WELCOME AND GREETINGS TO ALL

Corridor….

Inside ICU

Inside ICU

ICU Beds Inside

Inauguration…..

ICUWhat does it mean???

Intensive care units (ICU),

also called

critical care unit or

intensive therapy unit or

Intensive Treatment Unit (ITU)

ICU Are sections within a hospital

That look after patients:

whose conditions are life-threatening and need constant, close monitoring and support from equipment and

medication

to keep normal body functions going.

A person in an ICU needs constant medical attention and support to keep their body functioning.

They may be unable to breathe on their own and have multiple organ failure.

Medical equipment will take the place of these functions while the person recovers.

Intensive care is often needed when one or more of your organ

systems have failed.

For example, this might be your:

• lungs

• kidneys

• heart

• digestive system

Conditions and situations that can cause your organ systems to fail

• a serious accident – such as a road accident or a severe head injury

• a serious acute (short-term) health condition – such as a heart attack (where the supply of blood to the heart is suddenly blocked), or a stroke (where the blood supply to the brain is interrupted)

Cont…..

• a serious infection – (SIRS) such as a severe case of pneumonia (inflammation of the lungs) or sepsis(blood poisoning)

• major surgery – this can either be a planned admission to an ICU as part of your recovery after surgery or an emergency measure if there are complications during surgery

Intensive care units (ICUs) contain a variety of specialized

equipments, which may vary from one unit to another.

A series of tubes, wires and cables connect the patient to various equipments, which may look alarming at first.

Sounding and beeping of these may puzzle the patient and attendants.  

Main ICU machines

VentilatorMonitoring equipments• heart and pulse rate (measured by an

electrocardiogram or ECG)• air flow to your lungs• blood pressure and blood flow• pressure in your veins (known as central venous

pressure or CVP)• the amount of oxygen in your blood• your body temperature

Main ICU machines (Cont…)

IV lines and pumps• sedatives – to reduce anxiety and

encourage you to sleep• antibiotics – medication that is usually

given in high doses and used to treat infections caused by bacteria

• analgesics – also known as painkillers• Inotropes• Insulin

Main ICU machines (Cont…)

Kidney supportRespiratory supportFeeding tubeDrainsCathetersSuction pumpsOthers

Recovery

Once you are able to breathe unaided, and you no longer need intensive care and you will be transferred to a different ward to continue your recovery. (HDU)

Only Recoverable, acute condition patients are suitable candidate for ICU. Chronic, end stage diseases are not usually suitable…….

Common recovery problems

Severe weakness and tiredness

Loss of weight and muscle strength

Weak voice

Inability to grip small items

Feeling depressed

Cognitive function

Levels of Care"Comprehensive Critical Care" defined four

different levels of care:• Level-0 

Patients whose needs can be met through normal ward

• Level-1 Patients at risk of their condition deteriorating, or higher levels of care whose needs can be met on advice and support from the critical care team.

• Level-2 Patients requiring more detailed observation or intervention, single failing organ system or postoperative care, and higher levels of care.

Levels of Care (Cont..)Level-3 

Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

High dependency can refer to level 1 or 2 whereas intensive care usually means level 2 or 3.

Historical Backgrounds of ICU concepts

800 BC: Prophet Elisa- mouth to mouth…

460-70 BC: Hipocrates- 1st Endo-tracheal Intubation…(Treatise on air)…

1550: Paracelsus used “Fire Bellows”, 1st concept of mechanical ventilation.

1774: John Fothergill- mouth to mouth….

1774: Dr. William Haves establish “Royal Humane Society” contributed much…

Historical Backgrounds of ICU concepts (Cont…)

High pressure-tension pneumothorax…

1837: manual compression of chest…

1864: Dr. Alfred Jones devised “tank Ventilation” known as “Iron lung”.

1889: Alexander Graham Bell devised a vacuum jacket……

1929: Philip Drinker devised electrically powered tank ventilator, “iron lung”…

Historical Backgrounds of ICU concepts (Cont…)

Later developed cuirass

All these (tank & cuirass) were negative pressure ventilators

1st recorded concepts of ICU are paralytic poliomyelitis epidemics in …….

1948: Los Angels

1952: Scandinavia

Historical Backgrounds of ICU concepts (Cont…)

1952: Denmark (severe epidemics)- Ambu by medical students plus tank and cuirass.

All were managed by negative pressure ventilations….

Lassen and Ibsen: basic principle of IPPV with modern ventilation (volume, pressure, humidification, oxygen and physiotherapy)

1955: Stockholm and New England epidemics-IPPV…..

1960: IPPV, its superiority and CVS effect.

Mechanical Ventilation (1)

• Use of a machine to take over active breathing for a patient

• Used for patients who are unable to sustain the level of ventilation necessary to maintain the gas exchange functions - oxygenation and carbon dioxide elimination

Ventilator in RpMCH ICU

Mechanical Ventilation (2)

Goals: • Increase efficiency of breathing• Increase oxygenation• Improve ventilation/perfusion relationship• Decrease work of breathing

Indications:

A. Established acute respiratory failure

B. Incipient respiratory failure

C. Low output states

D. Purposeful hyperventilation

Mechanical Ventilation (Indications)

A) Established Acute Respiratory Failure Primary ventilatory failure

– Poisonings which depress the CNS– CNS and neuromuscular disorders ( poliomyelitis, infective polyneuritis, myasthenia)– Snake bites– Severe tetanus

Hypoventilating comatose patients Acute pulmonary disorders e.g. fulminant pneumonia,

acute lung injury (ARDS) Fulminant pulmonary oedema Major or massive pulmonary embolism Major or massive atelectasis Patients with COPD in acute crisis, unresponsive to

conventional therapy Patients with acute severe asthma , unresponsive to

conventional therapy

Mechanical Ventilation (Indications)

B) Incipient Respiratory Failure Obese patients who have undergone upper abdominal

surgery, or poor risk surgical patients Respiratory muscle fatigue in critical illnesses Patients with excessive ventilatory demands Patients with acute fulminant parenchymal lung disease

with rapidly progressive impairment of pulmonary function and reserve

C) Low output states Shock of any etiology

D) Purposeful hyperventilation To decrease intracranial tension in patients with head

injury To reduce cerebral edema after CPR or massive CVA

Commonly used modes of mechanical ventilation

Controlled mandatory ventilation (CMV)• Assist control ventilation (ACV)• Synchronized intermittent mandatory

ventilation (SIMV)• Pressure support ventilation (PSV)• Positive end expiratory pressure (PEEP)• Continuous positive airway pressure (CPAP)• Bilevel positive airway pressure (BIPAP)• Intermittent mandatory ventilation (IMV)• Pressure control ventilation (PCV)

Monitoring Mechanics

Pressure, flow, and volumeTime‐based graphics (waveforms)

– Pressure– Flow– Volume

Derived measures– Compliance– Resistance

Loops– Pressure volume– Flow volume

Care of a patient on respiratory

support

analgesia

Sedation

Muscle relaxatio

n

Nutrition

Care of lungs

Preventing complicationsChest infectionsVenous thrombosisPulmonary embolismGI bleed

Care of unconscious patient

Care of vascular lines and

tubes

Psychological care

Complications of mechanical

ventilation

PulmonaryPulmonary barotraumaChest infectionVenous thrombosisPulmonary embolismLung fibrosis (late)Alveolar hyperventilationAtelactasis

CardivascularDecreased cardiac outputDysrhythmiasPulmonary artery catheter complications

GastrointestinalPneumoperitoneumDecreased GI motilityGastrointestinal haemorrhage

Nutritional MalnutritionExcess CO2 production

RenalFluid retentionRenal failure

OthersBacteremiaMultiorgan failurePsychological consequencesEndocrine dysfunctionPressure sores

Weaning

• Process of withdrawal of mechanical ventilatory support that transfers the work of breathing from ventilator to the patient

• This period may take many forms ranging from abrupt to gradual withdrawal from ventilatory support

• The aim of ventilatory support is to unload the patient’s respiratory pump, while weaning is the process of reloading the respiratory pump

Why Wean

early ???

Increased risk of

VAP

Increased ICU length

of stay

Increased hospital length

of stay

Increased morbidity &

mortality

Increased cost

Decreases the availability of

ICU beds

Can adversely affect the patient

outcome

Weaning CriteriaClinical Criteria Objective Criteria

• Adequate cough

• Absence of excessive tracheobronchial secretions

• Resolution of the disease acute phase for which the patient was intubated

• Ventilatory criteria

• Oxygenation criteria

• Pulmonary reserve

• Pulmonary measurements

• Other factors

Basic monitoring requirements for seriously ill patients

• Heart rate

• Blood pressure

• Respiratory rate

• Pulse oximetry

• Hourly urine output

• Temperature

• Blood gases

Non-Invasive Monitoring

– Clinical variables – BP – ECG– Echocardiography – Esophageal doppler – Gastric tonometry

Invasive Monitoring

– Arterial line– Systolic pressure variation – Central venous pressure– Pulmonary artery catheterization– Cardiac output– Mixed venous oxygen

Maintaining Homeostasis to allow time for recovery

Continuous or repeated observation + vigilance in order to maintain homeostasis

Standard ICU personnelCrit Care Med 2003; 31(11):2677–2683• Vary significantly from hospital to hospital• With respect to structure, services provided,

personnel and their level of expertise, and organizational characteristics.

• Based on economic and political factors• Depend on the population served, the services

provided by the hospital and by neighboring hospitals, and the subspecialties of physicians on the hospital’s staff

Standard ICU personnel (cont..)Crit Care Med 2003; 31(11):2677–2683Large medical centers frequently have multiple

ICUs:• Cardiothoracic surgical ICUs, • Trauma ICUs,• Coronary care units, and • Neurologic/ neurosurgical ICUs. • NICUs

Small hospitals may have only one intensive care unit designed to care for a large variety of critically ill patients including adult and pediatric populations. (RpMCH???)

ICU personnel in RpMCH

No post of Doctors till now….(needs post creation)

Inadequate trained nurses…..

No organizational (Organogram) settings till now…

……………………

ICU admission Criteria

(Adapted from McQuillan et al BMJ 1998;316:1853-8.)

• Threatened airway

• All respiratory arrests

• Respiratory rate ≥40 or ≤8 breaths/min

• Oxygen saturation <90% on ≥50% oxygen

• All cardiac arrests

• Pulse rate <40 or >140 beats/min

ICU admission Criteria (Cont)

(Adapted from McQuillan et al BMJ 1998;316:1853-8.)

• Systolic blood pressure <90 mm Hg• Sudden fall in level of consciousness (fall

in Glasgow coma score >2 points)• Repeated or prolonged seizures• Rising arterial carbon dioxide tension with

respiratory acidosis• Any patient giving cause for concern

Multidisciplinary Approach

Acute organ failure (Recoverable)- ICU

Main disease- concerned to respective department

Any additional problem- to be concerned with respective specialty.

X-ray technicians, physiotherapists etc are also concerned.

Mortality rate and expectations

Rigon et al. Critical Care 2006 10:R5   doi:10.1186/cc3921 Characteristic Hospital mortalityOverall population 97/203 (47.8%)Autologous stem cell transplantation19/29 (65.5%)Clinically documented lung disease 17/27 (63.0%)Absence of congestive heart failure 3/25 (12.0%)Neurological impairment 36/52 (61.2%)Neutropenia 41/71 (57.8%)Unknown cause of acute resp failure 24/42 (57.1%)Acute respiratory distress syndrome 29/40 (72.5%)

Brain death and Medicolegal Aspects

• Cardiac death:– Heartbeat and breathing stop

• Brain death:– Irreversible cessation of all functions of the

entire brain, including the brain stem

Organ donation

• Call LifeLink for all deaths– Donor or not in your eyes– Tissue – bone, corneas, heart valves

• Mentioning organ donation to family– LifeLink will approach them after declared, but this

approach may (will) be changing back to times when the PICU docs talked with the parents

• If family asks you about donation– Acknowledge that it is a wonderful gift they are

considering– Tell them you will contact LifeLink to have them

available for questions– Contact LifeLink ASAP

References 1. Egan’s – Fundamentals of Respiratory Care 9th ed.2. International Anaesthesiology Clinics – Update on

respiratory critical care, vol 37, no 3, 1999.3. David W Chang, Clinical application of mechanical

ventilation 3nd ed4. Paul L Marino, The ICU Book, 3rd ed.5. Farokh Erach Udwadia-Principles of Critical Care, 2nd ed.6. Joseph M Civetta,Critical care, 3rd ed.7. Keith Sykes,JDYoung – Respiratory Support in Intensive

Care BMJ Publishers,20008. PKVerma – Mechanical Ventilation and nutrtion in Critically

Ill Patients ,19999. Curves and loops in mechanical ventilation – Manual by

Drager Medical 10. BiPAP - Manual by Drager Medical