Module 40 · Skills & practice

Handover, transport and ICU safety

NewPhase 3

The non-technical skills that keep ICU patients safe: structured handover and escalation (I-PASS, ISBAR), a systematic daily round, safe intra- and inter-hospital transfer, oxygen cylinder planning, incident reporting and safety culture, and mass casualty triage — adapted for Indian ICUs.

6 topics

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Noradrenaline (norepinephrine)

Alpha-1 > beta-1 agonist vasopressor

Indications
Maintaining MAP during transfer of a shocked patient
Adult dose
0.05–0.5 mcg/kg/min IV infusion titrated to MAP ≥65 mmHg (or individual target).
Preparation (India)
2 mg/2 mL ampoules (check base vs bitartrate labelling); 4 mg in 50 mL = 80 mcg/mL; 8 mg in 50 mL = 160 mcg/mL. For transfer, carry a second pre-filled syringe.
Cautions
Interruption during syringe change or line kinks causes abrupt hypotension — 'double-pump' or change syringes before departure.
Monitoring
Continuous arterial BP during transfer when on vasopressors.

Propofol

Short-acting IV sedative-hypnotic

Indications
Sedation of ventilated patients during transfer
Adult dose
Infusion 0.5–4 mg/kg/h (1% = 10 mg/mL); boluses 10–20 mg for procedures.
Preparation (India)
1% (10 mg/mL) 20 mL ampoules and 50 mL vials; use undiluted in a 50 mL syringe.
Cautions
Hypotension (especially in hypovolaemia), propofol infusion syndrome at high doses for prolonged periods; lipid load.
Monitoring
BP, sedation score (RASS), triglycerides with prolonged use.

Fentanyl

Synthetic opioid analgesic

Indications
Analgesia/sedation during transfer and for injured patients
Adult dose
Boluses 25–100 mcg IV; infusion 25–200 mcg/h (about 0.5–2 mcg/kg/h).
Preparation (India)
50 mcg/mL ampoules (2 mL, 10 mL); common infusion 500 mcg in 50 mL (10 mcg/mL) or undiluted 50 mcg/mL.
Cautions
Respiratory depression in non-ventilated patients, chest-wall rigidity with rapid large boluses, accumulation in hepatic failure.
Monitoring
RR, SpO₂, ETCO₂, pain and sedation scores.

Midazolam

Benzodiazepine

Indications
Seizure control; short-term sedation when propofol unsuitable
Adult dose
Seizures: 10 mg IM or 5–10 mg IV (0.1–0.2 mg/kg). Sedation boluses 1–2 mg IV; infusion 1–5 mg/h (avoid prolonged infusion where possible).
Preparation (India)
1 mg/mL and 5 mg/mL ampoules — check concentration (10-fold error risk).
Renal / hepatic
Active metabolite accumulates in renal failure; prolonged effect in hepatic failure and elderly.
Cautions
Delirium, respiratory depression, hypotension.
Monitoring
RASS, RR, SpO₂.

Tranexamic acid

Antifibrinolytic

Indications
Trauma patients with significant haemorrhage within 3 h of injury (including mass casualty incidents)
Adult dose
1 g IV over 10 min, then 1 g over 8 h; give within 3 h of injury (CRASH-2).
Preparation (India)
500 mg/5 mL ampoules widely available and inexpensive.
Renal / hepatic
Reduce dose in renal impairment.
Cautions
No benefit (possible harm) if started >3 h after injury; seizures at high doses.
Monitoring
Bleeding, neurological status.

Module references (18)

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    CRASH-2 trial collaborators; Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2). Lancet. 2010;376(9734):23-32.