Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...
critical care unit.
1. C.U.Shah College of Pharmacy & Research M.pharm Sem-3 (pharmacology Department) Prepared by Guided by maulikthakornimishpathak
2. Introduction The objectives of an Intensive Care Department (ICD) are the monitoring and support of failing vital functions in critically ill patients, in order to perform adequate diagnostic measures and medical and/or surgical therapies to improve outcome. CRITICAL CARE MANAGEMENT
3. Management of patients on admission to ICU Handover from transferring team to ICU staff Full clinical assessment Ongoing resuscitation/stabilisation Establishment of monitoring Review of medical and social history Communication (including explanation) with relatives Investigations to establish or confirm the definitive diagnosis Formulation and implementation of a management plan
4. Monitoring in ICU represents a mixture of clinical and automated recordings. Electrocardiogram (ECG), SpO2 (oxygen saturation derived from a pulse oximeter), BP (generally invasive arterial pressure) and usually CVP are established at an early stage, and recordings made at least hourly, on either a 24-hour chart or a computerised system Urine output is a sensitive measure of renal perfusion and early catheterisation is required in most patients. Clinical monitoring is particularly important. Physical signs such as respiratory rate, the appearance of the patient, restlessness, conscious level and indices of peripheral perfusion (pale, cold skin; delayed capillary refill in the nailbed) are just as important as a set of blood gases or monitor readings.
5. Daily clinical management in the ICU Review of progress reports from ICU nursing and medical staff, and any specialist opinions. Review of 24-hour charts. Examination: general (including skin, line sites, wounds etc.) and specific: cardiovascular, including haemodynamics, fluids and inotropes respiratory, including ventilator settings and ABGs gastrointestinal, including nutrition (calorie, protein intake, route), nasogastric aspirate and bowel function renal, including urine output, overall fluid balance, urea and electrolytes, and renal replacement therapy neurological, including sedation level, GCS and pupil responses where appropriate.
6. Laboratory results: haematology, including coagulation, and biochemistry. Microbiology: temperature, white blood count, line sites and other possible sources of infection, results of cultures, antibiotic therapy. Drug therapy: review with pharmacist, consider side-effects and interactions, and identify therapy that can be discontinued. Imaging: review X-rays and other specialist investigations. Monitoring: are all measures still required? Management plan: formulate an integrated plan, with specific goals for each organ system.
7. Sedation and analgesia Sedation is required for most patients in order to relieve anxiety, allow tolerance of an endotracheal tube, mechanical ventilation and invasive procedures, and control intracranial pressure in neurological disease. Over-sedation is a common occurrence, and can delay weaning from ventilation and prolong ICU stay. Daily sedation 'pauses' can allow better patient assessment, prevent sedative accumulation and have been shown to reduce ICU stay. Standard sedation consists of a mixture of either the short-acting anaesthetic agent propofol or the benzodiazepine midazolam, and an opioid analgesic, traditionally morphine Analgesia is required to relieve post-operative and other pain.
8. Muscle relaxants Muscle relaxants are used less now than previously. They are required to facilitate endotracheal intubation, to facilitate ventilation in patients with critical oxygenation and/or poor lung compliance, and to aid control of critically increased intracranial pressure. Delirium Delirium is a feature of severe illness, especially when patients are subjected to major organ dysfunction, metabolic derangement and polypharmacy. Haloperidol in 2.5-5 mg doses (i.v.) and the α2-adrenergic agonist clonidine are useful in immediate management.
11. Optimise volume status Fluid challenge(s) CVP < 6 mmHg: 250 mL 0.9% saline or colloid CVP > 6 mmHg or poor ventricular function suspected: 100 mL boluses and consider measuring cardiac output, e.g. PA catheter or oesophageal Doppler Optimisehaemoglobin concentration 70-90 g/L; 100 g/L if ischaemic heart disease Red cells as required Septic patients can become profoundly anaemic with crystalloid/colloid resuscitation due to haemodilution and require blood transfusion Achieve target BP Use vasopressor/inotrope once hypovolaemia is corrected
12. Achieve adequate CO and D O2 Inotropic agent if fluid alone inadequate Other measures Establish monitoring, including invasive measures, as resuscitation starts Trends in haemodynamics, ABG, H+, base deficit and lactate guide further treatment
13.
14. Neurological disease Coma of any cause Status epilepticus Drug overdose Respiratory muscle failure (e.g. Guillain-Barré syndrome, poliomyelitis, myasthenia gravis) Head injury: to avoid hypoxaemia and hypercapnia, and reduce intracranial pressure Bulbar abnormalities causing risk of aspiration (e.g. cerebrovascular accident, myasthenia gravis
16. Tracheostomy is usually performed electively when endotracheal intubation is likely to be required for over 14 days. Box 8.23 describes the advantages and disadvantages. Tracheostomy is usually carried out using a percutaneous technique in the ICU, avoiding the need for transfer to the operating theatre. This has led to its earlier and more frequent use. A recent multicentre RCT found that early tracheostomy (< 3 days) did not lead to earlier weaning or shorter ICU stay.
17. Advantages and disadvantages of tracheostomy Advantages Patient comfort Improved oral hygiene Reduced sedation requirement Enables speech with cuff deflated and a speaking valve attached Earlier weaning and ICU discharge Access for tracheal toilet Reduces vocal cord damage Disadvantages Immediate complications: hypoxia, haemorrhage Tracheal damage; late stenosis Tracheostomy site infection
18.
19. This is associated with fewer osmotic fluid shifts and hence greater haemodynamic stability than haemodialysis. It is carried out using a double-lumen central venous catheter placed percutaneously. Haemofiltration should be continuous in the early phase of treatment; higher rates of filtration (preferably > 35 mL/kg/hr) are associated with improved outcome. Obstruction of the renal tract should always be excluded by abdominal ultrasound and, if present, relieved.
20.
21. Ranitidine and sucralfate are both used to reduce the risk of gastrointestinal haemorrhage, although ranitidine is the more effective. Both agents are associated with an increased incidence of nosocomial pneumonia. Proton pump inhibitors are only required if upper GI bleeding due Three distinctive hepatic dysfunction syndromes occur in the critically ill: Shock liver or ischaemic hepatitis Hyperbilirubinaemia ('ICU jaundice') Transaminitis
22. Neurological support Intensive care is required to: manage acute brain injury with control of raised intracranial pressure (ICP) protect the airway, if necessary by endotracheal intubation provide respiratory support to correct hypoxaemia and hypercapnia treat circulatory problems, e.g. neurogenic pulmonary oedema in subarachnoid haemorrhage, autonomic disturbances in Guillain-Barré syndrome, spinal shock following high spinal cord injuries manage status epilepticus using anaesthetic agents such as thiopental or propofol. ICP is generally measured via pressure transducers inserted directly into the brain tissue. The normal upper limit for ICP is 15 mmHg and management should be directed at keeping ICP < 20 mmHg. Sustained pressures > 30 mmHg are associated with a poor prognosis.
23. Strategies to control intracranial pressure Prevent coughing with sedation, analgesia and occasionally paralysis Nurse with 30° head-up tilt and avoid excessive flexion of the head or pressure around the neck that may impair cerebral venous drainage Control epileptiform activity with appropriate anticonvulsant therapy; an electroencephalogram (EEG) may be necessary to ensure that this is achieved Maintain good glycaemic control with blood glucose between 5.5 and 8 mmol/L (∼99-144 mg/dL) Aim for a core body temperature of between 36 and 37°C Maintain sodium > 140 mmol/L using i.v. 0.9% saline Avoid volume depletion or fluid overload Provide ventilation aiming to reduce the PaCO2 to 4-4.5 kPa (∼30-34 mmHg) for the first 24 hours
24. Osmotic diuretic, mannitol 20% 100-200 mL (0.25-0.5 g/kg), coupled with volume replacement Hypnotic infusion, thiopental, titrated to 'burst suppression' on EEG Surgery: drainage of haematoma or ventricles; lobectomy, decompressivecraniectomy
25. DISCHARGE FROM INTENSIVE CARE The critical care team should give the receiving team a detailed handover, a written summary with relevant recent investigations, remain available for advice, and ideally visit the patient on the ward within the 24 hours after discharge
