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JICS Volume 11, Number 1, January 2010 69

Comment The Intensive Care Society 2010


T
he mnemonic FAST HUG
1
was proposed almost ve years
ago by Jean-Louis Vincent as a way of assisting healthcare
workers looking after critically ill patients. The mnemonic
stands for: Feeding, Analgesia, Sedation, Thromboembolic
prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, and
Glucose control. All the components are evidence-based and
have been used the world over. Although there has not been a
study of the concept of FAST HUG as a bundle for critical care,
common sense would dictate that rigorously using a package of
proven therapies can only enhance outcomes. However, while I
embrace the concept, I have since noticed that on its own, it
misses fundamental aspects of critical care, which are equally
important.
Often simple things like uid balance, investigation results,
constipation, and other treatments are overlooked to the
patients detriment. With the current medical training
programme whereby sometimes very junior trainees review
patients, or in very busy units, it is vital that a simple,
comprehensive systematic approach to reviewing a critically ill
patient is engendered. I propose a small extension to Vincents
mnemonic to: FAST HUG FAITH. FAITH is a mnemonic for
Fluid balance, Aperients, Investigation and results, Therapies,
and Hydration.
Fluid balance
Fluid resuscitation is an essential component of management
of critically ill patients. The amount of uid administered is
dependent on the diagnosis and the patients response to it.
Patients admitted with severe sepsis or septic shock require a
much larger volume of uid than other conditions. Inevitably
such patients rapidly develop a positive uid balance. Fluid
balance has been shown to be an independent predictor of
survival, especially in the rst three days of admission.
2,3
These
retrospective studies have shown that a negative uid balance
is associated with better survival. This trend has, however,
been conrmed by the SOAP study, which also found that
positive uid balance was among the strongest prognostic
factors for death.
4
McNeils et al found that a positive uid
balance in the rst 24 hours of admission was associated with
the development of abdominal compartment syndrome.
5
A
positive uid balance in mechanically ventilated patients with
ALI/ARDS has been shown to be associated with worse
outcome.
6
It is, therefore, an essential part of good critical care
management that an accurate daily and cumulative uid
balance is maintained and judiciously reviewed and an early
negative (or neutral) uid balance be achieved when possible.
Aperients
The true incidence of constipation in critical care patients
depends on the type of intensive care unit studied, but ranges
from 5 to 83%.
7-9
There are many causes of constipation
including, dehydration, immobility, electrolyte abnormalities,
neurological injuries, hypothyroidism, bowel pathology and
opioid-based sedation. Aperients are commonly used to
prevent or relieve constipation. Aperients fall into four groups;
bulking agents (eg bre supplements); lubricants/stool
softeners (eg microlax enema); gut stimulants (eg senna); and
osmotic agents (eg lactulose). Constipation in critically ill
patients is not a benign condition. Mostafa et al have shown
that constipation can lead to failure to wean from mechanical
ventilation and increase length of stay.
7
One other important
but yet not easily recognisable complication of constipation is
abdominal pain.
10-12
Judicious use of aperients may reduce the
incidence of constipation and associated complications.
Investigations and results
The majority of admissions to intensive care are unplanned or
emergencies. Consequently most of these critically ill patients
will not have had full investigation of their primary condition
prior to admission. It is incumbent upon intensivists to
investigate such patients in order to institute correct
management. Any tests or investigations ordered must have
results reviewed and acted upon daily. Included is inspection
of lines, catheters, insertion sites and wounds as potential
sources of infection.
13,14
A record of the duration of these lines
and catheters should be kept and made easily available for
daily review. The Institute of Health Improvement (IHI) in the
USA in its central line bundle recommends a daily review of
line necessity with prompt removal of unnecessary lines.
15
Therapies
A daily review of clinical progress is essential in order to assess
the effectiveness of the therapies rendered. In the case of
antibiotics a review of clinical progress as well as
microbiological results should lead to de-escalating antibiotics.
16
Severe sepsis and septic shock have high mortality and the early
administration of an appropriate antibiotic is associated with
improved outcome and reduced length of stay.
17,18
The Surviving
Sepsis Campaign guidelines (2008) recommend administration
of an appropriate antibiotic within one hour of admission.
14
It
has been estimated that for every hour of delayed antibiotic
therapy there is a mean decrease in survival of 7.6%.
18
The management bundle of the Surviving Sepsis
Campaign(SSC)
14
recommends intensive insulin therapy, low
dose corticosteroids, low tidal volume ventilation and activated
protein C.
It is of paramount importance that as the patient begins to
recover that they should be commenced on their essential
medications they were taking prior to current illness.
There is a tendency for polypharmacy in critical care
management. Drug interactions may occur. The intensivist
should review the drug chart daily in order to scale down and
rationalise the patients therapy.
Letters to the editor
Extend FAST HUG with FAITH
Volume 11, Number 1, January 2010 JICS 70
Comment
Hydration
Assessment of the hydration status of critically ill patients is
fraught with difculties. Often these patients are grossly
oedematous but intravascularly uid depleted. In addition,
some of these patients have cumulative positive uid balance.
Diuretics may have been used prior to current illness leaving
the patient overall uid depleted. Insensible uid loss is always
difcult to estimate. This may increase with pyrexia to 2 to
2.5 mL/kg/day for every degree temperature rise above normal.
Although both parenteral and enteral nutrition bags contain
water, additional water may still be needed to compensate for
excessive insensible loss, wound loss, diarrhoea, vomiting and
diabetes insipidus. Hypernatraemia and uraemia are common
signs of dehydration in the ICU patient. For the perioperative
patient, the British Consensus Guidelines Group (GIFTASUP)
have recently published guidelines on choice of intravenous
uid to be administered.
19
Addition of these ve components of critical care makes
sense and a replete mnemonic FAST HUG FAITH enhances
Vincents FAST HUG approach by encompassing a more
comprehensive bedside review of everything happening with
the critically ill patient. In addition to a sense of closeness to
your patient (FAST HUG), adding FAITH brings another
dimension of believing in the right things you are doing to get
them back home. As is increasingly becoming obvious, it is not
high technology medicine that is making the biggest positive
impact on our patients, but remembering the simple, easy-to-
do things.
References
1. Vincent JL: Give your patient a fast hug (at least ) once a day. Crit Care
Med 2005;33:1225-29.
2. Schuller D, Mitchell JP, Calandrino FS, Schuster DP. Fluid balance
during pulmonary oedema. Is uid gain a marker or a cause of poor
outcome? Chest 1991;100:1068-75.
3. Alsous F, Khamiees M, De Girolamo A et al. Negative uid balance
predicts survival in patients with septic shock. A retrospective pilot
study. Chest 2000;117:1749-54.
4. Vincent JL, Sakr Y, Sprung CL et al. Sepsis in European intensive care
units: Results of the SOAP study. Clinical Investigations. Crit Care Med
2006;34:344-53.
5. McNeils, Marini C, Jurkiewicz A et al. Predictive factors associated with
development of abdominal compartment syndrome in surgical intensive
care units. Arch Surg 2002;137:133-36.
6. Sakr Y, Vincent JL, Reinhart K, et al. High tidal volume and positive uid
balance associated with worse outcome in outcome in acute lung injury.
Chest 2005;128:3098-08.
7. Mostafa SM, Bhandari S, Ritchie G et al. Constipation and its
implications in the critically ill patient. Br J Anaesth 2003,91:815-19.
8. Mostafa SM, Bhandari S, Ritchie G. Constipation and its implications in
the critically ill: A national survey of United Kingdom intensive care
units. Br J Anaesth 2001;87:343P.
9. Montejo JC, for the Nutritional and Metabolic Working Group of
Intensive Care Medicine and Coronary Care Units. Enteral nutrition-
related gastrointestinal complications in critically ill patients; Multicentre
study. Crit Care Med 1999;27:1447-53.
10.Cameron JC. Constipation related to narcotic therapy. A protocol for
nurses and patients. Cancer Nurs 1992;15:372-77.
11.Held JL. Cancer care: preventing and treating constipation. Find out
your role in managing this common symptom. Nursing 1995;25:26-27.
12.Manara L, Bianchetti A. The central and peripheral inuences of opioids
on gastrointestinal propulsion. Ann Rev Pharmacol Toxicol 1985;25:249-73.
13.Burke JP. Infection control a problem for patient safety. NEJM 2003;
348:561-66.
14.OGrady NP, Alexander M, Dellinger P et al. Guidelines for the
prevention of intravascular catheter-related infections. CDC MMWR
Recomm Rep 2002;51:1-29.
15.Institute for Healthcare Improvement. Implementing the Central Line
Bundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/
Changes/ImplementtheCentralLineBundle.htm Accessed December 2009.
16.Dillinger RP, Levy MM, CarletJM, et al. Surviving Sepsis
Campaign:International guidelines for management of severe sepsis and
septic shock:2008. Intensive Care Med 2008;34:17-60.
17.Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and
appropriate antibiotic selection reduce length of hospital stay of patients
with community acquired pneumonia:link between quality of care and
resource utilisation. Arch Intern Med 2002;162:682-88.
18.Kumar A, Roberts D, Wood KE et al. Duration of hypotension before
initiation of effective antimicrobial therapy is the critical determinant of
survival in human septic shock. Crit Care Med 2006;34:1589-96.
19.Powell-Tuck J, Gosling P, Lobo D et al. Summary of the British
Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients (GIFTASUP)- for comment. JICS 2009;10:13-15.
Moses Chikungwa Consultant Anaesthetist/Intensivist,
Mid Staffordshire NHS Foundation Trust
mchikungwa@yahoo.co.uk
F
or patients treated in critical care units, it is easy to assume
that, having survived the acute illness, recovery will be
quick and problem-free. Unfortunately, patients are often left
with signicant long-term problems but it is widely accepted
that these complications can be reduced with careful handover
during discharge.
1
Despite this, adequate follow-up is rare.
2
In
July 2007, NICE published Clinical Guideline 50: Acutely ill
patients in hospital: recognition of and response to acute
illness of adults in hospital, aiming to overcome these failings
in communication and documentation.
3
The guidelines advocate a formal structured handover of
care...supported by a written plan to ensure continuity of care,
including a summary of the critical care stay, plans for ongoing
treatment and any needs identied.
3
On discharge from critical
care, medication should be reviewed to ensure that all
medication is still required and discontinued medication is
reassessed to ensure optimal patient therapeutics.
4
Physical
weakness and long-term psychological distress are common
complications of a prolonged admission but correct
rehabilitation and follow-up is proven to reduce the impact of
these problems.
5
Proper and systematic summaries, therefore,
must be completed to initiate correct follow-up and allow
preventable problems to be pre-empted.
An audit was performed in two tertiary and two district
hospitals in Wales to assess the implementation of the
guidelines. Data was collected from critical care discharge
An audit of compliance of critical care discharge summaries with NICE guidelines
JICS Volume 11, Number 1, January 2010 71
Comment
summaries from 218 live adult discharges (average 55 per
hospital) from critical care between 1st September and 30th
November 2008.
The results (Figure 1) demonstrate that discharge summaries
have been widely implemented by the four hospitals. Though
there were inconsistencies, the areas most relevant to ongoing
patient care were collectively completed thoroughly, such as
case summary (86%), ongoing treatment (82%) and nutritional
plan (89%) but had room for improvement. Infection status
(40%) and language needs (6%) were consistently poorly
completed. Infection status is of particular concern as it
suggests that current high prole campaigns, such as the
Welsh 1,000 Lives Campaign, are not having the desired effect
and may demonstrate a continued and needless risk to
patient safety.
The audit highlighted substantial disparities in form
completion between the hospitals studied, with Singleton and
Morriston Hospitals in the Abertawe Bro Morgannwg (ABM)
University Health Board performing considerably better than
both University Hospital of Wales (UHW) in the Cardiff and
Vale University Health Board and Ysbyty Gwynedd Hospital
(YG) in the Betsi Cadwaladr University Health Board. The
authors believe the use of an electronic discharge summary in
the ABM Trust contributed signicantly to this, as the
electronic format was clearly legible, easily accessible, well-
organised, expandable and gave guidance on completing each
section. In comparison, the paper forms used by both UHW
and YG had limited space and a more unstructured layout,
providing little assistance for those completing the form. The
documentation used in UHW and YG has been updated since
the audit.
This audit demonstrated the ability of a structured
electronic discharge form to achieve consistent standards,
which can improve patient safety. The full implementation of
NICE Clinical Guideline 50 will ensure continuity of care and
reduce patient complications.
Acknowledgement
The authors would like to thank their supervising tutor Dr.
Brian Jenkins and Dr. Dave Hope for their help and support in
completing this audit
References
1. Metnitz P, Fieux F, Jordan B et al. Critically ill patients readmitted to
intensive care units lessons to learn? Intensive Care Med 2003;29:
241-48.
2. Day V and the Department of Health Expert Group. Comprehensive
Critical Care: a review of adult critical care services. 2000.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4006585. Accessed Dec 2008.
3. National Institute for Health and Clinical Excellence. Clinical guideline 50:
Acutely ill patients in hospital. Recognition of and response to acute illness
in adults in hospital. NICE; London: July 2007. http://www.nice.org.uk/
nicemedia/pdf/CG50FullGuidance.pdf Accessed Oct 2008.
4. Campbell A, Bloomeld R, Noble D. An observational study of changes
to long-term medication after admission to an intensive care unit.
Anaesthesia 2006;61:1087-92.
5. Scragg P, Jones A, Fauvel N. Psychological problems following ICU
treatment. Anaesthesia 2001;56:9-14.
Figure 1 Overall audit results.
Complete
20% 80% 40% 0% 100%
Case summary
Diagnosis
Treatment summary
Ongoing therapy
Nutritional plan
Infection status
Physical & rehab needs
Psychological needs
Language needs
Incomplete
60%
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Olivia Curtis, Denise Duignan, Sheena Durnin
durnins@cardiff.ac.uk, William Kenyon, Rebecca Thomas,
Katherine Trigg, Simon Trundle,
Medical Students, Cardiff University
W
e read with interest Dr Astles survey on iatrogenic
anaemia and frequency of blood testing in the intensive
care unit (ICU).
1
The NHS Next Stage Review
2
focuses on
quality at the heart of patient care in the National Health
Service. The survey is a ne example of simple interventions
improving quality of patient care. It reiterates that improving
quality can reduce cost.
In health, haematopoiesis replaces about 50 mL blood per
day,
3
but this is suppressed in the critically ill. Not surprisingly,
almost 95% of the patients admitted to the ICU have a
haemoglobin level below normal by day three.
4
The factors inuencing sampling in the ICU are:
5
The ease of access to arterial blood
The work pattern prevalent within the unit
The belief that patients are critically ill enough to require
regular investigations.
The controllable variables to minimise iatrogenic anaemia in
the ICU are:
Reduction in sampling frequency (by education)
Reduction in discarded volume.
In previous research conducted in the UK, we have
established the role of education in reducing unnecessary
blood sampling.
6
In addition, closed sampling systems, now
available in the UK, have a signicant positive impact.
Modifying blood sampling technique
7
while using an open
arterial sampling system is benecial.
The survey correctly highlights that more experienced
nursing staff take samples less frequently. It is important
Correspondence regarding: Iatrogenic anaemia in the critically ill, JICS 2009;10:279-81.
Volume 11, Number 1, January 2010 JICS 72
Comment
to avoid ritualistic practice, especially for more inexperienced
staff.
The intended benets are
improvement in the quality of care
increased patient safety
reduction in workload
cost saving.
It is important that we continue to educate staff to achieve
the above-mentioned benets.
References
1. Astles, T. Iatrogenic anaemia in the critically ill: A survey of the frequency
of blood testing in a teaching hospital intensive care unit. JICS
2009;10:279-81.
2. Darzi, A. The Next Stage Review. NHS, London 2009 http://www.dh.gov.uk/
en/publicationsandstatistics/publications/publicationspolicyandguidance/
DH_085825 Accessed November 2009.
3. Bhaskaran NC, Lawler PG. How much blood for a blood gas? Anaesthesia
1988;43:9:811-12.
4. Rodriguez RM, Corwin HL, Gettinger A et al. Nutritional deciencies
and blunted erythropoietin response as causes of the anemia of critical
illness. J Crit Care 2001;16:36-41.
5. Roberts D, Ostryzniuk P, Loewen E et al. Control of blood gas
measurements in intensive care units. Lancet 337;1991:1580-82.
6. Hegde PS, Tarsey K, Blunt MC. Education reduces unnecessary
diagnostic blood sampling in the intensive care unit. Crit Care
2003;7(Suppl 2):P241.
7. Hegde PS, Tarsey K, Blunt MC. A modication of the blood sampling
technique in critical care to reduce blood wastage. Crit Care 2003;7
(Suppl 2):P240.
Thejas Bhari Specialist Registrar, Alexandra Hospital, Redditch
Prashant S Hegde Consultant in Anaesthesia and Intensive
Care, Worcestershire Acute Hospitals NHS Trust
prashant.hegde@worcsacute.nhs.uk