Icu monitoring

Icu monitoring

1. JAMIA MILLIA ISLAMIA CENTRE OF PHYSIOTHERAPY AND REHABILITATION SCIENCES TOPIC - ICU MONITORING PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS (402) SUBMITTED TO: DR. JAMAL ALI MOIZ SUBMITTED BY: AZIZA NAZNEEN BPT IV YEAR

2. INTRODUCTION In critical care, the monitoring is essential to the daily care of ICU patients, as the optimization of patient’s hemodynamic, ventilation, temperature, nutrition, and metabolism is the key to improve patients’ survival Patients are admitted to an intensive care unit (ICU) for intensive therapy, intensive monitoring or intensive support. They are not necessarily critically ill, but are at risk of failure of one or more major organs. Their needs range from observation of vital signs after major surgery to total support of physiological systems. The primary goal of the intensive care unit (ICU) team is the achievement of stable cardiopulmonary function and optimal oxygen transport. Monitoring implies regular observation and a systematic response if there is deviation from a specified range. They are complementary to clinical observation and not a substitute. 2

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4. NON INVASIVE MONITORING Non-invasive monitoring of a variety of parameters is practised in many areas, especially ICUs and operating theatres. These may all parameters be displayed on a single monitor screen. Temperature Temperature is continuously monitored by means of an oesophageal or rectal probe. This determines core temperature, which is usually at least 1°C higher than axillary temperature Heart rate Heart rate is measured from the electrocardiogram (ECG) trace. Artefacts are common. Interference (usually from patient movement or a warming blanket) may confuse the monitor into showing the presence of a tachycardia or arrhythmia, while small complexes may be interpreted as asystole . Physiotherapy may also cause movement artefacts . Respiratory rate Respiratory rate may be measured by making use of the changing impedance across the chest wall as it moves with respiration. In systems which offer this parameter, the sensors are built into the ECG leads. 4

5. Appropriate physiotherapy treatment (e.g. for lobar lung collapse) may reduce a rapid respiratory rate, but it must be emphasized that an already tachypnoeic patient should not be allowed to become exhausted during treatment as he may rapidly decompensate. Blood pressure Blood pressure is monitored with a pressure cuff around the upper arm. An oscillometric method is used to measure blood pressure, with automatic cuff inflation and deflation Non-invasive blood pressure monitoring is performed intermittently, but the interval between readings may be as short as 1 minute. Physiotherapy treatment may cause a patient to become hypertensive, especially if the treatment causes pain or anxiety. The hypotensive patient may occasionally become more unstable, and here the risks and benefits of treatment need to be carefully balanced Oxygen saturation Oxygen saturation (Clark et al 1992) is continuously measured by a pulse oximeter with a probe on a finger or ear lobe. Hypoxaemia has been shown to occur both during and after chest physiotherapy (Tyler 1982); awareness and careful monitoring are therefore important . 5

6. Capnography Continuous measurement of patient inhaled and exhaled CO2 Waveform display more information than the value 6

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8. INVASIVE MONITORING This requires the use of an invasive catheter, which is inserted into an artery, a central vein, the pulmonary artery or, in some neurosurgical centres , the extradural space (for intracranial pressure (ICP) monitoring). The catheter is connected to a transducer which is in turn connected to a pressure monitor The monitor displays pressure wave-forms and values on a real-time basis Common invasively monitored parameters include arterial blood pressure and central venous pressure (CVP). Arterial cannulation allows continuous monitoring of blood pressure as well as easy access for blood gas analysis. 8

9. CENTRAL VENOUS PRESSURE MONITORING CVP measures the filling pressure of the right ventricular (RV); it gives an estimate of the intravascular volume status and is an interplay of the: circulating blood volume venous tone and right ventricular function CVP measurement involves placement of a catheter into a central vein (generally the superior vena cava), usually via the subclavian or internal jugular vein. The basilic , external jugular, and femora] veins may also be used Normal CVP is approximately 0 to 5 cm H20 and 5 to 10 cm H20 if measured at the sternal notch and midaxillary line, respectively. 9

10. Equipment Sterile gloves Sterile gown and mask (optional) Sterile prep solution Local anesthetic Syringes Sterile flush solution Suture material (might be included in the kit) Dressing material Manometer set (this may vary according to whether C.V.P. to be transduced or not ) [Any piece of open IV tubing can be used] 500ml of0.9% Sodium Chloride. (500ml Sodium Chloride with 500 units heparin used in transduced circuits only) Pressure bag (only used in transduced circuits) [Pressure transducer - An electronic system with fast response time & gives a more accurate wave representation] Sedatives (if required) 10

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12. Waveform in CVP 12 It consists of three upwards (a, c, & v waves) and two downward defections (x and y descents). ‘a’ wave by right atrial contraction and occurs just after the P wave on the ECG. The ‘c’ wave due to isovolumic ventricular contraction forcing the tricuspid valve to bulge upward into the RA The pressure within the RA then decreases as the tricuspid valve is pulled away from the atrium during right ventricular ejection, forming the X descent. The RA continues to fill during late ventricular systole, forming the V wave The Y descent occurs when the tricuspid valve opens and blood from the RA empties rapidly into the RV during early diastole

13. PULMONARY ARTERY AND PULMONARY CAPILLARY WEDGE PRESSURE The introduction of pulmonary artery catheter (PAC) in clinical medicine is one of the most popular and important advances in monitoring. With a pulmonary artery catheter:- pulmonary capillary wedge pressure (PCWP) may be monitored under most circumstances provides an accurate estimate of the diastolic filling (preload) of the left heart cardiac output (CO) may be measured by means of the thermodilution technique. Systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), oxygen delivery, and oxygen consumption may also be calculated. The pulmonary artery catheter is inserted via a central vein through the right side of the heart into the pulmonary artery. 13

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15. INTRACRANIAL PRESSURE MONITORING Intracranial pressure monitoring may be performed in patients with head injuries, brain surgery, intracranial and subarachnoid haemorrhage , and cerebral oedema from other causes. The importance of ICP measurement is that it provides an estimate of cerebral perfusion pressure (cerebral perfusion pressure = mean arterial pressure — ICP) which in turn relates to cerebral blood flow Raised ICP causes reduced CBF which leads to tissue hypoxia and acidosis, raised PCO2 cerebral vasodilatation, and oedema , all of which cause a further rise in ICP. ICP may be measured by means of an extradural or subarachnoid bolt, an intraventicular catheter (inserted through the skull ino the lateral ventricle), or an epidural catheter. The former methods are the most widely used 15

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17. REFERENCES Dean, E & Frownfelter, D. Cardiopulmonary physical therapy ; (3 rd edition) Hough, A. physiotherapy in respiratory care ;(3 rd edition) Pryor, J.A & Webber, B. A Physiotherapy for respiratory and cardiac problems ; (2 nd edition) K. Bendjelid and J. A. Romand , “Fluid responsiveness in mechanically ventilated patients: a review of indices used in intensive care,” Intensive Care Medicine 17