Critical Care Challenge

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Critical Care Medicine

Simon Finfer, M.D., and Jean-Louis Vincent, M.D., Ph.D., Editors

The case description below highlights issues raised in an upcoming Critical Care Medicine article. A
77-year-old man is on mechanical ventilation in the ICU after an emergency colon resection,
complicated by septic shock and acute liver failure. Since it appears his stay in the ICU will be
prolonged, what measures would you take to optimize his long-term recovery?

Participate in the poll and share your comments. The editors recommendations and the
related review article will appear on April 24.

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ICU-Acquired Weakness and Recovery from

Critical Illness
Comments and Poll open through April 22, 2014

Presentation of Case

A well-nourished 77-year-old man whose medical history includes treated hypertension and
hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment is admitted
to the intensive care unit (ICU) of a university hospital from the operating room after a
Hartmanns procedure (resection of the rectosigmoid colon with closure of the rectal stump and
formation of an end colostomy) performed for fecal peritonitis due to a perforated sigmoid colon.
On arrival in the ICU, he was in septic shock. He is undergoing mechanical ventilation with the
use of a low-tidal-volume protocol with positive end-expiratory pressure (PEEP). His arterial
blood pressure is supported with a norepinephrine infusion. Analgesia is provided by a
continuous morphine infusion. Enteral nutrition was started on the day after ICU admission, and
target intake was achieved on day 6. Parenteral nutrition was not used. (In the previous
installment of this case, there were 2906 votes on strategies for feeding this critically ill patient.
A majority of respondents [53%] favored initiating enteral nutrition within 24 to 48 hours after
ICU admission and then starting parenteral nutrition on day 7 if the caloric target was not being
met. Another 30% favored initiating parenteral nutrition as soon as possible after the patients
arrival in the ICU and then starting enteral nutrition once bowel sounds return, whereas 11%
favored awaiting the return of bowel sounds and then initiating enteral nutrition. Only 4%
favored initiating total parenteral nutrition as soon as possible after the patients arrival in the
ICU.)
Question

Since it is likely that this patient will have a prolonged stay in the ICU, what measures would
you take to optimize his long-term recovery? Participate in the poll and, if you like, submit a
comment supporting your choice. The editors recommendations will appear here, along with a
link to the related review article, on April 24.

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How would you manage this patient?

61 Reader's Comments

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Data by Profession and Location

AJAYKUMAR BORSE | Student | Disclosure: None
NEW DELHI India
April 22, 2014

BED SORE PREVENTION

prevention of bed sore essentially needed.

ABRAHAM BABU | Other | Disclosure: None

Manipal India
April 22, 2014

Critical Care Rehabilitaiton

Sir, as previous authors have mentioned, an interdisciplinary approach is required and

also it is imperative for physiotherapy to be initiated early. Though frequently talked
about, it is sometimes clear that there is a delay in implementing rehabilitation programs
in the intensive care unit (ICU). Following critical care rehabilitation algorithms to
streamline the utilization of physiotherapy and to promote early initiation of
rehabilitation is crucial to the successful outcome of this patient. With regard to specific
interventions, the following points maybe useful: i) As mentioned, passive limb exercises
are important. Neuromuscular electrical stimulation to large muscle groups of the leg
would also be beneficial. However, care is to be taken to prevent skin burns. If the patient
is conscious, begin active assisted or active exercises ii) Good bronchial hygiene and
chest physiotherapy iii) Proper positioning to improve V/Q iv) Bedside mobilization
(once the patient is conscious) v) Inspiratory muscle training (once the patient is
conscious to facilitate weaning)

GERTRUDE JOHNSON, MD | Physician - UNSPECIFIED | Disclosure: None

TINLEY PARK IL
April 21, 2014

RHIA Professional

For this case of LTC of Critical illness it is important to determine and meet goals of
care, treatment plans and end-of-life plans. After the patient show hemodynamic stability,
progress to oral feedings from enteral feedings, elevate HOB if not contraindicated. Use
weaning protocols and begin P.T. as soon as possible to limit ICU-related weakness. This
patient will require continued monitoring.

HAFEZ BAYATMAKOO, MD | Physician - ABDOMINAL SURGERY | Disclosure:

None
Iran, Islamic Republic of
April 20, 2014

management in the ICU

as a surgeon , i try to stabilize the patient first with checking and correcting fluid,
electrolytes, and acid-base balance with giving him fluid with controling CVP through
the right sided subclavian central catheterization. keeping it in the normal range 12-15 cm
-h2o.giving him antibiotics, broad spectum , covering also anaerobics.. checking
coagulation profile and giving him heparin for venothrombosis prophylaxis.covering him
with warm blanket to avoid hypothermia and correcting acidosis( metabolic ).waiting for
ileus resolution then if there is no abdominal distention and flatus passed through the
stomy give him enteral nutrition as tolerated.considering checking CRP and ESR may
help to think of any collection in the abdominal cavity.. chest physiotherapy is begun the
next day.i also check serum amylase and lipase in this fellow as a baseline. intake , output
should be regularly charted and checked very carefully.

Ali Aldahbali | Physician - Internal Medicine | Disclosure: None

Yemen
April 20, 2014
Sedation must be minimized

sedation must be minimized,followed by completely ceasing.Initiate active and passive

mobilisation,physiotherapy,psychotherapy,immunotherapy,and strong hyhgen,with
consideration an acheivement of nitritional and supplemental target,getting out of
septicemia,and active vital organs recovery and glucose control.

maria florian | Physician - Critical Care Medicine | Disclosure: None

April 19, 2014

NO HOLIDAYS

SEDATE THE PATIENT PER GOALS AND MANTAIN AS AWAKE AS POSSIBLE ,

AS CALM AS NEEDED ,AND WITHOUT PAIN , USE SEDATION SCALES, PAIN
SCALES AND DELIRIUM SCALES ON PROTOCOL BASIS , BEGIN
MOBILIZATION AS SOON AS HEMODYNAMICALLY STABLE , PASSIVE AT
FIRST AND ACTIVE AS SOON AS POSSIBLE. THIS ABOLISHES THE NEED TO
STOP SEDATION DRIPS ABRUPTLY CAUSING WITHDRAWAL SYNDROMES .
DO NOT USE BENZO DRIPS ON REGULAR BASIS, USE NON
PHARMACOLOGICAL MEASURES TO AVOID DELIRIUM : GLASSES, HEARING
AIDS NEED TO GO BACK ON AS SOON AS POSSIBLE ; PICTURES , MUSIC CAN
HELP , STANDING THE PATIENT EVEN IF HES NOT OFF THE VENTILATOR
CAN BE HELPFUL.

DR BRUCE KIMZEY | Other | Disclosure: None

SHINGLE SPRINGS CA
April 18, 2014

Speaking as a patient, not as a physician

It is important to realize based upon the research Dr. Ely and colleagues with the
Vanderbilt Med Center ICU Delirium & Cognitive Impairment team that this as much or
more about brain injury as it is about the damage caused to any other organ or system.
This is not conjectural. They have learned there is a very specific brain loci of damage
which accompanies the majority of those whose clinical picture included ICU delirium.
With that in mind, I think it is important to realize that even after a patient has apparently
emerged from their state of delirium it remains highly likely that ICU delirium remains in
play and must continue to be managed through proper attention to titration of pain and
benzodiazapine levels. My own experience is instructive. Although I was no longer
acting "crazy" I have no memory whatsoever of having been spoken with regarding the
need for emergent surgery much less that I was asked to and did sign the consent form.
Control ICU delirium and cases like these will be minimized.

karan saraf | Physician - Internal Medicine | Disclosure: None

India
April 18, 2014
Multifactorial

In my view, steps to ensure early recovery should cover - 1. DVT prophylaxis. 2.

Temperature and sugar control (<180mg/dl) 3. Regular monitoring for HCAP /VAP.
Hand heigene (utmost imp) - in any case, upto 75% chance of acquiring VAP with 10
days stay - so bronch guided strategy in case of VAP. 4. Daily weaning trials according to
protocol. 5. Nutrition already optimized (according to previous segment) 6. Guard against
pressure sores. 7. Others - treatment of cause (sepsis in this case - with importance to
daily monitoring for renal impairment - dose adjustments of all meds)

SUE LITTLE | Other | Disclosure: None

IOWA CITY IA
April 18, 2014

Don't forget nutrition

Most get inadequate nutrition support during the first couple of weeks of ICU care. After
10 days repletion and adequate protein be the focus with PT to help turn it back into
muscle.

Nafidullah Khan | Physician - Internal Medicine | Disclosure: None

Pakistan
April 18, 2014

Monitoring a critically ill pt

Strict glycemic control Blood cultures Check acid base and electrolyte status and
urea/creat Avoid aspiration pneumonia Titrate the dose of morphine Look for signs of
DIC Daily intake and output monitoring Start enteral feeding once bowel sounds return
Avoid nephrotoxic drugs

surapee pinumphol, MD | Physician - FAMILY MEDICINE | Disclosure: None

thailand Thailand
April 17, 2014

ICU-Acquired weakness.

Decrease risk factor for the developement of ICU-acquired weakness and early active-
passive mobilization.

PANCHANAN KHAKHLARY, MD | Physician - INTERNAL MEDICINE | Disclosure:

None
India
April 17, 2014

icu acquired weakness

Dear sir, I would like to add Low molecular heparin in this patient as the patient is to be
bed ridden for long.Maintain Nutrition, Prevention of infection ,early mobilisation and
regular physiotherapy.

higinio malave | Physician - Orthopedics | Disclosure: None

Ecuador
April 17, 2014

splint hand and feet

remenber early mobilization and use of splits , the blood thinners are ok and attemp to
stand him in a bed try to return to circadian cycle day and nights

EDWARD HILL, MD | Physician - FAMILY MEDICINE | Disclosure: None

CANTON OH
April 17, 2014

Alcohol

Hoe long has he been off alcohol?

DONALD ADAMS MPAS PA-C | Other | Disclosure: None

SAN ANTONIO TX
April 17, 2014

short term stay

after resuscitation (normalization of BD, lactate, Svo2), ensure entra-vascular volume

status. our goal should be to do all that is necessary to ensure as short of an ICU stay as
possible. * Ensure aggressive Sleep Wake Cycle to prevent delirium 1. Daily Sedation
Holidays 2. Daily SBT (may require BID sedation holidays) 3. Extubation for all those pt
who meet criteria for extubation 4. Early Mobility via Nurses then Physical therapy, --
protocol driven - in stages 5. Transition out of ICU when pt no longer requires ICU care

JOSE ALFIE | Physician - INTERNAL MEDICINE | Disclosure: None

Argentina
April 17, 2014

deconditioning

Othostatic hypotension could represent an unrecognized source of weakness later at

home. Routine sodium restriction can aggravate this condition and should be avoided.

MICHAEL NABOZNY | Resident - GENERAL SURGERY | Disclosure: None

MADISON WI
April 17, 2014
Palliative care consult

This gentleman is heading down the road towards becoming part of the cohort now
discarded from the ICU to an LTAC as "chronically critically ill." No where in the story
has there been any discussion about what this guy would want in this situation, but many
of the suggestions of trach/PEG, etc. assume that he would be okay with a 6 month to 1
year recovery in the best case from something like this. If he has another major
complication, then these issues become more and more pertinent in the overall prognosis
and decision making.

CHRISTINE DOYLE, MD | Physician - ANESTHESIOLOGY | Disclosure: None

SAN JOSE CA
April 17, 2014

Food and Exercise

He's already in trouble given the scenario. He needs to be fed, and if his gut is not
working, he needs TPN/PPN. He is already catabolic, so he needs fairly high protein if
his kidneys will tolerate it. Assessment of lean muscle mass is still in evolution, but it
might be helpful. Many of these patients come in with low-grade malnutrition and it only
gets worse. He needs to get exercise. If he's awake/alert enough to cooperate (see earlier
comments about sedation), get him out of bed and walk him on a portable ventilator. Yes,
it's labor intensive for the staff, but it really helps both physically and mentally for patient
and family. Otherwise, passive exercises in bed (get the family involved), progressing to
more active exercises.

VIJAY ANAND | Physician - INTERNAL MEDICINE/NEUROLOGY | Disclosure:

None
chennai India
April 17, 2014

Diagnosis

We can supplement vitamins. Asses neuropathy by tendon jerk .

SCOTT WOOD | Other | Disclosure: None

St. Catharines ON Canada
April 17, 2014

Colloidal Silver + Body Chemistry Analysis and Adjusting

My first suggestion would be to administer Colloidal Silver in one way or another - to the
equivalent and minimum of 4 oz. per day orally - 1 oz. 4 times a day, or according to the
need, especially in this critical stage, and especially if any signs of infection are noticed.
Secondly, sufficient fluids must pass through his system for the removal of dead cell
debris via the bloodstream, kidneys and urinary tract - In a normal situation, anywhere
from 30% to approx. 40% of his body-weight (lbs.) in ounces per day. Thirdly, as the
fluids are administered, his blood sugars must be monitored and maintained at the best
level for optimum healing to take place, and the most accurate method of determining
one's blood sugars is by an analysis of the urine with a Refractometer. For the best chance
of healing, the urinary Brix reading should be from 1.0 to 2.0 - definitely no lower than
1.0. And 4th, monitor his urinary pH. The optimum healing numbers for the pH are 6.2 -
6.8. Various calciums, foods, juices, vitamins, etc. can be used to adjust the body's pH
especially with the calciums that are lacking according to the urine and saliva pH's.

RAQUEL ANNONI | Other | Disclosure: None

Brazil
April 17, 2014

Early physiotherapy

Physiotherapy should be implemented in day one with some strategies as: - Passive range
of motion and eletrical muscle stimulation while he is still sedated. - Early mobilization
as soon as possible (active exercises, sitting on edge of bed and outside bed, standing and
ambulating).

Teresa Goodell | Other | Disclosure: None

April 17, 2014

Mobilization: it takes a village.

There seems to be broad agreement on the benefits of early mobilization, even in

mechanically ventilated persons. What is often missed by my physician colleagues is that
mobilizing this type of person requires a nurse, a physical therapist, a respiratory
therapist, and someone to follow behind with a wheelchair. Coordinating these four
health care providers at a time when the client is awake and psychologically prepared for
the task is very time-consuming. It is important to remember that writing an order doesn't
necessarily accomplish this complex task. - Teresa Goodell, PhD,RN,CNS

MARY GRAPER | Other | Disclosure: None

Milwaukee WI
April 17, 2014

What about the sepsis?

What is being done about the sepsis? Are the SSC guidelines for the management of
severe sepsis and septic shock being followed?

VICTOR LESLIE SCOTT, MD | Physician - CRITICAL CARE (ANESTHESIOLOGY)

| Disclosure: None
PITTSBURGH PA
April 17, 2014
Preventing ICU PolyNeuropathy in the Critically ill with Septic Shock!

Prevention of ICU Polyneuropathy in ICU patients is imperative. The Following are

suggested but clearly not absolute in prevention of is development: 1. Start Physical
Therapy passive motions by day one with the escalation to active and resistive therapy as
tolerated by days 2 or 3 post-op. Early Ambulation if tolerated 2. Start Early Enteral
Nutrition referable with a Jejunual enteral feeding tube placed intra-operatively. If not
tolerated start TPN until GI tract recovers. Addition of Probiotcs at this time is imperative
as also suggested. 3. AVOID steroid base (NMBA) as this patient will most likely need
supplemental Adrenal support with IV hydrocortisone given the presenting disease matrix
of the patient and that the patient is on Norepinephrine with a prior history of
Hypertension. Cis-Atracurium or other, molecules (muscle relaxants) metabolized by
Hoffman-Hydrolysis are preferable. 4. ACTH Stimulation Test with ACTH baseline
level, whilst starting Dexamethasone preemptively pending results. 5. Maintain
Euglycemia along with normalization of Ionized Mg++ & Ca++. 6. Place an Epidural
Catheter for abdominal pain management.

JULIE KOBAK | Other | Disclosure: Employee of a maker of a relevant drug or device

Poland OH
April 17, 2014

Early consultation from speech pathologist

Early consultation from the speech pathologist to address communication and alleviate
anxiety and depression. Early tracheostomy to facilitate weaning, minimize
complications and damage to vocal tract, facilitate early communication and oral feeding.
Early cuff deflation and in-line speaking valve trials to restore normal physiology and
exhalation through upper airway, to prevent atrophy of oral/pharyngeal/laryngeal
muscles, to restore protective glottic closure reflex for swallow, to restore cough strength
and secretion management.