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1. Over view of ICU INTENSIVE CARE UNIT DIABETIC ASSOCIATION MEDICAL COLLEGE HOSPITAL,FARIDPUR. 1

2. INTRODUCTION Intensive Care U nits ( ICU) are specialist wards with a concentration of expertise and resources for the management of critically ill patients. These resources include provision of organ support, expertise and knowledge in management of critical illness and close monitoring of physiological variables. 2

3. INTRODUCTION I n intensive care there is a high level clinical input and high staff-to-patient ratio. As a result, intensive care is an expensive and high-demand resource. 3

4. Misconceptions About ICU For managing VIPs For managing moribund Patients For managing all patients with emergency conditions like emergency unit For managing  ALL  unconscious patients   It is not an Amenity ward, Palliative care nor for Geriatric care. 4

5. TYPICAL ICU SETTING 5

6. CATEGORIES OF ORGAN SYSTEM MONITORING AND SUPPORT Basic respiratory support • Need for more than 50% oxygen • Possibility of progressive deterioration to needing advanced respiratory support • Need for physiotherapy to clear secretions at least two hourly • Patients recently extubated after prolonged intubation and mechanical ventilation • Need for mask continuous positive airway pressure or non-invasive ventilation Advanced respiratory support • Mechanical ventilatory support (excluding mask continuous positive airway pressure (CPAP) or non-invasive ( eg , mask) ventilation) • Possibility of a sudden, precipitous deterioration in respiratory function requiring immediate endotracheal intubation and mechanical ventilation 6

7. CATEGORIES OF ORGAN SYSTEM MONITORING AND SUPPORT Circulatory support • Need for vasoactive drugs to support arterial pressure or cardiac output • Support for circulatory instability due to hypovolemia from any cause which is unresponsive to modest volume replacement (including post-surgical or gastrointestinal hemorrhage or hemorrhage related to a coagulopathy ) • Patients resuscitated after cardiac arrest where intensive or high dependency care is considered clinically appropriate Neurological monitoring and support • Central nervous system depression, from whatever cause, sufficient to affect the airway and protective reflexes • Invasive neurological monitoring Renal support • Need for acute renal replacement therapy ( hemodialysis , or hemofiltration . 7

8. Types of Admissions into ICU Planned admission Emergency admission 8

9. PLANNED ADMISSIONS Some patients are planned for admission into ICU prior to the commencement of the surgery or afterwards. Underlying condition. Related ailment. 9

10. EMERGENCY ADMISSIONS Medical personnel from the A & E or regular wards refer patients for higher level of monitoring or specialist treatment for reversible life threatening conditions. Patients frequently require a period of stabilization before it is safe to move them to the intensive care unit. I t may be necessary to perform emergency investigations including radiological investigations before the patient goes to intensive care. 10

11. EMERGENCY ADMISSIONS Patients at high risk of morbidity and mortality following planned surgery may require admission to intensive care for respiratory and cardiovascular support or increased monitoring in order to prevent or identify (and hopefully intervene early) postoperative complications. Undergoing surgical procedures can produce immense physiological strain for a variety of reasons including tissue damage, bleeding, fluid shifts, metabolic disturbance, inflammatory response, altered ventilatory mechanics and postoperative pain. 11

12. TYPES OF ICU ICUs can be categorized based on operation or patient group . Types Of ICU Based On Operation Are . Open units  -Primary physician is responsible for admission, treatment and discharge of the patient Closed units – Responsibility for admission, treatment and discharge of the patient is transferred to a specialized ICU team . 12

13. TYPES OF ICU Types Of ICU Based On Patient Group. General ICU : attend to surgical, medical, obstetric/gynecological, hematological and burns patients. Specialized types of ICUs : attend to specific group of patients. These include: Neonatal intensive care unit (NICU), Special Care Baby unit (SCBU), Pediatric Intensive Care Unit (PICU), Coronary Care Unit CCU), Cardiac Surgery Intensive Care Unit (CSICU), Cardio-Vascular Intensive Care Unit (CVICU), Mobile Intensive Care Unit (MICU), Medical Surgical Intensive Care Unit (MSICU), Surgical Intensive Care Unit (SICU), Neuro Intensive Care Unit (NICU), Burn Wounds Intensive Care Unit (BWICU), Trauma Intensive care Unit (TICU), Respiratory Intensive Care Unit (RICU). 13

14. FUNCTIONS OF THE ICU Monitoring in ICU can be achieved by  non-invasive  or  invasive  method, continuously or intermittently depending on the requirement of the patient. These settings are not seen in any other place in the hospital. 14

15. FUNCTIONS OF THE ICU Non-invasive monitoring does not require any device to be inserted into the body and therefore does not breach the skin. This is achieved by: Electrocardiography (ECG), heart rate, rhythm Non-invasive blood  pressure (NiBP) using a sphygmomanometer cuff attached to the ICU monitor or manual BP apparatus Body temperature RR and ETCO2 Pulse oximetry (O2 saturation reading and heart rate) Urine output Level of consciousness (LOC) using the Glasgow coma scale (GCS) 15

16. FUNCTIONS OF THE ICU Invasive monitoring  is achieved by the insertion of an arterial, central or pulmonary artery catheter. Arterial and central lines are used most commonly in ICU patients. This monitoring provides: Continuous and more accurate measurement of vital signs Allows for adjustment of treatments in more appropriate manner Provides continuous access for regular blood samples 16

17. Invasive monitoring in an ICU includes: arterial blood pressure, central venous pressure (CVP) measurement, pulmonary artery catheterization, arterial blood gas (ABG) analysis measurement of intracranial pressure (ICP) and intra-abdominal pressure (IAP). 17

18. Bedside Investigations In ICU Also called bedside testing or point-of-care testing , increase the likelihood that ICU care team will receive the results quicker, which allows for better immediate clinical management decisions to be made. Bedside testing is often accomplished through the use of transportable, portable, and handheld instruments . RBS check, PCV, blood gases and electrolytes analysis, rapid coagulation testing (PT / INR) , rapid cardiac markers diagnostics, drugs of abuse screening, urinalysis. 18

19. Hemodynamic Support: ICU patients may require intravenous fluids as well as administration of inotropes and vasoactive medications. Vasoactive drugs are the mainstay of hemodynamic management of vasodilatory shock when fluids fail to restore tissue perfusion. Vasopressor agents increase mean arterial pressure (MAP), which increases organ perfusion pressure and preserves distribution of cardiac output to the organs. 19

20. Sedation And Analgesia: Sedation is required in some ICU procedures like Mechanical ventilation. Pain control is an essential component of care for critically ill patients. Acute pain ( especially abdominal or thoracic pain) interferes with breathing patterns and can interfere with delivery of adequate tidal volume. 20

21. Enteral / Parenteral Nutrition Nutrition of the critically ill patient is of paramount importance in the ICU.  Feeding unconscious patients in ICU can be via nasogastric tubes; Intravenous fluids and Total parenteral nutrition (TPN). 21

22. Mechanical Ventilation Mechanical ventilation is a supportive therapy used to assist patients who are unable to maintain adequate oxygenation or carbon dioxide elimination. These patients usually exhibit signs of acute respiratory failure and are not candidates for less invasive methods of respiratory support. 22

23. WHO SHOULD BE ADMITTED TO ICU? The Intensive Care Unit is an expensive resource area and should be reserved for patients with reversible medical conditions with a reasonable prospect of substantial recovery . Because ICU beds are expensive to run and are limited in number the ICU admission decision may be based models: Prioritization model Diagnosis, and Objective parameters models These are used to avoid blocking the chance of those patients with a reasonable prospect of substantial recovery. 23

24. PRIORITIZATION MODEL SOCIETY OF CRITICAL CARE MEDICINE . Priority 1:   These are critically ill, unstable patients in need of intensive treatment and monitoring that cannot be provided outside of the ICU.  Usually, these treatments include ventilator support , continuous vasoactive drug infusions, etc. P ost-operative or acute respiratory failure patients requiring mechanical ventilatory support and shock or hemodynamically unstable patients receiving invasive monitoring and/or vasoactive drugs. 24

25. PRIORITIZATION MODEL Priority 2:   These patients require intensive monitoring and may potentially need immediate intervention .  No therapeutic limits are generally stipulated for these patients.  Examples include patients with chronic comorbid conditions who develop acute severe medical or surgical illness . 25

26. PRIORITIZATION MODEL Priority 3:   These unstable patients are critically ill but have a reduced likelihood of recovery because of underlying disease or nature of their acute illness.  Priority 3 patients may receive intensive treatment to relieve acute illness but limits on therapeutic efforts may be set such as no intubation or cardiopulmonary resuscitation.  Examples include patients with metastatic malignancy complicated by infection. 26

27. PRIORITIZATION MODEL Priority 4:   These are patients who are generally not appropriate for ICU admission.   Admission of these patients should be on an individual basis, under unusual circumstances and at the discretion of the ICU Director.  These patients can be placed in two categories. A . Little or no anticipated benefit from ICU care based on low risk of active intervention that could not safely be administered in a non-ICU setting (too well to benefit from ICU care).  Examples include patients with peripheral vascular surgery, hemodynamically stable diabetic ketoacidosis , mild congestive heart failure, conscious drug overdose, etc. 27

28. PRIORITIZATION MODEL B.  Patients with terminal and irreversible illness facing imminent death ( too sick to benefit from ICU care ).  For example: severe irreversible brain damage, irreversible multi-organ system failure, metastatic cancer unresponsive to chemotherapy and/or radiation therapy , brain dead non-organ donors, patients in a persistent vegetative state. 28

29. DIAGNOSIS MODEL Patient who need ICU care due to some specific diagnosis. 29

30. RESPIRATORY Acute respiratory failure requiring ventilatory support Acute pulmonary embolism with hemodynamic instability Massive hemoptysis Upper airway obstruction 30

31. CARDIOVASCULAR Shock states Cardiac arrest Life-threatening dysrhythmias Dissecting aortic aneurysms Hypertensive emergencies Need for continuous invasive monitoring of cardiovascular system(arterial pressure, central venous pressure, cardiac output) 31

32. NEUROLOGICAL Severe head trauma CVA with respiratory compromise Status epilepticus Meningitis with altered mental status or respiratory compromise Acutely altered sensorium with the potential for airway compromise Progressive neuromuscular dysfunction requiring respiratory support and / or cardiovascular monitoring (myasthenia gravis, Gullain-Barre syndrome) 32

33. RENAL Requirement for acute renal replacement therapies in an unstable patient Acute rhabdomyolysis with renal insufficiency 33

34. ENDOCRINE DKA complicated by hemodynamic instability, altered mental status Severe metabolic acidotic states Thyroid storm or myxedema coma with hemodynamic instability Hyperosmolar state with coma and/or hemodynamic instability Adrenal crises with hemodynamic instability Other severe electrolyte abnormalities, such as: - Hypo or hyperkalemia with dysrhythmias or muscular weakness -Severe hypo or hypernatremia with seizures, altered mental status -Severe hyperkalemia with altered mental status, requiring hemodynamic monitoring. 34

35. GASTROINTESTINAL Life threatening gastrointestinal bleeding Acute hepatic failure leading to coma, hemodynamic instability Severe acute pancreatitis 35

36. HEMATOLOGY Severe coagulopathy and/or bleeding diathesis Severe anemia resulting in hemodynamic and/or respiratory compromise Severe complications of sickle cell crisis Hematological malignancies with multi-organ failure 36

37. OBSTETRIC Medical conditions complicating pregnancy Severe pregnancy induced hypertension/eclampsia Obstetric hemorrhage Amniotic fluid embolism 37

38. MULTI-SYSTEM Severe sepsis or septic shock Multi-organ dysfunction syndrome Polytrauma Hemorrhagic fevers Drug overdose with potential acute decompensation of major organ systems Environmental injuries (lightning, near drowning, severe hypo/hyperthermia) Severe burns 38

39. SURGICAL High risk patients in the peri-operative period Post-operative patients requiring continuous hemodynamic monitoring/ ventilatory support, usually following: Vascular surgery Thoracic surgery Airway surgery Craniofacial surgery Major orthopedic and spine surgery General surgery with major blood loss Neurosurgical procedures 39

40. OBJECTIVES PARAMETERS MODEL Physical Findings (Acute Onset) U nequal pupils with LOC GCS < 8 B urns > 10%BSA A nuria A irway obstruction C ontinuous seizures C yanosis Vital Signs Respiratory rate ⩾40 or ⩽8 breaths/min Oxygen saturation <90% on ⩾50% oxygen Pulse rate <40 or >140 beats/min Systolic blood pressure <80 mm Hg 40

41. OBJECTIVES PARAMETERS MODEL Laboratory Values Sodium < 110 or > 170mmol/L Potassium <2.0 or > 7.0mmol/L PaO2 < 50mmhg pH < 7.1 or > 7.7 Glucose > 800 mg /dL Calcium > 15 mg/dL toxic drug level with respiratory compromise 41

42. PATIENTS WHO ARE GENERALLY NOT APPROPRIATE FOR ICU ADMISSION Irreversible brain damage End stage cardiac, respiratory and liver disease with no options for transplant Metastatic cancer unresponsive to chemotherapy and/or radiotherapy Brain dead non-organ donors Patients with non-traumatic coma leading to a persistent vegetative state 42

43. DISCHARGE CRITERIA Society of Critical Care Medicine (SCCM 1999) When a patient’s  physiologic status has stabilized   and the need for ICU monitoring and care is no longer necessary When a patient’s  physiological status has deteriorated and active interventions are no longer planned , discharge to a lower level of care is appropriate Once the patient can breathe unaided, and no longer needs intensive care, he/she will be transferred to a different ward to continue his/her recovery. Depending on the patient’s condition, this will usually either be a high dependency unit (HDU), which is one level down from intensive care, or a general ward. 43

44. DISCHARGE CRITERIA No Criteria 1. Stable hemodynamic parameters 2. Stable respiratory status (patients extubated with stable arterial blood gases) 3. Oxygen requirements not more than 60%. 4. Intravenous inotropic/vasopressor support and vasodilators are no longer necessary. Patients on low dose inotropic support may be discharged earlier if an ICU bed is required. 5. Cardiac dysrhythmias are controlled 6. Neurologic stability with control of seizures. 7. Patients who require chronic mechanical ventilation (e.g. motor neuron disease or cervical spine injuries) with any of the acute critical problems reversed or Resolved 8. Patients with tracheostomies who no longer require frequent suctioning 44

45. CONCLUSION I ntensive care unit is an expensive but limited unit with concentration of expertise and resources reserved for patients with reversible medical conditions. Admission criteria should be strictly adhered to, so as to avoid blocking the chance of patients with a reasonable prospect of substantial recovery. 45

46. REFRENCES Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine: Guidelines for intensive care unit admission, discharge, and triage. Society of Critical Care Medicine Ethics Committee: Consensus Statement on the Triage of Critically Ill Patients. Sprung CL, Geber D, Eidelman LA et al: Evaluation of triage decisions for intensive care admission. Truog RD, Brook DW, Cook DJ et al: Rationing in the intensive care unit. The National Institute for Health and Care Excellence (NICE) guidelines. Society Of Critical Care Medicine Updates. NNRH Ojo library 46

47. NNRH OJO ICU ADMISSSION PROTOCOL 47

48. CRITICAL CARE OUTREACH SERVICES The National Institute for Health and Care Excellence (NICE) identified the need to establish outreach services. Outreach teams are established to: A vert admissions to ICU S upport staff in the ward arears P rovide education programs for ward based staff S upport critical care patients following transfer from ICU in order to avert readmissions P rovide follow-up services on discharge from hospital, to determine impact of critical care on the patient 48

49. EARLY WARNING SIGNS 49