1. Weaning and De-escalation of Resuscitation Therapies

Once hemorrhage control is achieved and markers of perfusion normalize, the critical phase of de-escalation begins. The goal is to taper fluids and vasopressors using dynamic indices to avoid both the harm of persistent fluid overload and the risk of recurrent hypoperfusion from premature withdrawal of support.

1.1 Dynamic Fluid Responsiveness Markers for Weaning Decisions

Static markers like CVP are poor predictors of fluid responsiveness. Dynamic assessments are essential for guiding fluid de-escalation.

• PPV <13% or SVV <12% in a patient on controlled mechanical ventilation suggests it is safe to cease fluid administration.
• A PLR-induced stroke volume increase >10% predicts fluid responsiveness regardless of ventilation mode or cardiac rhythm.
• Always combine these indices with clinical assessment, including adequate urine output (≥0.5 mL/kg/h), improving mental status, and warming extremities.

1.2 Protocolized Fluid and Vasopressor Titration

A structured approach to weaning prevents abrupt hemodynamic changes.

• Crystalloids: Once markers of perfusion are stable (e.g., Cardiac Index >2.2 L/min/m², lactate <2 mmol/L), reduce continuous crystalloid infusions by 25–50% every 4 hours.
• Vasopressors: Taper norepinephrine by 0.01–0.02 µg/kg/min every 15–30 minutes, targeting a mean arterial pressure (MAP) of 65–70 mm Hg.
• Diuresis: For patients with persistent significant positive fluid balance (>2 L/day) after shock resolution, consider adding furosemide 0.1–0.2 mg/kg IV to facilitate active de-resuscitation.

2. Transition from Intravenous to Enteral Fluid and Medication Delivery

Early initiation of enteral nutrition is a key intervention that maintains gut mucosal integrity, prevents bacterial translocation, and supports the transition away from IV therapies. This should be prioritized as soon as the patient is hemodynamically stable enough to tolerate it.

2.1 Criteria for Initiating Enteral Access

• Hemodynamics: Stable MAP ≥65 mm Hg with a low and stable/decreasing dose of vasopressors (e.g., norepinephrine ≤0.05 µg/kg/min).
• GI Function: Evidence of bowel function (flatus, bowel sounds) and absence of contraindications like obstruction, uncontrolled GI bleeding, or a high-output fistula.
• Device Selection:
  • Nasogastric tube: Standard for short-term (<4 weeks) support.
  • Percutaneous endoscopic gastrostomy (PEG): For anticipated need >4 weeks.
  • Post-pyloric (jejunal) tube: For persistent gastric residuals >250 mL or recurrent aspiration.

2.2 Timing, Formulations, and Rate Adjustments

• Initiation and Titration: Start at 10–20 mL/hr and advance by 10–20 mL/hr every 8–12 hours as tolerated, moving toward the goal rate.
• Formulation: Choose standard isotonic formulas (1.0–1.2 kcal/mL) with adequate protein (1.2–2.0 g/kg/day). Adjust for specific organ dysfunction (e.g., renal, hepatic) as needed.
• Monitoring: Assess gastric residual volumes (GRVs) every 6 hours. If GRV >300 mL, hold feeds, consider a prokinetic agent like metoclopramide 10 mg IV, and resume at the previous tolerated rate once GRV decreases.
• Aspiration Prevention: Maintain head-of-bed elevation at 30–45 degrees at all times.

3. Mitigation of Post-ICU Syndrome (PICS)

Post-ICU Syndrome (PICS) is a constellation of new or worsened impairments in physical, cognitive, and mental health that arise after critical illness. Proactive, bundled interventions are essential to minimize its long-term impact on survivors.

3.1 ABCDEF Bundle Components

The ABCDEF bundle is a proven, evidence-based framework for improving ICU outcomes and reducing the incidence of PICS.

4. Medication Reconciliation and Discharge Planning

The transition from the ICU to the ward and eventually to home is a high-risk period for medication errors. A structured reconciliation, education, and handoff process is vital to ensure patient safety and continuity of care.

4.1 Comprehensive Review of Acute and Chronic Therapies

This process involves a meticulous comparison of medication lists.

• Compile a definitive pre-admission medication list from multiple sources (patient, pharmacy, prior records).
• Compare this list against the patient’s current ICU medication orders.
• Pay special attention to high-risk agents: anticoagulants, insulin, sedatives, antibiotics, and immunosuppressants.
• Clearly document the rationale for every decision: continuation, dose adjustment, or discontinuation.

4.2 Patient/Caregiver Education and Handoff Communication

Effective communication is the cornerstone of a safe transition.

• Use the teach-back method to confirm patient and caregiver understanding of each medication’s purpose, dose, frequency, and major side effects.
• Provide a clear, written discharge medication plan that explicitly highlights all changes made during the hospital stay.

4.3 Coordination of Follow-Up and Rehabilitation Services

• Arrange for outpatient physician follow-up within 7–14 days of discharge.
• Make referrals to physical, occupational, and speech therapy based on functional deficits identified during the ICU stay.
• For patients with significant cognitive or psychological symptoms, consider a referral to a specialized ICU survivor clinic for comprehensive PICS management.
• Patients with prolonged mechanical ventilation may benefit from a referral to pulmonary rehabilitation to aid in respiratory muscle recovery.