Patient's Monitoring in ICU - Lecture Notes PDF

‫جامعة العين‬ ‫كلية التقنيات الصحية والطبية‬ ‫قسم تقنيات التخدير‬ ‫‪PATIENT’S MONITORING IN‬‬ ‫‪ICU‬‬ ‫المحاضرة ‪ -4-‬النظري‬ ‫مادة تقنيات العناية المركزة ‪ /‬المرحلة ‪3‬‬...

‫جامعة العين‬ ‫كلية التقنيات الصحية والطبية‬ ‫قسم تقنيات التخدير‬ ‫‪PATIENT’S MONITORING IN‬‬ ‫‪ICU‬‬ ‫المحاضرة ‪ -4-‬النظري‬ ‫مادة تقنيات العناية المركزة ‪ /‬المرحلة ‪3‬‬ ‫الكورس االول‬ ‫‪BY: Dr. Hussein Ali Hussein‬‬ ‫‪PhD in Anesthesia technologist.‬‬  Introduction In medicine, monitoring is the observation of a disease, condition or one or several medical parameters over time. It can be performed by continuously measuring certain parameters by using a medical monitor (for example, by continuously measuring vital signs by a bedside monitor), and/or by repeatedly performing medical tests (such as blood glucose monitoring with a glucometer in people with diabetes mellitus).  The goal of monitoring the patient is to detect problems and manage them as early as possible. Important parameters should be monitored at regular intervals in a systematic manner. Recorded on the monitoring chart.  Introduction When a new symptom, sign, or a finding appears on routine monitoring , a search for the possible cause should immediately begin. The following parameters should be monitored in ICUs: Cardiac & Hemodynamic monitoring Respiratory monitoring Blood glucose monitoring Body temperature Renal Function Nutritional Status  Behaviors of the patient: Anxiety, Fear, Restlessness, Agitation Response to new environment / ventilator and other devices; Comfort, use sedatives. ↓Pao2 : Check Spo2, patient – ventilator system. Pain : check pain medication.  Behaviors of the patient: Confusion, Disorientation, Decreased Responsiveness, No Response To Stimuli: Use Glasgow Coma Scale (GCS) to determine patient’s level of alertness and conscious. ↓Perfusion to brain : Evaluate fluid balance, check BP, examine for any acute event (e.g. stroke). Rising PaCo2: Obtain ABG. Drugs : Check medication record. Inadequate sleep. Glasgow Coma Scale (GCS) Behaviors of the patient: Twitching / convulsions / tetany ↓ed serum levels of anticonvulsants in a patient with known convulsive disorder. ↓PaCo2 with rising pH. Breathlessness Anxiety, ↓ PaO2, ↓ed ventilation, pneumothorax.  Inspection Altered chest wall movements Paradoxical movement - flail chest. Inward movement of thorax during inspiration – Lower cervical cord transection. Asynchronous movement of the thorax and abdomen – Splinting after abdominal surgery, COPD, diaphragmatic paralysis, respiratory muscle fatigue with impending respiratory failure.  Inspection Unilateral decrease in chest wall expansion Intubation of right main stem bronchus Splinting secondary to pain, air, blood, or fluid in the pleural cavity, Atelectasis Consolidation Obstruction of major bronchus  Inspection Asynchrony with the ventilator (distressed patient) – Monitor every hour. Anxiety, pain : Comfort ability, manage pain. Airway obstruction at the level of ETT : pass a suction catheter to exclude airway obstruction Migration of tube, either above vocal cords or into the main stem bronchus.  Inspection  In-line continuous nebulization. Secretions. Fluid accumulation in the ventilator circuit. Inappropriate ventilator settings in terms of flow rate, I:E ratio, FiO2, trigger sensitivity, total minute ventilation. Leaks in the system (commonly at circuit level or around ETT).  Inspection  Pneumothorax ↓PaO2, ↑PaCO2 If no obvious cause is found, the first step is disconnection from the ventilator and manual ventilation with 100% oxygen. If patient improves promptly, the ventilator or external circuit is the source of problem If patient does not improve, then problem is with the ETT or the patient. Find out the cause and manage accordingly.  Vital Signs Blood pressure – monitor every 1 hour Hypotension Decreased intravascular volume, High external or internal PEEP, Cardiac failure, Drugs – sedatives and vasodilators. Check drainage system, Look for inadvertent discontinuation of inotropes or leak from IV site.  Vital Signs Hypertension Anxiety Inadequate sedation, ↑ed PaCO2, other causes of sympathetic stimulation, Drugs - vasopressors  Vital Signs Disparity between cuff and direct (intra- arterial) pressure measurements of 5- 20 mmHg may be considered normal as long as the pressure measurement is higher. When cuff pressure is high, check monitoring system for - leaks, bubbles, or other causes of damped pressure. Hypotension is late sign of decreasing cardiac output. Early signs of a decrease in cardiac output include tachycardia, cold peripheral extremities, confused or less responsive patient and a fall in the urine output. *A normal blood pressure does not guarantee adequate perfusion. Vital Signs Heart rate and rhythm (new arrhythmias, tachycardia, bradycardia) – monitor every 1 hour. Anxiety, inadequate sedation, drugs, ↓PaO2, ↑PaCO2 (check SpO2, ABG, patient-ventilator system), ↓ed intravascular volume. Evaluate other hemodynamic parameters for the adequacy of perfusion.  Vital Signs Urinary output – monitored & calculated hourly ↓ed urine output : inadequate perfusion of kidneys, low intravascular volume, and onset of acute renal failure. ↑ed urine output :(> 100 ml/hr) in the absence of diuretics or diuretic phase of renal failure (over hydration). Normal urine output : 0.5-1.0mL/kg/hr. in adults. 1mL /kg/hr. in children.  Vital Signs Temperature : monitor every 4-8 hours. Fever – overheated humidifier, atelectasis, infection, ↑ed metabolic rate caused by ↑ed inspiratory effort or patient ventilator asynchrony. Geriatric patients have a lower body temperature, and are more easily influenced by environmental temperature (as in new born and infants). In patients over 90 years of age, body temperature < 36 may be normal.  Vital Signs Hypothermia : ↓ed environmental temperature, infection (especially in new born) Axillary temperature is approximately 0.5 C lower than oral temperature, Rectal temperature (related more closely to core body temp.) is approximately 0.5 C higher than the oral temperature.  Vital Signs Respiratory rate (RR) : monitor every 1-4 hours RR may be influenced by altered ventilator settings. Changes in metabolic needs (anxiety, stress, infection, heart failure, pulmonary edema). ↓ed PaO2. ↑ ed PaCO2. Drugs (sedatives, narcotics, anesthetic agents). Unsuccessful weaning (rapid shallow breathing). ↑ ed intracranial pressure.  Vital Signs Weight gain, Peripheral Edema : monitor daily Heart failure, hypoproteinemia (↓oncotic pressure), venous or lymphatic obstruction, sepsis, shock, trauma etc. (altered capillary permeability) Increasing weight does not necessarily mean an adequate intravascular volume. The patient could be hypovolemic, because of shifting of fluid to the tissues or to “third space”  Vital Signs Oxygen saturation with pulse oximetry – monitor continuously. End tidal CO2. monitored hourly if needed. Central Venous Pressure (CVP). Hourly If patient has CVC. Capillary refill time: Normally, after a 5 second compression of the nail bed, the pink color should return to the blanched area within 3 seconds. If it takes longer, it indicates vasoconstriction or reduced cardiac output with decreased digital perfusion. This may not be reliable when the room temperature is low.  Physical Examination Air leak around ETT-monitor every 1-2 hours. Deflated / ruptured cuff. ETT lying above vocal cords. Airway secretions-monitor with every suction. Secretions thick : inadequate humidity. Secretions copious, thin : ↑ed humidity, infection, draining of fluid from tubing into trachea (reposition ventilator tubing's). Observe the colour of secretions.  Physical Examination Breath sounds-monitor every 1-4 hours. Unilateral ↓ed breath sounds: blocked ETT, ETT migration into a main stem bronchus, air, blood, or other fluid in the pleural space, pneumonia. ↓ed breath sounds and late inspiratory crackles in the dependent region: atelectasis or any condition of lung that causes a loss of volume (restrictive disorder). ↓ed (or absent) breath sounds along with mediastinal shift: tension pneumothorax (suspect in any patient who is difficult to ventilate during CPR or who deteriorates while being ventilated, especially when high peak pressures and PEEP are being used).  Lab. investigations Arterial blood gas (ABG) analysis: Evaluate with every change in ventilator setting or with any unexplained change in patient’s condition Serum electrolytes: Daily or twice weekly. Blood urea, serum creatinine: Twice a week o\Daily Lab. Cultures from various sites: As the condition demands as the Twice a week or less often.