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DESIGN AND

ORGANIZATION OF
INTENSIVE CARE UNITS
Prof. Amir B. Channa
Professor
Department of Anaesthesia
King Khalid University Hospital

Critical Care
of
MORIBUND Patient
Definition of Critical Care:

Care of the problem with


which the patient has been
admitted.

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Patient Care in the ICU

1.Holistic Approach
2.Challenges

General care
CNS
Respiration
CVS
Renal
Hemopoetic system care
Renal replacement therapy

Holistic Approach
GIT
Nutritional care: fluid & electrolyte status
maintenance
Psychological
Locomotor system
Skin care
Prevention of nosocomial infection
Patients are/may become
immunocompromised
In case of death or demise sympathy with

Design of ICU
Services required

Basic requirement of
ICU

Policies and procedures and protocols


Consultations of other subspecialties
Back of LABORATORIES, pharma depth
x-rays
MRI
CT
Facilities for emergency surgery
End stages diseases policies
Brain stem dead patients
Policies for harvesting organs transplant
surgery

ROLE OF THE ICU


Level I Adult ICU Small District Hospital.
Level II Adult ICU General Hospital
Level III Adult ICU Tertiary Hospital
Provide all aspects of intensive care required

by its referral role for indefinite periods.


Staffed by specialist intensivists with trainees,
critical care nurses, allied health professionals,
clerical and scientific staff.
Support of complex investigations, imaging
and specialists of all disciplines.
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Patient Care in the ICU

HIGH DEPENDENCY UNIT


An HDU is a specially staffed
and equipped section of an
intensive care complex that
provides a level of care
intermediate between intensive
care and general ward care.
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TYPE, SIZE AND SITE OF AN


ICU
Medical ICU
Surgical ICU

CCU

Burns ICU
Pediatric ICU
Neonatal ICUs
Multidisciplinary ICU

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TYPE, SIZE AND SITE OF AN


ICU
Number of ICU beds
1 to 4 per 100 total hospital beds
ICUs with less than 4 beds are
considered not to be cost effective
Over 20 non-high dependency beds
maybe difficult to manage

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TYPE, SIZE AND SITE OF AN


ICU
ICU should be sited in close proximity to
relevant acute areas
Operating rooms
Emergency department
CCU
Labour ward
Acute wards
Investigational departments (e.g. radiology,
organ imaging, and pathology laboratories)
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TYPE, SIZE AND SITE OF AN


ICU
Critically ill patients are at risk when

they are moved


Sufficient numbers of lifts
With door and corridors
Spacious enough to allow easy
passage of beds and equipment
Often ignored by planning experts
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Patient Care in
the ICU
Assess current status, interval history, and

examination
Review vital signs for interval period (since
last review)
Review medication record, including
continuous infusions: Duration and dose.
Change in dose or frequency based on
changes in renal, hepatic or other
pharmacokinetic function. Changes in route
of administration. Potential drug interactions
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Patient Care in the


ICU
Correlate changes in vital signs with

medication administration and other


changes by use of chronologic charting
Review, if indicated:
Respiratory therapy flow chart
Hemodynamics records
Laboratory flow sheets
Other continuous monitoring
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Patient Care in the


ICU
Integrate nursing, respiratory therapists, patient,

family, and other observations.


Review all problems, including adding, updating,
consolidating or removing problems as indicated
Periodically, review supportive care:
Intravenous fluids
Nutritional status and support
Prophylactic treatment and support
Duration of catheters and other invasive devices
Review and contrast risk and benefits of intensive
care.
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General ICU Care


Nosocomial infections, especially line-and

catheter related.
Stress gastritis
Deep venous thrombosis and pulmonary
embolism
Decubitus ulcers
Psychosocial needs and adjustments.
Toxicity of drugs (renal, pulmonary, hepatic,
CNS)
Development of antibiotic-resistant organisms.
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General ICU Care


Complications of diagnostic tests
Correct placement of catheters and tubes
Need for vitamins (thiamine, C, K)
Tuberculosis, pericardial disease, adrenal

insufficiency, fungal sepsis, rule out


myocardial infarction, pneumothorax, volume
overload or volume depletion, decreased
renal function with normal serum ceratinine,
errors in drug administration or charting,
pulmonary vascular disease, HIV-related
disease.

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Nutrition
Set goals for appropriate nutrition support
Avoid or minimize catabolic state
Acquired vitamin K deficiency while in ICU
Avoidance of excessive fluid intake
Diarrhea (lactose intolerance, low

protein,hyperosmolarity drug-induced,
infection)

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Patient Care in the ICU

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Nutrition
Minimize and anticipate hyperglycemia

during parenteral nutritional support


Adjustment of support rate or formula in
patients with renal failure or liver failure
Early complications of refeeding
Acute vitamin insufficiency

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Acute Renal Failure


Volume depletion, hypoperfusion, low cardiac

output, shock
Nephrotoxic drugs
Obstruction of urine outflow
Interstitial nephritis
Manifestation of systemic disease, multiorgan
system failure
Degree of preexisting chronic renal failure
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Diabetic
Ketoacidosis
Evaluate degree of volume depletion and relationship

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of water to solute balance (hyperosmolar component)


Avoid excessive volume replacement
Look for a trigger for diabetic ketoacidosis (infection,
poor compliance, mucormycosis, other)
Avoid hypoglycemia during correction phase
Calculate water and volume deficits
Evaluate presence of coexisting acid-base
disturbances (lactic acidosis, metabolic alkalosis)
Avoid hypokalemia during correction phase

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Hyponatermia
Consider volume depletion (nonosmolar

stimulus for ADH secretion)


Consider edematous state with
hyponatremia (cirrhosis, nephrotic
syndrome, congestive heart failure)
SIADH with nonsuppressed ADH
Drugs (thiazide diuretics)
Adrenal insufficiency, hypothyroidism
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Hypernatermia
Diabetes insipidus
Diabetes mellitus
Has patient been water-depleted for a

long-time?
Concomitant volume depletion?
Is the urine continuing to be poorly
concentrated?
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Hypotension
Volume depletion
Sepsis (Consider potential sources; may need

to treat empirically)
Cardiogenic (Any reason to suspect?)
Drugs or medications (prescribe or not)
Adrenal insufficiency
Pneumothorax, pericardial effusion or
tamponade, fungal sepsis, tricyclic overdose,
amyloidosis
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Swan-Ganz
Catheters
Site of placement (safety, risk, experience of

operator)
Coagulation times, platelet count, bleeding
time, other bleeding risk
Document in medical record
Estimate need for monitoring therapy
Predict whether interpretation of data may be
difficult (mechanical ventilation, valvular
insufficiency, pulmonary hypertension)
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Upper Gastrointestinal
Bleeding
Rapid stabilization of patient

(hemoglobin and hemodynamics)


Identification of bleeding site
Does patient have a non-upper GI
bleeding site?
Consider need for early operation
Review for bleeding, coagulation
problems
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Upper Gastrointestinal
Bleeding
Determine when excessive amounts

of blood products given


Do antacids, H2 blockers, PPIs play a
role?
Reversible causes or contributing
causes.

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Fever, Recurrent
Or Persistent
New, unidentified source of infection
Lack of response of identified or

presumed source of infection


Opportunistic organism (drug-resistant,
fungus, virus, parasite, acid-fast
bacillus)
Drug fever
Systemic noninfectious disease.
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Fever, Recurrent
Or Persistent
Incorrect empiric antibiotics
Slow resolution of fever (deep-seated

infection: endocarditis, osteomyelitis)


Infected catheter site or foreign body
(medical appliance)
Consider infections of sinuses, CNS,
decubitus ulcers; septic arthritis
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Pancytopenia
(After Chemotherapy)
Fever, presumed infection, response to

antimicrobials
Thrombocytopenia and spontaneous
bleeding
Drug fever
Transfusion reactions
Staphylococcus, candida, other
opportunistic infections
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Pancytopenia
(After Chemotherapy)
Infection sites in patient without

granulocytes may have in duration,


erythema, without fluctuance
Pulmonary infiltrates and opportunistic
infection

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DESIGN OF AN ICU
Single entry and exit point
Attended by the unit receptionist
NO Through traffic of goods
People to other hospital areas must

NEVER be allowed
Rooms for public reception
Patient management and support
services.
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PATIENT AREAS
Each patient bed area in an
adult ICU requires a minimum
floor space of 20 m2 (215 ft2)

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TABLE I.I Physical Design of a


Major ICU
Reception Area
Waiting room for visitors
Distressed (crying) / interview room
Overnight relatives room

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TABLE I.I Physical Design of a


Major ICU
Patient Areas
Open multi-bed wards
Central nurse station (including drug
storage)
Specialized rooms/beds if necessary, for
procedures/minor surgery (e.g.
tracheostomy), haemodialysis, burns,
and use of bypass or intra-aortic balloon
pump machines.
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TABLE I.I Physical Design of a


Major ICU
Storage and Utility Areas
Monitoring and electrical equipment
Respiratory therapy equipment
Disposables and central sterilizing supplies
Linen
Stationery
Fluids, vascular catheters and infusion sets
Non-sterile hardware (e.g. drip stands and bed rails)
Clean utility
Dirty utility
Equipment sterilization.
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TABLE I.I Physical Design of a


Major ICU
Technical Areas
Laboratory
Workshop for repairs, maintenance, and
development.

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TABLE I.I Physical Design of a


Major ICU
Staff Areas
Lounge/rest room (with facilities for
meals)
Changing rooms
Toilets and showers
Offices
Doctors on-call rooms
Seminar/conference room.
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TABLE I.I Physical Design of a


Major ICU
Other Support Areas
Cleaners room
Plant room/alcove

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TABLE I.I Physical Design of a


Major ICU
The ratio of single room beds to open-ward

beds would depend on the role and type of


the ICU, built 1:6 is recommended
Single rooms are essential for isolation cases
and (less importantly) privacy for conscious
long stay patients.VENTILATION !!!!!!!!!!!!
Sufficient numbers of non-splash hand wash
basins, one for every two ward beds, should
be built close to the beds.
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TABLE I.I Physical Design of a


Major ICU

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Utilities per bed space as recommended for a level III


ICU are:
3 oxygen
2 air
3 suction
16 power outlets
A bedside light
Adequate and appropriate lighting for clinical observation
Services are supplied from floor column
Wall mounted
Bed pendent
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STORAGE AND SUPPORTING


SERVICES AREAS
Most ICUs lack of storage space. Storage areas
should total a floor space of about 25-30% of all.
Equipment
Staffing
Medical Staff
- ICU director
- Sufficient specialist staff
- Administration
- Teaching
- Research
- Reasonable working hours.
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TABLE I.2 Equipment in a


Major ICU
Monitoring
Radiology
Respiratory Therapy
Cardiovascular Therapy
Support Therapy
Dialytic Therapy
Laboratory
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Intensive care Unit Bed

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Use of computers for patient


monitoring.

Automatic
control

Patient

Clinician

Transducers

equipment

Display

Computer

DBMS

Reports

Mouse and
keyboard

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ICU
Bed

Nurse station
WEB
connection

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Bed

Bed

Bed

Telemetry

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Some instruments in mind

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And more...

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Types of Data Used in Patient


monitoring in different ICUs

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TABLE I.3 Staff of a Major


ICU
Medical
Director
Staff Specialist intensivists
Junior Doctors

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TABLE I.3 Staff of a Major


ICU
Nurses
Nurse Managers
Nurse Specialists
Nurse Educators
Critical Care Nurse Trainees

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TABLE I.3 Staff of a Major


ICU
Allied Health
Physiotherapists
Pharmacist
Dietician
Social Worker
Respiratory Therapists

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TABLE I.3 Staff of a Major


ICU
Technicians
Secretarial
Secretary
Ward Clerk

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TABLE I.3 Staff of a Major


ICU
Radiographers
Supporting Staff
Orderlies
Cleaners

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TABLE I.3 Staff of a Major


ICU
Nursing Staff
1:1 Nursing
Single bed requires 6 nurses

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OPERATIONAL POLICIES
Clear cut administrative policies
An open ICU has unlimited access to multiple

doctors
A closed ICU has admission
Quality assurance, continuing education and
research
Consideration of relatives
Effective communication
Physical environment
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OPERATIONAL POLICIES
Other supportive measures
Social worker
Counselor
Priest or religious
Follow-up counseling
Emotional support for staff
Death occurs
Family should be allowed privacy to mourn, to

view, touch, and hold the deceased.

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Factors influencing
outcome from a critical
illness
Patient factors
- Pervious health status
- Physiological reserves
- Biological age
- Co morbidity
Disease factors
- Type of disease
- Severity of disease
Treatment factors
- Treatment available?
- Timing if therapy
- Suitability of therapy
- Response to treatment

Scoring systems for ICU & surgical patients


General scores
SAPS II and predicted mortality
APACHE II and predicted mortality
APACHE III
SOFA (Sequential Organ Failure Assessment)
MODS (Multiple Organ Dysfunction Score)
ODIN (Organ Dysfunctions and / or INfection)
INfection)
MPM (Mortality Probability Model)
on admission
24 hours
48 hours
MPM Over Time (admission-24 h-48 h)
MPM II (Mortality Probability Model)
on admission
24 h, 48 h, 72 h
LODS (Logistic Organ Dysfunction System)
TRIOS (Three days Recalibrated ICU Outcome Score)
RIYADH scoring system
MEES (Mainz Emergency Evaluation System)

General scores
PRISM (Pediatric RISk of Mortality)
DORA (Dynamic Objective Risk Asse
ssment)
PELOD (Pediatric Logistic Organ Dys
function)
PIM II (Paediatric
Index of Mortality II)
PIM (Paediatric Index of Mortality)

PGH MPM Philippines

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Scoring systems for ICU & surgical


patients
Specialized and Surgical Intensive
Care - Preoperative evaluation
EUROSCORE (cardiac surgery)
ONTARIO (cardiac surgery)
Parsonnet score (cardiac surgery)
System 97 score (cardiac surgery)
QMMI score (coronary surgery)
Early mortality risk in redocoronary
artery surgery
MPM for cancer patients
POSSUM (Physiologic and Operative
Severity Score for the enUmeration of
Mortality and Morbidity) (surgery, any)
Portsmouth POSSUM (surgery, any)
IRISS score : graft failure after lung
transplantation
Glasgow Coma Score
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Specialized : Neonatal,
Surgical, Meningococcal septic
shock
CRIB II (Clinical Risk Index for Babies)
CRIB (Clinical Risk Index for Babies)
SNAP (Score for Neonatal Acute Physiol
ogy)
SNAP-PE (SNAP Perinatal Extension)
SNAP II and SNAPPE II
MSSS (Meningococcal Septic Shock Scor
e)

GMSPS (Glasgow Meningococcal


Septicaemia Prognostic Score)
Rotterdam Score (meningococcal septic
shock)
Children's Coma Score (Raimondi)
Paediatric Coma Scale (Simpson &
PatientReilly)
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Scoring systems for ICU & surgical


patients
Trauma scores

Pediatric Trauma
Scores

ISS (Injury Severity Score),


RTS (Revised Trauma Score),
TRISS (Trauma Injury
Severity Score)
ASCOT (A Severity
Characterization Of Trauma)

Pediatric Trauma
Score

24 h - ICU Trauma Score

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TABLE 1: Scoring systems for


ICU & surgical patients
Therapeutic
intervention, nursing
ICU scores

Pediatrics : therapeutic
intervention, nursing
ICU scores

TISS (Therapeutic Intervention


Scoring System)

NTISS : Neonatal Therapeutic


Intervention Scoring System

TISS-28 : simplified TISS

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The APACHE II scoring system


Variable

Maximum points

Temperature
Mean arterial pressure
Heart rate
Respiratory rate
Oxygenation
Arterial pH
Sodium
Potassium
Creatinine
Haematocrit
White cell count
Glasgow coma scale
Acute physiology score
Age
Chronic health evaluation
APACHE II score
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4
4
4
4
4
4
4
4
8
4
4
12
16
6
5
71
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Scoring of Various Acute physiological


Variables
A APACHE II

+4

+3

+2

41

39-40.9

+1

+1

Temperature

MAP

160

130-159

110-129

70-109

50-69

49

HR

180

140-179

110-139

70-109

55-69

40-54

RR

50

Oxygenation1
pH

7.7

7.6-7.69

Na+

180

160-179

K+

6.6-6.9

Creat

Hct

60

50-59.9

46-49.9

WCC

40

20-39.9

15-19.9

15-GCS

FIO2

35-49
500

38.5-38.9 36-38.4

25-34
350-499

12-24

200-349

10-11
< 200

7.5-7.59 7.33-7.49
155-159

34-35.9 32-33.9

6-9

> 05/24/15
0.5 record A-aO2

3.5-5.4

2.5-2.9

30-45.9 20-29.9
3-14.9

1-2.9

+4
29.9

39

PaO2> 70 61-70
7.25-7.32 7.15-7.24 < 7.15
120-129

3-3.4

30-31.9

+3

150-154 130-149

5.5-5.9

+2

111-119

55-60

< 55

110

<2.5

< 20
<1

Patient
Care in the ICU
FIO2< 0.5 record
PAO2

77

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