Transcript 25-ICU.ppt

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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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 kin or kith
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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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
CCU
 Surgical ICU
 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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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 ICU’s
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Continuous
variables
Sampled
variables
Coded Data
Free Text
Cardiac
ECG
Heart rate
(HR)
HR variability
PVCs
Temperature
Central
Peripheral
Patient
observation
Color
Pain
Position
Etc.,
All other
observations
or
interventions
that cannot
be measured
or coded
Blood pressure
Arterial/venous
Pulmonary
Left/right
atrial/ventricular
Systolic/Dyastol
Per beat/average
Systolic time
intervals
Respiratory
Frequency
Depth/vol/flow
Pressure/Resist
Respiratory
gases
Neurological
EEG
Frequency
components
Amplitudes
Coherence
Blood Chemistry
Hb
PH
PO2
PCO2
Etc.,
Interventions
Infusions
Drugs
Defibrillation
Artificial
ventilations
Anesthesia
Fluid balance
Infusions
Blood plasma
Urine loss
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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
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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)
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
Assessment)
PELOD (Pediatric Logistic Organ
Dysfunction)
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
Specialized : Neonatal, Surgical,
Meningococcal septic shock
CRIB II (Clinical Risk Index for Babies)
CRIB (Clinical Risk Index for Babies)
SNAP (Score for Neonatal Acute Physiology)
SNAP-PE (SNAP Perinatal Extension)
SNAP II and SNAPPE II
MSSS (Meningococcal Septic Shock Score)
GMSPS (Glasgow Meningococcal Septicaemia
Prognostic Score)
Rotterdam Score (meningococcal septic
shock)
Children's Coma Score (Raimondi)
Paediatric Coma Scale (Simpson & Reilly)
Glasgow Coma Score
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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, Pediatrics : therapeutic
intervention, nursing ICU
nursing ICU scores
scores
TISS (Therapeutic Intervention
Scoring System)
TISS-28 : simplified TISS
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NTISS : Neonatal Therapeutic
Intervention Scoring System
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The APACHE II scoring system
Variable
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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Maximum points
4
4
4
4
4
4
4
4
8
4
4
12
16
6
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Scoring of Various Acute physiological Variables
A APACHE II
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+4
+3
+2
+1
+1
+2
+3
34-35.9
32-33.9
30-31.9
+4
•
Temperature
•
MAP
≥160
130-159
110-129
70-109
50-69
•
HR
≥180
140-179
110-139
70-109
55-69
40-54
≤39
•
RR
≥50
35-49
12-24
10-11
6-9
≤5
•
•
•
Oxygenation1
≥500
350-499
pH
≥7.7
7.6-7.69
•
Na+
≥180
160-179
•
K+
≥7
6.6-6.9
•
Creat
≥
•
Hct
≥60
•
WCC
≥40
•
15-GCS
•
1
FIO2
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≥41
39-40.9
> 0.5 record δA-aO2
38.5-38.9 36-38.4
25-34
200-349
155-159
< 200
PaO2> 70
7.5-7.59 7.33-7.49
61-70
150-154 130-149
7.25-7.32
120-129
2.5-2.9
≤49
55-60
7.15-7.24
< 55
< 7.15
111-119
≤110
5.5-5.9
3.5-5.4
50-59.9
46-49.9
30-45.9
20-29.9
< 20
20-39.9
15-19.9
3-14.9
1-2.9
<1
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≤29.9
FIO2< 0.5 record PAO2
<2.5
77
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