FAST HUG and NICE-SUGAR

FAST HUG is a mnemonic proposed five years ago by Jean-Louis Vincent as a way of assisting healthcare workers looking after critically ill patients.

The mnemonic stands for:

F= Feeding
A = Analgesia
S = Sedation
T = Thromboembolic prophylaxis

H = Head-of-bed elevation
U = stress Ulcer prophylaxis, and
G = Glucose/glycemic control.

All the components are evidence-based and have been used the world over.

Reference:
Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005 Jun;33(6):1225-9.

The above paper requires a subscription for full access and therefore I cannot upload here.
However, I have found an interesting power point slides that explains rather clearly what FAST HUG is. Click here.

Further literature search showed that ever since the original FAST HUG has been described by Vincent JL; many other subsequent variants and additions to the original have been proposed and published by many other authors, for example,

FAST HUG+S (S = Skin care, prevention of pressure ulcer)

FAST HUG(S) + BID OVER (S = Spontaneous breathing trial; B = bowel care; I= indewelling catheter removal; D= deescalation of antibiotics)

FAST HUG + EACH HOUR (E = Electrolytes; A = Airway; C = Catheters; H = Hematology; H = Hemodynamics; O = Oral care; U = Urine analysis; R = Relatives)

FAST HUG + FAITH (F = Fluid balance; A = Aperients; I = Investigation and results; T = Therapies, and Hydration.


In fact, the variations can go on and on, but to quote the author of the original FAST HUG, Jean-Louis Vincent, who said it succinctly:

“…….we could continue expanding the mnemonic almost indefinitely, creating long phrases, even poems (!), but this would defeat the original concept underlying the FAST HUG, which was to provide a short and simple mental checklist that can be easily remembered by all staff members, but that includes most important aspects of patient management to be checked whenever attending an intensive care unit patient. A longer mnemonic is less likely to be remembered and hence less likely to be applied”

Most of original FAST HUG components are relevant to an emergency medicine setting, except for feeding as feeding is usually not started in emergency department ward itself. The “F” for feeding can be substituted to “Fluid resuscitation and management”, which is much more relevant to emergency medicine.

Specifically for glycemic control, one should read up findings from NICE-SUGAR study, published in NJEM.

In this multicenter trial, investigators randomized more than 6000 critically ill patients (63% medical; 37% surgical) to either intensive glucose control (target glucose level, 81–108 mg/dL) or conventional glucose control (target glucose level, 144–180 mg/dL). Control of blood glucose was achieved with intravenous insulin infusions. Participants were randomized within 24 hours after admission to intensive care units and were expected to require ICU treatment for 3 or more consecutive days.

The primary endpoint — death by 90 days after randomization — occurred significantly more often in the intensive-control group than in the conventional-control group (27.5% vs. 24.9%).

When data were analyzed separately for medical and surgical patients, results were similar to those for the whole cohort. Not surprisingly, severe hypoglycemia (blood glucose level, ≤40 mg/dL) was significantly more common in the intensive-control group than in the conventional-control group (6.8% vs. 0.5%). No differences between the groups were observed in median number of ICU or hospital days or median days of mechanical ventilation or renal replacement therapy.

This study therefore, suggests that a tight, intensive glucose control could actually harm rather do good to critically ill patients in terms of death and complications of severe hypoglycemia.

Reference:
The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009 Mar 26; 360:1283.

Note: the full text of this study can be accessed free in NJEM. Click here.