CARE OF CRITICALLY ILL PATIENTDr Eunice Rabiatu Abdulai

26TH August 2015. VENUI: ENT DEPARTMENT KOR-BU TEACHING HOSPITAL

OUT LINE• Introduction• Definition• Anatomy• Aetiology/pathogenesis• Clinical characteristics{signs and

symptoms}• Investigations• Treatment• Conclusion

INTRODUCTIONProper management of a critical ill patient require

• Early identification of the critical ill patient

• Identification of the immediate problem that can kill the patient

• Taking and performing quick measures to save the persons life.

Some pathology require high index of suspicion.

DEFINITION: (CRITICALLY ILL PATIENTS)

• Patients at high risk for actual or potential life-threatening health problems

• They are •Highly vulnerable•Unstable•Complex

• There by requiring intense and vigilant nursing care in addition to medical and or surgical care

ANATOMY•ALL systems can be involved•CVS•CHEST•ABDOMEN•CNS•MUSCULOSKELETAL•HORMONAL

AETIOLOGY• CONGENITAL:

• e.g. ENT • bilateral choanal atresia, • bilateral vocal cord paralysis, • Tracheoesophageal fistula• ect

• INFECTIONS:• E.g. ENT

• complicated sinusitis,• complicated otitis media • retropharyngeal abscess• ect

• OTHERS • typhoid perforation, • retroperitoneal abscess,• diabetic foot,• necrotising fasciitis of scrotum,• cerebral abscess,• MI,• acute renal failure,• septicaemia, • septic shock• ect

AETIOLOGY• TRAUMA:

• laryngeal fracture, • ruptured spleen, • multiple abdominal organ rupture, • poly trauma, • tension pneumothorax, • heamothorax, • head injury, • neurogenic shock.

• TUMOUR: • subglottic polyp

• OTHERS: • aspirated foreign body, • anaphylactic shock, • cardiogenic shock, • hypoglycaemia, • Hyperglycaemia• Ruptured ectopic pregnancy• Thyroid storm

AETIOLOGY•Can be from any system•CNS,•CHEST, •CVS,•ABDOMEN,•GENITOURINARY,•MUSCULOSKELETAL,• ENDOCRINE

PATHOGENESIS•VARIED , DEPEND ON

THE CAUSE

•Embryonic• Inflammatory•Trauma•Tumour• Iatrogenic•Unknown

CLINICAL CHARACTERISTICS {SIGNS AND SYMPTOMS}

•Assessment of deranged physiology and immediate resuscitation must proceed diagnostic consideration

• Initial diagnostic uncertainty and need for immediate monitoring and physiological support defines critical care

SYMPTOMSGENERAL: dizziness, headache

CHEST: Difficulty in breathing, cessation of breathing, Chest pain,

CVS: Palpitations, saviour Sharp pain radiating to shoulder, orthopnoea, PND

CNS: Unconscious, Deteriorating consciousness, Confused, Abnormal behaviour (aggression)

GENETOURINARY: Small urine or cessation of urination

MUSCULOSKELETAL: Ascending paralysis, inability to sit or walk

SYMPTOMS(ENT ARRANGEMENT(EXAMINATION FINDINGS))• GENERAL

• STATUS LOCALIS (ear, nose and throat and head and neck(lymph nodes and cranial nerve palsy))

• CNS• CVS• CHEST• ABDOMEN• GENITOURINARY• MUSCULOSKELETAL

SIGNS(EMMERGENCY(call for help))• ASSESSMENT AND CLINICAL EXAMINATION:: • A: AIRWAY (Secretions or blood, falling tongue, loss of denture, recovery position (mind full of cervical fracture and fix neck collar))• B: BREATHING (Chest movement,FAN,ICR,SCR,Trachial tagging, retrosternal in drawing, chest examination(inspect, palpitation, auscultation) oxygen saturation, blood gasses)• C: CIRCULATION Iv line ,sample, pulse(characteristics), heart rate,BP, bleeding points)• D: DISABILITY (Fracture(Step formation, chest and pelvic compression tenderness))• E: EXPOSURE(Cut through clothes(poly trauma patient))

SIGNS (AIR WAY AND BREATHING PROBLEMS)• AIR WAY PROBLEMS• Secretions/blood in airway(nasal and oral cavity)• Vomiting( unconscious patient)• Noisy breathing(stridor)• Mouth breathing• Use of accessory muscles of respiration• ↑RR,• Sniffing dog position(acute epiglottitis)

• BREATHING PROBLEMS• ↓Oxygen saturation• Absent or ↓chest movement• Deranged Blood gasses

SIGNS OF ADEQUATE INTRAVASCULAR FLUID VOLUME REPLACEMENT

• CIRCULATION

• Heart rate < 100 beats. min -1

• Pulse pressure > 30 mmHg

• Urine output > 0.5 – 1 ml.kg-1.h-1

• Absence of metabolic acidosis

• Minimal effects of positive pressure ventilation on blood pressure.

INVESTIGATION• HEAMATOLOGY :

• (FBC, Clotting profile, sickling, HB electrophoresis, Grouping and cross matching,??ESR)

• BIOCHEMISTRY:• ( Arterial blood gasses, BUNCr electrolyte, LFT,RBS,FBS)

• MICROBIOLOGY:• (C/S, CSF cell count, Microscopy, ZN-AFB, Gram stain, urine and stool R/E, MP’S)

• BIOPSY:( eg:Therapeutic Excisional biopsy of subglottic polyp)

• IMAGING(X-Ray,U/S,ECHO)• (Depends on pathology)

• OTHERS :• (hormonal(eg TFT,))

REQUIREMENT OF MANAGEMENT(CRITICALLY ILL PATIENT)• Immediate availability of • surgeons/ physicians, • anesthesiologists, • nurses • facilities, • emergency room, • theatres, • ICU beds, • radiology, • laboratory, • blood bank

• 24 hours every day of the year.

Requirement of management1. Airway equipment/devices

Oro/Nasopharyngeal airways,,orotrachial tube,nasotrachial tube,tracheostomy tubes,esophageal obdurate airway,crocothyroid tube, pharyngotrachial lumen tube(PTL)(Combination of esophageal obturator

tube(airway)+endotracheal tube)

- Magill’s forceps- Laryngoscopes, endotracheal tubes

2. Ambubags3. Mechanical ventilator.4. Anesthesia machine5. Monitoring devices. 6. Blood pumps and primed infusion sets in blood warmers.7. Drugs in labelled syringes.8. Electrical defibrillator.

Air way mx

cricothyrotomy

TREATMENTGUIDING PRINCIPLES:: • DELIVERY OF OPTIMAL AND APPROPRIATE CARE .• RELIEF OF DISTRESS • COMPASSION AND SUPPORT • DIGNITY • INFORMATION • CARE AND SUPPORT OF RELATIVES AND CARE GIVERS

TREATMENT (medical,surgical,combined)• INTENSIVE CARE MEDICINE INVOLVES

1. A :Airway management.2. B: Ventilation of the lungs.3. C: I.V administration of potent and rapidly acting drugs.4. D: Fluid, electrolyte and blood administration including parental

nutrition.5. Non invasive and invasive monitoring of vital organs

A--AIRWAY• Suction(secretions, blood

foreign body)

• Position(recovery possition,prop up)

• Airway use(nasopharyngeal tube, oropharyngeal tube,)

• Intubation or other alternatives

B-- BREATHING• Chest movement• Use of accessory muscles of

respiration• Oxygen saturation• Arterial Blood gasses• Give oxygen• Chest tube

(pneumothorax,heamothorax,chylothorax,pneumohaemothorax,pyothorax)

Options of airway management• Percutaneous dilatational

tracheostomy• NPPV(Non invasive positive

pressure ventilation)• Laryngeal mask airway(LMA)• Endotracheal intubation• Trans tracheal needle ventilation• Cricothyroidotomy

(minitracheostomy/laryngotomy)

C--Circulation• IV line,• Take sample,• Intraosose cannulation• Iv

fluids--(crystalloids(R/L,N/S,D/S),Colloids()• Blood and blood product transfusion

(whole blood, fresh blood,RBC concentrate, albumin concentrates,FFP act.)• fluid and temp. chart,• CPR• Pass urethral catheter• NG Tube

D--DRUGS• IV antibiotics•Analgesics• Steroids•Naloxines (↑ BP)•Oxygen radical scavengers(superoxide

dismutase,Allopurinol,vit C)•Antithrombin III (Prevent further coagulopathy)• Inotropic Agents(heart failure; dopamine/dobutamine)•Monoclonal antibodies to TNF,IL-1,IL-6

MANAGEMENT OF OTHER ORGAN (status locales)• ABDOMEN: (Liver failure, peritonitis, peritoneal abscess, pancreatitis Intestinal

obstruction, raptured spleen, feeding tube,)

• GENUTOURINAL: (kidney failure, trauma to kidneys empyema, UTI ( Unconscious elderly),Testicular necrotising fasciitis)

• PELVIC: (Septic abortion, ectopic pregnancy, postpartum sepsis,PID)

• MUSCULOSKELETAL: ( Diabetic foot gangrene(amputation),prevent bed sore, physiotherapy)

MANAGEMENT OF OTHER ORGAN (status locales): continuation• CNS: (SEIZURES, craniotomy(heamatoma,abscess,tumour))

• ENT: ( Retropharyngeal abscess, mastoid abscess, complicated sinusitis, complicated otitis media, advance head and neck tumours, necrotising fasciitis of the ear)

• Others: burns, hypovolemia(vomiting, diarrhiour, ),allergic reaction, immunosuppression,leukemia,carcinoma

MANAGEMENT OF CRITICALLY ILL PATIENT:

• COMPLETE MONITORING • RESPIRATORY CARE • CARDIO VASCULAR CARE • VENOUS THROMBOSIS PROPHYLAXIS INFECTION CONTROL • FLUID, ELECTROLYTE AND GLUCOSE BALANCE• GASTROINTESTINAL/NUTRITIONAL CARE • BLADDER CARE • NEURO MUSCULAR• COMFORT AND REASSURANCE • COMMUNICATION WITH THE PATIENT • SKIN CARE• GENERAL HYGIENE AND MOUTH CARE • DRESSING AND WOUND CARE COMMUNICATION WITH RELATIVES

1. COMPLETE MONITORING

• Temperature• BP• HEART RATE{HR}• ECG• RESPIRATORY RATE{RR}• OXYGEN SATURATON• ARTERIAL BLOOD GASSES • INPUT AND OUTPUT CHART• RENAL FUNCTION ( BUNCr and Electrolytes(SODIUM,CLORIDE,POTASSIUM))• HAEMATOLOGY{HB,WBC AND DEFFERENCIALS}

EXAMPLES OF ORGAN SYSTEM FAILURE TREATED IN THE INTENSIVE CARE UNIT

• Acute respiratory failure

• Congestive heart failure

• Sepsis

• Head injury

• Acute renal failure

• Acute hepatic failure

• Malnutrition

ACUTE RESPIRATORY FAILURE• Not a single dx. Entity

• Combination of pathophysiologic derangements that arise from a variety of etiologic insults.

• Therefore considered as ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)

PATHOPHYSIOLOGY OF ARDS• Many mediators have implicated in the pathophysiology:

• complement,

• cytokines,

• O2 radicals,

• arachidonic acid products,

• nitric oxide and

• proteases.

AETIOLOGY ARDS

1. DIRECT injury to lung – • aspiration, • pneumonia, • pulmonary contusion, • thermal inhalation, • amniotic fluid, • embolism and • particle inhalation.

2. INDIRECT injury to lung via mediator release • e.g.

• pancreatitis, • sepsis, • bacteremia.

• The presence of multiple insults increases the risk of ARDS

• Cardiac dysfunction Shock (hemorrhage, sepsis) Congestive heart failure Post – cardiopulmonary bypass

Central nervous system dysfunction Hypothalamic injury

Depressant drug overdose

Neuromuscular dysfunction Myasthenia gravis Spinal cord transection

Guillain – Barre syndrome Tetanus Drugs (muscle relaxants, antibiotics)

Miscellaneous Massive blood transfusion Disseminated intravascular coagulation Morbid obesity Uremia

Acute pancreatitis

MORTALITY OF ARDS: 40 – 60% in most studies

• FULL ETIOLOGY OF ACUTE RESPIRATORY FAILURE

• Trauma with associated multiple organ system failure.

• Pulmonary dysfunction• Obstructive pulmonary disease• Restrictive pulmonary disease• Pneumonia• Inhaled toxins (gastric fluid, smoke,

meconium)• Oxygen toxicity• Emboli (blood, fat, amniotic fluid)• Lung contusion• Near – drowning• Hyaline membrane disease

CLINICAL DIAGNOSIS OF ARDSAcute onset

1. Arterial hypoxemia PaO2 < 60mmHg despite supplemental inhaled O2. PaO2/FiO2(FRACTION OF INSPIRED OXYGEN) ratio < 200

2. Pulmonary oedema despite pulmonary artery occlusion pressure < 18 OR no evidence of left atrial hypertension.

3. ↓ Pulmonary compliance

4. Bilateral (patchy, diffuse, homogenous) infiltrates on CXR consistent with pulmonary oedema.

DIFFERENCES BETWEEN ACUTE RESPIRATORY FAILURE AND CHRONIC RESPIRATORY FAILURE

Relationship of PaCO2 to the pH.

• ARF – Abrupt ↑ in PaCO2 and corresponding ↓ pH.

• CRF – ↑ PaCO2 but pH near normal (compensation by renal reabsorption of HCO3 ions).

TREATMENT OF ARDSSupport pulmonary function till lungs can recover from insult.

Usually necessary to intubate and ventilate.- PEEP (Positive End – Expiratory Pressure) for IPPV(intermittent partial pressure ventilation) patients.- CPAP (Continuous Positive Airway Pressure) for spontaneously breathing patients.

- Inhalation of nitric oxide.

More than 75% of patients dying of ARDS now die of multiple organ system failure rather than impaired gas exchange.

SEPSIS

Hospital acquired infections- Important cause of death in ICU

Common sources of infection1. Urinary tract2. Surgical wounds3. Pneumonia4. Intravascular devices5. Sinusitis ( may be unexplained cause of fever, esp. if Nasotracheal tube is in place)6. Leading cause of mortality - PNEUMONIA

SEPTIC SHOCK

1. Hypotension (BP< 90mmHg) in presence of peripheral vasodilation2. Oliguria

Suspect if symptoms occur following operations or instrumentation of the genitourinary tract.

3. in state of consciousness e.g. contusion and disorientation- Measure C.O(cardiac output) and S.V.R( systemic vascular resistance) to confirm diagnosis- Positive blood culture is diagnostic but not always present.

TREATMENT OF SEPTIC SHOCK

1. I.V fluids 2. Dopamine to support cardiac and renal function3. Antibiotics – 2 usually selected. One ( e.g. Chindamycin) effective

against gm +ve bacteria. The other e.g. aminoglyeoside derivative) effective against gm –ve bacteria.

4. Steroids ???5. Surgical intervention may be necessary6. Ketamine – good induction agent for anaesthesia

CONGESTIVE HEART FAILURE1. ↓ C.O

• Requires pharmacologic treatment with isotropic or vasodilator drugs or both based on information from pulmonary artery catheter.

• Drug-induced ↑ in C.O are reflected in ↓atrial filling pressures, improved arterial oxygenation and PVO2.

TREATMENT OF CCF

Vasodilatore.g. - Nitroprusside 0.5 – 5mgKg -1 min -1

Nitroglycemia 0.5 – 5mgKg-1min -1Hydralazine

Vasodilators increase cardiac output by ↓ impedance to forward ejection of Lt. ventricular stroke volume.

(*But ↓ BP results in ↓coronary perfusion pressure! Be careful).

2. INOTROPIC drugs (dopamine, dobutamine, ephinephrine) improve C.O by ↑ myocardial contractility

ACUTE RENAL FAILURE (ARF)

• Best treatment is prevention by maintaining optimal I.V fluid volume and cardiac output.

• Relative fluid overload → pulmonary oedema may be necessary to prevent oliguria and risks of ARF. Iatrogenic pulmonary oedema treatable!

• Acute tubular necrosis (ATN) – only treatment is HAEMODIALYSIS.

INCREASED RISK OF ACUTE RENAL FAILURECo-existing renal diseaseProlonged renal hypoperfusion (hypovolaemia, hypotension)High risk surgery (abdominal aneurysm resection, cardiopulmonary

bypass)Advanced ageCongestive heart failureExtensive burnsSepsis and/or jaundiceTreatment with prostaglandin inhibitors

TESTS USED FOR EVALUATION OF RENAL FUNCTION1. Glomerular filtration rateBlood, urea, nitrogenSerum creatinineCreatinine clearanceProteinuria

2. Renal tubular functionRine specific gravityUrine osmolarityUrine sodium

ACUTE HEPATIC FAILURE (AHF)

Regardless of aetiology, AHF is associated with poor progress.- Hyperventilation constant feature. Reflects stimulation of ventilation by ammonia.- Hypoglycaemia common- C.O tends to ↑ (due to ↑ arteriovenous shunting)- Bleeding diathesis resembling DIC.- Terminal events – renal failure, arterial hypoxaemia, hypotension and hepatic

encephalopathy.

Treatment of AHF – Symptomatic and supportive, Neomycin, lactulose or both to decrease ammonia production

MALNUTRITIONCritically ill patients often experience malnutrition (negative caloric intake) complicated by hypermetabolic

states 2° trauma (multiple fractures energy about 25% and burns by as much as 100%), fever,

(every 1° C increase energy needs by 15%), sepsis and wound healing.

Give enteral nutrition (tube feeding) OR Total Parenteral Nutrition (TPN) usually delivered through a catheter placed in a central vein e.g. subclavian.

Complications of Total Parenteral Nutrition (TPN) 1. Hyperglycaemia2. Hypoglycaemia3. Hyperchloremic metabolic acidosis4. Increased carbon dioxide production5. Electrolyte abnormalities6. Catheter – related sepsis

CONCLUSIONSEvery one is involved(doctor and nurse) in given special attention and close monitoring of the patient.Patient should be regularly reviewed by doctorsPatient should be in a bed that is easily viewed by Nurse and near emergency trolley.Urgency is essential in patient management.• All the systems should be examined at each review.• Vital signs should be monitored regularly• Fluids input and output chart• Nutrition• Others : wound care ,physiotherapy, bathing, oral care, nails care

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