Basics of ICU care

Dr Guvera Vasireddy
What is critical care?

Critical care is medical care for

patients whose illness requires close,
constant watch by a team of
specially trained caregivers.
Most critical care takes place in an
intensive care unit (ICU) or a trauma
centre.
How does it differ from other
branches of medicine? (Wikipedia)
Intensive care usually takes a system by system approach to treatment,
rather than the SOAP (subjective, objective, analysis, plan) approach of
high dependency care.
The nine key systems are each considered on an observation-
intervention-impression basis to produce a daily plan.
Intensive care treatment raises other issues including psychological
health, pressure points, mobilisation and physiotherapy, and secondary
infections.
The nine key IC systems are (alphabetically): cardiovascular system,
central nervous system, endocrine system, gastro-intestinal tract (and
nutritional condition), hematology, microbiology (including sepsis
status), peripheries (and skin), renal (and metabolic), respiratory
system.
Many disciplines, one team.
The concept of critical care is to ensure the survival of
the patient and prevent end organ damage by providing
optimal support.
It involves the institution of set interventions based on
evidence based medicine to improve the survival of
critically ill patients with minimal disability.
Critical care givers comprise a team care givers with
special training.
Each member of the team has specific role in the care
giving and includes a check list to monitor at each level.
Who needs to be admitted to ICU
Depending on the severity of illness patient care is
devided in to three levels.
Level 1 basic care with intermittent monitoring.
Level 2 continuous monitoring with ability to provide
hemodynamic support and invasive monitoring.
Level 3 invasive ventilator support along with level 2
care.
Level 2 and level 3 care areas are combined in most
hospitals with lower resources and called as ICUs.
How to recognize the severity of
illness?
Back to basics

assess:
1. Consciousness
2. Airway competency
3. Features of respiratory insufficiency
4. Hemodynamic stability
What to do?
Early goal directed therapies to counter the deleterious
effects of loss of homeostasis.
Try to bring back the physiological parameters as close
to their normal levels as possible.
Intensive care bundles
A bundle is a structured way of improving the processes
of care and patient outcomes:
Small, straightforward set of evidence-based practices.
Generally three to five that, when performed
collectively and reliably, have been proven to improve
patient outcomes
Most commonly implemented
bundles
1. Ventilator Bundle
2. Central Line Bundle
3. Sedation and analgesia bundle
4. Sepsis Resuscitation Bundle
5. Sepsis Management Bundle
Importance of implementation of
bundles :
all or none rule
All the elements of the bundle are necessary and removing any
one of them will result in inferior result.
All the elements in the bundle are based on randomized
controlled trial (Level 1 evidence) and the recommendations are
beyond any controversy.
A bundle rather focuses on how to deliver this evidence of care
rather than what the right care should be.
All elements in the bundle involve an all or none phenomenon
and the Bundle itself also bears
Implementation of all Bundle elements should take place
simultaneously at a specific time and place with a minimum delay.
Ventilator care bundle
Elevation of the Head of the Bed
Daily interruption of sedation and assessment of
readiness to wean
Peptic Ulcer Disease Prophylaxis
Deep Venous Thrombosis Prophylaxis
Daily Oral Care with Chlorhexidine
What else to do for improving
outcomes?
Daily interruption of sedation protocol
Coordinate interruption of sedation with weaning
protocol
Use of validated sedation scale
Incorporate other ICU staff
Use visual cues
Standardized order sets
Checklists / multidisciplinary rounds
Central line bundle
Appropriate hand hygiene
Chlorhexidine skin prep
Maximal barriers for central line insertion
Subclavian vein placement is preferred site
Review lines daily and remove unnecessary catheters
How to implement these bundles?
Rigorous staff education
Central line checklist
Keep all necessary equipment in an easily accessible cart
Empower nursing to enforce use of a central line
checklist
Include daily review of line as part of multidisciplinary
rounds and daily goals sheet
Easy to find record of date and time of placement
Sedation and analgesia bundle
Protocol-directed sedation
Use of validated sedation scale
Bolus doses of benzodiazepines instead of a continuous
infusion
Sedatives with a short duration of action
Daily interruption of sedation (DIS) also referred to as
spontaneous awakening trials
Sepsis resuscitation bundle
Describes seven tasks that should begin immediately,
but must be accomplished within the first 6 hours of
presentation for patients with severe sepsis or septic
shock.
Some items may not be completed if the clinical
conditions described in the bundle do not prevail in a
particular case, but cliniciansshould assess for them.
The goal is to perform all indicated tasks 100 percent of
the time within the first 6 hours of identification of
severe sepsis.
Details of sepsis resuscitation
bundle
1. Serum lactate measured
2. Blood cultures obtained prior to antibiotic
administration
3. Improve time to broad-spectrum antibiotics
4. Treat hypotension and/or elevated lactate with fluids
5. Apply vasopressors for ongoing hypotension
6. Maintain adequate central venous pressure
7. Maintain adequate central venous oxygen saturation
Sepsis management bundle
Lists four management goals.

Efforts to accomplish these tasks should also begin

immediately.

These items may be completed within24 hours of

presentation for patients with severe sepsis or septic
shock
Details of sepsis management
details
1. Administer Low-Dose Steroids by a Standard Policy
2. Administer Drotrecogin Alfa (Activated) by a Standard
Policy
3. Maintain Adequate Glycemic Control
4. Prevent Excessive Inspiratory Plateau Pressures