LIFE IN THE ICU

by Doris Louise Cellona-Obra MD

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SOUND OF PNEUMATIC DRILLING: 50 DECIBELS
SOUNDS IN
THE ICU:
60-80
DECIBELS
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 Types of patients that can
benefit from ICU admission

1) Those that require monitoring and

treatment
when > 1 vital functions are
threatened by an
acute disease or by sequelae of
surgical
procedures leading to life
threatening
conditions
 Types of patients that can
benefit from ICU admission
2) Those that are already having
failure of one or
more vital functions (CVS, renal,
respiratory,
metabolic, cerebral) but with
reasonable
chance of recovery.
 Types of patients that can
benefit from ICU admission
2) Those that are already having failure of one or
more vital functions (CVS, renal, respiratory,
metabolic, cerebral) but with reasonable
chance of recovery.

End stage untreatable terminal diseases

are not admitted
Brain dead patients or those whom brain
death is expected--- for organ transplant
 Levels of Care
Level of Care III

o Highest level of care

o Patients with multiple ( 2 or more) acute
vital organ failure of an immediate life
threatening character
o Patients depend on pharmacologic,
hemodynamic or device related organ
support
 Levels of Care
Level of Care II

o Patients with one acute vital organ

failure of an immediate life
threatening character
o Needs hemodynamic support,
respiratory assistance, renal
replacement therapy
 Levels of Care
Level of Care I
o Patients experience signs of organ
dysfunction necessitating continuous
monitoring
o Patients at risk for developing one or more
organ failures
o Patients recovering from one or more acute
organ failures but still unstable
o Needs minor pharmacologic or device
related support
 Level of Nurse to
Care Patient
Ratio
III 1:1
II 1:2
I 1:3
 Staf
I. MEDICAL STAFF
> Medical Director of the ICU
> Medical staf members
> Medical trainees

II. NURSING STAFF

 Staf
III. ALLIED HEALTH CARE
PERSONNEL
> Respiratory therapists
> Physiotherapists
> Technicians
> Psychologist
IV. CLEANING PERSONNEL
V. ADMINISTRATIVE PERSONNEL
FOCUS:
THE MEDICAL
DIRECTOR
 Role of the Medical Director

o Protocols, practice guidelines,

and order sets
> established protocols for
management
result in better outcomes
> Detailed protocols
> Driven protocols
> ICU director may develop, review,
accept,
 Role of the Medical Director
o Quality of Care Assurance
> Patient satisfaction
> Analyzing quality of delivery of care
> Monitoring complications
> Duration of hospitalizations
> Analysis of mortality data
> Privileges to practice in the ICU-
competence

Most effective global determination:

Patient outcome
 Role of the Medical Director
o Infection Control
> Prevention and management of
nosocomial
infection
> Nosocomial infections
preventable by
adherence to policies designed to
limit
spread of infection
 Role of the Medical Director
o Infection Control
>Infection control protocols
aseptic technique for invasive procedures
standards for universal precautions
duration of invasive catheter placements
suctioning
appropriate use of antibiotic
procedures for antibiotic resistant
organisms
isolation as needed
 Role of the Medical Director
o Education and Errors
o Communication
> liaison between MDs, nurses, allied
staf
> address complaints, procedures,
policies
o Burnout
o Outcome and alternatives
> decisions on admission, discharge,
transfers
FOCUS:
PRINCIPLES OF CRITICAL CARE
 I. EARLY IDENTIFICATION OF
PROBLEMS

Needs frequent and regular review of

all info
Rapid response team
> For patient deteriorating outside
the ICU
> Mini-ICU environment even before
patient is
transferred to the ICU
 Routine Patient Care in
the ICU
o Assess current status, interval
history, exams
o Review vital signs
o Review medication record
o Correlate vital signs with medication
administration by chronology
o Integrate observations by nurses,
respiratory therapists, patient, and
family
 Routine Patient Care in
the ICU
o Review
> respiratory therapy flow chart
> hemodynamic records
> laboratory flow sheets
> Other continuous monitoring
o Review all problems
o Review supportive care: nutrition, IV,
catheters
o Review risks and benefits of ICU care
 II. Efective Use of Problem
Oriented Medical Record
o Each problem listed separately and
reviewed
o Problem must not be restricted by
diagnosis
o Share patients problem oriented
medical record with non-physicians
caring for the patient
REMEMBER: PATIENTS
RECORDS ARE
 III. MONITORING AND DATA
DISPLAY
o ECG
o BP
o Pulse oximetry
o Serial glucose and
electrolytes
o ABG
o Ventilator settings
o Temperature
o I and O
o Weight
 IV. SUPPORTIVE AND
PREVENTIVE CARE
In the ICU, there is high incidence of:
o GIT hemorrhage
o Deep venous thrombosis
o Decubitus ulcers
o Inadequate nutritional support
o Nosocomial infections and VAP
o UTI
o Psychosocial problems
o Sleep disorders
Example:
Giving prophylaxis vs stress ulcers
> Highest in those with respiratory failure or
coagulopathies
> Otherwise, risk of significant bleeding
only
0.1 %
ERGO: Give anti- ulcer prophylaxis only in
those with high risk to GIT bleed
V. UNDERSTANDING PSYCHOSOCIAL
AND OTHER NEEDS OF PATIENT

Reasons for psychological

consequences of ICU care:
o Patients lack of control over their
environment
o Disruption of sleep-wake cycle
o Inability to communicate easily and
quickly
o Pain and other discomfort
o Financial concerns
 PATIENT COMFORT
Explain Orient
all the
procedu patient
res as to
before time
starting and
them place

Facilit
Involve ate a
patient
proper
and
family day
Provide night
in plan suitable
of care rhyth
means of
communicatio
m
ns for the
patient
 Communication:
Alternative Ways
o Mouthing words
o Writing
o Pointing to pictures
or letters
o Use of tablets/
laptops

Needs patience,
dedication, and
creativity
VI. UNDERSTANDING THE LIMITS
OF CRITICAL CARE

o Limitations as physicians
o Critical illness have high morbidity
and mortality
o Ethical and legal : determination of
brain death, patient autonomy,
consent of care, advance directives,
surrogate decision makers
o Alternative to ICU care reviewed
periodically
FOCUS: FAST HUG
Vincent JL. Give your
patient a fast hug (at
least) once a day.
Crit Care Med. 2005
Jun 33(6):1225-9.
Give your patient fast hug (at
least) once a day
F Feeding
A Analgesia
S Sedation
T Thromboembolic
prevention
H Head of bed
elevated
U Ulcer (stress)
prophylaxis
Pain Scoring System
FASTHUG MAIDENS
FOCUS: PROBLEM BASED
MEDICAL HISTORY
 Basic Components
o Data base:
Name, History, PE, Labs
o Complete problem list
o Initial Plans
o Daily Progress Notes
o Final Progress Notes or Discharge
Summary
 General Data
o Religion
o General survey
o Anthropometric
measurements
o Vital signs
HR, RR, Temp
BP
o Informant: %
reliability
 In Pediatrics,
o Birth rank
add:
o Prenatal , Natal history, Post-
natal history
o Feeding history
o Developmental milestones
o Immunization history
Physical Examination
 In the chest

oObservation
oPalpation
oPercussion
oAuscultation
 In the chest

oObservation
oPalpation
oPercussion Chest: Barrel chested,
equal chest expansion,
oAuscultation hyperresonance on
percussion, (+)
wheezing
all over lung fields
 Problem List
o May be a :
1) diagnosis
2) non-diagnosis
> symptom or a sign
> abnormal laboratory result
> presence of catheters and
date of
insertion
A.B. , 25 days old, male, Roman Catholic
Chief complaint: Difficulty in breathing
HPI:
PE: RR= 70/min HR= 170/min Temp=
37C
Chest: (+) intercostal retraction,
palpation and percussion not done, (+)
rales both lung fields
CBC: WBC= 35, 000 Segmenters: 80%
Proble Date Problem Problem
m no. Entered List Resolved
1 11/3
Tachypnea
2 11/5
Tachycardi
a
3 11/4
Retraction
s
Proble Date Problem Proble
m no. Enter List m
ed Resolve
d
1 11/5 Neonatal
pneumoni
a
 After the Problem List
oThen give your
Assessment
oFinally, give your Initial
Plans
 Progress Notes
o S : subjective complaints
o O : objective findings (e.g. physical
exam)
o A : assessment
o P : plan
> diagnostic
> therapeutic
> supportive
> plan for discharge
 11/24/2015
S : Patient no longer complains of difficulty in
breathing, cough not as frequent and is now
productive, appetite is improving
O:
V/S: RR= 30/min HR= 90/min Temp= 36.5
Chest: No more retractions, bilateral equal vocal
fremitus, occasional wheezing, (-) rales
A: Acute asthma attack- improving
Pneumonia - resolving
P: Therapeutic-- cont meds, refer for pulmonary
toileting
Diagnostic for repeat chest xray
 Basic Components
o Data base:
Name, History, PE, Labs
o Complete problem list
o Initial Plans
o Daily Progress Notes
o Final Progress Notes or Discharge
Summary
 is not written,
did not happen!