Cardiac ICU: AHA Drafts Guidance for Best Practices

Critically ill cardiovascular patients require special care in the cardiac ICU due to the unique complications that they are prone to suffer, according to the American Heart Association (AHA).

Best practices to help reduce complications in the cardiac ICU environment were recommended in an AHA scientific statement, published online in Circulation, with many principles borrowed from other medical and surgical ICU settings:

• Hand hygiene to prevent hospital-acquired infections
• Routine screening for delirium and minimizing the use of benzodiazepines and other medications associated with delirium
• Adhering to safe mechanical ventilation parameters to prevent ventilator complications (e.g., keeping tidal volume at 6-10 mL/kg ideal body weight for most patients and tailoring applied positive end-expiratory pressure to each patient’s underlying pathophysiological condition)
• Early mobilization for most patients (except those with active ischemia or infarction) to prevent muscle weakness
• Early initiation of enteral nutrition in most people who are unable to eat and providing stress ulcer prophylaxis for those at increased risk of gastrointestinal bleeding

Unique to the cardiac ICU, however, are complications related to cardiogenic shock and the specialized use of invasive cardiovascular monitoring and support devices that carry their own risks, according to the writing group chaired by Christopher Fordyce, MD, MHS, of the University of British Columbia and Vancouver General Hospital.

Invasive diagnostic and therapeutic procedures should be anticipated and performed before they become emergency, and any invasive catheter or mechanical circulatory support device removed promptly when no longer needed, the authors said.

Fordyce and colleagues provided a bedside checklist to standardize best practices in the cardiac ICU.

“Cardiac critical care is a growing field, and there is an urgent need to implement strategies to optimize care among patients admitted to the CICU [cardiac ICU],” said Fordyce in a press release. “These strategies can help CICU professionals anticipate and prevent complications in this unique patient population, and we encourage critical care teams to reflect upon their current practices and consider implementing these strategies where any gaps exist.”

The AHA writing group had made their recommendations after reviewing data from the general medical and surgical ICU literature, given the paucity of direct evidence from the cardiac ICU setting.

“In the opinion of the writing group, this extrapolation of evidence is reasonable given that patients in the modern CICU appear to have significant overlap with respect to concomitant medical conditions and critical care-restricted therapies,” the authors argued.

“Future research and quality improvement efforts are required to better define the epidemiology of critical illness-related complications in the CICU patient population and to evaluate existing and novel therapies with rigorous multicenter clinical trials and large prospective registries,” according to the group.

The AHA had previously stated the need to enhance care of geriatric patients in particular in the cardiac ICU.