Post on 01-Jul-2015
transcript
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