DKA
ICU requirement for DKA is insulin gtt in this institution. Smart text available is .dkaadmit (from author Alexandra Bandy). For those young adults struggling with compliance because of the psycho-social challenges of having T1DM download a resource sheet (there are no support groups in the Inland Empire for young adults with T1DM). Not every DKA admission requires an Endocrinology consult; but most of our patients benefit from reviewing nurse education. Check out this great review of initial DKA management or our own ICU powerpoint regarding our local population.
HHS
Many patients with T2DM will present along a spectrum of DKA and HHS. Check serum osm to help differentiate; ketones may appear in either state. Use a calculator to evaluate the corrected sodium. HHS is traditionally defined by very high glucoses >1000 with severe dehydration due to prolonged glycosuria and thus requires significant fluid resuscitation before attempting to normalize serum glucose. Upwards of 10L would be appropriate in many scenarios. Be sure not to correct glucose too quickly as this can lead to intracranial fluid shifts. For this reason, the HHS orders set a goal glucose of 250 and cut the rate of insulin after a reduction to 300.
DBS Stage I or II
Dr. Hussain and Dr. Lopez-Gonzalez perform DBS placements (watch this video!) at EC OR for movement disorders like essential tremor and Parkinson's Disease. Dr. Lopez-Gonzalez does two surgeries, two weeks apart (first lead placement, then battery placement) and Dr. Hussain will do lead placement and battery placement concurrently. Post-operatively and prior to ICU admission they go to CT scan to verify lead placement is appropriate. Battery is not active at time of admission so patient's underlying tremors should remain. Progress note (H&P completed by the surgical team) smart text available is .dbsadmit (from author Alexandra Bandy). Specific parameters per Neurosurgery for ICU care are: HOB 30-45, SBP <140 and DBP <95, neurochecks Q1 to 2H, and pain mgmt PRN. A lines placed intraop can be maintained for ease but cuff pressures are adequate. Some of the post-op concerns we have encountered have included brief personality changes and unequal pupillary response due to lead edema or hemorrhage. For any acute issues read this article and page Nsgy on call. If no response by Nsgy resident/PA/NP within 15 minutes, please call Nsgy attending directly. Dr. Lopez-Gonzalez can be reached directly at 216-682-6045. Dr. Hussain can be reached directly at 909-525-0878. If a brain MRI is requested by Nsgy, the patient needs to be transported to the MC MRI as our machine at EC is incompatible with the Medtronic leads. Patient's should discharge directly home the next day.
Decompressive Laminectomy with Instrumentation and Fusion
Dr. Kim, Dr. Hussain, and Dr. Lopez-Gonzalez sometimes admit to ECICU for 24 hour post-op monitoring post- laminectomy. Progress note (H&P completed by the surgical team) smart text available is .lamiadmit (from author Alexandra Bandy)
Maxillary and Mandibular Hypoplasia
These OMFS cases (most frequently: Lefort I 3-piece maxillary osteotomy with mandibular bilateral sagittal split osteotomy and genioplasty with or without custom splint) are usually under the care of Dr. Stringer, Dr. Hereford, or Dr. Thakker. OMFS will place all admit orders and should be notified for any surgical complications and will order follow up imaging or labs if necessary. ICU can manage other needs without consultation such as pain or nausea. Progress note (H&P completed by the surgical team) smart text available is .lefortadmit (from author Alexandra Bandy).
Upon admission, be sure to remind patients and family members of the following goals to meet before discharge: (1) ambulate; (2) void; (3) pain and nausea control; (4) 500cc oral intake. Goals must be met by 0600 when OMFS surgeons round, and most patients have difficulty meeting the oral intake goals due to either PONV or lack of motivation. Please emphasize that it's going to require effort and that they must drink all night long to meet their goal. You may want to d/c IVFs at midnight to encourage thirst. They should actively report nausea as soon as they feel it in order to get pre-medicated. Phenergan suppositories are very well tolerated by these patients if you explain why it's being recommended; add as second line drug after IV Zofran. Scopolamine patches also work to good effect. Consider d/c Sudafed and/or Afrin if persistently tachycardic after fluids given. Ensure family has necessary discharge prescriptions (specifically, Hycet) and that they fill them night of admission at LLUMC Outpatient Pharmacy OR Community Pharmacy. If not, their discharge may be delayed as many pharmacies do not have this elixir.
Chronically Critically Ill (or LTACH- Ready)
Each of the ICUs share a portion of the burden of the chronically critically ill with prolonged hospitalizations or inability to discharge. Given our 8 beds, we can take 2 long-term (months to years) patients at a time. This would include difficult discharges due to severe recurrent issues requiring ICU level-of-care or insurance issues (including emergency or straight MediCal and our own Risk Management Tapestry which does not contract with sub acute or LTACH). Being creative with care plans and consider wholeness in a way not typically done in the ICU is very important for these patients. Multi-disciplinary planning (with staff, the patient, and the family) is key as is utilization of the ABCDEF bundle. Involve Palliative Care, who has access to Neuropsychology students for talk therapy. If stable, encourage time outside in the garden. If specialty mobility equipment could help, consider calling Assurance Medical, a DME company who works with our Rehab to set the patient up with customized wheelchairs, lifts, etc. State-provided communication devices that may assist the patient can be obtained through social worker's assistance.