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Chapter 143: Prevention in the Intensive Care Unit Setting

Nishay Chitkara

INTRODUCTION

Key Clinical Questions

  • image What are the common preventable complications of intensive care unit (ICU) care?

  • image How do you reduce catheter-related blood stream infections and ventilator-associated pneumonia?

  • image How do you prevent venous thromboembolism in ICU patients?

  • image Which ICU patients require pharmacologic prophylaxis to prevent stress ulcer bleeding? When should prophylaxis be discontinued?

  • image What are the essential elements of interdisciplinary care in the ICU?

Critical illness places patients at high risk for iatrogenic complications during hospitalization. Invasive monitoring devices, mechanical ventilatory support, immobility, and debility increase susceptibility to these complications. Previously considered unavoidable consequences of critical illness, many ICU-related complications may be prevented.

The Institute for Health Care Improvement (IHI) and other national organizations have advocated the adoption of a series of “bundles” with the goal of reducing the rate of complications in the ICU. Bundles aggregate evidence-based practices relevant to a diagnosis or procedure into a single intervention. The rationale for the use of bundles is that, when their elements are reliably applied together, they allow more uniform application of best practices and, thus, improve patient outcomes. Bundles represent one of many tools needed to prevent ICU-related complications (Table 143-1).

TABLE 143-1Components of the Institute for Health Care Improvement Central Line and Ventilator Bundles
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TABLE 143-1 Components of the Institute for Health Care Improvement Central Line and Ventilator Bundles
IHI Central Line Bundle* IHI Ventilator Bundle†

  1. Hand hygiene

  2. Maximal barrier precautions

  3. Chlorhexidine skin antisepsis

  4. Optimal catheter site selection, with avoidance of the femoral vein for central venous access in adult patients

  5. Daily review of line necessity, with prompt removal of unnecessary lines

  1. Elevation of the head of bed (to between 30° and 45°)

  2. Daily interruption of sedation and assessment of readiness to extubate

  3. Prophylaxis for peptic ulcer disease

  4. Prophylaxis for deep venous thrombosis

  5. Daily oral care with chlorhexidine

*5 Million Lives Campaign. Getting Started Kit: Prevent Central Line Infections How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008 (available at www.ihi.org).

†5 Million Lives Campaign. Getting Started Kit: Prevent Ventilator-Associated Pneumonia How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2010 (available at http://www.ihi.org).

For each preventable ICU complication, this chapter will address epidemiology, strategies for prevention, and goals of care. Members of the critical care team should incorporate a worksheet for daily goals of care to ensure that the essential elements of preventive care are implemented in the ICU.

COMMON COMPLICATIONS

CENTRAL LINE-ASSOCIATED BLOOD STREAM INFECTIONS

Central line-associated blood stream infections (CLABSIs) cause significant morbidity and mortality in the ICU, increased length of stay and cost. Primary blood stream infections are most often related to infected intravascular devices, mostly central venous catheters. At least 80,000 new cases of CLABSIs occur in the ICU each year ...

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