developed specific guidelines. The initial evaluation for any patient requiring airway management should begin with prediction of risk factors that would increase the risk of difficult intubation. The MOCOCHA score (Table 9.1) is a scoring system (>3 of 12 items present suggests higher risk) to predict a difficult airway. We recommend the early use of video‐assisted laryngoscopy (GlideScope™) for difficult intubation to avoid multiple attempts, airway trauma, esophageal intubation, and/or prolonged hypoxia.Table 9.1 MACOCHA score calculation worksheet.Points*Factors related to patientMallampati score III or IV5Apnea syndrome (obstructive)2Cervical spine reduced mobility1Opening mouth <3 cm1Factors related to pathologyComa1Severe Hypoxemia (<80%)1Factor related to operatorNon‐Anesthesiologist1Total12* Score 0 to 12: 0 = easy airway, 12 = very difficult airway.
Airway management can be divided into three parts: pre‐, peri‐, and post‐intubation. The pre‐intubation period focuses on oxygenation with 100% non‐rebreather or non‐invasive ventilation such as high flow oxygen, which we prefer over non‐invasive bilevel positive pressure ventilation. Complications with BIPAP involve ineffective seal, lung hyperinflation, and introduction of air to the stomach.In patients with GI bleed or those with emesis, we highly recommend nasogastric suctioning while setting up for intubation to remove any gastric residuals and reduce the risk of aspiration. The peri‐intubation period focuses on hemodynamic monitoring and anticipation of circulatory collapse with the administration of sedatives. Intravenous fluids should be initiated with standby vasopressor support to maintain mean arterial pressure above 65 mmHg.The post‐intubation period should focus on the immediate confirmation of the endotracheal tube with capnography, initiation of appropriate sedatives, and the initial use of lung protective ventilation. The use of point‐of‐care ultrasound pre‐ and post‐intubation to assess lung sliding can be helpful in confirming adequate endotracheal tube placement and ruling out mainstem intubation while awaiting radiographic confirmation.
Infection control in ICU
Health care‐associated infections account for approximately 1.7 million infections and 99 000 deaths annually in the USA. The two most common device‐related infections encountered in the ICU are central line‐associated bloodstream infections (CLABSIs) and catheter‐associated urinary tract infections (CAUTIs).
A CLABSI is a bloodstream infection in a patient with a central venous catheter which cannot be attributed to an infection at any other site. CLABSIs are associated with increased hospital LOS, health care costs, and overall patient mortality. A 2013 meta‐analysis of the financial impact of health care‐associated infections in the USA found that CLABSIs had the highest financial cost in the health system at $45 814.
Implementation of prevention bundles and checklists have led to a 46% decrease in CLABSIs from 2008 to 2013. However, there are still an estimated 30 100 CLABSIs per year across the ICU and acute care facilities of the USA. An infection prevention checklist focuses on some of the main methods of CLABSI prevention including optimal site selection (avoiding femoral access sites), proper hand hygiene, use of chlorhexidine disinfectants, and use of maximal sterile barrier precautions during insertion.The use of ultrasound guidance for placement of internal jugular catheter devices has been shown to reduce the risk of CLABSI and other non‐infectious complications and should be utilized when possible. Maintenance of these devices is important and may further reduce the rate of infection. Therefore, it is recommended to disinfect catheter hubs prior to access, maintain sterile dry dressing with routine dressing changes, and most importantly to remove the device as soon as it is no longer needed.
Urinary tract infections (UTIs) are common hospital‐acquired infections with an estimated 93 000 UTIs documented in acute care hospitals in 2011 in the USA. UTIs account for approximately 12% of nosocomial infections reported in the ICU. Urinary catheters pose additional risk factors in the elderly such as need for physical restraint, reduced mobility leading to risk of venous thromboembolism, and hematuria.The use of procedure checklists and bundles similar to those utilized for CLABSIs have been shown to decrease the risk of CAUTIs and reduce the inappropriate use of urinary catheters. Hand hygiene and the use of aseptic placement of the urinary catheter are key in reducing the risk of infection. Maintenance of the catheter with a closed drainage system and prompt removal when no longer necessary are equally important in reducing CAUTI rates.
Ventilator‐associated pneumonia (VAP) occurs in 9–27% of all intubated patients. The incidence of VAP not only increases the mortality rate but is also associated with increased ventilator days and increased LOS.Prevention strategies including patient positioning, equipment and hand hygiene, and bedside respiratory care (e.g. regular suctioning) have been shown to reduce VAP rates.The use of oral chlorhexidine decreases bacterial colonization of oropharyngeal secretions and therefore the incidence of VAP in those intubated for the short term.
Please also refer to Chapter 44 (Infections Acquired in the Intensive Care Unit).
Reading list
1 Barr J, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit: executive summary. Am J Health Syst Pharm 2013; 70(1):53–8.
2 Buendgens L, Koch A, Tacke F. Prevention of stress‐related ulcer bleeding at the intensive care unit: risks and benefits of stress ulcer prophylaxis. World J Crit Care Med 2016; 5(1):57–64.
3 Carson JL, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA 2016; 316(19):2025–35.
4 Chousterman BG, et al. Prevention of contrast‐induced nephropathy by N‐acetylcysteine in critically ill patients: different definitions, different results. J Crit Care 2013;5:701–9.
5 Cook DJ, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 1994; 330:377–81.
6 De Jong A, et al. Early identification of patients at risk for difficult intubation in ICU: development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med 2013; 187:832–9.
7 Tamma PD, Srinivasan A, Cosgrove SE. Infectious Disease Clinics of North America. Antimicrobial stewardship. Preface. Infect Dis Clin North Am 2014; 28(2):xi–xii.
Suggested websites
https://www.cdc.gov/hai/surveillance/progress‐report/index.html
Additional material for this chapter can be found online at:
www.wiley.com/go/mayer/mountsinai/criticalcare
This includes multiple choice questions.
CHAPTER 10 Palliative Care
Umesh
