Intensive Care Units (ICU)

• Intensive Care Unit (ICU) is defined as a service for patients with potentially recoverable diseases who can benefit from detailed observation and treatment.
• An ICU is a designated area within a hospital dedicated to the care of seriously ill patients.

Different Types of ICU Units

• The names of ICU units vary, depending on their specific purpose and the patient's level of dependency.
• Common ICU types include:
  • MICU: Medical ICU
  • SICU: Surgical ICU
  • TICU: Trauma ICU or Transplant 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

Other Types of Care Units

• ITU (Intensive Treatment Unit) provides the highest level of patient care for those with the highest level of dependency, using aggressive treatments and monitoring.
  • An example of an ITU are cardiac surgery units.
• SCBU (Special Care Baby Unit) is for neonatal problems that often require IPPV and invasive monitoring techniques.
• HDU (High Dependency Unit) is a recovery area for patients with low monitoring needs and high level of nursing care (such as post-operation).

Main Functions of any ICU

• Provide optimum life support.
• Provide adequate monitoring of vital functions.

ICU Patient Characteristics

• Typically critical, with multiple diagnoses.
• Multi-organ failure.
• Immunocompromised.
• Major trauma and post-surgery.
• Limited movement.
• Malnourished.
• Obtunded or deaden (Glasgow coma scale).
• Heart, kidney, or liver failure.

Preparation of the ICU Unit

• The unit should always be ready and include:
  • A special bed with specific features:
    • A detachable headboard for intubation during cardiopulmonary arrest.
    • A firm, non-yielding surface to facilitate cardiac massage.
    • A tilting mechanism to adjust the patient's position.
    • Side rails to prevent falls (especially for psychiatric or anxious patients).
    • A bedside locker.
    • Over-bed table.
    • A foot stool adjacent to the bed.
  • Cardiac monitor system with alarms, connected to a central console.
  • Oxygen and suction apparatus (ideally a pipeline model).
  • Resuscitation unit with equipment like:
    • Syringes
    • Needles
    • IV catheters
    • Blood sets
    • Scalp vein sets
    • Intravenous fluids.
  • Spirit, swabs, and adhesive plaster (micropore/transpore).
  • Tourniquets.
  • Arm boards.
  • Airways including endotracheal tubes.
  • Laryngoscopes of different sizes
  • Ambu bag and suction catheters.
  • Oxygen cylinders with special trays for tracheostomy and catheterization.
  • Drugs: antiarrhythmics, antianginals, antihypertensives, diuretics, anticoagulants, antibiotics, and anticonvulsants.
  • Infusion pump

Essential Equipment for ICU

• Easily accessible equipment includes:
  • Defibrillator in working order, with electrodes and gel.
  • Cardiac pacemaker with pacing catheters in a sterile tray.
  • Mechanical ventilators for respiratory arrest.
  • Invasive and non-invasive procedure facilities (CVP line, intra-arterial pressure monitor).
  • Portable X-ray machine.
  • ECG machine.
  • Oxygen therapy equipment

Indications for ICU Admission

• Pre- and post-operative patients undergoing major surgeries.
• Craniotomy patients.
• Thoracotomy patients.
• Patients undergoing ultra-major surgeries.
• Unstable multiple trauma patients.
• Patients with head or spine trauma requiring mechanical ventilation.
• Any surgical patient requiring continuous monitoring or life support.

ICU Monitoring Systems

• The monitor screen displays various parameters:
  • Blood pressure
  • Central venous pressure (CVP)
  • Heart rate
  • Pulmonary artery pressure (PAP)
  • Oxygen saturation
  • Patient temperature
  • Intracerebral pressure (ICP)
  • ECG

Invasive Blood Pressure Monitoring (IBP)

• Arterial cannulation is used to access arterial blood samples for ABG checks and arterial pressure monitoring.
• Arterial cannulas are not for intravascular drug administration.
• A saline-filled tube connects the cannula to the transducer, which displays IBP on a beat-to-beat basis.

Central Venous Pressure (CVP)

• A CVP cannula is inserted into the internal or external jugular or subclavian vein.
• The tip is positioned approximately 2cm above the right atrium in the superior vena cava.
• CVP provides access to intravenous drugs, especially those causing irritation to peripheral veins (e.g., strong potassium chloride).

Heart Rate Monitoring

• Normal heart rate is 60-100 beats per minute.
• Less than 60 bpm is bradycardia.
• More than 100 bpm is tachycardia.

Bradycardia

• Bradycardia can be:
  • Symptomatic.
  • Asymptomatic, with or without signs of shock.

Symptomatic Bradycardia Symptoms

• Acute altered mental status.
• Ongoing chest pain.
• Hypotension.
• Showing signs of shock.

Symptomatic Bradycardia Management

• Assess ABCs (airway, breathing, circulation).
• Maintain patent airway.
• Assist breathing.
• Start oxygen.
• Monitor vitals.
• Establish IV access (Atropine).

Asymptomatic Bradycardia

• Characterized by a heart rate of less than 60 bpm.
• Patient exhibits no symptoms and is stable.
• Usually requires no specific management.

Stable Tachycardia

• Heart rate is more than 100 bpm.
• Treat the underlying problem.
• Symptoms include:
  • Dizziness
  • Shortness of breath
  • Lightheadedness
  • Rapid pulse rate
  • Heart palpitations (racing, uncomfortable, or irregular heartbeat)
  • Chest pain
  • Fainting (syncope)

Tachycardia Management

• Vagal maneuvers.
• Pharmacologic interventions:
  • Adenosine 6-12mg.
  • Amiodarone 150mg slow IV.

Unstable Tachycardia Management

• Synchronized Cardioversion at 50-100 joules.

Pulmonary Artery Pressure (PAP) Monitoring

• Pulmonary artery catheter (PAC) insertion is important for monitoring by measuring the pressure at three locations: right atrium, pulmonary artery, and pulmonary capillaries.
• PAP measures oxygen levels in the blood, cardiac output, PAP, PCWP, and CVP.
• It can also determine the overall blood flow out of the heart.

Pulmonary Capillary Wedge Pressure (PCWP)

• PCWP is recorded when the balloon-tipped catheter is inflated, and the tip occludes a small pulmonary artery.
• An inflated balloon records the pressure in the pulmonary capillary.
• PCWP reflects left atrial pressure.
  • Decreased PCWP indicates hypovolemia.
  • Increased PCWP indicates increased preload due to fluid overload.

Oxygen Saturation (SpO2)

• The pulse oximeter measures oxygen saturation, and it can be used in settings with a potential risk of arterial hypoxemia.
• It provides a warning of hypoxemia.
• If SpO2 is below 95%, the oxygen delivery system may be inadequate or cause cardiac output to be low.
• Start oxygen if SpO2 is less than 95%.

Patient Temperature

• Maintaining temperature regulation is important for patient survival.
• Hypothermia below 32°C is ominous.
• Ventricular irritability increases, and cardiac decreases to 28°C.
• Shivering can increase oxygen demand by 135%-468%.

Sites for Monitoring Body Temperature include

• Oral.
• Tympanic membrane.
• Esophageal.
• Nasopharyngeal.
• Pulmonary arterial blood.
• Rectal.
• Bladder.
• Axillary.
• Forehead.

Drains and Tubes

• A surgical drain removes pus, blood, or other fluids from a wound.
• Drains do not speed healing or prevent infection.
• It is necessary to drain body fluid that may accumulate and become a focus of infection.

Jackson-Pratt Drain

• Also known as JP drain or Bulb drain.
• Constant suction is used to pull excess fluid from the body.
• The device has a flexible plastic bulb and an internal plastic drainage tube.

Penrose Drain

• It is a surgical device placed in a wound to drain fluid.
• A soft rubber tube is placed in a wound area to prevent fluid buildup.

Corrugated Rubber Drain

• It is fixed with a suture and a safety pin to prevent it from slipping inwards.
• Corrugated rubber drains can be used for the deep wound for drainage.

T-Tube

• It consists of stem and cross head shaped like a T.
• The cross head is placed into the common bile duct while the stem connects to a small pouch, such as a bile bag.
• It is used as a temporary post-operative drainage.
• A T tube Handles the common bile duct during procedures like dissection, dilatation, choledochotomy, and cholecystectomy, preventing spasm of the sphincter of Oddi.
• Reduced pressure and the motility in the common bile duct while reducing spasm of the sphincter of Oddi are benefits of it.
• It relieves back pressure and reduces the risk of sutures coming apart in the choledochotomy incision, preventing surgical complications.
• Keep the T-tube in place for about 10 days.
• Bile is allowed to flow out to reduce pressure on the suture line until the sphincter spasm subsides.

Chest Tube Or Pleural Drainage Tube

• Used to remove air or fluid in the pleural space.
• Drains haemothorax, pneumothorax, chylothorax, pleural effusion, and empyema.
• It is inserted into the pleural space in the 4th intercostal space.

Nasogastric Tubes

• A naso-gastric tube goes through the nostrils (or the oral cavity), reaching the stomach, duodenum, or even jejunum.
• During insertion:
  • Direct point should be downward toward the xiphoid process.
  • Minimize the risk of coiling by twisting the tube 180 degrees as it reaches the nasopharynx.
  • Lubricate the tube with lidocaine jelly to ease insertion.
  • Ask the patient to swallow whilst in place

Endotracheal Tubes

• These tubes are inserted into the trachea, establishing and maintaining patent airways and ensure adequate exchange of oxygen and carbon dioxide.
• Indications include:
  • Assisted ventilation.
  • Isolate trachea to permit control of airway.
  • Direct route of suctioning.
  • Administration of medication

Endotracheal Tube Placement

• Proper ETT is 5cm above the carina.
• Usually level with T4 vertebra.
• 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 should be positioned between the stoma and carina, unaffected by flexion or extension.

Catheters And Lines

• A catheter is a hollow flexible tube inserted into a body cavity, duct or vessel for injecting fluids.

Types Of Catheters

• Diagnostic Catheters are used for angiographs.
• Guiding Catheters are used for angioplasties, and are more stiff than angiography catheters as it carries balloon catheters, PTCA wires and stent delivery systems.

Butterfly Catheters

• Butterfly catheters are for vein puncture, accessing a superficial vein intravenous injection.

Foley Catheters

• It is a thin, sterile tube inserted into the bladder to drain urine that is referred to an indwelling catheter.
• These are used to:
  • Collect uncontaminated urine specimens.
  • Monitor a patient's urine output.
  • Manage urination during surgery.
  • Use before and after cesarean sections.
  • Use on patients that are under anesthesia or sedated

Central Venous Catheters

• Central venous catheters are used for venous access for critically ill patients and to measure central venous pressure and intravascular blood volume.

Percutaneous Intravascular Central Catheters (PICC)

• PICCs are a long-term access solution that is small, inserted through antecubital vein, and the tip lies in the superior vena cava.

Pulmonary Artery Catheter

• It is known as swan-ganz catheter
• It is inserted in pulmonary artery
• used to detect heart failure and monitor therapy.
• Allows measurement of pressures in the right atrium, right ventricle, pulmonary artery, and wedge pressure.