Basics of ICU careDr 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. Consciousness2. Airway competency3. Features of respiratory insufficiency4. 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 bundles1. Ventilator Bundle 2. Central Line Bundle3. Sepsis Resuscitation Bundle4. 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 clinicians should 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 bundle1. Serum lactate measured2. Blood cultures obtained prior to antibiotic administration3. Improve time to broad-spectrum antibiotics4. Treat hypotension and/or elevated lactate with fluids5. Apply vasopressors for ongoing hypotension6. Maintain adequate central venous pressure7. 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 within 24 hours of presentation for patients with severe sepsis or septic shock

Details of sepsis management details1. 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