Introduction to ICU Basics in ICU

INTRODUCTION TO ICU
Rahul AP.
BPT,MPT, MIAP (CRD&ICU Management )
Assi Proff: LIAHS –Kannur,Kerala

INTENSIVE CARE UNIT
 It can be defined as a “service for patients with
potentially recoverable diseases who can be benefit
from more detailed observation and treatment than
is generally available in standard wards and
departments” [Petros et al..,1995]
Or
The intensive care unit is a designated area of a
hospital facility that is dedicated to the care of
patients who are seriously ill.

DIFFERENT UNITS
 There are verity of names depends on specific purpose
and the degree of dependency of the patient
 Many different hospitals have many different terms.
Frequently seen are
MICU = Medical ICU
SICU = Surgical ICU
TICU = Trauma ICU orTransplant ICU
NICU = Neuro ICU or Neonatal ICU
PICU = Pediatric ICU
CVICU = Cardiovascular ICU
CCU = Coronary Care Unit
CICU = Cardiac ICU
BICU = Burn ICU
RCU = Renal care unit

 ITU-(intensive treatment unit )highest level of
patient dependency ,most aggressive treatment
and monitoring protocols … CSU-cardiac surgery
units are best example
 SCBU-(special care baby unit)neonatal problems
often requiring IPPV and invasive monitoring
techniques
 HDU-(high dependency unit)recovering area of
an operating theatre)with low level of monitoring
and high level of nursing care

The main functions of any ICU is to
Provide optimum life support
&
Provide adequate monitoring of vital
functions.

ICU PATIENTS
 critical patients (multiple diagnoses, multi-organ
failure, immunocompromised and major trauma
and post surgery)
 Move less
 Malnourished
 More obtunded / deaden (Glasgow coma scale)
 Heart, kidney, liver failure etc…

PREPRATION OF THE UNIT
The unit should be kept ready all the time which
should include the following
1.special bed having the following facilities
 Head board should be detachable to facilitate
intubation (in case of cardio pulmonary arrest)
 Bed should be firm and non yielding to facilitate
cardiac massage
 Should have a tilting mechanism (to keep
position of patient)

 Should have side rails to prevent falling
(psychiatric and anxious patient)
 There should be a bed side locker an over bed
table and a foot stool kept adjacent to the bed
2.Cardiac monitor system with alarm that may be
connected to the central console
3.Oxygen and suction apparatus (preferably pipe
line model)
4.Resuscitation unit containing the following
 Syringes,needles, IV cath, intravenous
administration sets, blood sets, scalp vein sets
and intra venous fluid

 Spirit, swabs, adhesive plaster (micropore/transpore),
torniquets and arm board
 Airways, endotracheal tubes and laryngoscopes of
different sizes
 Ambu bag and suction catheters
 Oxygen cylenders special trays such as tracheostomy
tray, and catheterization tray
 Drugs such as
(antiarrhythmics,antianginals,antihypertensive,diure
tics,anticoagulents,antibiotics,anticonvulsants etc…
 Infusion pump

Following equipments should be easily available
 Defibrillator in working mode with electrodes and
jell
 Cardiac pacemaker with pacing catheters in the
sterile tray
 Mechanical ventilators (to ventilate the lungs in
case of resp:arrest)
 Facility for invasive and non invasive procedure like
(CVP line, intra arterial pressure monitor )
 Portable X-Ray machine
 ECG machine
 Oxygen therapy

Indications for admission
 Pre and post-operative patients and who
underwent major surgeries.
 Craniotomy patients.
 Thoracotomy patients.
 Ultra major surgeries.
 Unstable multiple trauma patients.
 Patients with head or spine trauma requiring
mechanical ventilation.
 Any surgical patient who requires continuous
monitoring or continuous life support

The monitor screen above the patient will display
 Blood pressure
 Central venous pressure CVP
 Heart rate
 Pulmonary artery pressure PAP
 Oxygen saturation
 Patient temperature
 Intracerebral pressure ICP
 ECG
Monitoring system

INVASIVE BLOOD PRESSURE
MONITORING (IBP)
 Arterial cannulation is used in patients in ICU to
access arterial blood sample , for checking ABG
and for arterial pressure monitoring
 Arterial cannula is not used for intra vascular drug
administration
 A saline-filled tube is used to connect the
cannula to the transducer, to the display.
 It measures IBP on beat to beat basis.

CENTRAL VENOUS PRESSURE (CVP)
 The CVP cannula is inserted in to the internal or
external jugular vein or subclavian vein
 The tip is situated approximately 2cm above the
right atrium in the superior vena cava
 They provide access for intra venous drugs
particularly which produce irritation to peripheral
veins eg-strong potassium chloride

HEART RATE
 Normal : 60 -100 beats per min
 Less than 60 : Bradycardia
 More than 100:Tachycardia

BRADYCARDIA
 Symptomatic
 Asymptomatic

SYMPTOMATIC BRADYCARDIA
SIGNS AND SYMPTOMS
 Acute altered mental status
 Ongoing chest pain
 Hypotension
 Signs of shock

MANAGEMENT
 Assess ABC (airway breathing and circulation)
 Maintain patent airway
 Assist breathing
 Start oxygen
 Monitor vitals
 IV access (Atropine)

ASYMPTOMATIC
 Heart rate of less than 60
 Patient completely asymptomatic (stable)
 Requires no specific management

TACHYCARDIA
Stable
 Heart rate more than 100
Treat underlying problem
 Dizziness.
 Shortness of breath.
 Lightheadedness.
 Rapid pulse rate.
 Heart palpitations -a racing, uncomfortable or irregular
heartbeat
 Chest pain.
 Fainting (syncope)

MANAGEMENT
 Vagal maneures
 Pharmacologic
 Adenosine 6mg-12mg
 Amiodarone 150 mg slow IV

 Unstable
Management
 Synchronised Cardioversion 50 - 100 joules

Pulmonary artery pressure PAP
 The introduction of pulmonary artery catheter
(PAC) is the most popular and important
advances in monitoring.
 It measures the pressure at three different
places right atrium, pulmonary artery, and
pulmonary capillaries.
 It measures amount of oxygen in the blood ,
cardiac output, PAP, PCWP & CVP It is also used
to figure out how much blood flows out of your
heart overall.

 Pulmonary capillary wedge pressure PCWP
is recorded when the balloon tipped
catheter is inflated and the tip moves along
with the blood flow to occlude a small
pulmonary artery
 The inflated balloon records the pressure
in the pulmonary capillary
 PCWP reflects left atrial pressure
 Decreased PCWP means hypovolaemia
 Increased PCWP means increased preload
caused by fluid over load

Oxygen saturation SpO2
 The pulse oximeter measures the oxygen
saturation
 It is noninvasive and risk free when used
properly, the pulse oximeter should be used in all
clinical settings in which there is a potential risk
of arterial hypoxemia
 It provide an early and immediate warning of
hypoxaemia
 If SpO2 is below 95% means the O2 delivering
system is inadequate to meet the needs of the
tissue or poor cardiac output
 Start O2 if SPO2 less than 95%

Patient Temperature
 Temperature regulation is important to the
survival of the patient
 Although uncommon, hypothermia below 32° C is
ominous
 Ventricular irritability increases, and if the
temperature decreases to 28° C cardiac arrest is
likely
 shivering can increase oxygen demand 135% to
468%,when respiratory and cardiovascular
systems may be unable to respond normally to the
increased demand

Sites for monitoring body temperature
1.Oral.
2.Tympanic membrane
3.Esophageal
4.Nasopharyngeal
5.Pulmonary arterial blood
6.Rectal
7.Bladder
8.Axillary
9.Forehead

Drains and tubes
Definition
 A surgical drain is a tube used to remove pus,
blood or other fluids from a wound.
 Drains inserted after surgery do not result in
faster wound healing or prevent infection but
are sometimes necessary to drain body fluid
which may accumulate and itself become a
focus of infection

Jackson-Pratt drain
 Jackson-Pratt drain, JP drain, or Bulb drain, is a
drainage device used to pull excess fluid from
the body by constant suction.
 The device consists of a flexible plastic bulb
that connects to an internal plastic drainage
tube

Penrose drain
 A Penrose drain is a surgical device placed in a
wound to drain fluid.
 It consists of a soft rubber tube placed in a
wound area, to prevent the build up of fluid

Corrugated Rubber Drain
 The drain is fixed by a suture at the end of the
wound and a safety pin is placed through the end
to prevent the drain slipping inwards.
 Corrugated rubber drains can be used for the deep
wound for drainage.

T-Tube
 T tube is a tube consisting of a stem and a cross
head (thus shaped like aT ).
 The cross head is placed into the common bile
duct while the stem is connected to a small
pouch (i.e. bile bag).
 It is used as a temporary post-operative drainage

 Purpose of aT tube Handling of the common bile
duct in the form of dissection, dilatation,
choledochotomy and cholecystectomy can lead to
spasm of the sphincter of Oddi
 This can cause back pressure and give way of
sutures used to suture the choledochotomy incision
leading to a surgical calamity.
 It is used to slowing down the motility in the
common bile duct as well as to reduce spasm of the
sphincter of Oddi

 TheT tube should be kept for a period of 10 days
allowing the patient to recover from the stress of
surgery.
 The bile should be allowed to flow out easily
through theT tube.This reduces the pressure on the
suture line until the sphincter spasm disappears
allowing free egress of bile into the duodenum.

ChestTube or Pleural drainage tube
or intercostals drain
 Used to remove either air or fluid in the pleural
space
 Used to drain; haemothorax, pneumothorax,
chylothorax, pleural effusion and epyema.
 Tube is inserted in to the pleural space in the 4th
intercostal space

NasogastricTubes
 Naso-gastric tube passes through the nostrils
(sometimes through oral cavity!) to the stomach,
to the duodenum or even jejunum
 During the insertion the tube has to point
downward toward the xiphoid process
 once reach the nasopharynx, twist it to 180
degrees this minimizes the risk of tube coiling at
the pharynx
 lubricate the proximal part of the tube with
lidocain jelly and push
 ask the patient to swallow, the tube is now in the
stomach..

Endotracheal tubes
A tracheal tube is inserted into the trachea for the
primary purpose of establishing and maintaining a
patent airway and to ensure the adequate exchange
of oxygen and carbon dioxide
Indications
 Assisted ventilation
 Isolate trachea to permit control of airway
 Direct route of suctioning
 Administration of medication via ETT

 Inserted ETT should lie at least 5cm above the
carina
 Carina usually at the level ofT4
 The tip may change by 2cm with flexion and
extension

Tracheostomy tube
Indication
 Airway obstruction at or above level of larynx
 Respiratory failure
 Paralysis of muscle that effect swallowing or
respiration
 The tip lies between stoma and carena
 Tip placement not effected by flexion and extension

Catheter and lines
 A catheter is a hollow flexible tube that can be
inserted into a body cavity, duct or vessel.
Catheters thereby allow injection of fluids ,
distend a passageway or provide access by
surgical instruments.
 The process of inserting a catheter is called
catheterization .

Catheters can be broadly classified Under these
groups
DIAGNOSTIC CATHETERS
 Used for Angiographs
GUIDING CATHETERS
 Used for Angioplasty
 Guiding catheters are like angiography catheters
only difference is that guiding catheters are more
stiffer & firm as it carries Balloon catheters, PTCA
wires and stent delivery system.
 Mild stiffness comes due to the wire braided design.

Butterfly Catheters
 It is a device specialized for vein puncture: i.e for
accessing a superficial vein for either intravenous
injection or for fluid maintain

Foley ’s Catheters
A Foley catheter is a thin, sterile tube inserted into the
bladder to drain urine. It can be left in place in the
bladder for a period of time, it is also called an
indwelling catheter
 Used to collect uncontaminated urine specimen
 Urine output monitoring
 Managing urination during surgery
 Before and after cesarean sections
 On patients who are in anesthesia or sedated

Central venous catheters
 Used in critically ill patients for venous access
 To measure central venous pressure and
intravascular blood volume

Percutanious intravascular Central catheters PICC
 It is used for long term access
 It is small in size
 It is inserted through antecubital vein
 The tip lie with in superior vena cava

Percutanious intravascular Central catheters

Pulmonary artery catheter
 Also known as Swann-ganz catheter
 It is inserted into the pulmonary artery
 Its purpose is diagnostic, it is used to detect heart
failure and monitor therapy
 The pulmonary artery catheter allows direct
measurement of pressures in the right atrium,
right ventricle, pulmonary artery, and wedge
pressure

Introduction to ICU Basics in ICU

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