1Royal Adelaide HospitalIntensive Care Unit

Medical Manual2003 Edition

Website: http://health.adelaide.edu.au/icu

2Foreword

Welcome to Intensive Care.

This manual has been written to facilitate the daily running of the RAH Intensive CareUnit. It is by no means the definitive answer to all Intensive Care protocols andprocedures, nor is it designed to be a textbook.

A standardised approach to management is desirable for optimal patient care and safety,improving communication and understanding between members of the ICU team andassociated specialities. This approach provides a common platform for staff who comefrom different countries and training backgrounds.

This manual outlines various Protocols, which represent a standard approach to practicewithin the Unit. These have been derived from the available literature, clinicalexperience and where appropriate, cost-effectiveness. Guidelines designed to assist inclinical management are included, however patient management will ultimately dependupon the clinical situation.

Assistance is always available from the Duty Consultant and senior nursing staff. Useyour time in the Unit to get the most out of the large clinical caseload. Ask questionsabout clinical problems, equipment and procedures with which you are unfamiliar.There are numerous textbooks, journals and references available in the Unit.

This manual has undergone numerous changes, with contributions from many of theICU staff and from other specialty services within the hospital.

Dr Peter Toby ThomasDirector

January 2003 7th Edition

3CONTENTS

Contents............................................................................................................................ 3Royal Adelaide Hospital Intensive Care Unit .................................................................. 5Administration.................................................................................................................. 6

A. Staffing.................................................................................................................. 6B. Rostering and job descriptions .............................................................................. 9C. Orientation .......................................................................................................... 10D. Weekly programme............................................................................................. 11E. Admission and discharge policies ....................................................................... 12F. Clinical duties in the intensive care unit ............................................................. 13G. Documentation.................................................................................................... 16H. ICU Ward round ................................................................................................. 19I. Clinical duties outside the Intensive Care Unit ................................................... 21J. Emergency consultation and retrieval ................................................................. 26K. Hospital Emergencies ......................................................................................... 29L. Research in ICU.................................................................................................. 31M. Information Technology in ICU.......................................................................... 32

Clinical Procedures ........................................................................................................ 33A. Introduction......................................................................................................... 33B. Procedures........................................................................................................... 33C. Peripheral IV catheters........................................................................................ 34D. Arterial Cannulae ................................................................................................ 35E. Central venous catheters ..................................................................................... 36F. Urinary catheters ................................................................................................. 38G. Epidural catheters................................................................................................ 39H. Pulmonary artery catheters.................................................................................. 39I. Pleural drainage .................................................................................................. 43J. Endotracheal intubation ...................................................................................... 45K. Emergency Surgical Airway Access ................................................................... 50L. Fibreoptic bronchoscopy..................................................................................... 51M. Tracheostomy...................................................................................................... 53N. Minitracheostomy ............................................................................................... 56O. Pericardiocentesis ............................................................................................... 58P. Jugular bulb oximetry ......................................................................................... 59Q. Intra-aortic balloon counterpulsation .................................................................. 61R. Cardiac pacing .................................................................................................... 64S. Oesophageal tamponade tubes ............................................................................ 66

Drugs and Infusions ....................................................................................................... 67A. Policy .................................................................................................................. 67B. Principles of drug prescription in Intensive Care................................................ 67C. Cardiovascular Drugs.......................................................................................... 68D. Respiratory drugs ................................................................................................ 78

4E. Sedation, analgesia and muscle relaxants ............................................................ 80F. Anticoagulation ................................................................................................... 86H. Renal drugs.......................................................................................................... 95I. Gastrointestinal drugs.......................................................................................... 97J. Antibiotics ........................................................................................................... 99

Fluids And Electrolytes ................................................................................................ 106A. Principles of fluid management in Intensive Care............................................. 106B. Nutrition ............................................................................................................ 108C. Haemotherapy ................................................................................................... 112D. Guidelines for management of electrolytes ....................................................... 118

Clinical Management.................................................................................................... 129A. Cardiopulmonary Resuscitation ........................................................................ 130B. Failed intubation drill ........................................................................................ 133C. Respiratory therapy ........................................................................................... 134D. Management of Cardiothoracic Patients............................................................ 156E. Renal failure ...................................................................................................... 159F. Neurosurgical protocols..................................................................................... 167G. Microbiology protocols ..................................................................................... 176H. Drug overdose ................................................................................................... 184I. Withdrawal of treatment.................................................................................... 192J. Brain Death and Organ Donation ...................................................................... 192

5ROYAL ADELAIDE HOSPITALINTENSIVE CARE UNIT

The Royal Adelaide Hospital is a 700 bed teaching hospital affiliated with theUniversity of Adelaide. The Intensive Care Unit is a division of the academicDepartment of Anaesthesia and Intensive Care and was commissioned in 1969.

The existing ICU is a multidisciplinary unit with a complement of 20 intensive care and8 high dependency beds, while a new unit is due for completion mid-2003 with 24 ICUand 10 HDU beds.

There are approximately 1200 Intensive Care and 1400 High Dependency admissionsper year. The casemix is equally split between medical and surgical patients.Traditionally, the unit has had a large trauma load (approx. 20% of admissions) and isthe major tertiary referral centre for all surgical and medical specialities includingneurosurgery, cardiothoracic surgery, burns, spinal injuries, surgical and medicaloncology and hyperbaric medicine. Services not provided by the hospital includeobstetrics, paediatrics and neonatology, and solid organ transplantation.

As a major referral centre and due to the geographic nature of South Australia, a highlydeveloped retrieval service has evolved which is based from the Intensive Care Unit.The service currently performs about 500 retrievals per year.

Two private ICUs are staffed by the RAH ICU consultant staff. Rotation by registrarsthrough these units is possible:

1. Wakefield Hospital Intensive Care Unit is a 12 bed multidisciplinary level 3 privateIntensive Care Unit that predominantly manages post-cardiac surgical patients.There are 6 intensive care and 6 high dependency beds. This Unit managesapproximately 450 patients per year and is accredited for Advanced Training (C6)by the Joint Faculty of Intensive Care Medicine.

2. St Andrews Hospital Critical Care Unit is a 12 bed unit which is a combined private

level 3 intensive/high dependency unit. The casemix is predominantly post-surgicalwith a vascular predominance and the unit manages approximately 250 patients peryear.

6ADMINISTRATION

A. Staffing

1. Consultant Medical Staff

Department of Anaesthesia and Intensive CareProfessor and Head Prof W B Runciman

Royal Adelaide Hospital ICUDirector Dr P D ThomasConsultants Dr D R Catt

Dr M J ChapmanDr D G ClaytonDr N. EdwardsDr M E FinnisDr W M GriggsDr P SharleyDr M G WhiteDr R J Young

Wakefield Hospital ICUDirector Dr D R Catt

St Andrews Hospital ICUDirector Dr M G White

Retrieval and ResuscitationActing Director Dr P Sharley

72. Senior Nursing Staff

Royal Adelaide Hospital ICUNursing Director: Ms M CattonarNurse Manager: Ms A JonesClinical Nurse Consultant: Mr I L BlightClinical Nurse: Ms R Acott

(Equipment/retrieval)

Wakefield Hospital ICU Clinical Manager Ms A Rischbieth

St Andrews Hospital ICUClinical Nurse Consultants Ms S Cantor

Ms S Reay

3. Registrars

a) A Chief Registrar is appointed each year as the registrar spokesperson and isresponsible for rosters.

b) Two levels of registrars are rostered in the Unit:i) Senior registrars: Usually advanced vocational trainees who have

completed anaesthetic and/or physician training, who are rosteredaccording to seniority and experience.

ii) Junior registrars: vocational trainees or experience registrars.c) Portfolios are determined by experience and rostering requirements.d) All registrars rotate through both the Intensive Care and High Dependency

Units.e) Participation in the retrieval service is a requirement for suitably experienced

registrars working in ICU.f) Leave is in accordance with the State industrial award (5 weeks annual and 1

week study leave) and registrars are required to forward a signed copy of leaverequests to the Senior Registrar for rostering purposes.

g) Training positions at Royal Adelaide Hospital: i) Intensive Care Positions

a) The Joint Faculty of Intensive Care Medicine, (ANZCA & RACP)has accredited the RAH as a C24 Unit for training for the Fellowshipin Intensive Care (FJFICM). Registered trainees with the Facultymay spend up to 24 months continuous (core and/or elective)training in the Unit.

8b) Registrars not enrolled in the above training scheme but wishing togain further postgraduate experience in Intensive Care may apply forthese positions. Applications including a current c.v. should beforwarded to Dr R. Young.

c) Trainees enrolled in formal training programs are given priority ofappointment.

ii) Positions for non-Intensive Care Traineesa) Rotations of registrars in these positions are made from the

respective specialty based training programs at Royal AdelaideHospital.

b) Anaesthetic trainees: 2 positions (accredited by the Australian andNew Zealand College of Anaesthetists for training towards theFellowship in Anaesthesia (FANZCA)) for 3-6 month terms.

c) Physician trainees: 1 position for a 3 or 6-month term.d) Surgical trainees: 1 position for a 3-month term. (1)e) Emergency Medicine trainees: one position for 3 or 6-month term.

iii) Supervisors of Training at Royal Adelaide Hospital:a) Intensive Care: Dr R J Youngb) Medicine: Dr S M Guhac) Anaesthesia: Drs G Christie-Taylord) Surgery: Mr P G Devitte) Emergency Medicine: Dr R Skalickyf) Wakefield Intensive Care Unit:

(1) Accredited as C6 Unit, ie. for 6-month elective ICU training,however is currently unavailable for training purposes.

g) St Andrews Hospital Critical Care Unit (1) Four career medical officer positions are available,

administered by St Andrews Hospital.(2) This Unit is not accredited for advanced Intensive Care

training.(3) Director of ICU: Dr M.G. White.

9B. Rostering and job descriptions

Monday - Friday 0800 - 1900ICU Team 1 Consultant 1 Manages Q4 A & B.

Coordinates ward consults. Beds 1-11 Registrar 1 Beds 1-6.

Emergency pager & MET Calls.Registrar 2 Beds 7-11.

Consults pager.

ICU Team 2 Consultant 2 Manages Q4 C & DBeds 12-20 Registrar 3 Beds 12-20.

ICU Team 3 Consultant 3 Manages HDU, Ward TPN.Registrar 4 HDU beds 1-8.

Backup to Registrar 3.

Wakefield ICU ConsultantRegistrar

Wakefield Intensive Care, HighDependency & Coronary Care Units

St Andrews ICU ConsultantRegistrar

St Andrews Intensive Care& High Dependency Units

Monday - Friday 1830 - 0830, Weekends, Public holidays.ICU Team Consultant 1 Manages ICU and HDU.

Coordinates retrievals, consults.Consultant 2 Backup to Consultant 1 and Private

ICUs. TPN on weekends.Night Registrar 1 Q4 A, B. Ward consults* Night Registrar 2 Q4 C, D. Backup registrar 1.Night Registrar 3 HDU Backup registrars 1&2.Senior Registrar Weekend days: Registrar 1 duties.

NB: *The night registrar carrying the Arrest Pager also attends MET Calls.

Wakefield ICU ConsultantRegistrar

Wakefield Intensive Care, HighDependency & Coronary Care Units

St Andrews ICU ConsultantRegistrar

St Andrews Intensive Care& High Dependency Units

NB: Migration to the new ICU is due to commence mid 2003 and while specificward/bed designations may change, the unit will continue to be run as 3 teams (2 ICUand 1 HDU) with the same allocation of duties as above.

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RetrievalsConsultant Mon-Fri 08:00-18:00 Dedicated Retrieval Consultant

available to coordinate and/orperform retrievals.

Mon-Fri 18:00-08:00Weekends & P-Hol.

Duty ICU Consultant coordinatesretrievals.

Mon-Tue 12:00-22:00 Rostered to perform retrievals &assist in ward activities

Mon-Tue 22:00-08:00 1st On-Call for retrievalsSat & Sun 08:00-17:00 Rostered to perform retrievals &

assist in ward activities

Registrar

Sat & Sun 17:00-08:00 2nd On-Call for retrievals

Volunteers All times not coveredabove

1st On-Call for retrievals/2nd On-Call for retrievals

NB: Volunteers may be registrars, consultants or VMOs from the RAH or otherhospitals within the Adelaide area.

C. Orientation

1) Registrars commencing duty within the unit at the major RMO changeover dateswill undergo a half-day orientation program

2) This will include sessions from:a) The Director of ICUb) The Director of Retrievalsc) The Chief Registrard) Infectious Diseases / Clinical Microbiologye) The Acute Pain Service

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D. Weekly programme

Daily 0800 Handover Ward Round ICU/HDU Teams1100 Main Ward Round:

Conference roomAll Staff

1200 Fluid and clinical round ICU/HDU Teams1700 Consultant Handover ICU/HDU Teams1830 Registrar Handover ICU/HDU Teams

Monday 0730 Departmental meeting:Sando Room

All Staff

1200 Surgical Grand Round:Lecture Theatre 1

All Staff

1330 ICU Consultants meeting Consultants1500 ICU Audit:

Conference RoomAll Staff

Tuesday 1230 Medical Grand Round:Robson Theatre

All Staff

1500 Journal Club:Conference Room

All Staff

1600 Registrar teaching session RegistrarsThursday 1630 Anaesthesia Audit: Theatre All Staff

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E. Admission and discharge policies

1. Admission Policy

a) The patient is managed by the ICU staff during their stay in ICU and/or HDU.b) All admissions to ICU and HDU must be approved by the Duty Consultant.

i) Resuscitation or admission must not be delayed where the presentingcondition is imminently life threatening, (eg profound shock or hypoxia),unless specific advanced directives exist and are clearly documented.

ii) Such admissions should be discussed with the Duty Consultant ASAP.c) Admission is reserved for patients with actual or potential vital organ system

failures, which appear reversible with the provision of ICU support.d) Patients are admitted under the bed-card of the original clinic or taking unit

while in the ICU.e) Clinics requesting elective postoperative surgical beds must confirm bed

availability on the day of surgery, prior to the operation commencing.f) Admission disputes must be referred to the duty ICU consultant.

2. Discharge Policy:

a) All discharges must be:i) Approved by the duty ICU consultant.ii) Discussed with the parent clinic prior to patient transfer, including any

potential or continuing problems.b) Patients discharged on TPN must entered in the TPN folder in Q4A.c) Notify the Acute Pain Service of patients discharged under their care.d) Treatment limitation/non-escalation directives must be discussed with the patient

or patients family, the parent clinic and clearly documented prior to discharge.e) A discharge summary must be completed and a copy included with the patient

casenotes. 3. Deaths Policy:

a) The duty ICU consultant must be informed of all deaths.b) The duty ICU registrar must ensure:

i) a death certificate is completedii) that the parent clinic or duty intern is notifiediii) referring doctors (ie GPs, other specialists / hospitals) are notified.

c) Where indicated, consent for a post-mortem should be obtained from relatives assoon as possible.

d) The Coroner must be notified in all cases where:i) Death is due to violence

a) Trauma deaths: vehicle, home, industrialb) Homicide / suicide

ii) Death results from non-natural causes within 24 hours of admission.iii) The cause of death is unknown or uncertain.

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iv) No medical practitioner in attendance who can issue a death certificatev) Death is peri-operative (ie within 24 hours of an operation)vi) Death occurs in a psychiatric institution, or in a RAH inpatient from one of

these institutionsvii) Death occurs while in jail or in custodyviii) Death occurs after admission for fractured neck of femurix) The patient is certified Dead on arrival.

e) Withdrawal or limitation of therapy is a consultant responsibility.

F. Clinical duties in the intensive care unit

1. Infection Control in ICU

a) Prevention and containment of nosocomial infection is a fundamental principle ofeffective medical practice.

b) The critically ill patient is highly vulnerable to nosocomial infection, whichresults in significant morbidity, prolonged length of hospital stay, increased costand attributable mortality.

c) It is the responsibility of every member of the health care team to ensurecompliance with Hospital and Unit infection control policies. This may includereminding senior colleagues or visiting teams to conform to basic issues such ashand-washing or barrier nursing measures.

d) If you are reminded by a colleague to conform to these policies (eg hand-washingafter examining a patient), then this should not be regarded as a criticism, butrather as responsible practice.

e) Hand-washing remains the only established method of effective infection controland must be assiduously performed by all members of the health care team:i) Compulsory before and after entering a patients cubicle for:

a) Physical examination of the patientb) Manipulation of patients environment including respiratory

equipment, infusion pumps, dressings, drains, linen or bedding.c) Inspection or handling of the patient chart, casenotes or overway when

these are placed inside the cubicle (ie Q4C).d) Following all procedures, even if aseptic techniques are used.

ii) This may be performed by either:a) Washing for a minimum of 1 minute using Microshield hand

cleanser (at the basin closest to, or within the patients cubicle), orb) Thorough application of Aqium Alcohol Gelc) In the MRSA area (Unit D) Triclosan cleanser is preferred.

f) Glovesi) Disposable gloves must be worn for all contact with patients bodily fluids,

dressings and wounds.ii) The use of gloves does not preclude hand-washing before and after patient

contact.iii) Gloves must be disposed of within the patient cubicle on leaving.

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g) Barrier nursing measures :i) The following patients are regarded as infective risks requiring barrier

nursing:a) Infection or colonisation with:

(1) Methicillin Resistant Staph. Aureus(2) Vancomycin Resistant Enterococcus(3) Multiresistant gram negatives(4) Clostridium difficile

b) Burnsc) Febrile neutropeniad) High risk immunosuppressed patients as directed by Infection

Controlii) HDU patients who are infective risks must be managed in Q4IC.iii) An Additional precautions sign is placed outside cubicles of patients

identified as infective risks.iv) New disposable gowns and gloves must be used for each person entering

the cubicle and disposed of within the cubicle upon leaving.v) Attending nurses may use one gown per shift, provided it is kept within

the cubicle.vi) Consumable stock within the cubicle should be kept to a minimum.vii) Notify appropriate staff if patients are transported to theatre, for

diagnostic procedures, or for ambulance transport.viii) Once the patient has been transferred or discharged, the area should

remain vacant until terminally cleaned in accordance with policy.ix) Environmental swabbing in Intensive Care is conducted as required by

Infection Control staff.h) Aseptic technique

i) Aseptic technique is to be used for all patients undergoing major invasiveprocdures (refer to procedures section).

ii) This includes:a) Hand disinfection: surgical scrub with chlorhexidine for >1 minuteb) Sterile barrier: full gown, mask, hat, gloves and sterile drapes.c) Skin prep with chlorhexidine 1% in 75% alcohol: let the skin dry.

i) Sharps disposali) The person performing the procedure is responsible for disposal of all

sharps (needles, blades) using the sharp disposal containers.ii) Nursing staff are not responsible for cleaning-up sharps after a medical

procedure.j) Traffic control

i) Movement of people through the Unit should be kept to a minimum.This applies equally to visiting clinics and large numbers of relatives.

ii) All visitors are expected to conform to the above infection controlmeasures and should be tactfully reminded or instructed about theseissues.

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k) Quarantine policyi) Beds 19 and 20 in Q4IC are nominated as isolation/quarantine rooms for

highly contagious infections such as haemorrhagic fevers.ii) These rooms are sealed with independent airconditioning units.

2. Guidelines for admission of a new patient to ICU

a) Handover from the referring doctor. Obtain as much information as possible.b) Primary survey:

i) Ensure adequate airway, breathing and place patient on highest FiO2 (1.0)until a blood gas is done.

ii) Check circulation and venous access.c) Secondary survey: fully examine patient.d) Document essential orders:

i) Ventilationii) Sedation / analgesiaiii) Drugs, infusionsiv) Fluids

e) Outline plan to nursing staff.f) Secure appropriate basic monitoring/procedures:

i) SpO2ii) ECGiii) Arterial lineiv) IDC, nasogastric tubev) CVC for the majority

g) Basic investigations:i) Routine biochemistry, blood picture and coagulation studies.ii) Septic screen/microbiology as indicated.iii) Arterial blood gasiv) CXR (after placement of appropriate lines)v) ECG

h) Notify the duty consultant.i) Advanced investigations: CT, angiography, MRI, etcj) Advanced monitoring where indicated: eg PA catheter, ICP, SjO2.k) Document in case notes. (See below)l) Notify the parent clinics of patients admitted directly to ICU

NB: this applies particularly to patients who have been retrieved.m) Clinic Interns and RMOs should clerk hospital admissions direct to ICU.n) Inform and counsel relatives.

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3. Daily management in ICU/HDU.

a) Daily investigations: i) Routine blood tests (biochemistry and haematology) are ordered on the daily

flow chart and signed for on the 1100 am fluid round. Drug levels or othertests are requested as required and may also be requested on the daily flowchart.

ii) The night duty nurses have kindly agreed to take the bloods at 0600 andcomplete the request form, which must be signed by the night registrar.

iii) Registars are responsible for taking blood specimens:a) When nursing staff request assistance.b) For blood transfusion

(1) The requesting registrar must ensure that the labelling of therequest form and the specimen matches the patients wristband.

iv) Chest x-rays are ordered before 0800 and signed request forms are handedto the duty radiographer.

b) Handover ward rounds are at 0800 and 1830. These are brief business rounds tohandover essential information to the next team (either day or night) and areattended by the duty consultant, team registrars and nursing coordinator.

c) A full teaching ward round is held at 1100 daily, followed by a bedside fluid andclinical round.

d) Liaison with parent clinics is essential to ensure continuity of management.Clinics must be informed of significant changes in a patients condition or therequirement for specialist investigations or interventions.

e) Complex investigations (eg CT, MRI scans) and procedures must be authorisedby the duty ICU consultant and discussed with the parent clinic whereappropriate.

G. Documentation

The following guidelines are designed to facilitate the recording of clear, relevantinformation that is essential for continuity of care, audit and medicolegal review.

Entries should establish a balance, being concise but still accurately recording allrelevant information and events.

1. Documentation by ICU registrars includes:a) Admission note for all patients admitted to ICU and HDUb) Daily entry in case notes during admissionc) Discharge summaryd) Death certificates.

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2. ICU Admission Note:a) All patients admitted to the ICU must have an admission summary.b) The admitting clinic must be notified and invited to record an admission

summary for patients admitted directly to ICU. This is to ensure thatadmitting clinics are aware that a patient has been admitted under theirbedcard.

c) The admission note should incorporate all relevant aspects of the patientsmedical history, clinical examination and results of appropriate investigations.

3. HDU admission summarya) Complicated non-ventilated HDU patients require the same level of detail as

ICU patients.b) Routine postoperative short stay patients do not need detailed admission notes.

In these patients record:i) Relevant operative/anaesthetic detailsii) Significant comorbidities and historyiii) Anticipated problemsiv) Procedures eg epidural, invasive monitoring, TPN

4. Daily entry in ICUa) A daily entry must be made in the case notes.

i) Notes are most efficiently recorded after the 1100 ward round so thatcurrent results and management plans are recorded

ii) On weekdays, these may be dictated and handed to the secretary who willtype and place these notes in the case notes.

iii) On weekends/public holidays these must be written in the case notes.b) Additional notes must be made for the following:

i) Significant changes in physical condition necessitating changes inmanagement, eg renal failure requiring dialysis.

ii) Major procedures, eg laparotomy, tracheostomy, PA catheteriii) Results of specific investigations or tests, eg CT scans, endocrine testsiv) Changes in policy, eg non-escalation of treatment, advance directives.

5. Discharge Summariesa) All patients transferred from ICU require a Medical Transfer Summary (MR

42) form completed. This includes deaths and patients transferred to HDU.b) This is a single page document outlining all relevant transfer information.c) The reverse side of the form is a nursing transfer summary, which will be

completed by the attending nurse. The original should be filed in the casenotes and a photocopy placed in the box in the communications room forfiling by the secretary.

d) The duty registrar on day of transfer is responsible for completing the form.Incomplete or missing summaries will be forwarded to the responsibleregistrar for completion.

e) Short term HDU patients do not require detailed discharge summaries: onlypertinent information relating to the stay in HDU is necessary.

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6. Consent in ICUa) Competent patients:

i) All competent patients undergoing invasive procedures in ICU or HDUshould have a standard Royal Adelaide Hospital consent form (MR:60.16) completed and signed by the patient.

b) Incompetent patients (sedation, coma or encephalopathy) i) Third party consent is not necessary for routine ICU procedures; these

include:a) endotracheal intubationb) arterial linesc) central venous linesd) pulmonary artery catheterse) transvenous pacing wiresf) underwater seal drainsg) jugular bulb cathetersh) intra-aortic balloon counterpulsationi) oesophageal tamponade tubesj) bronchoscopy

ii) However, relatives should be informed prior to the procedure if presentand the indications, conduct and complications of the procedure shouldbe clearly documented in the casenotes.

iii) Major invasive procedures such as percutaneous tracheostomy, coronaryangiography, permanent pacemaker insertion or acute surgical proceduresrequire completion of a consent form:a) Emergency procedures signed by two doctorsb) Non-urgent procedures by third party consent (next-of-kin).

iv) Ultimate responsibility for consent lies with the operator performing theprocedure, however ICU registrars should ensure appropriate consent isobtained.

v) A person, not necessarily next-of-kin, who has been nominated by thepatient as a medical power of attorney may sign or refuse consent onbehalf of the patient.

vi) Relatives must always be informed of any procedures and the consentissue explained, irrespective of the presence or absence of a medical orlegal power of attorney.

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H. ICU Ward round

1. The daily ICU 1100 am ward round is an integral feature of the running of the Unit. Itis the forum to openly discuss management issues and is a useful teaching forum. Allcurrent X-rays are displayed on a multi-viewer and current results are displayed viacomputer projection.

2. Registrars are expected to present their allocated patients at this round and to actively

participate in the discussion. Presentations at this round should be of a standardsuitable for a fellowship examination.

3. The ward round is attended by:

a) Team 1/2/3 ICU consultants and registrarsb) A radiologistc) An infectious diseases consultantd) Senior nursing staffe) Physiotherapistsf) A pharmacistg) A dieticianh) Invited clinics when appropriatei) Medical students

4. Presentation at ward round

a) Presentation should take no more than 5-10 minutes.b) Emphasise the relevant and pertinent issues only:

i) Patient details and demographics.ii) State day of ICU admission (eg Day 6 ICU).iii) Diagnosis or major problems.iv) Relevant pre-morbid history pertinent to this admission.v) Relevant progress and events in ICU

(deterioration/improvement, procedures, investigations).vi) Current clinical status (system by system).vii) Outline features on daily pathology and radiology.viii) Current plan of management:

a) Medicationsb) Further investigations / proceduresc) Discharge / Prognosis

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5. Bedside fluid round

a) Team consultants and registrars review each patients condition.b) Flowcharts are re-written daily and include orders for ventilation, procedures,

medications, infusions and fluid therapy.c) Printed stickers should be used for routine medications and infusions.d) All orders must be signed by a doctor.e) Requests for routine blood tests are made on the chart.f) Patients transferred to HDU or to the wards must have the hospital blue

folder completed. As a general rule, all medication orders are re-written andfluid or nutrition orders for the next 24 hours are prescribed. Patients startedon TPN should have their details entered in the TPN folder kept in Unit A.

g) Similarly, HDU patients have their charts reviewed, however all medicationsand fluids are recorded on the hospital blue treatment folders.

6. Laboratory results

a) Biochemistry, haematology and coagulation results for the 1100 ward round areprojected from a PC in the conference room. Instructions for use of this PC arelocated on the adjacent wall.

b) Other results must be obtained by the registrar, either by phone or via thecomputer terminals in each nursing station.

c) The ward clerks will demonstrate how to access the pathology mainframe.d) Each registrar will need to obtain a code and allocate a password (see ward

clerks).

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I. Clinical duties outside the Intensive Care Unit

1. Policy regarding outside consults:

a) NB: The Unit must not be left unattended at any time to attend outside calls.(ie. at least one registrar must remain on the floor)

b) The consults and cardiac arrest/trauma/MET pagers are allocated as follows:i) Day (0800-1830):

a) Team 1 & 2 registrars as requiredii) Night (1830-0800):

a) Q4IC night registrar - consults pagerb) Resuscitation registrar - cardiac arrest/MET pager

iii) These roles may be delegated according to the workload in ICU by theduty ICU consultant.

c) All consults should be addressed as soon as possible.d) MET calls should be attended immediately.e) All consults/MET calls potentially requiring admission to ICU must be

discussed with the Duty Consultant.f) If the ICU workload is heavy, refer ward consults to the duty ICU consultant who

will delegate appropriately.g) Notify the senior nurse and fellow registrar when leaving the floor.h) The following duties accompany the Consults pager (pager no #89 1122*):

i) Ward consultsii) Requests for vascular access (CVC insertion)iii) Requests for Total Parenteral Nutrition (refer to Team 3)iv) Requests for retrieval (refer to Retrieval or Duty Consultant)

i) The following duties accompany the Emergency pager (#33)i) Cardiac arrest callsii) MET callsiii) Trauma (P1) resuscitation

a) Trauma pages are subdivided into levelsb) Attendance by the ICU registrar is only required for Level 1 calls.

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2. Ward Calls

a) Consults regarding potential admissions from the general wards, theatre, A&Eand ESS.

b) Pre-operative consults for potential or booked surgical patients.c) Advice regarding fluid and electrolyte management, oxygen therapy, sedation

and analgesia.d) Review as requested:

i) Admissions to the Spinal Injuries Unit with potential respiratory failure.ii) Admissions to the Burns Unit for airway / breathing assessment, venous

access and resuscitation.e) Requests for central venous access:

i) Requests must come from registrar level or above.ii) ICU staff are responsible for obtaining consent for insertion. The risks and

benefits must be discussed with the home team and the patient.iii) Most CVCs are elective and can be placed during working hours. iv) CVCs inserted for emergencies are performed as indicated.v) Consider insertion of a PICC line (via radiology) for appropriate patients.

f) Haematology patients:i) Elective CVC lines are inserted under radiological guidance, not by ICU.ii) Blind CVC lines should only be placed by senior staff, ie. Senior

Registrars or Consultants, following specific discussion and agreement.iii) Lines for resuscitation should be inserted as clinically indicated.

g) Requests for TPN.h) Requests for peripheral IV access must come from registrar level or above after

reasonable attempts have been made to obtain IV access.

3. Total Parenteral Nutrition (TPN)

a) ICU provides a TPN service for the hospital.b) Requests for TPN are essentially elective (ie Mon to Fri: 0800-1800) and should

be made according to recommended indications.c) Requests are made to the Senior Registrar via the consults pager. The Team 3

Consultant is available for assistance and will delegate responsibility for:i) Initial consultation with the requesting clinic.ii) Recording TPN patients in the TPN Folder in Q4A.iii) Insertion of a central venous catheter.iv) Daily:

a) Review of electrolytes and fluid balance,b) Review of the central venous catheter,c) Prescription of TPN orders vitamins / trace elements,d) Issue a request form for serum electrolytes.

d) The second on-call ICU consultant is responsible for TPN on the weekends.e) Refer to the section on nutrition in the clinical protocols for indications &

complications.

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4. Cardiac Arrest & MET Calls

a) 33 is the Royal Adelaide Hospital emergency code. This is the emergencynumber dialled (33#) to switchboard for general medical emergencies. Theseinclude:i) In-hospital cardiac arrestii) Out of hospital arrest admitted to EDiii) Emergencies in theatre, general and ESS recoveries, radiology, outpatients

and CCU.iv) Collapse of unknown aetiology in the hospital environs.v) MET team calls.

b) The following people are automatically paged:i) ICU registrar or resuscitation registrarii) ICU equipment nurseiii) Medical registrar

c) All medical emergency calls (33# calls) must be responded to promptly.d) When a 33 is displayed on the pager, phone 33#. Switchboard will state the

location of the arrest. Clearly state who you are (ie ICU registrar) and go to thelocation.

e) Ensure that the ICU staff know where you are going and that the Unit is not leftunattended.

f) At the emergency:i) This hospital follows the Australian Resuscitation Council guidelines for

cardiopulmonary resuscitation (refer to flowcharts for basic and advancedlife support in the clinical protocols)

ii) The ICU/resuscitation registrar is responsible for initial assessment, securingthe airway and establishing effective ventilation.

iii) Basic life support is done by attending nursing and medical staff and may bedirected by either ICU or medical registrar.

iv) Advanced life support is directed by the more senior registrar present. Thisis usually the ICU registrar.

v) Depending on the outcome of the arrest, the patient may be admitted to ICU,HDU or CCU according to standard admission policies.

vi) As a general rule, it is better to admit a patient if previous details are notimmediately available than to prematurely abandon resuscitation.

vii) Document your involvement with the resuscitation in the casenotes.

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5. Trauma Calls

a) As in cardiac arrest, a 33# call is activated for trauma patients who meetspecified trauma criteria. (Refer to trauma directives.)

b) Trauma pages will appear as 2 Levels:i) Level 1: major trauma requiring immediate attendance / airway supportii) Level 2: trauma requiring full assessment in P1.

c) The following people are paged and the level response detailed on the pager:i) ICU/resuscitation registrarii) Trauma Service registrariii) Accident and emergency registrar

d) On receiving a Level 1 call the ICU registrar should proceed directly to P1 in theEmergency Surgical Suite (ESS).

e) Ensure that ICU staff know where you are going and that the Unit is not leftunattended.

f) At the trauma resuscitation:i) This hospital follows the guidelines of the Early Management of Severe

Trauma System, Royal Australasian College of Surgeons.ii) The team leader is designated by the current Trauma Service Directive

(found on the wall in P1 in ESS).iii) Role of the ICU / resuscitation registrar:

a) Primarily as a backup for acute life threatening situations in the eventthat sufficiently experienced personnel are not available in P1.

b) If anaesthetic staff are present in P1, there is no requirement for ICUregistrars to attend the resuscitation unless specifically requested bythese personnel or the Trauma Director.

c) If anaesthetic staff are not immediately available, the following role isindicated until appropriate personnel arrive:(1) Initial airway management: ie assessment and intervention as

appropriate.(2) Establishing effective ventilation(3) Assistance with vascular access and restoration of circulation.(4) Other acute interventions (eg. UWSD) as required

d) Once anaesthetic & trauma team members are present and the situationis under control, return to ICU: do not leave ICU unattended forlengthy periods of time. If prolonged resuscitation is anticipated, call inthe ICU or Trauma Consultant and/or delegate to theanaesthetic/resuscitation registrars if necessary.

e) Transportation of trauma patients to CT scan, angiography etc are theresponsibility of the ESS anaesthetic staff.

f) ICU registrars must not do prolonged intrahospital transports fortrauma patients without approval by the duty ICU consultant.

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iv) General principles:a) Document your involvement with the resuscitation in the casenotes b) Once the primary survey is completed, proceed to the secondary survey

and order the appropriate investigations - generally all patients needlateral C-spine, chest and pelvis X-rays, group and cross-match. Thisis coordinated by the Trauma team leader.

c) In critically ill patients, ensure that a suitably qualified person (in termsof resuscitative skills) remains with the patient at all times. This ismandatory if the patient is transported from ESS (eg to radiology, ICU,theatre).

d) Notify ICU staff of pending admissions.e) Demarcation disputes are referred to the duty Trauma Consultant.

6. MET Calls

a) The RAH will introduce a MET team early in 2003 as a part of the activeintervention arm of a national multi-centre collaborative study, coordinated bythe ANZICS Clinical Trials Group.

b) The registrar carrying the Emergency pager will also attend MET calls.c) MET calls can be initiated by any staff member of the hospital and are to be

attended immediately that is providing the ICU is adequately covered.d) The night Medical Registrar will also receive these calls but cannot be relied

upon to be able to attend, therefore the ICU registrar will assume primeresponsibility.

e) Further details regarding MET calls will be found in the study documentationheld in the ICU communications room.

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J. Emergency consultation and retrieval

1. Retrieval Service policy documents

a) A complete list of policy documents for the retrieval service is available in thecommunications room table-top folder.

b) These policies include:i) 01-2002 Mental Health Patientsii) 02-2002 Mediflight Australiaiii) 03-2002 Rapid Response Or Standby For Retrievaliv) 04-2002 Retrieval Requests And Activationv) 05-2002 Minimum Dress Requirements For Helicopter Operationsvi) 06-2002 Helipad Protocolsvii) 07-2002 Stretcher Patients On Qantasviii) 08-2002 Retrieval Diversionix) 09-2002 Retrieval Medical Staffing Policyx) 10-2002 Retrieval Blood Protocolxi) 11-2002 Retrieval Nurse Staffing Policyxii) 12-2002 Observer/Student Ride-Along Program

c) Staff participating in retrieval activities should familiarise themselves with thecontents of these documents.

2. Retrieval familiarisation and competency policy

a) This is coordinated by Dr Peter Sharley A/Director of Retrieval andResuscitation.

b) Adequate familiarisation and orientation with communications, geography,helipad access, aircraft and medical equipment is mandatory prior for anyregistrar wishing to perform retrievals.

c) Adequate airway, vascular access and trauma resuscitation skills are essential.d) Aeromedical retrieval is an obligatory activity for suitably qualified ICU and

anaesthetic registrars and represents an important and unique part of ICUtraining. However, registrars with serious apprehensions about flying are notcompelled to do retrievals.

e) All RAH retrieval teams are fully covered by the South Australian HealthCommission with respect to life and medicolegal insurance.

3. Rapid Response Or Standby For Retrieval

a) The SA Ambulance Service may advise the RAH Retrieval Service to eitherbe on standby or request that there is rapid activation of a retrieval team.

b) Whilst every effort must be made to respond to a rapid response request at nostage may the ICU be left unattended. This may result in an inability torespond or a delay in response.

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c) Rapid Response criteria may include;i) an entrapped patient with apparent severe injuries and or deterioration.ii) multiple patientsiii) extrication time and transit time that exceeds the likely time for delivery

of a team to the site.d) Standby implies that;

i) The relevant ICU Consultant is notified.ii) The medical and nursing personnel are activated and dressed in retrieval

uniform.This means that after hours, the team doctor, if not on site is tomove towards the hospital. (callback payment is approved if doctordeparts his/her place of residence)

iii) Blood supply is confirmed from the retrieval blood fridge.e) If the Standby request is confirmed team mobilisation occurs without further

consultant authorisation, who can be subsequently notified that the mission isunderway.

f) If the mission is cancelled, Stand-down procedure includes notification ofteam members and the relevant ICU Consultant.

g) If activated, transportation to the crash site is usually by helicopter or roadand is usually confined to 150 kms radius of Adelaide.

h) Ensure that the local hospital in closest proximity and their Medical Officerare notified. If the local MO is likely to be able to attend the scene prior to thatof the retrieval team then he/she should be invited to attend.

4. Retrieval Requests And Activation

a) The log book located in the communications room is for the essentialdocumentation of all incoming retrieval and all other emergency calls. Calls are tobe logged whether a team has been mobilised, or a rural MO or other healthprofessional is merely asking for advice. Tact and understanding of the difficult roleof doctors and nursing staff in isolated locations is vital.

b) Requests for consultation may originate from a number of sources. Namely,c) the direct emergency number (8222 4222)d) ambulance radio both located in the communications roome) other ICU telephonesf) ICU registrar pagerg) other clinics who have been consulted by outside medical officers.

h) Vital data to be recorded is indicated by prompts on the log page. This includes dateand time, callers name, location, return phone number and brief synopsis of theproblem. Advice on urgent resuscitation if indicated. This data is essentialinformation for staff on later shifts, audit and subsequent medico-legalinvestigation.

i) The Duty ICU Consultant after hours and the Retrieval Consultant during workinghours Mon-Fri must be notified of all calls received. ALL RETRIEVALS MUSTBE AUTHORISED BY THE DUTY ICU CONSULTANT OR RETRIEVALCONSULTANT.

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j) Other disciplines may be included in the consultation as relevant. A neurosurgeonfor example may be required to be a part of the retrieval team to perform surgery atthe distal site and thus would require early consultation.

k) Initiation of transport arrangements with the Ambulance Service is via telephone8204 3540. All conversations with the Ambulance Service are recorded. The modeof transport is usually determined by the Ambulance Service.

l) The retrieval team from the RAH always involves a doctor and a critical care nurse.The Pilot has autonomy regarding the suitability of the usage of an aircraft and thenumber of staff able to be carried. Extra retrieval personnel must be approved bythe pilot at the time of booking.

m) Retrieval team usually assembles and travels to the airport by taxi for fixed wingmissions. The RAH helipad is usual for helicopter departure unless inclementweather dictates an alternate departure site.

n) If a retrieval is activated, notify the caller with arrival time and offer furtherresuscitation advice if required until the team arrives. Frequent communication isencouraged if the patient is unstable.

o) Notify return destination tertiary hospital and destination site within that hospital.This must include confirmation of an available bed and notification to the relevantclinic. All RAH trauma must be admitted direct to the ED trauma resuscitation area.

p) The retrieval team is expected to communicate with the ICU prior to departure fromthe distal site. This may be essential to plan a surgeon, an available theatre, an ICUbed, suitable protective precautions etc.

q) With returning helicopter missions an additional radio contact from the team to theICU is required at least 20 minutes prior to arrival to permit Helicopter LandingOfficer and Crane lowering protocols to be activated.

r) Verbal and written hand-over is essential to the receiving team. Retrieval data formand retrieval clinical note duplicates are to be returned to the box in the ICUcommunications room.

5. Intrahospital transportation of Intensive Care patients

a) All transports must be authorised by the duty consultant. Thetransport/investigation must be considered in the best interests of the patient.

b) All ventilated and potentially unstable transports need a medical escort.c) Patients who are not ventilated and are stable may be transported by an ICU

nurse; if there is any concern expressed by the nursing staff, then a medical escortmust accompany the patient.

d) At no stage must the Unit be left uncovered.e) If the Unit is busy, or transports clash with ward rounds, other personnel may be

deployed to do the transport. This is coordinated by the duty ICU consultant.f) As a general rule, ICU staff are responsible for transportation of ICU patients. g) Anaesthesia is responsible for transport of the following ICU patients:

i) Trauma resuscitation patients (P1)ii) Patients to and from theatreiii) Patients to and from hyperbaric medicine.iv) After hours transports (as part of duties of the resuscitation registrar)

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h) Prolonged investigations/treatments: eg MRI, angiographic embolisation,invasive radiological procedures (eg TIPS). The transport of these patientsshould be discussed with the duty ICU consultant and Duty Anaesthetist.

i) Guidelinesi) Registrars must familiarise themselves with transport monitors, portable

ventilators and infusion pumps.ii) Inform and discuss the transport with the nursing staff as soon as possible.iii) Patients must be appropriately monitored during the transport and

observations recorded on the flow chart.iv) Document any problems which may occur during transport.v) Ensure that the results of investigations performed (ie CT scans etc) are

recorded in the case notes by the appropriate person.

K. Hospital Emergencies

1. The emergency number is 33# : state nature and location of emergency 2. Fire

a) A copy of the hospital emergency procedures (fire, smoke, bomb-threat) is keptin the Q4A and Q4D nursing stations.

b) The chief fire and emergency officer is the overall controller during a fire orsmoke emergency (code red).

c) Become familiar with the location of fire exits, extinguishers and blankets in theUnit.i) Unless a fire is small and easily contained do not attempt to fight the fire

yourself.ii) Remove yourself from the immediate vicinity of the fire, alerting other staff

members as indicated, and position yourself behind the automatic fire doors.iii) The MFS has a 3 minute response time to the RAH. Wait for the arrival of

the Fire Chief and assist in any patient movement/evacuation only asindicated by the Fire Chief.

d) Role of medical staffi) There is no place for heroic action. Ensure your own safety first.ii) Wait for the arrival of the MFS.iii) Assist in patient assessment/management under the coordination of the Fire

Chief.iv) In the event of a significant fire / smoke hazard, staff will only re-enter the

danger zone in the immediate company of a MFS fire-fighter, withappropriate breathing apparatus.

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3. Counter Disaster procedures

a) A copy of the counter disaster plan is displayed in the communications room.b) Cards outline the responsibilities of key personnel located in ICU during the alert

and activation phases:i) Directors of ICU, Trauma and Retrievalsii) ICU medical staff (consultant or registrar after hours)iii) Nursing staffiv) HERNIA (radio network) operator

c) The duties of the ICU medical staff are listed on Card 12dd) Key points,

i) The ICU medical officer becomes the temporary controller, until this duty istransferred to the duty medical administrator, during both alert andactivation phases.

ii) In this situation follow the Controllers card (card 33d)iii) Approve dispatch of medical team(s) to disaster site only if this does not

compromise on-site staffing.iv) Liaise with the senior consultant, nursing staff and Director of ICU to decide

whether to proceed to full activation.

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L. Research in ICU

1) Personnel:a) Coordinator of Research Dr Marianne Chapmanb) Clinical Trials Coordinator Stephanie Creed (Ext 24624)c) Research nurses Sandra Andrenacci, Leesa Stanley, Justine Rivettd) Statistical and computing advise Dr Mark Finnise) Intensive Care Unit Research Committee. As above and:

i) Dr PD. Thomasii) Dr RJ. Youngiii) Mr I. Blight CNC.

2) Members of the medical and nursing staff are encouraged to become involved inresearch during their stay in the Unit. Registrars are expected at least to obtainconsent for ongoing studies as part of their responsibility within the unit.Knowledge of these studies can be obtained from either the coordinator of researchor the clinical trials coordinator. Further involvement is encouraged and there aresupports within the unit to facilitate research to occur.

3) There are broadly 3 types of research project undertaken in the unit:a) Drug company sponsored projectsb) Locally initiated projects (supported by funding from a)c) Studies performed with the ANZICS Clinical Trials Group (see below).

4) Staff are encouraged to present completed research at either local or interstatescientific meetings. Some funding is available for both nurses and medical staffwho present work at any meeting.a) Applications should be made to the Coordinator of Research.b) Eligible meetings include, but are not limited to:

i) ANZICS Annual Scientific Meeting (http://www.anzics.com.au/asm)(1) Abstracts must be sent by July.(2) Free papers/posters(3) Prizes are awarded for:

(a) Best medical and nursing free papers(b) Best medical and nursing reviews(c) Best poster(d) Best paper by a JFICM trainee (Matt Spence Medal).

ii) ANZCA ASM (ICU Section): free papers. Annual - May.iii) Thoracic Society of Australia and New Zealand: Annual - March.

c) Further details can be obtained from the Coordinator of Research. 5) Most projects must obtain approval from the Royal Adelaide Hospital Research

Ethics Committee prior to commencement.a) Dates for submission and forms may be obtained from the Clinical Trials

Coordinator.b) If the study involves drugs then it must first go to the Investigational Drugs

Subcommittee.c) A copy of the ethical approval letter and protocol must be given to the clinical

trials coordinator. The clinical trials coordinator will also keep details ofprogress of research projects.

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6) The intensive care research committee meets once per month to:a) discuss ongoing issues regarding research in the unitb) assess proposed studies for ethical and scientific validityc) act as a resource for protocol planningd) manage funding of research in the unit.

7) Further information:a) Facilities are available in the Adelaide University Department of Anaesthesia

and Intensive Care for laboratory research work. There is an animal laboratoryperforming predominantly pharmacokinetic/pharmacodynamic studies.Resource personnel: Prof WB Runciman, or Dr Richard Upton.

b) ICU database. We have a database extending back many years containing dataon all intensive care patients (not HDU). This includes demographics, illnessseverity scores and outcomes. We also have access to a national database. Wealso collect other data locally. Resource person: Dr Mark Finnis.

c) Australian Incident Monitoring Study. Resource person: Prof WB Runciman.d) ANZICS Clinical Trials Group. There is a national clinical trials group to

facilitate multicenter trials in Australia. The group is open to all interestedparties and proposals for multicentre trials can be presented for consideration.Meetings twice per year April and October. Resource person: Dr MarianneChapman.

M. Information Technology in ICU

a) All consultant and both registrar offices are equipped with IBM-PCs, whichare connected to the RAH local area network (LAN).

b) Facilities available through the LAN include:i) Internet e-mail accountsii) WWW browsing facilities (available on application).iii) Intranet resources, which are being continuously expanded:

a) A copy of this manual.b) Internal phone directoryc) Australian business directoryd) Medline via OVIDe) Poisons Index (via Emergency Services)

iv) On application registrars will be allocated a username, which will carrywith it an Internet e-mail account for the duration of their stay.

c) In addition, many of the consultants have direct access to the internet viaaccounts with the University of Adelaide, plus access to the University Libraryresources (Medline - Silverplatter, Toxicology databases, etc)

d) The Unit has a Web presence at http://www.health.adelaide.edu.au/icu.

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CLINICAL PROCEDURES

A. Introduction

1. Registrars are encouraged to become proficient in all Intensive Care procedures.2. Invasive procedures should be authorised by a senior registrar or the Duty ICU

consultant.3. Adequate familiarisation and supervision with unfamiliar procedures is essential:

there is always someone available to help.4. The relative risk vs benefit of all procedures must be carefully considered.5. Do not persist if you are having difficulty with the procedure: call for help 6. Consent for procedures: *refer to Administration / Consent

a) Competent patients undergoing invasive procedures should have a standardRAH Consent Form (MR:60.16) completed and signed by the patient

b) Third party consent is not necessary for incompetent patients undergoingroutine ICU procedures.

c) Major ICU procedures such as percutaneous tracheostomy orenterogastrostomy require third party, or two-doctor consent.

7. Indications, conduct and any complications of the procedure should be clearlydocumented in the casenotes in addition to a consent form if this is completed.

8. Discuss the planned procedure with the attending ICU nursing staff and allowsufficient time for setting up of trays and equipment. Remember: the nursing staffhave extensive experience with these procedures.

9. It is the responsibility of the operator to discard all sharps used in the procedure andto ensure that they are placed in a sharps disposal container.

B. Procedures

1. Registrars are expected to become proficient in all routine procedures.2. Specialised procedures are done either by the Duty Consultant or strictly under

consultant supervision.3. Protocols for the undermentioned routine and specialised procedures are outlined in

the following sections

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Routine ICU procedures

1. Endotracheal intubation2. Peripheral venous catheterisation3. Central venous catheterisation4. Arterial cannulation5. Pulmonary artery catheterisation6. Urinary catheterisation7. Lumbar puncture8. Epidural catheterisation9. Underwater seal drain insertion10. Pleurocentesis11. Peritoneocentesis12. Nasogastric tube insertion

Specialised ICU procedures

1. Percutaneous tracheostomy2. Fibreoptic bronchoscopy3. Jugular bulb oximetry4. Transvenous pacing5. Pericardiocentesis6. Oesophageal tamponade tube insertion7. Intra-aortic balloon counterpulsation

C. Peripheral IV catheters

1. Indications:a) First line IV access for resuscitation including blood transfusionb) Stable ICU/HDU patients where a CVC is no longer necessary

2. Management protocol:a) Remove all resuscitation lines inserted in unsterile conditions as soon as

possible.b) Generally avoid peripheral IV use in ICU patients and remove if not in use.c) Local Anaesthesia in awake patients.d) Aseptic technique:

i) handwash with MiniPREP (chlorhexidine/alcohol) + glovesii) skin prep. with Persist Plus (chlorhexidine 1% / 75% alcohol)

e) Dressing: adhesive occlusive (Opsite or equivalent)f) Change / remove all peripheral lines after 48 hours.

3. Complicationsa) Infectionb) Thrombosisc) Extravasation in tissues

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D. Arterial Cannulae

1. Indications:a) Routine measurement of systemic blood pressure in ICUb) Multiple blood gas and laboratory analysisc) Measurement of BP during transport of patients in hostile environments (eg

during retrieval)

2. Management protocol:a) Remove and replace lines inserted in unsterile conditions as soon as possible.b) Brachial and femoral arterial lines must be changed as soon as radial or

dorsalis pedis arteries are available.c) Aseptic technique:

i) clinical handwash with MiniPREP (chlorhexidine/alcohol) + gloves.ii) skin prep. with Persist Plus (chlorhexidine 1% / 75% alcohol)

d) Local anaesthesia in awake patients.e) Cannulae:

i) Arrow (Seldinger technique): radial or femoral kits.ii) 20G Insyte.iii) Single lumen 18G CVC for femoral arterial lines.

f) Sites: (order of preference): radial, dorsalis pedis, ulnar, brachial, femoral.g) The femoral artery may be the sole option in the acutely shocked patient.h) Dressing: occlusive Opsite + sutured i) There is no optimal time for an arterial line to be removed or changed.j) IA cannulae are changed/removed only in the following settings:

i) Distal ischaemiaii) Mechanical failure (overdamped waveform, inability to aspirate blood)iii) Evidence of unexplained systemic or local infection (cf CVC lines) iv) Invasive pressure measurement or frequent blood sampling is no longer

necessary.k) Measurement of pressure:

i) Transducers should be zeroed to the mid-axillary line.l) Maintenance of lumen patency

i) Continuous pressurised (Intraflo) heparinised saline flush (1u/ml) at3ml/hr.

3. Complicationsa) Infectionb) Thrombosisc) Digital ischaemiad) Vessel damage / aneurysme) HITS (secondary to heparin infusion)

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E. Central venous catheters

NB: Registrars should be familiar with the interpretation and limitations ofhaemodynamic variables derived from central catheters (CVC and PAC) in critically illpatients.

1. Indications:a) Standard IV access in ICU patients:

i) Fluid administration (including elective transfusion)ii) TPN, hypertonic solutions (amiodarone, nimodipine, etc.)iii) Vasoactive infusions

b) Monitoring of right atrial pressure (CVP)c) Venous access for:

i) Pulmonary artery catheterisation (PAC)ii) Continuous renal replacement therapy (CVVHDF), plasmapheresis.iii) Jugular bulb oximetry.iv) Transvenous pacing.

d) Resuscitationi) Standard 3-lumen CVCs are not appropriate for acute volume

resuscitation (consider a PAC sheath)

2. Management protocol: (applies to all types of CVC):a) Types:

i) The standard CVC for all ICU patients at the RAH is a Cookantimicrobial impregnated (rifampicin/minocycline) 20cm triple lumencatheter.

ii) Non-impregnated catheters inserted outside the ICU should be changedto a impregnated catheter according to clinical indication.

iii) Vascath catheters are used for CVVHDF and plasmapheresis iv) Pulmonary artery catheter sheath (part of the PAC kit)

b) Sites:i) Subclavian is the preferred site for routine stable patients, followed by

internal jugular.ii) Femoral access is preferable where:

a) Limited IV access (burns, multiple previous CVCs),b) Thoracic approach is considered hazardous:

(1) Severe respiratory failure from any cause (PaO2/FiO2 < 150)(2) Hyperexpanded lung fields (severe asthma, bullous lung

disease)(3) Coagulopathy (see below)

c) Inexperienced staff requiring urgent access, where supervision is notimmediately available.

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c) Coagulopathic patients:i) INR > 2.0 or APTT > 50s correct with FFPii) Platelets < 50,000 transfuse 1 pack (5u) plateletsiii) Failure to increment platelet count after transfusion avoid subclavianiv) Uncontrolled coagulopathy use femoral approach or PICC

d) Technique policyi) Local anaesthesia in awake patients.ii) Strict aseptic technique at insertion:

a) Hand disinfection: surgical scrub with chlorhexidine for >1 minuteb) Sterile barrier: gown, glove, cap and mask and sterile drapes.c) Skin prep: Persist Plus (chlorhexidine 1% / 75% alcohol)

iii) Seldinger technique only.iv) Suture all linesv) Dressing: non occlusive dressingvi) Flush all lumens with heparinised salinevii) Check CXR prior to use.

e) Maintenancei) Routine IV administration set change at 5 days.ii) Daily inspection of the insertion site and clinical examination for

infection irrespective of duration of insertion.iii) Catheters are left in place as long as clinically indicated and changed

when:a) Evidence of systemic infection

(1) New, unexplained fever (2) Unexplained rise in WCC (3) Deterioration in organ function (4) Positive blood culture by venipuncture with likely organisms

(S. epidermidis, candida spp.), and/orb) Evidence of local infection - inflammation or pus at the insertion

site.iv) Guidewire exchanges are actively discouraged. They may be indicated

in the following situations, after discussion with a Consultant:a) Mechanical problems in a new catheter (leaks or kinks)b) Difficult or limited central access (eg burns).

v) Maintenance of lumen patencya) Central venous catheters (pre-printed on the patient flowsheet)

(1) Flush unused lumens with 1ml heparinised saline (1u/ml) 8hourly

b) Vascath: into each lumen 8 hourly, (printed sticker)(1) Withdraw 2ml and discard.(2) Flush with 2ml normal saline.(3) Flush 1.5ml solution (5000U heparin/2ml).

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3. Complications:a) At insertion

i) Arterial puncturea) Haematoma with mass effectb) Arterial thrombosis/embolism

ii) Pneumothorax, haemothorax, chylothoraxiii) Neural injury (phrenic, brachial plexus, femoral nn.)

b) Passage of wire/catheteri) Arrhythmiasii) Perforation of SVC, RA; tamponade

c) Presence of catheteri) Catheter infection: rates increase under the following conditions:

a) Size of catheter - thicker catheters (pulmonary artery catheters,Vascaths)

b) Site of catheter - femoral > internal jugular > subclavian sitesc) Number of lumensd) Nature of fluid through catheters - TPN or dextrose solutions

ii) Thrombosisiii) Catheter/Air embolismiv) Knotting of catheters (esp PAC) v) Pulmonary infarct / arterial rupture (PAC)vi) HITS secondary to heparin.

NB: Where insertion of a CVC presents significant risk in a non-urgent situation,consider insertion of a PICC line as an alternative.

F. Urinary catheters

1. Standard in all ICU patients2. Management protocol:

a) Aseptic technique at insertion.i) Hand disinfection: surgical scrub with chlorhexidine for >1 minuteii) Sterile barrier: gloves and sterile drapes.iii) Skin prep: chlorhexidene 1%

b) Local anaesthesia gel in all patients.c) Foley catheters for 7 days and change to silastic thereafter if prolonged

catheterisation is anticipated. (ie > 14 days)d) Remove catheters in anuric patients and perform intermittent catheterisation

weekly, or as indicated.

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G. Epidural catheters

1. Indications a) Post operative pain relief (usually placed in theatre)b) Analgesia in chest trauma.

2. Management protocol:a) Notify the Acute Pain Service of any epidural placed in ICU/HDUb) Epidural cocktails should follow the Acute Pain Service protocolsc) Strict aseptic technique at insertion. d) Daily inspection of the insertion site. The catheter should not be routinely

redressed, except under the advice of the APS.e) Leave in for a maximum of 5 days and then remove.f) Remove if not in use for > 24 hours or clinical evidence of unexplained sepsis

or positive blood culture by venipuncture with likely organisms (S.epidermidis, candida).

g) Heparin/Warfarin Protocol

3. Complicationsa) Hypotension from sympathetic blockade / relative hypovolaemia

i) This usually responds to adequate intravascular volume replacementb) Pruritis, nausea & vomiting, or urinary retention (opioid effects)c) Post-dural puncture headached) Infection: epidural abscesse) Pneumothorax (rarely)

4. NB: Further guidelines for the management of epidural catheters can be obtainedfrom The Acute Pain Service Guidelines for Anaesthetists (revised 11/1/2000)

H. Pulmonary artery catheters

1. Policy:a) Insertion of PA catheters must be authorised by the Duty Consultant.b) Become familiar with the theory of insertion, indications, interpretation and

complications of PACsc) Insertion of PA catheters must never delay resuscitation of shocked patients.d) Allow sufficient time for nursing staff to set up insertion trays and transducer

manifolds.e) Remove catheters once they are not being routinely used.

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2. Indications:a) Haemodynamic measurement (cardiac output, stroke volume, SVR)

i) Diagnostic assessment of shock states (cardiogenic, hyperdynamic,hypovolaemic)

ii) Assessment of response to treatment in the aboveb) Measurement of right heart pressures (RAP, PAP):

i) Acute pulmonary hypertension ii) Pulmonary embolismiii) Cardiac tamponade

c) Estimation of preload / left heart filling (PAOP)i) Intravascular volume statusii) LVFiii) Response to fluid loading

d) Measurement of intracardiac shunt: (Acute VSD)e) Derivation of oxygen variables (VO2, DO2): not routinely done in this Unit.

3. Management protocol:

a) Insertion protocol as per CVCb) Specific features of PACs

i) Insertion protocola) Sheath introducer (8.5 Fr) with side port, haemostatic valve and

plastic contamination shield.b) Shared transducer for RAP (proximal) and PAP (distal) lumens c) Check competence of balloon and concentric positiond) Ensure all lumens are flushed with hep saline prior to insertion.e) Ensure adequately zeroed system and appropriate scale (0-40mmHg)

on monitor prior to insertion.f) Insert catheter using changing waveforms (RA RV PA) on

monitor with balloon inflated and locked until catheter displayspulmonary artery occlusion tracing: usually 50cm on catheter inmost patients using subclavian and left IJ approach; right IJ 40 cm.

g) Deflate balloon and ensure adequate PAP trace. Adjust catheterdepth until a PAOP trace appears with 1 - 1.5ml air in balloon.

h) Suture introducer and attach contamination shield to the hub of theintroducer.

i) Apply a non-occlusive dressing.ii) Ensure an adequate PA tracing is on the monitor at all times:

wedged tracings must be corrected as soon as possible:a) Flush distal lumen with 2ml N.Salineb) Withdraw the catheter until a PA trace is visible

iii) Measurement of pressures:a) Reference pressures to the mid axillary lineb) Measure at end-expiration of the respiratory cyclec) Do not disconnect ventilated patients to measure pressures.

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d) Measurement of PAOP:(1) End expiration: lowest point in ventilated patients, highest point

in spontaneously ventilating patients(2) Use the electronic cursor on Marquette monitors after 2-3

respiratory cycles.iv) Haemodynamic measurements

a) These are routinely performed by the nursing staff, howeverregistrars should become familiar with the procedure.

b) Record all measurements in the flow chart in the results folder.(1) Cardiac outputs:

(a) Injectate: 10 ml 5% dextrose @ room temperature(b) Inject throughout the respiratory cycle(c) > 3 measurements and ignore values > 10% from average.

(2) Derived variables:(a) CO/CI and SVR are routinely recorded (8 hly or as

indicated ) on the ICU chart.(b) Other variables including PVR(I), SV(I), L(R)VSWI are

recorded in the haemodynamics flowsheet.(c) Oxygen delivery variables are not routinely measured due

to limited clinical utility: if they are measured oxygensaturation should be directly measured with co-oximetry.

(d) Table of derived haemodynamic variables (see table)

4. Complicationsa) Related to CVC cannulation (see CVC section)b) Related to insertion/use of a PAC

i) Tachyarrhythmiasii) RBBBiii) Cardiac perforationiv) Thromboembolismv) Pulmonary infarction (2 persistent wedging) ~ 0-1.4%vi) Pulmonary artery rupture ~ 0.06-0.2% (mortality 50%)vii) Catheter related sepsisviii) Endocarditisix) Pulmonary valve insufficiencyx) Catheter knottingxi) Balloon fragmentation/embolism

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Standard Haemodynamic VariablesVariable Formula Normal rangeCardiac index CO/BSACI = 2.5-5 l/min/m2Systemic vascularresistance SVR

MAP RAPCO

= 79 9. 750-1500dyn.sec/cm5/m2Systemic vascularresistance index BSA79.9CO

RAPMAPSVRI = 1400-2400dyn.sec/cm5/m2Pulmonary vascularresistance index PVR

MAP RAPCI

= 79 9. 150-250dyn.sec/cm5/m2

Stroke volume index SVICIHR

= 33- 47 ml/beat/m2

Left ventricular strokework index ( )LVSWI MAP PAOP SVI= 0 0136. 50-120 g/m2 / beatRight ventricular strokework index ( )RVSWI MAP RAP SVI= 0 0136. 25-55 g/m2 / beatArterial oxygen content ( ) ( )CaO Hb SaO PaO2 2 2134 0 003= + . . 17-20 ml/100mlVenous oxygen content ( ) ( )CvO Hb SvO PvO2 2 2134 0 003= + . . 12-15 ml/100mlOxygen delivery index DO I CI CaO2 2 10= 550-750 ml/min/m2Oxygen consumptionindex ( )VO I CI CaO CvO2 2 2 10= 115-160 ml/min/m2Oxygen extraction ratio O ER

VO IDO I2

2

2= 0.24-0.4

Shunt equation( )( ) 010OvCOcC CaOOcCQtQs 22 22 = 5-15%

End capillary oxygencontent

( ) ( )0.003PAO1.01.34HbOcC 22 += 80-100 ml/100mlAlveolar gas equation ( ) ( )PAO FiO PaCO2 2 2760 47 125= . 100-650 mmHg

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I. Pleural drainage

1) Indications:a) Pneumothoraxb) Tension pneumothorax may require urgent needle thoracostomyc) Haemothoraxd) Large symptomatic pleural effusion

2) Management protocol:

a) Needle thoracostomy (tension pneumothorax):i) 16G cannula placed in mid clavicular line, 2nd intercostal spaceii) Always place an UWSD following this procedure

b) Pleurocentesis: (pleural effusion)i) Local anaesthesia and sterile techniqueii) Cannula technique:

(1) 3 way tap attached to 12 - 14 G IV cannula, syringe and rubber hose(closed system)

(2) Remove needle from cannula and aspirate pleural effusion until dry.iii) Seldinger technique

(1) Pigtail pericardial catheter (preferred) or single lumen CVC kit.(2) Insert guidewire through needle into pleural space(3) Insert catheter into pleural space over wire(4) Aspirate intermittently with closed system or attach to an underwater-

seal drainage system.iv) Record volume removed and send for MC&S, cytology & biochemistry.v) Check CXR post-procedure.

c) Underwater seal drainage:

i) Local Anaesthesia in awake patients.ii) Strict aseptic technique at insertion:

ie full gown/glove/mask & cap; chlorhexidine skin preparationiii) Site: mid axillary line, 3 - 4 intercostal spaceiv) ICU patients need large drains: 28F catheter or largerv) Remove trochar from catheter: do not use trochar for insertion of tube.vi) 2-3 cm skin incision parallel to the ribs (#10 or #15 scalpel)vii) Blunt dissection to and through intercostal space with index finger or

Howard Kelly forceps until within pleural space.viii) Insert finger into pleural space to enlarge hole and insert tube directly into

pleural space or with forceps.ix) Connect to underwater seal apparatusx) Insert 2 purse string sutures:

1 to fasten the tube, and 1 (untied) to close the incision on removal.xi) Dressing: occlusive dressing (Hypafix)xii) Check CXR.

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xiii) Maintenance(1) Remove or replace drains inserted in unsterile conditions as soon as

possible.(2) Leave drain in situ until radiological resolution, no further bubbling,

or drainage (

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J. Endotracheal intubation

1. Policy:a) Endotracheal intubation in ICU patients is a high risk but vital procedure:

i) Usually an emergency procedure, with limited time.ii) Usually indicated for acute respiratory failure, or associated with limited

respiratory reserveiii) Patients may have cardiovascular instability and significant comorbiditiesiv) Patients may have cervical spine or oropharyngeal trauma/surgeryv) Patients are at risk of vomiting and aspiratingvi) Positioning is difficult.

b) Familiarisation with the intubation trolleys, equipment and drugs is essential.c) Intubation should ideally not be done as a sole operator procedure. Skilled

assistance should always be sought.d) If you are alone (ie after hours): call for help!

Expertise in intubation is always available. Remember ESS anaesthesia staff.e) The majority of ICU patients mandate rapid sequence induction.

2. Indications

a) Institution of mechanical ventilationb) To maintain an airway

i) Upper airway obstructiona) Potential eg early burnsb) Real eg epiglottitis, trauma

ii) Patient transportationc) To protect an airway

i) Patients at risk of aspiration ii) Altered conscious stateiii) Loss of glottic reflexes

d) Tracheal toilet 3. Techniques

a) Orotracheal intubation is the standard method of intubation in this unit.b) Nasotracheal intubation may be indicated where:

i) Patients require short-term ventilation and are intolerant of oral ET tubes.ii) Fibreoptic intubation is indicated:

a) Following head and neck surgeryb) Inability to open the mouth:

e.g. intermaxillary fixation, TMJ trauma, rheumatoid arthritis. c) Upper airway obstruction

iii) Contraindicated in base of skull & LeForte facial fracturesc) Methods:

i) Direct visualisation under rapid sequence inductionii) Fibreoptic bronchoscopic awake intubationiii) Intubating laryngeal mask LMA (Fastrac)

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4. Endotracheal Tubesa) Standard tube: low pressure, high volume PVC oral tube.

i) Males 8-9 mm: secure at 21-23cm to incisorsii) Females 7-8 mm: secure at 19-21cm to incisorsiii) Do not cut tubes to less than 26 cm long.

b) Double lumen tubes: *rarely indicated in ICU:i) Unilateral lung isolation for bronchopulmonary fistula, abscess or

haemorrhageii) These tubes should be inserted as a temporary manoeuvre prior to a

definitive procedureiii) Allow differential lung ventilation

c) Intubated patients from theatre may have the following tubes that are notrecommended for prolonged intubation. These tubes must be changed ifintubation anticipated > 48 hours if safe and feasible.i) Plain PVC tubes: change to standard EVAC translaryngeal tubeii) Armoured tubes: problems:

a) High pressure, low volume cuffb) Once kinked, remain kinked: beware in patients who bite tubes.

iii) RAE tubes: problemsa) Difficulty in suction due to bendb) Fixed length from bend: frequently advance down right main bronchusc) High pressure, low volume cuff

5. Protocol for endotracheal intubation in ICU

a) Personnel: Intubation is a 4 person procedure; skilled assistance is mandatory:i) Top end intubator who coordinates the intubationii) One person to administer drugsiii) One person to apply cricoid pressure once induction commences:

a) This is recommended as a routine for emergency intubationsb) The intubator should direct the person who is applying cricoid

pressure so that pressure is correctly applied and removed ifdistortion of the larynx or difficulty in intubation occurs as a result.

c) CP is considered safe in the presence of suspected spinal injury.iv) One person to provide in line cervical spine immobilisation (trauma and

spinal patients only). Consider the use of Fastrac LMA for spinal patients tominimize neck movements.

b) Secure adequate IV accessc) Equipment (kept in intubation trolleys in Q4A, B, C & D). Ensure the

following equipment is available and functional: i) Adequate lightii) Oropharyngeal airwaysiii) Working suction with a rigid (Yankauer) sucker iv) Self inflating hand ventilating assembly and maskv) 100% oxygen, ie working flowmeter at 15 l/minvi) 2 working laryngoscopesvii) Magill forceps

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viii) Malleable introducer and gum elastic bougieix) 2 Endotracheal tubes

a) Normal size + 1 size smallerb) Check cuff competence

x) Access to difficult intubation equipment.a) Be aware of Failed Intubation Drill.b) Cricothyroidotomy equipment (#15 scalpel / #6.0 cuffed ETT)

d) Monitoring (on all patients) :i) Pulse oximetryii) Capnographyiii) Arterial blood pressure

(place an arterial line before intubation in most patients)iv) Electrocardiography

e) Drugsi) Induction agent (thiopentone, fentanyl, ketamine, midazolam)ii) Suxamethonium (1-2 mg/kg) is the muscle relaxant of choice.

a) Contraindicated in:(1) Burns > 3 days(2) Chronic spinal injuries (ie spastic plegia)(3) Chronic neuromuscular disease (eg Guillain Barre, motor neurone

disease)(4) Hyperkalaemic states. (K+ > 5.5)

b) Consider Rocuronium (1-2 mg/kg) if Sux. contraindicatediii) Atropine (0.6 - 1.2 mg)iv) Adrenaline (10 ml 1:10000 solution)

f) Procedure: Rapid sequence induction and orotracheal intubationi) Pre oxygenate with 100% oxygen for 3-4 minutes.ii) Preload with 250-500ml colloid intravenouslyiii) Induction agent + suxamethoniumiv) Cricoid pressure appliedv) Direct visualisation of vocal cords and tracheal intubationvi) Inflation of cuff until sealedvii) Confirmation of end-tidal CO2 and chest auscultation with manual

ventilationviii) Cricoid pressure releasedix) Secure tube at correct length x) Connect patient to ventilator (see default ventilator parameters)xi) Ensure adequate sedation muscle relaxantxii) Consider insertion of a naso/oro-gastric tube. Required by the majority

of ICU patients and insertion will avoid repeating the CXR.xiii) Chest X-rayxiv) Confirm blood gas analysis and adjust FIO2 accordingly.

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g) Sedation post intubation:i) None if comatose or haemodynamically unstableii) Morphine midazolam, propofol, fentanyl, diazepam as indicated by the

clinical scenario. 6. Maintenance of endotracheal tubes

a) Tapes i) Secure tubes with white tape after insertion.ii) Ensure that loop of tape is snug around back of neck but not too tight to

occlude venous drainage. Should allow 2 fingers under tape.iii) Retape with adhesive tape once X-Ray check done.

b) Cuff checksi) Volumetric (sufficient air to obtain a seal + 1 ml) tests are done following

insertion and whenever a leak is detected with a manual hyperinflationonce per nursing shift.

ii) Seal is assessed by auscultation over trachea during normal ventilation.iii) Manometric tests are inaccurate and do not correlate with mucosal

pressure. These are an adjunct only if cuff malfunction is suspected.c) Persistent cuff leaks

i) Tubes requiring more than 5ml of air to obtain a seal or if there is apersistent cuff leak must be examined by direct laryngoscopy as soon aspossible even if the tube appears to be taped at the correct distance at theteeth.

ii) Ensure that:a) The cuff has not herniated above the cordsb) Tube has not ballooned inside the oral cavity and pulled the cuff

above the cords.iii) High risk patients for cuff leaks:

a) Inappropriately cut tubes: do not cut tubes < 26 cmb) Facial swelling (burns, facial trauma)c) Patients requiring high airway pressures during ventilation

d) Aspirate EVAC tubes 2 hourly, or more frequently (hourly) if > 10 mlsupraglottic secretion per hour

7. Endotracheal tube change protocol

a) Ensure adequate skilled assistance, equipment, drugs and monitoring as for denovo intubation.

b) Procedurei) Set the FIO2 = 1.0 and change SV modes to SIMV.ii) Ensure sufficient anaesthesia and muscle relaxation (fentanyl / propofol +

neuromuscular blockade)iii) Perform laryngoscopy and carefully identify patency of upper airway

after suction, anatomy of larynx, degree of laryngeal exposure andswelling.

iv) Clear view of larynx and no or minimal laryngeal swelling:

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a) Application of cricoid pressure by assistant and careful, gradedextubation under direct laryngoscopic vision.

b) Maintain laryngoscopy and replace tube under direct vision.v) Impaired visualisation of larynx:

a) Use gum elastic or ventilating bougieb) Place bougie through tube under direct vision and insert to a length

that would be just distal to the end of the ETT (approximately 30cmfrom end of tube)

c) Have an assistant control the bougie so that it does not move duringmovement of the endotracheal tube

d) Application of cricoid pressure by assistant and careful, gradedextubation

e) Maintain laryngoscopy and ensure bougie is through the cords onextubation

f) Replace tube over bougie and guide through laryn