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Chapter 136. Prevention in the Intensive Care Unit Setting

Laura Evans, MD, MSc; Nishay Chitkara, MD

  1. What are the common preventable complications of intensive care unit (ICU) care?

  2. What components are included within the care bundles to reduce catheter-related blood stream infections and ventilator-associated pneumonia?

  3. What pharmacologic and nonpharmacologic interventions may be used for prevention of venous thromboembolism in the ICU?

  4. Which ICU patients are high risk for stress ulcer bleeding and require pharmacologic prophylaxis? When should prophylaxis be discontinued?

  5. What are the essential elements of interdisciplinary care in the ICU?

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

In recent years, the Institute for Healthcare 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 136-1).

Table 136-1 Components of the Institute for Healthcare Improvement Central Line and Ventilator Bundles
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Table 136-1 Components of the Institute for Healthcare 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 degrees)

  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)

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Practice Point
  • Care bundles allow for more uniform application of all elements of evidence based practice and, thus, result in improved patient outcomes.

For each preventable ICU complication, this chapter will address epidemiology and strategies for prevention. Finally, daily goals of care will be addressed. Critical care practitioners can ensure the essential elements of preventive care in the ICU are implemented by incorporating a worksheet for daily goals of care.

Catheter-Related Blood Stream Infections

Catheter-related blood stream infections (CR-BSIs) cause significant morbidity and mortality in the ICU, and increased length ...

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