Management of critically ill

patients in the ICU

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• History of Critical care medicine dates back to
the middle of the previous century.
• During this time, the field approaches to the
management of
Mechanical ventilation, hemodynamic support,
sedation, renal replacement therapy,
• Modern critical care focuses on inter-
professional care, family engagement, and long-
term outcomes.
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 Levels of care
• Level 1; units having staff and technologic
equipment so that every critical patient can be
managed
• Level 2; units managing critically ill patients
with specific fields. Eg neurosurgery icu.
• Level 3 units where critically ill patients can be
temporarily stabilized with criteria's for
transfer for other units.

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 Management principles
Clinical examination
• A, patent, protected or not
• B, respiratory distress,lung expansion
• C, rhythm assesment,active bleeding,
pulse volume
• D, neurologic deficits,
• E, exposure and whole body examination
 Management principles
Monitoring
 Continues vital sign
monitoring(BP,PR,RR,T,pain)
• Both invasive and non invasive BP monitoring
 ECG monitoring; rhythm assessment, signs of
myocardial ischemia, electrolyte abnormalities
 Management principles
 Respiratory monitoring
• Pulseoxymetry monitoring
• Capnograhy monitoring; detects end
expiratory CO2
• ABG analysis; indicated mainly for
mechanically ventilated patients
Respiratory support and care
• Patient may have air way obstruction,
• Altered ventilation,
• Poor secretion clearance
• Impaired muscle function
• Invasive and non invasive ventilation
support
 Respiratory care includes
• Deep breathing and alveolar recruitment
• Chest percussion
• Positioning
• Suctioning
• Tracheostomy care
Cardiovascular support and care
• Assessment of hemodynamic status, volume
states
• Positioning
• Inotropic and vasopressor support
• DVT prophylaxis
 DVT prophylaxis
• Pulmonary embolism is the most common
preventable cause of hospital death
• All patients admitted to ICU are considered
high risk for VTE
• Patients with active malignancy
• Stroke wit limb paralysis
• pregnancy
• Mechanical and pharmacologic DVT
prophylaxis
• Intermittent pneumatic compression stocking
• UFH, LWH, direct thrombin inhibitors, factor x
inhibitors
• Commonly encountered risk factors are;
sepsis, IBD, known thrombophilia, prolonged
immobility>= 3days, age >60
 Bleeding risk assesment
• Before using pharmacologic DVT prophylaxis
 Contra indications for pharmacologic DVT
prophylaxis
• Active bleeding, intracranial hemmorhage
• Thrombocytopenia < 50k or <100k with
additional risk factor
• Planned surgical procedure in 12 hours
Gastrointestinal care
• Immobility and pain is associated with
gastric stasis and aspiration
• Patients 30 degree head up prevents
aspiration.
• Early enteral feeding
• Stress ulcer prophylaxis
 Stress ulcer prophylaxis
• Stress ulcer usually occurs in the fundus and body of
stomach
• Stress ulceration begins with in hours of major trauma
or illness
• Two major risk factors for clinically important GI
bleeding is
 Mechanical ventilation >48 hours
 Coagulophaty with platelet <50,000,INR>1.5 ,PT >2X
upper limit
 Additional indications for GI prophylaxis
• Shock, multiple trauma, History of GI
ulceration
• Head trauma, spinal trauma, burn injury
• Glucocorticoid therapy with hydrocortisone
>250 mg or equivalent.
• Sepsis, ICU staty >1 week.
• For critically ill patients who are able to receive
enteral medications oral PPI are preferred
• If oral PPI is not tolerated oral H2 blocker or
antacids
• If patient does not tolerate PO intravenous PPI,
or H2 blocker.
• In situations when cost is not an issue IV ppi is
prefered
Neuromuscular care
• Immobility and prolonged neuromuscular
blockage prompts atrophy
• Result in joint contracture and foot drops
• Neuromuscular weakness in the ICU is most
often due to myopathy and neurophaty
• Occurs in 25% of patients mechanically
ventilated in the ICU for >1 week
• Clinically appear with symmetric flaccid limb
weakness and ventilatory muscle weakness
• Failure to wean from MV
• Extra ocular muscle weakness occur rarely
• Patients with critical illness myophaty had
intact sensation
• Elevated CK support CIM
• Management
• Aggressive management of medical conditions
• Rehabilitation
• Minimizing sedation
• Limiting use of NMB
• Early mobilization
Infection control
• Hand washing is vital to prevent transmission
of organisms between patients
• Gloves, gowns , plastic apron for sterile
procedures
• Isolation for transmissible infections
• Change arterial and central venous dressings
every 48-72 hours
Skin care, mouth care
• Cutaneous pressure sores due to local
pressure
• Friction oedema
• Turn patient every 2 hours and protect
susceptible areas
Pain;
• Inadequate pain control is paramount.
• Inadequate pain control is linked
agitation, and anxiety.
• Contribute to stress response
• Immobilization, endotracheal tubes,
invasive monitors
Critical care nutrition
• Catecholamines and other hormones increases the
outputs of the respiratory, cardiovascular, and
metabolic systems
• β2-adrenergic stimulation increases glycogenolysis,
hepatic gluconeogenesis, and glucagon release
while blocking glycogen synthesis
• Lipolysis is increased by β2- and β3-adrenergic
stimulation but inhibited by α2-stimulation
• If patients are eating on their own, then
monitoring their intake is necessary.
• The enteral route is favored over the parenteral
method
• It costs less, no need for intravascular access, the
maintenance of gut function.
• maintaining gut integrity (the gut derives up to
70% of its nutrients from luminal food) reduce
the translocation of bacteria from the gut
• Cardiopulmonary resuscitation
• Forward systemic arterial blood flow
continues after cardiac arrest until the
pressure gradient between the aorta and right
heart reaches equilibrium.
• A similar process occurs with forward
pulmonary blood flow between the
pulmonary artery and the left atrium.
• The arterial and venous pressures reach
equilibration ; 5 minutes after no-flow cardiac arrest,
• At this time coronary perfusion and cerebral blood
flows stop.
 The goal of cardiopulmonary resuscitation (CPR)
thus is
• To maintain oxygen and blood supply to vital organs,
• Restore spontaneous circulation,
• Blood flow is generated as a result of actual
compression of the heart between the
sternum and the vertebral column
• During chest compression,
 the tricuspid and mitral valves close,
 the left and right ventricular volumes
decrease, and blood is ejected into the arterial
system
• During the decompression phase of CPR;
 The pressure gradient between the systemic
venous system and thoracic cavity facilitates
blood flow into the heart chambers.
 Increases in the intrathoracic pressure, as
might occur with overventilation during CPR,
will impair venous return
• Blood flow rather than arterial oxygen content
is the limiting factor for oxygen delivery to
coronary, cerebral, and systemic circulation
during CPR.
• Thus rescue breaths are less important than
initiating effective chest compressions as soon
as possible after SCA
 BASIC LIFE SUPPORT
 Aspects of adult BLS include
• Immediate recognition of SCA
• Activation of the emergency response system,
• Early CPR, and rapid defibrillation with an
automated external defibrillator (AED).
• The recommended sequence for a single
rescuer is to initiate chest compressions
before giving rescue breaths [C-A-B]
• The single rescuer should begin CPR with 30
chest compressions followed by 2 breaths.
• Pause of chest compressions may still be
required for accurate rhythm analysis.
• But the compressions should be resumed as
soon as possible after rhythm analysis or
defibrillation.
 Recognition of Sudden Cardiac Arrest
• The necessary first step in the management of
cardiac arrest is its immediate recognition.
• The healthcare provider should take no more
than 10 seconds to check for a pulse and,
• If the rescuer does not definitely feel a pulse
within that time period, start chest compressions.
• If the victim is unresponsive with absent or
abnormal breathing, the rescuer should assume
that the victim is in cardiac arrest
 The components of high-quality CPR include
• Compressing the chest at an adequate rate
and depth,
• Allowing complete chest recoil after each
compression,
• Minimizing interruptions in compressions, and
• Avoiding excessive ventilation
 Defibrilation
• For adult witnessed cardiac arrests when an AED is
immediately available, the defibrillator should be used
as soon as possible.
• For adults with unmonitored cardiac arrest or for
whom an AED is not immediately available,
• It is reasonable that chest compressions be initiated
while the defibrillator equipment is being retrieved
and applied,
• Defibrillation, if indicated, be attempted as soon as
the device is ready for use.
• Ventricular fibrillation (VF) and pulseless VT are
the most common cardiac arrhythmias in adults
cardiac arrest.
• If a monophasic defibrillator is available, then a
single 360 joule (J) shock should be delivered.
• With biphasic defibrillators, a much lower
energy level (150-200 J) is usually sufficient to
terminate the arrhythmia
• Chest compressions are immediately resumed
after shock delivery;
• Cardiac rhythm is reanalyzed as indicated after
2 minutes of chest compressions and rescue
breathing; and
• Defibrillation is attempted only for VF and
rapid VT.
• The 2015 AHA Guidelines for CPR and ECC
recommended a 2-minute period of chest
compressions after each shock instead of immediate
successive shocks for persistent VF.
• The rationale for this is that when VF is terminated, a
brief period of asystole or pulseless electrical activity
(PEA)
• A perfusing rhythm is unlikely to be present
immediately, necessitating chest compressions to
provide organ perfusion and circulation of ACLS drug
 Airway Management and Ventilation
in Cardiac Arrest
• Options include standard bag-mask ventilation
versus placement of an advanced airway (i.e.,
ETT or SGA device).
• Bag-mask ventilation with a head tilt–chin lift or
head tilt–jaw thrust maneuver is recommended
for initial airway control in most circumstances
• The choice of bag-mask device versus advanced
airway insertion is determined by the skill and
experience of the provider
 Asystole
• Asystole is the complete and sustained
absence of electrical activity and portends
extremely poor prognosis.
• Following the steps in the ACLS Pulseless
Arrest Algorithm and identifying and
correcting any treatable, underlying causes for
the asystole.
• In most patients, asystole is irreversible, but a
brief trial of resuscitation, beginning with
effective chest compressions,
• Oxygen therapy, and
• Intravenous (IV) epinephrine,
 Pulseless Electrical Activity
• PEA refers to the presence of organized electrical
activity without a palpable pulse.
• Priority must be given to identifying possible
reversible causes of PEA,
• Referred to as the five Hs (Hypoxia, Hypovolemia,
Hypothermia, Hyper- or Hypokalemia, Hydrogen
ions or acidosis)
• Ts (Tamponade, Tension pneumothorax, Toxins,
Thrombosis Pulmonary, and Thrombosis Coronary).
• Prompt initiation of chest compressions and
the administration of 1 mg epinephrine are
recommended as temporizing measures
• Until more definitive therapy can be provided
once the cause for the PEA is identified.
• Asystole or VF can develop if PEA is not
corrected.
 Pulseless Ventricular Tachycardia or
Ventricular Fibrillation
• Pulseless VT and VF are shockable rhythms and
hence the most treatable causes of cardiac arrest,
• Early defibrillation, not pharmacologic
intervention, is responsible for the improved
survival after VF cardiac arrest
• If ROSC does not occur after an initial
defibrillatory attempt, then five cycles of CPR
consisting of 30 compressions to 2 ventilations
(nonintubated patient)