Module 36 · ICU care & pharmacology

ICU care bundles and infection prevention

NewPhase 2

ICU care bundles and infection prevention: the daily FAST HUGS BID checklist, VAP, CLABSI and CAUTI prevention bundles, VTE and stress ulcer prophylaxis, hand hygiene and isolation precautions, and pressure injury prevention with early mobilisation.

6 topics

Drugs in this module

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

Enoxaparin

Low-molecular-weight heparin

Indications
VTE prophylaxis in critically ill adults
Adult dose
Prophylaxis: 40 mg SC once daily. CrCl < 30 mL/min: 30 mg SC once daily (or use UFH). BMI ≥ 40: 40 mg SC every 12 h is commonly used.
Preparation (India)
Prefilled syringes 20, 40, 60 mg (multiple Indian brands).
Renal / hepatic
Accumulates in renal failure - reduce dose or switch to UFH; consider anti-Xa level (prophylactic target 0.2-0.5 units/mL).
Cautions
Hold 12 h before neuraxial procedures/LP and before most surgery; avoid in active bleeding, platelets < 30-50 × 10⁹/L, HIT.
Monitoring
Platelets (HIT), haemoglobin, renal function.

Unfractionated heparin (subcutaneous)

Anticoagulant

Indications
VTE prophylaxis, especially in severe renal impairment or when rapid reversal may be needed
Adult dose
5,000 units SC every 8-12 h (every 8 h in higher-risk or obese patients).
Preparation (India)
5,000 units/mL and 25,000 units/5 mL vials.
Cautions
HIT (higher risk than LMWH); bleeding.
Monitoring
Platelet count every 2-3 days from day 4 to day 14 of exposure.

Pantoprazole

Proton pump inhibitor

Indications
Stress ulcer prophylaxis in high-risk ICU patients
Adult dose
40 mg IV (or enteral) once daily; stop when risk factors resolve.
Preparation (India)
40 mg vial for IV; 40 mg tablets (cannot be crushed - use IV or a suitable liquid alternative via tube).
Cautions
Possible association with C. difficile infection and pneumonia; avoid continuing at ICU or hospital discharge without an indication.

Famotidine

H2-receptor antagonist

Indications
Stress ulcer prophylaxis (alternative to PPI)
Adult dose
20 mg IV/enteral every 12 h.
Renal / hepatic
CrCl < 50 mL/min: 20 mg once daily.
Cautions
Delirium/confusion in elderly and renal impairment; thrombocytopenia (rare).

Module references (18)

  1. 1

    Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. Intensive Care Med. 2026;52(5):863-936. Co-published in Crit Care Med. 2026 (doi:10.1097/CCM.0000000000007075)

  2. 2

    Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023;27:80.

  3. 3

    Devlin JW, Skrobik Y, Gelinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med 2018;46:e825-73.

  4. 4

    Farkas J. The Internet Book of Critical Care (IBCC). EMCrit Project; continuously updated.

  5. 5

    Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med 2005;33:1225-9.

  6. 6

    Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2022;43:687-713.

  7. 7

    Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2022;43:553-69.

  8. 8

    Patel PK, Advani SD, Kofman AD, et al. Strategies to prevent catheter-associated urinary tract infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2023;44:1209-31.

  9. 9

    Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018;2:3198-225.

  10. 10

    Arabi YM, Al-Hameed F, Burns KEA, et al. Adjunctive intermittent pneumatic compression for venous thromboprophylaxis (PREVENT). N Engl J Med 2019;380:1305-15.

  11. 11

    Cook D, Deane A, Lauzier F, et al. Stress ulcer prophylaxis during invasive mechanical ventilation (REVISE). N Engl J Med 2024;391:9-20.

  12. 12

    Krag M, Marker S, Perner A, et al. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU (SUP-ICU). N Engl J Med 2018;379:2199-208.

  13. 13

    Ye Z, Reintam Blaser A, Lytvyn L, et al. (Scandinavian/European) Clinical practice guideline on gastrointestinal bleeding prophylaxis for critically ill patients. Acta Anaesthesiol Scand 2021;65:681-94.

  14. 14

    World Health Organization. WHO guidelines on hand hygiene in health care. Geneva: WHO; 2009.

  15. 15

    Siegel JD, Rhinehart E, Jackson M, Chiarello L; HICPAC. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(10 Suppl 2):S65-164.

  16. 16

    National Centre for Disease Control, DGHS, MoHFW. National guidelines for infection prevention and control in healthcare facilities. New Delhi: Government of India; January 2020.

  17. 17

    European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The international guideline, 3rd ed. 2019.

  18. 18

    TEAM Study Investigators and the ANZICS Clinical Trials Group. Early active mobilization during mechanical ventilation in the ICU. N Engl J Med 2022;387:1747-58.