ERH HDU Clinical Management Guidelines Oct 17 PDF

Echuca Regional Health
High Dependency Unit

Clinical Management Guidelines
Purpose
To complement the High Dependency Unit - Management Manual and guide the
clinical management of High Dependency Unit patients.
Table of Contents
Referral Centres .............................................................................................. 3
CARDIAC ......................................................................................................... 4
1. Acute Coronary Syndrome ......................................................................... 4
2. Acute Pulmonary Oedema requiring Non-invasive ventilation or CVC

monitoring or low level inotrope support (*Not requiring invasive
ventilation or percutaneous intervention) ................................................. 5
3. Arrhythmia at risk of cardiac arrest or arrhythmia requiring

antiarrhythmic infusion ............................................................................. 6
4. Elective DCR for Atrial Fibrillation/Flutter ................................................. 7
5. Acute asthma requiring non-invasive ventilation or Type 2

respiratory failure requiring non-invasive ventilation ................................ 8
6. Acute pneumonia with high pneumonia severity index .............................. 9
RESPIRATORY ............................................................................................... 10
7. Obstructive Sleep Apnoea (OSA) with acute illness ................................. 10
8. Intercostal catheter (ICC) management .................................................. 11
9. Upper Airway Obstruction ........................................................................ 12
METABOLIC ................................................................................................... 13
10. Diabetic Ketoacidosis ............................................................................... 13
11. Hyperglycaemic hyperosmolar non-ketotic (GCS > 8) ............................. 14
12. Snake bite and poisoning (including overdose) with GCS >8 ................... 15
13. Sepsis with secondary organ failure, or high risk comorbidities .............. 16
14. Elective Iron Infusion .............................................................................. 17
15. Infusions ................................................................................................. 18

Prompt Doc No: ERH0000903v8.0 Approval Date: 03/01/2013 Review & Update by:31/10/2020
UNCONTROLLED WHEN DOWNLOADED OR PRINTED Page 1 of 36
RENAL ........................................................................................................... 19
16. Acute renal failure with hyperkalaemia at risk of a cardiac arrest ........... 19
17. Acute on chronic renal failure at risk of acute pulmonary oedema ........... 20
18. A patient with suicide risk ....................................................................... 21
19. Post ictal with antiepileptic infusion at high risk of seizure ..................... 22
20. Altered conscious state with GCS > 8 at risk of deterioration .................. 23
21. Acute Stroke– refer to separate ERH Stroke Management Policy on

PROMPT ................................................................................................... 24
22. Elective surgery in patients with significant comorbidities ...................... 25
23. Defined surgeries ..................................................................................... 26
24. Patients with Obstructive Sleep Apnoea (OSA) for post-operative

management ............................................................................................ 27
25. Unstable post-operative patient not requiring mechanical ventilation .... 28
26. Multi trauma – not for transfer ................................................................ 29
27. Massive haemorrhage .............................................................................. 30
28. Liver failure ............................................................................................. 31
29. Pre-eclampsia with MgSO4 infusion with immediate transfer pending. ... 33
30. Post partum pre-eclampsia ...................................................................... 34
OBSTETRIC .................................................................................................... 36
31. Significant post-partum haemorrhage at risk of coagulopathy ................ 36
List of Referral Resources:
General Physician
Consultant Physician
General Surgeons
Mr Dan Fletcher
Ms Janine Arnold
Mr Manny Cao
Mr LP Cheah
Central Victoria Cardiology
Dr Nim Nadarajah
Dr Anthony Jackson
Respiratory Physician
Dr Kate Carroll
Renal Physician
Dr Pat Cooney
Endocrinologist
Dr Esther Briganti
Obstetrician and Gynaecologist
Dr John Cullen
Opthalmologist
Dr Joseph San Laureano
Thoracic Surgeon
Mr Simon Barling
Toxicology
Austin Health
Psychiatry
Bendigo Health - Mental Health, Echuca
Referral Centres
 Bendigo Health
 Austin Health
 St Vincent’s Hospital
 Royal Melbourne Hospital
 Alfred Hospital
 Royal Children’s Hospital
CARDIAC
1. Acute Coronary Syndrome
 Positive history, ECG changes, Troponin positive (2 of 3)
 Not for acute percutaneous intervention
Investigations (admission):
 FBE/CUE/LFT/CK/Trop/RBSL/Coags
 CXR
 ECG
 ABG (if systemically unwell)
Monitoring:
 Vital signs
 Continuous cardiac monitoring (CCM)
Interventions to consider:
 Oxygen
 Antiplatelet agent
 Aspirin
 Clopidogrel
 Tirofiban
 Anticoagulation
 Therapeutic clexane
 Therapeutic heparin
 Rate control
 Betablocker (in absence of phx asthma)
 Centrally acting calcium channel blocker
 Pain relief
 GTN (consider infusion)
 Morphine
 Risk factor assessment
 Fasting BSL/lipids (inc HDL/LDL) (preferably on Day 1)
 Risk factor modification
 Betablocker
 Statin
 ACEi
 Warfarinisation for large anterior infarct
 Smoking cessation
Referrals:
 Central Victoria Cardiology
 Bendigo Health
 Tertiary Centres in Melbourne
Discharge Criteria:
 To ward when pain free for 24 hours
 Requires 48 hours telemetry and anticoagulation
CARDIAC
2. Acute Pulmonary Oedema requiring Non-invasive ventilation or CVC

monitoring or low level inotrope support (*Not requiring invasive
ventilation or percutaneous intervention)
 FBE/CUE/LFT/CK/Trop/RBSL/Coags
 CXR and ECG
 ABG
Monitoring:
 Vital signs
 Continuous cardiac monitoring
 Daily weight
 Strict fluid balance
 CVC
 Echocardiogram
 Oxygen
 Decrease afterload
 CPAP
 morphine
 GTN
 Decrease preload - diuretic
 Increase contractility - inotropes, antiarrythmics
 Antiplatelet agent - aspirin
 Anticoagulation - warfarinisation
 Risk factor assessment
 TTE,
 Fasting BSL/lipids (inc HDL/LDL)
 TSH
 Risk factor modification
 Betablocker (when LVF stable)
 Statin
 ACEi
 Warfarinisation
 Cardiac interventions
 implantable defibrillator
 cardiac transplant
Referrals:
 Bendigo Health
Discharge Criteria:
 ABG/CXR stable
 WOB stable
CARDIAC
3. Arrhythmia at risk of cardiac arrest or arrhythmia requiring

antiarrhythmic infusion
 FBE/CUE/LFT/CK/Trop/RBSL/Coags/CMP/TSH
 CXR
 ECG
 ABG
Monitoring:
 Vital signs
 Echocardiogram
 Oxygen
 Treat hypercapnoea
 DCR if patient haemodynamically unstable
 Establish the cause
 Review medications
 Treat IHD/CCF if required
 Stabilise myocardium if hyperkalaemia (calcium gluconate)
 Optimise electrolytes (esp K and Mg)
 Antiarrhythmic infusion as per protocol
 Vagal manoeuvres
Referrals:
 Bendigo Health
Discharge Criteria:
 Non-malignant rhythm
CARDIAC
4. Elective DCR for Atrial Fibrillation/Flutter
 FBE/CUE/LFT/RBSL/Coags/CMP/TSH to be reviewed
 DCR can be done if AF < 48/24 (without anticoagulation)
 Needs 4 weeks INR >2 if AF present for > 48/24 (and echocardiogram
reviewed)
 ECG
Monitoring:
 Vital signs
 Patient fasted for 6 hours
 Anaesthetist present for sedation with resuscitation equipment available
Referrals:
 Bendigo Health
 Tertiary centres in Melbourne
Discharge Criteria:
 As per VMO’s orders
RESPIRATORY
5. Acute asthma requiring non-invasive ventilation or Type 2

respiratory failure requiring non-invasive ventilation
Investigations (on admission):

 ABG
 FBE/CUE/LFT
 CXR
 ECG
 Consider atypical pneumonia serology
 Sputum culture
Monitoring:
 Vital signs, aim O2 sat > 92%
 Serial ABGs
 Oxygen
 BiPAP
 Beta agonist (salbutamol)
 anticholinergic (atrovent)
 Steroid therapy
 Aminophylline
 Establish the cause, treat infection
 If PaCo2 does not improve within 2 hours of therapy liaise with ICU
 MgSO4
 Lung transplant
Referrals:
 Dr Kate Carroll (Visiting Respiratory Physician)
 Consultant Physician
Discharge criteria:
 Improved work of breathing
 PaCO2 at baseline
RESPIRATORY
6. Acute pneumonia with high pneumonia severity index

(after discussion regarding suitability for ICU transfer)
Investigations (at admission):

 ABG
 FBE/CUE/LFT/Coags/CRP
 CXR
 ECG
 Consider atypical serology
 Sputum culture
Monitoring:
 Vital signs
 Serial ABGs
 Oxygen
 Antibiotics as per the therapeutic guidelines
 BiPAP
 Beta agonist (salbutamol), anticholenergic (atrovent)
 Steroid therapy
 Smoking cessation, vaccination
 Chest physiotherapy
 Pleural aspirate if effusion (diagnostic and therapeutic)
Referrals:
 Dr Kate Carroll (Visiting Respiratory Physician)
 Consultant Physician
Discharge criteria:
 Decreased work of breathing
 ABGs reassuring
RESPIRATORY
7. Obstructive Sleep Apnoea (OSA) with acute illness
The priority in this instance is to ensure adequate oxygenation while the

treatment of the acute illness takes place.
Both the acute illness or treatment for the acute illness may exacerbate OSA.
 Requires continuous oximetry monitoring and nurse alert via an alarm.
 Aim O2 sat > 94% with aid of the CPAP machine while patient is asleep.
Referral:
 Dr Kate Carroll (visiting respiratory physician)
Discharge criteria:
 Resolution of acute illness.
 To ward with own CPAP.
 If newly diagnosed OSA, demonstrate nil desaturations while asleep in
HDU without CPAP.
RESPIRATORY
8. Intercostal catheter (ICC) management

The patient must be admitted under a share bed card, between surgical and
medical bed cards.
The priority is to ensure adequate functioning of the chest tube, while

avoiding the serious complication of tension pneumothorax.
The surgeon is responsible for the chest tube placement and management, while
the medical team can review other management issues relevant to the patient’s
admission.
Referral:
Mr Barling (Bendigo Thoracic surgeon)
Discharge criteria:
Remove ICC 24 hours after the lung has expanded and air leak has stopped. If
the lung fails to re-expand within 48 hours, or if there is a persistent air leak,
seek specialist thoracic surgical advice (if suction is suggested thereafter – high
volume/low pressure systems are required).
RESPIRATORY
9. Upper Airway Obstruction
Patients may be admitted to HDU if they are at risk of upper airway obstruction
and require continual nursing observation, provided a mandatory discussion
about the management plan has taken place with the ED VMO and the
Anaesthetic VMO on call on that day, and that both VMOs agree with the plan. A
general surgeon, or suitably qualified VMO, must also be informed of the
admission given that, by definition, the patient may (although unlikely) require a
surgical airway if the condition deteriorates.
Additional advice may be sought from an ENT specialist about the suitability of
admission.
Cases may include:

 upper airway infection
 upper airway haemorrhage
 post-surgical (including thyroidectomy)
Exclusion Criteria (in addition to general HDU exclusion criteria)

 Inhalational burns - intubation is preferable if there is risk of obstruction.
 Clinician with skills to perform a surgical airway not on the roster
 Acute ENT surgery necessary.
Investigations to consider at admission
CT oropharynx (collection)
Interventions to consider
 Antibiotics
 IV Dexamethasone
 Clot extraction
 Nebulised adrenaline
The difficult intubation trolley (including the CMAC when purchased by the
hospital) and thyroidectomy tray must be easily accessible and in the unit when
the patient satisfies this admission criteria.
Discharge criteria
 Both ED VMO and Anaesthetic VMO consulted.

 Absence of signs of acute upper airway obstruction and low risk of
recurrence of upper airway pathology.
METABOLIC
10. Diabetic Ketoacidosis

 BSL/ketone
 FBE/CUE/amylase/LFT
 Blood culture
 CXR (consider)
 ECG and cardiac enzymes (consider)
Monitoring:
 Vital signs
Interventions:
 Rapid IV rehydration
 Hourly BSL/CUE/VBG
 Insulin infusion
 K+ replacement when K+ < 5mmol/L
 Consider IDC
 Treat infection
 DVT prophylaxis
 Consider the cause
 (Refer ERH DKA Protocol)
Referrals:
 Dr Esther Briganti (Endocrinologist)
Discharge Criteria:
 Rehydration complete and patient taking oral fluid
 Subcutaneous insulin regimen established
METABOLIC
11. Hyperglycaemic hyperosmolar non-ketotic (GCS > 8)

 BSL/ketones (nil ketones)
 Osmolality: 2(Na+) + urea + glucose (>340mosmol/kg)
 ABG
 FBE/CUE/LFT/Coags
 ECG and cardiac enzymes (inc CK)
Monitoring:
 Vital signs
 Hourly urinary output (IDC)
Interventions:
 Rehydration over 48 hours
 Heparinisation (fully anticoagulate)
 K+ replacement when UO established
 Delay use of insulin before establishing response to hydration (at least 1
hour)
 Establish the cause (eg. bowel ischaemia/AMI/drugs etc.)
Referrals:
 Dr Esther Briganti (Endocrinologist)
Discharge criteria:
 GCS 15 and stable BSL and CUE after 48 hours management
METABOLIC
12. Snake bite and poisoning (including overdose) with GCS >8
The management of a snake bite or poisoning (including overdose) is critical to

ensuring the patient does not have a rapid deterioration.
The management plan should be sought through the POISON’S HOTLINE in

combination with a toxicologist and clear aims for the patient’s progress
documented.
In the setting of suicide attempt, a psychiatrist must be recruited.
Referral:
 Poison’s Hotline
 Toxicologist (Austin Health)
 Psychiatrist (Echuca Mental Health)
Discharge criteria:
 On advice of toxicologist +/- psychiatrist (if suicide attempt)
METABOLIC
13. Sepsis with secondary organ failure, or high risk comorbidities
Please refer to guideline 6 (acute pneumonia with high pneumonia severity

index) and pay particular attention to the organ system that is affected and
recruit other guidelines as per the organ system affected.
Specific points to consider:

 Blood cultures are mandatory
 ERH HDU has the capability to run low level inotropic support, in which
case an arterial line and CVC is required.
 Sepsis of unknown source should be covered by antibiotics as per the
antibiotic guidelines, which includes staph cover (ie flucloxacillin or
vancomycin)
Referrals:
Infectious diseases registrar at tertiary centres

Austin Health: http://www.austin.org.au/page?ID=685
Vic Health: http://ideas.health.vic.gov.au/
NSW Health: http://www.health.nsw.gov.au/infectious/Pages/default.aspx
METABOLIC
14. Elective Iron Infusion
Please refer to ERH Policies – Iron Polymaltose Infusion on PROMPT

 Policy applies to inpatients as per ERH protocol.
 Elective outpatients can be referred to Medical Day Treatment Unit (as per
policy)
Referrals:
 ERH Policy.
METABOLIC
15. Infusions
Please refer to ERH Policy for specific drugs.

 Policy applies to inpatients as per ERH protocol.
RENAL
16. Acute renal failure with hyperkalaemia at risk of a cardiac arrest
Please refer to guideline 3 (Arrhythmia at risk of cardiac arrest or arrhythmia

requiring antiarrhythmic infusion)

 FBE/ESR/CUE/CMP/LFT/CK/LDH /Coags
 Protein electrophoresis
 Blood cultures
 MSU and acute phase microscopy
 Renal US
 Autoantibodies, hepatitis serology
 ECG and CXR
Monitoring:
Vitals
Continuous cardiac monitoring
IDC +/- CVC
Interventions:
 If there are ECG changes consistent with hyperkalaemia, the priority is to
stabilise the myocardium with calcium gluconate. Hyperkalaemia is
thereafter lowered with insulin/ dextrose and resonium +/- salbutamol.
 Treat underlying cause;
o Prerenal
 crystalloid +/- blood
o Renal
 treat sepsis
 treat hypertension (labetolol)
 review drugs
 consider vasculitis
o Post renal
 urology referral
 Correct acidosis with sodium bicarbonate
 Dialysis if;
o K+ persistently > 6
o acidosis (ph < 7.2)
o pulmonary oedema without substantial diuresis
o pericarditis
Referrals:
 Dr Patrick Cooney (Renal physician) – may need renal biopsy
 Dr Michael McClatchey or Dr Rohan Hall (Visiting urologists)
Discharge criteria:
 Adequate urine output
 Normovolaemic
 non-malignant ECG
 stable cardiac function
RENAL
17. Acute on chronic renal failure at risk of acute pulmonary oedema
Please refer to guideline 13 (Acute renal failure with hyperkalaemia at risk of a

cardiac arrest)
and guideline 2 (acute pulmonary oedema requiring NIV or CVC monitoring or
low-level inotrope support)
PSYCHIATRIC
18. A patient with suicide risk
 Any patient identified as a potential suicide risk must have an

assessment using the Mental Health Risk assessment tool prior to
admission. Mental Health triage must be contacted and Assessment
discussed. If patient is deemed Low risk for Suicidality, Aggression and
Risk to others, and an overall risk rating of LOW, they may be admitted
to the HDU.
 Patient is to be visualised when ever possible and “hard wiring” monitor
is to be used whilst in HDU to assist in patient supervision, as removing
monitoring leads would alert staff to patient moving away from the bed
area.
 Mental health patients are NOT permitted to leave the HDU
environment unescorted for any reason.
 Exclusions to admission to HDU for Mental health patients:

 Patient assessment order is in place or completed (patient would be
returned to the secure environment of the ED)
 Patient is assessed as Mod or High overall, or in the areas of
Suicidality, Aggression or Risk to others.
 Patient is non compliant
If at any stage the patient attempts to leave the HDU, the nurse must call
security and the patient is transferred to the Emergency Department.
If the patient requires physical or medical restraint, the nurse must call security
and the patient is transferred to the Emergency Department.
Referrals:
 Bendigo Mental Health
Discharge criteria:
 At the direction of the Mental Health team
NEUROLOGICAL
19. Post ictal with antiepileptic infusion at high risk of seizure

 BSL/FBE/CUE/LFT/CMP/Coags
 ABG
 Toxicology screen (incl. paracetamol levels and BAL)
 Anticonvulsant levels
 ECG and CXR
 CTB +/- cervical spine imaging
 BC +/- LP if meningitis suspected
Interventions:
 O2
 Thiamine IV (if PHx ETOH)
 Rehydration
 Benzodiazepines
 Phenytoin infusion
 Dexamethasone
 Antibiotics
 Acyclovir
Referrals:
 Consultant Physician)
 Neurology registrar tertiary centres
Discharge criteria:
 Cause established and drug levels at steady state without further seizures
NEUROLOGICAL
20. Altered conscious state with GCS > 8 at risk of deterioration
This criteria includes:

 head injury not requiring transfer for neurosurgical intervention
 CVA not requiring neurosurgical intervention
 post ictal patient
 encephalitis/meningitis after discussion with specialist regarding
suitability of management at ERH HDU
 poisoning
 metabolic crises
An assessment by the Emergency Department confirms the patient is unlikely

to require ICU management
Please assign the relevant Management Guidelines
NEUROLOGICAL
21. Acute Stroke– refer to separate ERH Stroke Management Policy on

PROMPT
Admission Criteria
 Post thrombolysis requiring strict blood pressure management or,

 Where further organ support is required (eg. aspiration and NIPPV)
SURGICAL
22. Elective surgery in patients with significant comorbidities
Surgical patients in HDU will be admitted under a Surgical bedcard.

The Surgical team may ask for input from the Medical team on call on any
particular day if they require Medical input.
For elective patients having major surgery who may require HDU post
operatively, the anaesthetist must notify the Theatre Liaison Officer who
will notify HDU.
Such patients may include those with significant cardio-pulmonary or renal

disease, unlikely to require intubation and positive pressure ventilation post-
operatively. (Patients requiring prolonged intubation would require transfer).
Patients who have received a Spinal anaesthetic using Morphine may be required
to be admitted to the HDU for 24/24 monitoring as detailed in the Intrathefcal
(Spinal) Anaesthetic and Opioid Analgesic policy
All high risk surgical patients require a 12 lead ECG on return to HDU and then
daily whilst in HDU.
SURGICAL
23. Defined surgeries
Of the major elective surgery offered at ERH, the following cases should be
booked pre-operatively for HDU management post-operatively:
 Revision of major joint replacement surgery
 Bowel resection where major comorbidities exist
Emergency surgery where HDU booking is appropriate:

 Bowel resection for ischaemic gut, where extubation is deemed
appropriate post operatively
 Post any surgical procedure where the patient’s clinical condition is
unstable, requiring close monitoring of vital signs and fluid
management.
SURGICAL
24. Patients with Obstructive Sleep Apnoea (OSA) for post-operative

management
If a patient does not present with their own CPAP machine, or if they are newly
diagnosed and not assessed for CPAP therapy, they need HDU management post
operatively. Refer to guideline 7.
SURGICAL
25. Unstable post-operative patient not requiring mechanical

ventilation
Patients at the conclusion of emergency or elective operations may present with

unstable organ systems.
Considering the need for prolonged intubation and positive pressure ventilation
must occur prior to transfer to HDU for post-operative management.
Some patients may require transfer for ICU management to optimise their post-
operative outcomes.
An unstable patient admitted to HDU must have the provisional diagnosis made
of what single organ group is affected and the relevant management guideline
applied.
SURGICAL
26. Multi trauma – not for transfer
ERH HDU has the surgical and medical capabilities to manage multi-trauma, not
requiring transfer to a trauma unit or ICU.
A discussion with a tertiary centre is recommended prior to HDU accepting the

management from the Emergency Department.
Please apply the relevant management guideline, paying particular attention to

haemorrhage and secondary organ failure.
Resources:
Massive Blood Transfusion Policy and Protocol at

http://system.prompt.org.au/download/document.aspx?id=8468361&code=11C5
DD876DEFEC6DB8C82D52EC068959
and Massive Blood Transfusion Policy and Protocol Appendix 1

http://system.prompt.org.au/download/document.aspx?id=8468342&code=3537
C78B854F4995F9BC0ED00134DA5B
Discharge criteria:
 Haemodynamically stable
 No active bleeding
 Coagulopathy stable
SURGICAL
27. Massive haemorrhage
To be admitted to HDU after discussion with on call surgeon and after
consideration re ICU transfer.
Commonly upper GIT bleed – endoscopy within 4 hours if variceal bleed

suspected, within 12 hours if shocked at admission

 FBE/CUE/LFT/Coags
 G&H or XMatch
Monitoring:
 Vital signs 15 minutely minimum
 Consider CVC/art line
 IDC
 6 hourly Coags/platelets
Interventions:
 O2
 2 large bore cannulas
 Colloid/crystalloid or blood (beware Na+ if liver failure)
 Hypotensive resuscitation may aid haemostasis
 Vit K/FFP/platelets
Referrals:
 Haematology input re: clotting factors (tertiary centre registrar)
Resources:
 Massive Blood Transfusion Policy and Protocol
http://system.prompt.org.au/download/document.aspx?id=8468361&code=11C5
DD876DEFEC6DB8C82D52EC068959
and Appendix 1 at:

C78B854F4995F9BC0ED00134DA5B
Discharge criteria:
 Haemodynamically stable
 No active bleeding
 Coagulopathy stable
SURGICAL
28. Liver failure
Admission after discussion with Austin Liver Transplant Unit regarding suitability
Important considerations:
 Treat the cause.
 Consider paracetamol overdose
 Monitor blood glucose
 Daily FBE/CUE/LFT/Coags/Blood cultures
 Daily weights
 Lactulose to aim for 2 loose stools per day
 Neomycin
 Transfer for dialysis if acute renal failure
 Proton pump inhibitor
 Avoid sedatives
 Treat sepsis aggressively, cover spontaneous bacterial peritonitis
 Endoscopy if bleeding varices +/- octreotide
Discharge criteria:
 Synthetic liver function improving (Coags and bilirubin)
 Encephalopathy resolved
SURGICAL
ERH Intrathecal (Spinal) Anaesthetic and Opoid Analgesic Management Policy,

HDY may be used for monitoring for up to 36 hours after spinal morphine
administration.
29. Pre-eclampsia with MgSO4 infusion with immediate transfer
pending.
If birth is not planned at ERH, and MgSO4 is indicated in order to prevent the
complications of pre-eclampsia with transfer to another centre pending, HDU
provides an option for patient management in order to optimise maternal safety
prior to transfer.
The patient remains under the care of the on-call Obstetric VMO and the HDU
nursing staff need 24 hour access to midwifery services. Midwifery to provide
direction and reviews re routine post-partum care and observations and care of
the baby.
Referrals:
 NETS
 Tertiary obstetric centres
Resources:
Massive Transfusion Policy and Procedure at:
C78B854F4995F9BC0ED00134DA5B
and Appendix 1 at:

C78B854F4995F9BC0ED00134DA5B
Policies:
Maternity – Pre – Eclampsia (Management of) – Appendix 1 – Standard
Administration of Magnesium Sulphate - Obstetric
http://system.prompt.org.au/download/document.aspx?id=8838987&code=656F
89EEB5B088F84A0FAFBBEF041EB0
Maternity - Pre Eclampsia (Management of) Policy and Procedure

http://system.prompt.org.au/download/document.aspx?id=10654463&code=FA5
8A9A0973B9B94692ABA7E5B80EBE4
OBSTETRIC
30. Post partum pre-eclampsia
Admission criteria:
A patient with severe pre-eclampsia may be admitted to ERH HDU at the request
of the obstetric VMO in consultation with the anaesthetic VMO.
The patient remains under the care of the On Call Obstetric VMO.
The high acuity nursing HDU staff need 24 hour access to midwifery services.
Midwifery to provide direction and reviews re: routine post partum care and
observations.
Blood pressure control

 labetolol infusion followed by oral labetolol
 hydrallazine infusion
Seizure prophylaxis
 magnesium infusion - refer to policy
Strict fluid management

 avoiding pulmonary oedema
Strict monitoring of coagulation status
Baby visits kept to a minimum
Resources:
Transfer Policy on PROMPT
Inpatient and Emergency Department Patient Transport Policy and Procedure

(includes NETS)
http://system.prompt.org.au/download/document.aspx?id=6184662&code=38E1
79E34D470386307293FDEBAFC5CF
and Appendix 1 at:

C78B854F4995F9BC0ED00134DA5B
Mercy Hospital for Women Anaesthetic Department - Obstetric HDU

Massive Transfusion Policy and Procedure at: insert link to:
C78B854F4995F9BC0ED00134DA5B and Appendix 1 at:
C78B854F4995F9BC0ED00134DA5B
Discharge Criteria:
Magnesium infusion ceased
Good urine output
Clear CXR
Oral antihypertensives
OBSTETRIC
31. Significant post-partum haemorrhage at risk of coagulopathy
Please refer to Guideline 23.
Admit under the Obstetric VMO bed card.

Notify surgeon on call who may provide back up.
Referrals:
 Liaise with on call haematology registrar at tertiary centre about clotting
factors.
Revision History:
Date Issued: May 2012
Date of Last Review: Oct 2017
Primary author/reviewer: HDU Medical Leader
Sub authors/reviewers: VMO Staff Group, Director Medical Services
Committee/Staff Member to Review VMO Staff Group
Approved By: Chief Medical Officer
Date of Next Review: November Oct 2020

ERH HDU Clinical Management Guidelines Oct 17 PDF

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ERH HDU Clinical Management Guidelines Oct 17 PDF

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Echuca Regional Health

High Dependency Unit

Referral Centres .............................................................................................. 3

1. Acute Coronary Syndrome ......................................................................... 4

2. Acute Pulmonary Oedema requiring Non-invasive ventilation or CVC

3. Arrhythmia at risk of cardiac arrest or arrhythmia requiring

4. Elective DCR for Atrial Fibrillation/Flutter ................................................. 7

5. Acute asthma requiring non-invasive ventilation or Type 2

6. Acute pneumonia with high pneumonia severity index .............................. 9

7. Obstructive Sleep Apnoea (OSA) with acute illness ................................. 10

8. Intercostal catheter (ICC) management .................................................. 11

9. Upper Airway Obstruction ........................................................................ 12

10. Diabetic Ketoacidosis ............................................................................... 13

11. Hyperglycaemic hyperosmolar non-ketotic (GCS > 8) ............................. 14

14. Elective Iron Infusion .............................................................................. 17

15. Infusions ................................................................................................. 18

18. A patient with suicide risk ....................................................................... 21

21. Acute Stroke– refer to separate ERH Stroke Management Policy on

22. Elective surgery in patients with significant comorbidities ...................... 25

23. Defined surgeries ..................................................................................... 26

24. Patients with Obstructive Sleep Apnoea (OSA) for post-operative

25. Unstable post-operative patient not requiring mechanical ventilation .... 28

26. Multi trauma – not for transfer ................................................................ 29

27. Massive haemorrhage .............................................................................. 30

28. Liver failure ............................................................................................. 31

30. Post partum pre-eclampsia ...................................................................... 34

31. Significant post-partum haemorrhage at risk of coagulopathy ................ 36

2. Acute Pulmonary Oedema requiring Non-invasive ventilation or CVC

3. Arrhythmia at risk of cardiac arrest or arrhythmia requiring

4. Elective DCR for Atrial Fibrillation/Flutter

5. Acute asthma requiring non-invasive ventilation or Type 2

Investigations (on admission):

6. Acute pneumonia with high pneumonia severity index

Investigations (at admission):

7. Obstructive Sleep Apnoea (OSA) with acute illness

The priority in this instance is to ensure adequate oxygenation while the

8. Intercostal catheter (ICC) management

The priority is to ensure adequate functioning of the chest tube, while

9. Upper Airway Obstruction

Cases may include:

Exclusion Criteria (in addition to general HDU exclusion criteria)

Investigations to consider at admission

 Both ED VMO and Anaesthetic VMO consulted.

10. Diabetic Ketoacidosis

Investigations (on admission):

11. Hyperglycaemic hyperosmolar non-ketotic (GCS > 8)

Investigations (on admission):

The management of a snake bite or poisoning (including overdose) is critical to

The management plan should be sought through the POISON’S HOTLINE in

In the setting of suicide attempt, a psychiatrist must be recruited.

13. Sepsis with secondary organ failure, or high risk comorbidities

Please refer to guideline 6 (acute pneumonia with high pneumonia severity

Specific points to consider:

Infectious diseases registrar at tertiary centres

14. Elective Iron Infusion

Please refer to ERH Policies – Iron Polymaltose Infusion on PROMPT

Specific points to consider:

Specific points to consider:

16. Acute renal failure with hyperkalaemia at risk of a cardiac arrest

Please refer to guideline 3 (Arrhythmia at risk of cardiac arrest or arrhythmia

Investigations (on admission):

17. Acute on chronic renal failure at risk of acute pulmonary oedema

Please refer to guideline 13 (Acute renal failure with hyperkalaemia at risk of a