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to treat drug overdosePast, present and fu-
ture.Anaesthesia 2009; 64:119121
3. Sirianni AJ, Osterhoudt KC, Calello DP, et al:
Use of lipid emulsion in the resuscitation of a
patient with prolonged cardiovascular collapse
after overdose of bupropion and lamotrigine.
Ann Emerg Med2008; 51:412415
4. Finn SD, Uncles DR, Willers J, et al: Early
treatment of a quetiapine and sertraline over-
dose with intralipid. Anaesthesia 2009; 64:
191194
5. Doulcourt BA, Aaron CK: Intravenous fatemulsion for
refractory veralpamil and ateno-
lol induced shock: A human case report [ab-
stract].Clin Toxicol2008; 46:119120
6. Harchelroad FP, Palma A: Efficacy and safety
of intravenous lipid therapy in a beta blocker
overdose [abstract].Clin Toxicol2008; 46:634
DOI: 10.1097/CCM.0b013e3181aabcd7
The author replies:
I agree with the remarks of Cave andHarvey (1) regarding my
recent editorialarticle (2). Their letter provides an oppor-tunity
to reflect on the question of howbest to proceed in the evaluation
of theapparently promising use of lipid emul-sion therapy (LET) in
the treatment ofpoisoned patents.
My use of the adjective apparently isno mere quip. Rather, it
describes thecurrent state of scientific wisdom con-cerning the
efficacy of LET. Cave andHarvey articulate the fundamental
truththat the pleural of anecdote is not data.However, as alluded
to in my editorial, the
justification of LET is not purely anecdotal.There is a
substantial body of animal data
propelling the widespread interest in thehuman use of this
treatment. However, wecan never know if a therapy is efficacious
inhumans unless it is studied in humans inreal clinical
scenarios.
Although I agree with Cave and Har-vey that the next logical
step in the eval-uation of LET is to establish a formalregistry, it
is ironic to note that registrydata are still anecdotal and, thus,
willnever definitively answer the question ofthe true clinical
utility of LET. It is likelythat this question would only be
unam-
biguously resolved with a randomizedclinical trial. However, the
relative rarityof relevant poisonings and the need foron-the-spot
immediate entry into a ran-domized clinical trial dramatically
erodethe likelihood that such a trial will be per-formed. Thus, we
are left with the registryconcept as the next best solution.
For a registry of cases of LET use to betruly informative, it is
imperative that itfulfills certain fundamental criteria: 1)
itshould be prospective, 2) it must capture
all cases in participating centers regard-less of the outcome,
and 3) cases shouldbe cared for at the bedside by
specialistsfamiliar with the use of LET and cogni-zant of the
necessary data that should becollected for the registry.
Coincidently, Toxicology InvestigatorsConsortium of the American
College ofMedical Toxicology is presently develop-ing a registry of
the use of LET meeting
the stringent criteria outlined earlier.Toxicology Investigators
Consortium is anetwork of medical toxicology practicesproviding
bedside inpatient care for10,00020,000 cases in the United
Statesannually. A retrospective series of casescared for by the
Toxicology InvestigatorsConsortium network has already been
as-sembled. The prospective phase is due tobegin shortly.
The author has not disclosed any po-tential conflicts of
interest.
Jeffrey Brent, MD, PhD, Toxicology As-sociates, University of
Colorado, HealthSciences Center, Denver, CO
REFERENCES
1. Cave G, Harvey M: Lipid emulsion as antidotal
therapyReady to register? Crit Care Med
2009; 37:23252326
2. Brent J: Poisoned patients are different
Sometimes fat is a good thing. Crit Care Med
2009; 37:11571158
DOI: 10.1097/CCM.0b013e3181a9edf9
Critically ill patients need FAST
HUGS BID (an updated mnemonic)
To the Editor:
We have recently reviewed the excel-lent article by Vincent (1)
describing adaily FAST HUG checklist, initially de-
veloped to highlight the key aspects ofcare for all critically
ill patients, to beused by the multidisciplinary care team.
We pro pose an updated mne mon ic,
FAST HUGS BID, which includes dailyassessment for ventilator
separation witha spontaneous breathing trial (S), evalu-ation and
maintenance of appropriatebowel function (B), removal of
indwellingcatheters (I), and de-escalation (D) of an-timicrobial
and other pharmacotherapies(Table 1). Although we suggest the use
ofthis checklist at least twice daily (i.e.,BID), systematic
approaches to patientcare should, ideally, be used
repeatedlythroughout work shifts.
The daily assessment of a spontaneousbreathing trial has been
shown to be asafe, effective, and highly predictivemethod for
determining which patients
will tolerate ventilator separation (2, 3).Prolonged mechanical
ventilation hasbeen associated with increased rates of
ventilator-associated pneumonia and in-hospital and total
mortality. A spontane-ous breathing trial should, therefore,
beconsidered at least daily and performed ina highly protocolized
fashion by a well-trained team of nurses and
respiratorytherapists.
Disorders of gastrointestinal motility,including ileus,
constipation, and diar-rhea, are common in critically ill
patientsand may contribute to additional diseaseburden. Diarrhea
may result in electrolyteimbalances, dehydration, hemorrhoidal
ir-
ritation with resultant anemia, and deli-rium. Constipation, in
contrast, may resultin significant patient discomfort,
feedingintolerance, and delirium. Institutionalguidelines and use
of standardized defini-tions of constipation and diarrhea
mayfacilitate bowel dysfunction management(4). Routine assessment
and treatment tomaintain normal bowel function shouldbe conducted
in all critically ill patients.
Indwelling catheters, including uri-nary, arterial, central
venous, pulmonaryartery, and dialysis catheters, are com-
monly used in critically ill patients. Be-cause they penetrate
through the bodysnatural protective mechanisms, they areat high
risk for local and systemic infec-tions. Early discontinuation and
removal,
when thes e catheters are no longerneeded, remains an important
strategy tocombat catheter-associated infections.Daily (or more
frequent) assessmentshould be performed of the ongoing needfor
these catheters, and their removal,
when not medically necessary.
Table 1. Components of FAST HUGS BID
F FeedingA AnalgesiaS SedationT Thromboembolic
prophylaxis
H Head of bed elevationU Ulcer (stress) prophylaxisG Glycemic
controlS Spontaneous breathing
trial
B Bowel regimenI Indwelling catheter
removalD De-escalation of antibiotics
2326 Crit Care Med 2009 Vol. 37, No. 7
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Following the collection of appropriatespecimens for microbial
culture, promptempirical antimicrobial therapy is crucialfor the
treatment of serious, nosocomialinfections. Once a pathogen has
been iden-tified and antimicrobial susceptibilitieshave been
reported, the regimen should beconverted to the most
narrow-spectrum,cost-effective, and pathogen-specific anti-biotic.
This practice, known as antibiotic
de-escalationor streamlining, minimizesexposure to
broad-spectrum antimicro-bial therapy (5). The same principle
ofde-escalation can be applied to otherpharmacologic treatments,
which shouldbe regularly re-evaluated for appropriateindications to
minimize risk of adverseeffects and medication errors.
Multidisciplinary protocols and check-lists are an essential and
evolving compo-nent of excellent evidence-based criticalcare. We
suggest giving patients FASTHUGS BID, as a modification to a
widelyused mnemonic, which can be used on aroutine basis during
multidisciplinaryrounds to improve the care provided toall
critically ill patients.
The authors have not disclosed anypotential conflicts of
interest.
William R. Vincent III, PharmD, Arnold& Marie Schwartz
College of Pharmacyand Health Sciences, Division of Phar-
macy Practice, Long Island University,Brooklyn, NY; Kevin W.
Hatton, MD,Department of Anesthesiology, Divisionof Critical Care,
University of KentuckyCollege of Medicine, Lexington, KY
REFERENCES
1. Vincent JL: Give your patient a FAST HUG (at
least) once a day. Crit Care Med 2005; 33:
12251229
2. Girard TD, Ely EW: Protocol-driven ventilatorweaning:
Reviewing the evidence.Clin Chest
Med2008; 29:241252
3. Robertson TE, Mann HJ, Hyzy R, et al: Multi-
center implementation of a consensus-
developed, evidence-based, spontaneous
breathing trial protocol. Crit Care Med2008;
36:27532762
4. Dorman BP, Hill C, McGrath M, et al: Bowel
management in the intensive care unit.Inten-
sive Crit Care Nurs2004; 20:320329
5. Ibrahim EH, Ward S, Sherman G, et al: Expe-
rience with a clinical guideline for the treat-
ment of ventilator-associated pneumonia.Crit
Care Med2001; 29:1109 1115
DOI: 10.1097/CCM.0b013e3181aabc29
The author replies:
I appreciate the interest expressed byVincent et al (1) in my
article (2). I, too,can think of other elements that could beadded
to the original mnemonic. For ex-ample, we should also pay
attention toElectrolytes, Airway, Catheters, Hematol-
ogy, Hemodynamics, Oral care, Urine anal-ysis, and Relatives;
this would give us FASTHUG EACH HOUR, even better than thetwice
daily suggested by Vincent et al!
In fact, we could continue expandingthe mnemonic almost
indefinitely, creat-ing long phrases, even poems (!), but this
would defeat the original concept under-lying the FAST HUG,
which was to pro-
vide a short and simple mental checklist
that can be easily remembered by all staffmembers, but that
includes most impor-tant aspects of patient management to bechecked
whenever attending an intensivecare unit patient. A longer mnemonic
isless likely to be remembered and henceless likely to be
applied.
The author has not disclosed any po-tential conflicts of
interest.
Jean-Louis Vincent, MD, PhD, FCCM,Department of Intensive Care,
ErasmeHospital, Universite libre de Bruxelles,Brussels, Belgium
REFERENCES
1. Vincent W, Hatton KW: Critically ill patients
need FAST HUGS BID (an updated mne-
monic).Crit Care Med2009; 37:23262327
2. Vincent JL: Give your patient a fast hug (at
least) once a day. Crit Care Med 2005;
33:12251229
DOI: 10.1097/CCM.0b013e3181a9eefb
2327Crit Care Med 2009 Vol. 37, No. 7
