ Better marker of overdistention (volutrauma)
✓ Measure with end-inspiratory hold in a passive patient
✓ Goal < 30 cm H2O
High Peak +Normal Plateau
• Increased airway resistance (bronchospasm)
• Kinked or twisted ETT
• ETT obstruction (secretions)
Wood S, et al. EM Critical Care 2013
•Intrathoracic
✓ ARDS, Pneumonia
✓ Pulmonary edema
✓ Auto-PEEP
✓ Pneumothorax
•Extrathoracic
✓ Positioning
✓ Ascites
✓ ACS
Wood S, et al. EM Critical Care 2013
High Peak +High Plateau
Caring for the ICU Boarder in YOUR
EDMichael Winters, MD, MBA, FACEP
Professor of Emergency Medicine and MedicineVice Chair for Clinical and Administrative Affairs
University of Maryland School of MedicineTwitter: @critcareguys
Analgesia✓ Vital signs alone are inadequate
✓ Implement protocols (BPS, CPOT)
✓ Start with analgesics (opioids)
✓ Consider adjuvants to opioids
Sedation✓ Early sedation depth may be associated
with increased mortality
✓ Target lighter levels of sedation
✓ RASS -2 to +1
✓ Propofol or dexmedetomidine
✓ Minimize benzodiazepine use
Mechanical Ventilation• ED Ventilator Settings Matter!
✓ Tape measure for accurate height
✓ Tidal volume: 6 ml/kg PBW
✓ Decrease FiO2 (SpO2 90-95%)
✓ Elevate HOB
✓ Measure plateau pressure
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