FAST HUG : ICU Prophylaxis

OLEH : Faundra arieza Firdaus

Anasthesiologi dan terapi itensif
RSSA Saiful Anwar
 HISTORY

Prof Jean-Louis Vincent

Intensive care at
University of Brussels
PLAY THE IMPORTANT ROLES !!

Reduce errors

Encourages teamwork

Help improves the quality of care received by intensive care

patient
 Educate Review
patient & Goal communications
family
Infection Check
control ventilator
settings &
mode

Monitoring Outline of Care of ETT

presentation

General Care
Physiotherapy
- FAST HUG
- FAST HUGSBID
Oral, Eyes &
Radiation Skin Care
Sleep
Goals of Monitoring & Managing the
ventilated patient

Pastikan jalan napas paten

Pastikan oksigenasi dan ventilasi yang memadai

Menjaga stabilitas hemodinamik

Memahami Interpretasi alarm ventilator & cara kerjanya

Mencegah infeksi

Mencegah komplikasi yang terkait dengan posisi tidur selama pasien di

rawat
REVIEW COMMUNICATIONS
1) Komunikasi antara tenaga medis
~ meningkatka hasil yang optimal untuk kondisi pasien
~ mencari tahu tujuan terapi untuk pasien
~ indikasi untuk ventilasi mekanik
~ indikasi masuk ICU
~ Status kapan kita boleh melakukan resusitasi ?

2) Komunikasi dengan pasien

~ menyediakan alat tulis atau papan komunikasi, sehingga pasien
dapat mengungkapkan kebutuhannya
 Check Ventilator Settings & Modes
Mengetahui cara kerja ventilator

Membiasakan dengan alarm ventilator dan respon untuk tindakan

Menyiapkan tas resusitasi dan obat resusitasi

Mengetahui teknik untuk hiperventilasi dan preoxygenasi

Check following settings:
1) Respiratory rate
2) Fraction of inspired oxygen ( fio2)
3) Tidal volume
4) Peak inspiratory pressure (PIP)

Ventilator mode of patient:

- Ventilator itself
- Respiratory flow sheet
Care of ETT
Memastikan posisi yang benar

Menjaga tube ETT

Menjaga tekanan Cuff ETT

Mencurigai kebocoran

Mencurigai adanya plack di ETT

Suctioning
Size of ETT
7.0- 7.5mm for

8.0- 9.0mm for

Larger ETT in Asthma, COPD

Tube position, confirmed by:

- Clinical examination 5 point auscultation
- Photo Thoraks
SUCTIONING
General suctioning recommendation:

1) Suction only as needed not according to a schedule.

2) Hyperoxygenate the patient BEFORE & AFTER suctioning
to help prevent O2 desaturation
3) Dont instill normal saline into the ETT in an attempt to
promote secretion removal
2004 American Association for respiratory care CPG
4) Limit suctioning pressure to the lowest level needed to
remove secretions
5) Suction for the shortest duration possible
 Type of suction

Open suction Closed suction

 Open suction

Fresh cathether with every use

Preoxygenate with 100% o2
Suction cycle < 20s
Occlude catheter while passing in
membersihkan cateter dengan air steril
Repeat if required
 Closed suction

Use in hypoxic
patient
( FiO2 >0.6),
PEEP > 10

Multi drug
infection
infections
 Monitor BP, HR,SPO2 &Arryhtmias

** Combine suction with physiotherapy & postural drainage

GENERAL CARE
FAST HUG

FAST HUGS BID

F
A
S
T

H
U
G
 FAST HUG

- digunakan di unit perawatan intensif (ICU) untuk membantu team medis

dalam persiapan untuk evaluasi kondisi pasien, membantu
mengidentifikasi dan mencegah kesalahan pengobatan, meningkatkan
keselamatan pasien, dan memaksimalkan intervensi terapeutik

- Setidaknya minimal dilakukan 1x sehari

- Dapat digunakan sebagai informasi yang berkala untuk setiap team

tenaga medis di ICU
GENERAL CARE
F= Feeding
A= Analgesic
S= Sedation
T= Thromboembolic prophylaxis

H= Head- of- bed elevation

U= Stress Ulcer prevention
G= Glucose control
F = Feeding
 Malnutrisi dapat mengakibatkan komplikasi dan dapat pula memberikan
penurunan kondisi pada pasien kritis

In general, 20- 25 kcal/kg/day

Disarankan Sedini mungkin , (24-48 jam)

Clinical Condition Rekommended Intake (g/kg/day)

Healty adult, normal organ fungtion O,8

Post operative 1,0 1,5

Sepsis 1,2 1,5
Multiple trauma 1,3 1,7
Major burn 1,8 2,5

Guidelines for Protein Intake in Adults

The ASPEN nutrition support practice manual. Silver Spring MD, 1998. American Society for Parenteral and Enteral Nutrition
A = Analgesic
penyakit yang sudah ada sebelumnya, prosedur invasif, luka traumatik,
perangkat monitoring invasif dan non-invasif, perawatan rutin dan
imobilitas berkepanjangan.
Rangsangan ini dapat mempengaruhi pemulihan fisiologis dan psikologis
yang mengarah ke tidur yang tidak memadai,
disfungsi paru dan respon stres akut yang dapat bermanifestasi sebagai
imunosupresi,
hiperkoagulabilitas,
katabolisme protein
peningkatan konsumsi oksigen miokard.
tingkat nyeri menjadi tanda vital kelima
 Wong-Baker FACES Pain Rating Scale:
 Visual Analog Scale:

1 10

Verbal Rating
Scale: 0 = No Pain, 10 = Worst pain ever
Pharmacological therapies to relieve pain included:
opioids
non opioids

Continuous infusion of analgesic drugs or regularly

administered doses are more effective than bolus
doses given as needed

I.V. administration of analgesic allows closer and

more rapid titration to patients needs than I.M. or
subcutaneous administration.

Care should be taken to ensure analgesic is adequate

but not excessive.
S = Sedation

No rules governing how much to give & how often.

Sedative administration must be titrated individual.

( Calm, comfortable and collaboration) rule help to determine whether

patients are appropriately sedated.

Daily discontinuation of sedation may reduce the length of ICU stay

Kress et al
T = Thromboembolic prophylaxis
 T Thromboembolic Prophylaxis
Sering dilupakan,
Kematian dan morbiditas disebabakan thromboembolism
Paasien yang tidak mendapatkan prophylaxis, resiko terkana DVT sekitar
13-31%
Di rekomendasikan penggunaan heparin kecuali ada kontraindikasi
 Metode yang efektif masih belum jelas

Manfaat profilaksis harus dipertimbangkan terhadap resiko komplikasi

H= Head- of- bed elevation
Several studies demonstrated that having the head of
bed inclined at 45 degrees can decrease the risk
incidence of gastroesophageal reflux.

reduce rate of nosocomial pneumonia.

A randomised trial. Lancet 1999
U= Stress Ulcer prevention

Pencegahan stress ulkus penting , terutama untuk pasien yang beresiko

pendarahan gastrointestinal

Masih belum didapatkan obat yang optimal

Ranititidien lebih signifikan daripada sukralfat untuk mencegah
pendarahan gastrointestinal

Multicenter study by Cook et al

G= Glucose control
 Menjaga kadar gula di bawah 8.3 mmol/L sesuai pedoman surviving
sepsis
Dari penelitian, dipadatkan 29,3% penurunan kematian dan 10%
penurunan hari perawatan yang dibutuhkan di ICU

Krinsley
FAST HUGSBID

S = Spontaneous Breathing Trial

B = Bowel Care
I = Indwelling Catheter removal
D = De-escalation of Antibiotitcs
S = Spontaneous Breathing Trial

Penilaian secara berkala merupakan metode yang aman, efektif dan

sangat terprediksi untuk menentukan SBT

Penggunaan secara lama ventilator dapat meningkatkan resiko

ventilator assosiated pnemonia
 WEANING: Readiness
pengurangan bantuan hingga penghentian pemberian therapi oksigen
ventilasi mekanik karena kebutuhan ventilasi pasien terpenuhi.
Tujuan : Mempersingkat kebutuhan ventilasi mekanik sehingga resiko
untuk terjadi infeksi nosokomial dapat diminimalisir dan lama perawatan
pasen di ruang intensif dapat dipersingkat.
During weaning trial all patient must be observed
Closely to identify the existence of distress

High RR
Respiratory patern ( paradox, nasal flaring)
Low VT
Drop in O2 saturation < 90%
Increased hr ( > 20% from baseline)
Anxiety, agitation, diaphoresis
Somnolence
B = Bowel Care
 B = Bowel Care
Ganguaan GI motilitas termasuk ileus, constipasi dan diare merupakan
penyakit umum yang didapatkan pada pasien kritis

Penilain rutin dan terapi untuk mempertahankan fungsi normal usus harus
dilakukan pada semua pasien kritis
 I = Indwelling Catheter removal
Merupakan cateter urine, vena central, arteri pulmonalis dan dialisis yang
sering kita jumpai pada pasien kritis

Dikarenakan alat yang mengubungkan (dalam tubuh ke luar tubuh) >>>

resiko infeksi

Diperlukan menjaga kebersihan dan perawatan berkala untuk menurunkan

resiko infeksi
D = De-escalation of
Antibiotitcs/Streamlining

Secepat mungkin dilakukan untuk pengambilan kulture, agar mendapatkan

terapi antibiotik yang sesuai dan optimal

meminimalkan paparan obat antimicrobial broad-spectrum

Oral, Eyes &
Skin care
 Oral Care
preferably 8 hourly
Remove oral airway
Move ET tube to opposite corner
Clear mouth of all secretions
Paint mouth with 2% chlorhexidine

** Reduces rates of VAP

Eye Care
Moisol eyes drop
Tape both eyes in paralysed pt
Appropriate antibiotic drops
 Skin Care
Daily Bath
makes patient comfortable & fresh
improves circulation
Observe skin daily for redness, injuries, swelling,
rashes or other infections & bony prominences for bed
sore.

Cut short the finger & toe nails

Hair care- Shampoo as required

Back care- Apply olive oil from shoulders to buttocks

with brisk circular movement
 SLEEP IN ICU
Cause of sleep deprivation in ICU:

Environmental factors

Pathophysiological factors
 Enviromental factors

Noise
Lighting practices
Pt care activities
Diagnostic procedures
Sedatives
Analgesics
 Pathophysiological factors

Stress
Organ dysfunction
Inflammatory response
Pain
Psychosis
Integrated strategy to promote sleep in the
intensive care unit:

Noise reduction ( < 50dB)

Diurnal lighting practices

Use of sleep- promoting pharmacologic agent

Minimizing use of pharmacologic agents inhibiting sleep

Uninterrupted time for adequate sleep

Appropriate physiologic support

Active promotion of patient orientation

Patient- ventilator synchrony

Relaxation techniques
RADIATION
A daily CXR is indicated for pt with acute
cardiopulmonary problems & for patients on mechanical
ventilation.

In pt with a central venous catheter, a Swan- Ganz

catheter, Feeding tube, chest tube placement, only post
procedure radiographs indicated.

Stable cardiac monitoring pt & those with purely

extrathoracic disease require only admission films upon
entry to ICU, unless clinical condition demands.

American College Of Radiology

 PHYSIOTHERAPY
Specialized job
Round the clock
Continuum from preventing respiratory failure, to
managing pt on ventilator to pt who have been
weaned
Prevented complications related to MV
Percussion, vibration, change of position, postural
drainage ,suction for chest physiotherapy
Limb physiotherapy
MONITORING
1) VENTILATION
ABG
2) OXYGENATION

3) HEMODYNAMIC

4) URINE OUTPUT
Infection Control Measures
Control of the reservoirs of infection
Interruption of the transmission of bacteria from
person to person
Individual device related measures
Staff education
Surveillance
Regular audit
 Control of the reservoirs of
infection
Disinfection of pt area/bay between pt ( include bed,
monitor, ventilator, other equipment, furniture,
floor , walls)

Appropriate sterilization of reusable equipment

Appropriate disposal of disposable equipment including

sharps

Appropriate surveillance of personnel as reservoirs.

Cross contamination
Put on gloves before handling respiratory secretions @
contaminated objects.

Wash hands with soap & water or an alcohol- based

antiseptic hand rub before & after contact with mucous
membrane, respiratory secretions, or contaminated
objects and before and after contact with pt with
respiratory device.

Wear gown when you anticipate being soiled with

respiratory secretions and change it before caring for
another patient.
Between their uses on different patients, sterilize or
subject to high-level disinfection reusable hand-
powered resuscitation bags ( AMBU)
In addition to routine hand hygiene the following
should also be considered in ventilated pt:

Intubation: If elective- standard handwash + sterile

gloves
Emergency handrub + sterile gloves
Suctioning : Alcohol hand rub before & after procedure
Clean glove
Bronch: Surgical hand/forearm scrub
Full sterile field, gown & gloves.

Always consider masks, splash guard & eyewear ( PPE)

Full chlorhexidine handwash if accidental exposure to

secretions.
 Educate family & patient
Seeing a loved one attached to mechanical ventilation
frightening.

To ease distress in pt & family, teach them why

mechanical ventilation is needed & emphasize the
positive outcomes it can provide.

Explain what you are doing

Communicate desired outcomes so the patient &

family can actively participate in the plan of care.
 REFERENCE
1) Give your patient a fast hug ( at least) once a day Jean- Louis Vincent,
MD, PhD,FFCM
2) [PPT] Care of the ventilated patient: FAST HUG-SBID
3) Critically ill patients need FAST HUGS BID ( an update mnemonic)
4) Top 10 Care Essentials for ventilator Patients
Evidence-based Interventions and Teamwork are crucial when
caring for patients on Mechanical Ventilators, Laura C.
Parker,MSN,RN,CCRN