VOLUME 23

2023

Patients
ISSUE 5

and Families
Bringing Back the Forgotten Puzzle Piece: Family Empowerment in the Long-Term Home Ventilation in Children: Facing the Challenge, M Pons,
Care of the Critically Ill Patient, B Lobo-Valbuena, S Garcia-Manzanedo, E Esteban, P Corniero, GD Carrillo, FJC Lasaosa
AR Alcaraz, M-M Garcia-Arias, F Gordo
Treating the Whole Human In Intensive Care – Patient-Centred Outcomes
The Internet and the Rise of Artificial Intelligence in Critical Care in Sepsis, Surgery and Trauma, LA Belon, J Poole
Medicine: Opportunities, Threats, and the Practitioner-Patient
Relationship, L Hawryluck, MJ Douma, PG Brindley Acute Subarachnoid Haemorrhage - An Epidemiological Perspective,
E Brogi, L Querci, A Chierega
Administering Care to Critically Ill Patients with FAST HUGS IN BED
PLEASE - Revisited Mnemonic, E Arriaga-Morales, OR Pérez-Nieto,
D Cuellar-Mendoza, GBE Sánchez de la Barquera, AC Siller-Serna,
E Deloya-Tomas

INTENSIVE CARE I EMERGENCY MEDICINE I ANAESTHESIOLOGY icu-management.org @ICU_Management

 PATIENTS AND FAMILIES 207

Ernesto Arriaga-Morales
Emergency Department. Hospital San Ángel Inn Sur
Administering Care to Critically Ill Patients with
FAST HUGS IN BED PLEASE - Revisited Mnemonic
Ciudad de México, México.
urgencias.sur@hsai.com.mx
@Ernesto_AM_MD

In the ICU, providing better care with less is the holy grail. This mnemonic tries to resume a list of the key interventions for human,
evidence-based and patient-centred care.

Orlando R. Pérez-Nieto Background (30°) for intubated patients; proactive Ulcer prophylaxis; vigilant
Intensive Care Unit Glucose control; thorough Skin and Eyecare, along with proper
Hospital General San Juan del Río In 2005, Prof Jean-Louis Vincent introduced the mnemonic
suctioning; management of Indwelling catheters; Nasogastric tube
Querétaro, México. “FAST HUG,” advocating for a comprehensive approach to patient
Orlando_rpn@hotmail.com maintenance; meticulous Bowel care; Environment optimisation
care encompassing seven key components: Feeding, Analgesia,
@OrlandoRPN (including temperature control and conducive surroundings for
Sedation, Thromboembolic prevention, Head-of-bed elevation
delirium management); De-escalation strategies (pertaining to
to 30-45°, stress Ulcer prophylaxis, and Glucose control (Vincent
end-of-life decisions and cessation of unnecessary treatments);
2005). This paradigm shift has had a profound impact within the
and comprehensive Psychosocial support for patients, families,
critical care domain, fostering a patient-centred approach that
and staff (Nickson 2021). This updated rendition provides a
prioritises mental well-being, reduces invasive interventions,
more encompassing framework, rendering it a highly practical
and promotes judicious fluid management.
Daniela Cuellar-Mendoza tool. Within our medical practices, it has been embraced across
Intensive Care Unit Subsequently, in 2009, William Vincent and Kevin Hatton the spectrum - from the intensive care unit to the emergency
Hospital General San Juan del Río refined the mnemonic to “FAST HUGS BID”, tailoring it for department and hospital wards.
Querétaro, México.
surgical patients. This expanded version incorporates additional
cuellarmdan@outlook.com
@Daniela90CM elements: Fluid management, consideration of Spontaneous
breathing trials, meticulous Bowel care, timely removal of Administering Care to Critically Ill Patients with
Indwelling catheters, and prudent De-escalation of antibiotic FAST HUGS IN BED PLEASE
use (Vincent and Hatton 2009). We present a revised iteration of the mnemonic, incorporating
In a more contemporary context, 2021 saw Chris Nickson’s often overlooked aspects:
contribution through the “Life in the Fast Lane” blog, wherein
George B. Edgar Sánchez de la Barquera F: Feeding
the mnemonic was further enhanced to “FAST HUGS IN BED
Anatomy Department Conduct a thorough nutritional assessment and provide support
Faculty of Medicine
Please”. This iteration takes into account the intricacies of care
UNAM in the emergency department, encompassing Fluid therapy and as required. Emphasise the importance of adequate nourishment,
Ciudad de México, México Feeding; Adequate Analgesia, administration of Antiemetics, and as prolonged fasting can detrimentally impact outcomes. Even
benjamin.edgar@insp.edu.mx provision of Diphtheria booster/vaccine; thoughtful Sedation in surgical scenarios, short fasting is the prevailing practice. In
and consideration of Spontaneous breathing trials; Thrombo- the emergency department, proactive measures can be taken to
prophylaxis measures; Tetanus prophylaxis; Head elevation ensure meal provision and, if necessary, consultation with nutri-

ICU Management & Practice 5 - 2023

208 PATIENTS AND FAMILIES

interventional analgesic techniques (Devlyn 2018). Antiemetic on mechanical ventilation, may find positioning at an incline
Ana Cristina Siller Serna agents such as ondansetron or alcohol in cotton swabs can be of 35-45° advantageous (Maschmann et al. 2019; Dabrowski et
Private Practice
Ciudad de México, México
contemplated for patients grappling with nausea triggered by al. 2021). Humanised care and improving communication can
ana_siller2006@hotmail.com analgesic use or underlying medical conditions. empower the patient and family and promote personal care
@anacris_97 and hygiene. The use of hearing aids, glasses, and dentures are
S: Sedation and Spontaneous Breathing Trial feasible and established recreation strategies (Wilson et al. 2019).
Administer sedation only as necessary and strive for prompt
withdrawal. Prioritise optimal analgesia and anxiolysis, favouring U: Ulcer Prophylaxis
short-acting medications over benzodiazepines. Caution should Gastrointestinal ulcer prophylaxis, while not linked to reduced
be exercised with agents like propofol and dexmedetomidine mortality, effectively mitigates the risk of gastrointestinal bleed-
(Escamilla et al. 2022; Narayan and Petersen 2022). Incorporating ing. Indications for commencing prophylaxis should encompass
Ernesto Deloya-Tomas awakening and spontaneous breathing trials into the care regimen patients enduring positive pressure ventilation exceeding 48
Intensive Care Unit
Hospital General San Juan del Río
is pivotal, especially for mechanically ventilated patients whose hours, those reliant on extracorporeal life support, individuals
Querétaro, México. intubation cause is controlled. These interventions contribute to with a platelet count below 50x10^9/L, INR surpassing 1.5,
deloyajmr@hotmail.com a judicious balance between patient comfort and their progres- aPTT exceeding twice the norm, history of recent gastrointes-
@E_DeloyaMD
sion towards self-regulated respiration. tinal bleeding within the past year, acute traumatic brain injury
or spinal cord injury, and substantial thermal injuries covering
T: Thromboprophylaxis more than 35% of total body surface area (Saeed 2022). The
Thromboembolic occurrences persist as significant contributors early initiation of enteral nutrition, even in the presence of
tion specialists for patients with specific needs such as diabetes,
to morbidity and mortality within the inpatient setting. Utilising significant risk factors, contributes to reducing the likelihood
hypermetabolic conditions (e.g., burns, hyperthyroidism), or
scoring systems such as Caprini and Padua offers insights to tailor of gastrointestinal bleeding, while the incorporation of proton
malnutrition (Compher et al. 2022). Comprehensive nutritional
optimal prophylactic strategies for each individual. From early pump inhibitors (PPIs) brings benefits to the aforementioned
evaluation and suitable oral or enteral diets are advantageous for
mobilisation to employing parenteral thromboprophylactic agents patient groups (El-Kersh et al. 2018).
critically ill and most hospitalised patients, with parenteral routes
like enoxaparin or compression pneumatic stockings, tailored
reserved for select cases (Weimann et al. 2021; Singer et al. 2019). G: Glucose Control
approaches are pivotal. Specialised evaluation considering ortho-
A: Analgesia and Antiemetic Agents paedic, cancer, autoimmune, critically ill, and surgical contexts The ADA annually publishes guidelines that outline glucose
play a pivotal role in averting thromboembolic complications. thresholds for hospitalised patients. These recommendations
Pain management ranks among the prime concerns for patients
Recognising that a universal approach doesn’t suffice, it becomes categorise patients based on their vulnerability to hypoglycaemia
seeking medical attention. Systematic pain assessment, regardless
imperative to individualise interventions for enhanced efficacy and hyperglycaemia. Adherence to these guidelines, combined
of intubation status, should be undertaken employing validated
(Sebaaly and Covert 2018; Amer et al. 2023). with vigilant management of glucose fluctuations, places signifi-
scoring systems such as the critical care pain observation tool
cant emphasis on preventing hypoglycaemia while concurrently
(CPOT) or the behavioural pain scale (BPS). Effective analgesia H: Head Position and Humanised Care addressing hyperglycaemic episodes. This approach yields positive
markedly influences the perception of care quality and enhances
Adapting the head position to suit individual needs is paramount. outcomes by substantially reducing the risks of morbidity and
outcomes across a spectrum of cases, ranging from minor bruises
Varied positions offer unique benefits, and even a single patient can mortality, including conditions like decompensation, infec-
to postsurgical and critically ill ventilated patients. Optimal
derive advantage from different orientations at distinct phases of tions, and electrolyte imbalances. Integrating nutritional and
approaches encompass a blend of opioid and non-opioid agents,
care. Meticulous assessment and adherence to guidelines not only rehabilitative interventions further enhances control by consid-
including acetaminophen, non-steroidal anti-inflammatory drugs
enhance patient comfort but also ensure their safety. Individuals ering energy provision and anticipated expenditure (American
(NSAIDs), antineuritic medications, and, where applicable,
vulnerable to or exhibiting cranial hypertension, particularly those Diabetes Association 2023). It’s noteworthy that while insulin

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 PATIENTS AND FAMILIES 209

of skin and eye care. Additionally, careful skin evaluation can N: NEWS2 Score
aid in the identification of adverse drug reactions (Bromley et al. The implementation of early warning systems, exemplified by
2023). Particularly noteworthy are pressure ulcers, which pose the NEWS2 score, holds a pivotal role within hospital settings,
a significant challenge for immobilised patients. Implement- functioning akin to a triage mechanism. As patients traverse
ing standardised prevention protocols involving healthcare their hospital journey, these systems adeptly detect shifts in
professionals across the spectrum, from doctors to auxiliary their clinical trajectory, facilitating timely adjustments in the
staff, is essential to mitigate this concern (Mervis and Phillips level of care, including potential transfer to the ICU. Moreover,
2019). Simultaneously, ocular health demands attention, with they serve as triggers for rapid response teams to promptly
corneal epithelial defects occurring in 20-42% of ICU patients. address critical situations, thereby substantially elevating patient
Impaired tear production and reduced blinking heighten the risk safety and overall outcomes (Scott et al. 2020). The integration
of eye injury. The adoption of standardised eye care protocols of specialised rapid response teams, accompanied by tailored
has demonstrated efficacy in reducing complication rates and protocols, emerges as a cornerstone for bolstering adherence to
safeguarding ocular health (Hearne et al. 2018). standardised procedures. This concerted effort yields a marked
I: Interdisciplinary Care enhancement in clinical outcomes across a spectrum of medical
domains. Illustrative examples encompass sepsis, myocardial
Specialised care administered by interdisciplinary teams compris- infarction, obstetric emergencies, paediatric crises, respiratory
ing doctors, nurses, pharmacists, physical therapists, and complications, and both ischaemic and haemorrhagic strokes
nutritionists yields improved patient outcomes. Contrasting (Girotra et al. 2022). Through such deliberate implementation,
the multidisciplinary approach, where specialists operate within hospitals cultivate an environment characterised by efficient and
their defined domains, the interdisciplinary model orchestrates coherent responses, culminating in a pronounced enhancement
comprehensive patient assessment and synthesis of information of patient well-being.
to devise a unified and cohesive care strategy (Choi et al. 2006).
Central to this approach is the collaboration of diverse specialists B: Bowel Care
who collectively scrutinise patient cases. This cohesive teamwork Comprehensive bowel care necessitates evaluating the suitabil-
enables the creation of a comprehensive care plan, encompassing ity of oral or enteral routes for medication and diet tailored to
inputs from all relevant disciplines (Giusti et al. 2017). The value individual needs and circumstances. Rigorous monitoring of
of early engagement with suitable specialists cannot be overstated. bowel movements and assessment of stool characteristics are
Prompt consultations expedite interventions when required. For paramount, accompanied by proactive management of constipa-
instance, infectious disease consultations have demonstrated tion or diarrhoea. Should concerns arise regarding intrabdominal
is commonly used to manage hospital hyperglycaemia, eugly- their capacity to reduce mortality rates in both critically ill and pressure, its measurement assumes significance while mitigating
caemic agents such as metformin and GLP-1 receptor agonists non-critically ill patients within the intensive care unit (Jimé- the potential risks associated with bacterial translocation (Bowel
can also prove valuable. nez et al. 2019). Similarly, oncology team involvement coupled Care in Critical Care 2020).
with general surgery consultations has proven instrumental in
S: Skin/Eye Care enhancing long-term outcomes for patients newly diagnosed E: Environment
Dermatological complications often emerge during hospitalisa- with cancer (Hujits et al. 2021; Butt et al. 2015). By embracing Crafting a conducive environment holds pivotal importance in
tion, contributing to significant morbidity even if not typically an interdisciplinary approach, healthcare teams synergise their ensuring patient comfort. Sustaining an appropriately warm room
life-threatening. Manifestations like pressure sores, intertrigo, expertise to provide holistic, timely, and tailored care, thereby temperature fosters well-being. Meticulous modulation of light
and symmetrical peripheral gangrene underscore the importance augmenting patient well-being and treatment efficacy. and noise, aligned with circadian rhythms, alongside regulated

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210 PATIENTS AND FAMILIES

exposure to natural sunlight, establishes essential day-night patient outcomes and reduces complications (Benjamin et al. Conducting medication reconciliation yields multifaceted benefits,
routines. Frequent reorientation, active family engagement, and 2017; Nollen et al. 2023). not only curbing secondary hospital-related morbidity but also
accessible critical care spaces coalesce to avert delirium, resulting curtailing the length of stay and associated costs. Continuation
in heightened patient perception of quality and enhanced clinical P: Psychosocial Support of chronic drug regimens serves to prevent decompensation in
outcomes (Saran et al. 2020; Horsten et al. 2018). Providing comprehensive psychosocial support, encompassing patients with chronic illnesses, further underlining its significance
patients, families, and staff, is a fundamental aspect that extends (Bosma et al. 2018). Medication reconciliation is pivotal in avert-
D: De-escalate/Escalate/Discontinue Care (Chronic and Acute to the implementation of a standardised suicide protocol. The ing drug interactions and potential adverse effects, translating
Treatments) hospital environment frequently witnesses challenges of anxiety into a reduction in secondary hospital-associated complications,
The timely initiation of antibiotics, especially in cases of sepsis, and depression among patients, particularly those facing prolonged thereby curbing the length of stay and expenses. Ensuring the
is paramount. Innovative microbiological molecular diagnos- stays, issues such as stomas, limb amputations, disabilities, and continuation of chronic medications is instrumental in prevent-
tics implemented within the initial hours can inform judicious chronic or catastrophic diseases. Swift intervention from mental ing the exacerbation of chronic illnesses (Nieto et al. 2015). In
antibiotic use, given their ability to provide insights into resis- health specialists proves pivotal, enhancing patient outcomes and specific circumstances, the ongoing use of chronic treatments
tance genes. Swift and aggressive control of the infection source well-being. For critically ill patients, vigilant depression screening may be deemed appropriate, while in other cases, adjustment
significantly enhances patient outcomes. Subsequent adjustment is essential, considering its significant prevalence (Fernando et al. might be necessary even if the treatment isn’t directly linked to
or discontinuation, guided by culture antibiograms and protein 2022). The establishment of a suicide protocol represents a crucial the primary cause of hospitalisation. For example, anticoagulation
C and procalcitonin levels, facilitates the reduction of antibiotic step towards rendering holistic care for individuals with suicidal drugs, antibiotics, immunosuppressants, antihypertensives, and
usage, consequently diminishing the risk of resistant infections tendencies. This protocol should extend its reach to encompass thyroid medication could necessitate adaptation when a patient
and overexposure. This approach leads to a reduction in ICU and the mental well-being of the patient’s family. Regrettably, such is dealing with severe illness or undergoing major surgeries.
hospital stays (Honda et al. 2010; Butt et al. 2015). For vasopres- events can also impact hospital staff, making their mental health Similarly, diabetes medication generally remains suitable for most
sors, mechanical ventilation, sedation, and all therapeutic agents, equally relevant. The comprehensive approach underscores the patients, although it may require modification to ensure optimal
a careful evaluation is imperative to determine the continuation, interconnectedness of well-being within the hospital environment, management during the hospital stay. This tailored approach to
adjustment, or discontinuation of IV lines based on the patient’s embracing patients, families, and staff alike (Liao et al. 2020). medication management ensures that patient health and safety
clinical status and prognosis. Peripheral lines can often suffice are upheld in diverse clinical scenarios. Detecting medications
for patients who require IV treatment, while peripheral-inserted L: Limiting Care that are contraindicated for a patient is feasible, particularly in
central catheters (PICCs) are suitable for prolonged therapies. In some instances, patients may reach a stage where the benefits the geriatric population. Beer’s criteria, STOPP/V2, or EU(7)
Central venous access, which is reserved for specific cases, serves of ICU or hospital care are limited. Acknowledging this juncture protocols can be referenced to identify inappropriate medications
as an option for drugs that can damage vessels or involve high is crucial, enabling open discussions among the medical team (Wilson et al. 2019). This conscientious approach to medication
osmolarity solutions. The use of ultrasound guidance should be and family to navigate end-of-life considerations. At this stage, management enhances patient safety and well-being.
emphasised for both central and peripheral venous access. It’s palliative measures such as benzodiazepines and opioids can
critical to limit unnecessary central access, as even peripheral be employed to provide comfort and ease symptoms associated A: Admission/Discharge/Transfer
lines benefit from ultrasound-guided insertion. Implementing with the advanced disease stage. This compassionate approach The emergency department often presents an environment condu-
catheter clinics specialising in complications prevention not only encompasses the physical and emotional well-being of the patient, cive to delirium, characterised by noise, constant illumination,
enhances outcomes but also curtails morbidity, underscoring the ensuring a dignified and supportive transition (Nieto et al. 2015). high activity levels, and occasional chaos. Timely admission is
importance of prompt line removal (Lakbar et al. 2020). Inva- crucial as delaying it can heighten the risk of delirium, espe-
sive devices, including extracorporeal support, Foley catheters, E: Evaluate Drug Interactions and Avoid Potentially Inap- cially in predisposed patients. Similarly, delaying discharge can
and nasogastric tubes, should be promptly removed once their propriate Medications lead to anxiety and discomfort due to the same environmental
necessity diminishes. This approach aligns with the principle of Vigilantly assessing drug interactions and steering clear of poten- factors while also potentially congesting patient flow within the
minimising unnecessary interventions, a practice that improves tially inappropriate medications is a critical aspect of patient care. emergency department. Transferring patients to specialised units

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 PATIENTS AND FAMILIES 211

promptly has been shown to enhance outcomes, particularly contributing to reduced ICU and hospital stays. Furthermore, it contribute to patient well-being. By adhering to this principle,
evident in cases of acute myocardial infarction, stroke, cerebral aids in facilitating successful weaning and enhancing discharge positive outcomes are paralleled in their impact to that of timely
haemorrhage, or severe trauma (Rosa et al. 2020; Yang et al. outcomes (Menges et al. 2021). Implementation of standardised interventions. Refraining from initiating unnecessary treat-
2016; Escamilla et al. 2022). protocols for fall prevention is pivotal. This encompasses compre- ments bears the potential to avert complications, shorten ICU
hensive patient and family education, provision of anti-slip shoes, or hospital stays, and enhance patient recovery. It is essential
S: Shock (Suspect, Workup, and Treatment) execution of transfer protocols involving specialised technicians, to recognise that this mnemonic functions not as a prescrip-
Early detection of severe conditions is pivotal to ensure optimal and even the incorporation of bed sensors for high-risk patients. tive “to-do” list but as a gentle reminder to consider the unique
care delivery. Adhering to current treatment recommendations Such a multifaceted approach effectively minimises the risk of needs and circumstances of each patient. The aim is to foster a
not only improves outcomes but also curtails hospitalisation days falls, spanning from the emergency department to the discharge comprehensive and personalised approach to care that optimises
and resource utilisation. The various types of shock—septic, phase (Benjamin et al. 2017). patient outcomes and well-being.
hypovolaemic (haemorrhagic and non-haemorrhagic), obstruc-
tive, cardiogenic, and distributive (metabolic, toxic, medullary,
Conclusion Acknowledgements
neurogenic, anaphylactic)—all necessitate specific workups and
tailored treatments. However, accurate suspicion and confirmation The critical care unit demands a patient-centred approach that We would like to extend our heartfelt gratitude to Prof Jean-
of shock are imperative to initiate these targeted interventions. extends beyond addressing the disease itself, encompassing Louis Vincent for his daily inspiration in the management of
(Narayan et al. 2022). the holistic well-being of the individual. Embracing the key critical patients. His contributions have greatly enriched our
principles highlighted in this mnemonic aids in streamlining understanding and approach to medical care. We would also
E: Early Mobilisation and Falls Prevention care, minimising unnecessary interventions, and maximising like to thank Heber Alejandro Pérez-Arreguin for his valuable
Commencing early rehabilitation from day one proves instrumental beneficial outcomes. Keeping these essential pearls in mind ideas and insights.
in bolstering muscle strength and facilitating early mobilisation. during medical rounds serves to curtail oversights and avoid
This practice not only diminishes the risk of delirium but also undue interventions. In today’s medical practice, the adage “less
Conflict of Interest
mitigates the likelihood of deep vein thrombosis (DVT), thereby is more” rings true, underlining the significance of discontinuing
treatments and removing invasive devices once they no longer None.

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ICU Management & Practice 5 - 2023